At Health 2.0, Ted Eytan, MD, and I talked for a bit about why Kaiser Permanente’s “virtual health care system” has had such great success. According to his bio, Ted is a family doc from DC with a background in “working with large medical groups, patients, and technologists to bring health care consumers useful information and decision-making health tools, to ensure that patients have an active role in their own health care.”
Ted is Permanente’s Medical Director for Delivery Systems Operations Improvement. Permanente’s online system strives to bring the doctor and patient together online via the electronic health record (EHR), decision making tools and communications tools such as email. It further empowers the patient to be an active participant in the health care system by having access to the EHR and being able to book appointments online, renew prescriptions, contact health providers, and see labs and tests. Eytan has a wonderful summary of the system and the demonstration they did at Health 2.0 on his blog here.
Here are the highlights of our chat:
Dr. Gwenn: What makes Kaiser work so well compared to other areas of the country, for example Massachusetts?
Dr. Eytan: The key difference between Kaiser and here (MA) is adoption.
Dr. Gwenn: Why is that?
Dr. Eytan: The important point to teach doctors is the customer service approach. We do things because the members want it. That should be the reason for all change in health care. If places focus on quality not customer service, the system won’t work well and nothing will change.
Dr. Gwenn: What has helped Kaiser be so successful?
Dr. Eytan: Three major points that have worked well in Kaiser’s system: accountability, physician leadership and valuing members.
1. At Kaiser we have 100% accountability over everything. We own up to mistakes when they occur and help physicians learn from them.
2. Kaiser encourages physician leadership to spark reform and help IT departments facilitate change: Physicians do have value and can create the clinical vision. They work with IT to facilitate the technological changes that need to occur to make the doctor-patient encounter work better and to make the physician’s work life more manageable.
3. Kaiser listens to members… members have advisory groups, teen groups: they are involved and their voices are heard at all levels and all ages.
Dr. Gwenn: How do you oversee the online world with patients?
Dr. Eytan: The patients are the customers and the EHR must be usable to them – that is the MO of the entire system. In addition, there is an online, full time medical director responsible for the patient interface. There is no other way to have a patient-involved online system without a dedicated staff overseeing that system lead by a physician.
Dr. Gwenn: What problems do you help the clinical staff anticipate with online care?
Dr. Eytan: With virtual care, patients will see lab results and parts of the EHR they are not used to seeing and that could prompt questions or concerns. There has to be commitment from everyone to be ready to answer those questions fro the system to work well for the patient. They provide a great deal of training and support so the clinical staff will be prepared for questions from patients they may not have had when patients were not so involved in their care and seeing so much of their EHR.
Dr. Gwenn: How does virtual care help the system?
Dr. Eytan: There are a number of important ways virtual care helps the system on many levels:
1. It builds confidence in the doctor patient relationship by fostering conversation.
2. There’s a database to give patient’s article-based information (Permanente uses the “healthwise knowledge base”).
3. They use true medical terms with patients and in the EHR that patients will Google. This helps patients be more savvy in the health care system and know what terms to search for should they seek more information or have questions to ask of the clinical staff.
Dr. Gwenn: What are the benefits of virtual care for the patients and the physicians?
Dr. Eytan: There are three primary benefits:
1. Online care helps empower the patients to be part of their care and shapes use with guidance from the staff.
2. Patients become so involved they become invested in making sure the EHR is accurate and often point out mistakes they note, such as typos.
3. Doctors can be more efficient by using pre-visit emails to organize their time.
Dr. Gwenn: What’s your take on the Health 2.0 vs. Ix (Information Therapy) debate during this conference?
Dr. Eytan: Useful, accurate information is the goal. Give people what they want, when they want it. All systems need to use more health 2.0 tools member to member. Ultimately the goal is to connect to the doc.
Dr. Gwenn: How can docs be more health 2.0 savvy?
Dr. Eytan: All docs should ask patients if they use the internet. It’s the 6th vital sign.
Dr. Gwenn: Many patients don’t live in a virtual health care system like Kaiser, how can they get from their system what you offer at Kaiser?
Dr. Eytan: Ask and demand! Most electronic medical record systems have the tools in place, like email, and just have to start using them. Patients need to ask for what they want. Physicians want to do a great job and hate waste.
My final thoughts:
With such great models such as Permanente in many areas of our country, it’s frustrating we can’t get similar systems everywhere. Perhaps it is not just the patients who have to “ask and demand” for what they want in the health care system. Perhaps it’s time docs everywhere stood up and demanded a system where docs were compensated well, treated respectfully, and had a system that actually supported good care.
*This blog post was originally published at Dr. Gwenn Is In*
Bolstered by the stimulus, there’s no doubt that there’s a significant push for doctors and hospitals to adopt digital medical records.
I’ve written before how we’re essentially throwing money at Windows 95 technology, but now, as an article from BusinessWeek points out, there’s a real danger in moving too fast.
Somewhat under-publicized were the incompatibilities with older systems in the Geisinger Health System, which after spending $35 million on software, noticed a spike medication errors that required another $2 million to fix.
Or what happened at the University of Pennsylvania, which found medication errors stemming from software designed to prevent mistakes.
Worse, there is no national database tracking the errors that are caused from electronic medical records. Because most of the programs are not open-source, confidentiality agreements meant to protect proprietary technology also serve to hide mistakes.
Ideally, these issues need to be resolved before throwing more money into bad technology. But, because of the intuitive notion that technology automatically improves health care, no one seems to be advocating a more cautious route which may, in actuality, better serve patients.
***
Better Health Editor’s Note: Please read this post for more in-depth coverage of how difficult it is to transfer health records electronically.
Thanks to Andrew Sullivan who cited my post on the uninsured, I’ve gotten a lot of new comments on that subject. While my post was just a gripe about the problem, the comments were mainly focused on solutions. How do you fix the problem? I even got an e-mail specifically asking me what I would do to deal with the problem of the uninsured.
You have to realize that I’m basically chicken (as are most doctors). I like to point the finger and avoid the fingers of others. It’s much easier to gripe than to fix things. It’s much easier to criticize than it is to say things that can be criticized. But I will break from the safe position of critic and give some thoughts on what I think needs doing on the problem of the uninsured/underinsured. Those who doubt the reality of this problem have only to spend a few days in primary care physician’s office to realize that it a huge problem that is getting worse.
So here are my suggestions:
1. The government has to take on tasks that are in the best interest of the public.
Preventive healthcare should be paid for. This could be done via public health clinics, but having having some sort of preventive health insurance for the uninsured would not have much overall cost (compared to the whole of healthcare) and would potentially save money.
There certainly is debate as to what prevention is really worth it (the PSA test debate is a good example), but some prevention is clearly beneficial (immunizations, Pap Smears). Simply building a relationship between people and primary care physicians also has benefits by itself.
The overall goal is to improve the overall health of the American public. Promote behavior that deals with problems when they are still small or before they happen at all. Just visiting a PCP isn’t the solution by itself, but it is probably a necessary component to achieve a healthier public.
2. Promote proper utilization
One of the main costs to any system, public or private, is overutilization of services. Any solution that does not somehow look at utilization will automatically fail. More care costs more.
Here are areas of increased utilization:
Emergency room visits for non-emergencies.
Visits to specialty physicians for primary care problems.
Unnecessary tests ordered – more likely in a setting where the patient is not known.
Patient perception that “more care is better.”
Nonexistent communication – ER doesn’t know what PCP is doing, PCP doesn’t know what happened at specialist or in the hospital. This causes duplication of tests.
Solutions to these problems include:
Better access to primary care or other less costly care centers
Increase the ratio of primary care to specialists
Care management for high utilizing patients
Public education (not through the press but through better public health).
Promoting connections between information systems – better IT adoption would help, but that IT must communicate.
Make the malpractice environment less frightening to doctors. A large amount of questionable care is given to protect physicians from lawsuits. (A good example is PSA Testing. Even though recent studies question the benefit, many doctors fear that not ordering them will expose them to risk should the patient develop prostate cancer).
How does this help the problem of the uninsured? It reduces the overall cost of non-catastrophic care, which makes either public or private insurance focused on this more feesable.
3. Fix problems with Pharma
Medication costs are a huge problem to my uninsured and insured populations. There are many reasons for this, but some of them are simply due to a bad system. For example:
Medication discount programs cannot include Medicare patients. Why should I be able to give a discount card to my patients with private insurance, even my uninsured, but not Medicare patients?
High cost of generic drugs. When a drug goes generic, there is usually only a slight drip in the price. The system allows only limited competition for price, so the cash price remains high. Encourage cost competition.
Drug Rebates. This raises the overall cost of drugs to everyone. Rebates are sent to insurance companies by drug companies for inclusion on the formulary. It pretty much looks like extortion. The cost of these rebates is not absorbed by Pharma, it is passed on to those who aren’t covered by insurance companies getting the rebate. These need to be eliminated.
Get rid of direct to consumer marketing of drugs. This is pure capitalism that encourages over-utilization.
All of these programs would allow reduced overall cost of medications, which would make either drug coverage more possible or make the cash price of drugs more affordable.
4. Address Conflicts of Interest
Insurance companies are largely publicly-traded companies. This means that their main business goal is to maximize profits by either cutting their costs or increasing revenue. Having them the ones managing care is like putting the kid in charge of the cookie jar. Insurance companies should get back to the business of insuring. Care management is certainly important to control overutilization, but that should not be done by those who could profit from it (insurance companies, hospitals, physicians).
Insurance companies promote themselves as healthcare companies. They don’t provide care, and they shouldn’t. Perhaps there needs to be a third-party that does care management – I am not certain – but it is clear that good care management would greatly reduce overall utilization and profiteering.
How does this help the uninsured? It reduces the footprint of the insurance industry on healthcare as a whole, which should bring down the cost if insurance. It should let insurance companies compete solely on cost, not on provider pannels or other services they shouldn’t be giving in the first place. If insurance costs less, there are less uninsured.
5. Focus on the “uninsurable”
5% of Americans account for over 50% of the overall cost of care (reference). These are the uninsurable people – those who are truley expensive to treat. There needs to be very close management of these people. Leaving them uninsured doesn’t reduce cost, it just shifts it to hospitals and local government. It also leaves them unmanaged. Of the waste in healthcare, the likelihood is that a very large percent of it is in the high-utilizers (by definition). These people need management, either in a “medical home” or by some sort of care management.
There you have it. Follow these rules and everything will be fine.
Yeah, right. Alright everyone, have at it! Tell me what you think, but don’t be a chicken: criticism should be accompanied by an alternative solution.
Our office has been on Electronic Medical Records (EMR) for nearly thirteen years. We see a high volume of patients, keep our overhead down, and are able to be quite successful financially. All of the “EMR is impossible” and “EMR makes things worse” stuff you read around the web are disproved quickly with a step into our office. We implemented EMR successfully in a private practice setting without help from an economic stimulus, a hospital system, or a magic wand.
Not that it was easy; we went through many years of struggle to get to where we are today. We struggled mainly because we were exploring unknown territory. We had very few other successful EMR implementations to learn from. We used slow computers and programming developed in the pre-Internet era. We made huge mistakes and struggled at times to make our monthly budget.
But we did it, and practices implementing now can learn from my and others’ success. Probably the main lesson we learned is to put office function ahead of implementation. Since we are a business, we must stay profitable while implementing. Since we are practicing medicine, we must never compromise quality in the process. This meant that we implemented over time, focusing on parts that would either improve our process or at least not bring us down.
Now we are at the position I thought might never come: survival is no longer in question, so we can dream. We don’t have to act defensively, we can push the envelope. We can afford to ask the question: “How can we build the best medical experience for our patients?” We can imagine a destination and actually attempt to get there.
The ideal destination is one in which our patients’ care is improved by maximizing efficiency on our end. Obviously I don’t want to make things harder for our practice, I want to make things easier. But the goal of care is ultimately centered on the patient, not us. So is there a way to accomplish both goals? I think there is, and I think that our EMR is the tool that makes it possible.
Here are our goals in the process:
Simplify how things are done
Always have the right information available
Make communication clear and easy
Achieve the highest quality possible
I’m sure some think this is just idealism and can’t happen in reality. I agree and disagree. No system can be perfect, but the current healthcare system is so inefficient and ineffective that huge gains can be made. The best way to show that is to get down to specifics. Here is where our practice is heading:
Simplify
The thing that takes the most time away from actual patient care is documentation. Doctors are paid by the volume of documentation, not its quality. Still, the main purpose of a record is to accurately know what is going on with the person facing you in the exam room. Unfortunately, the patient is continually changing, so some information is only accurate for a short time. Has the patient seen a specialist or been in the hospital? Have the medications been changed, or just not taken? Have they changed jobs, quit smoking, or gotten married? Did their sister just get diagnosed with cancer? The task of keeping this information up to date is extremely difficult.
Patients are the ones who know these things best, but they are only passive participants in the process. To keep the record accurate, I must ask them all the right questions on a regular basis. This cuts into time that should be devoted to care. So why can’t the patients be allowed to maintain this part of the record? Why shouldn’t they have access to parts of their record and the ability to correct errors? Here is how we see this happening:
Certain parts of the record should be available for patients to review online. Basic demographics, medications and allergies, family history, and lifestyle information is a good start. If something new has happened, the patient can either update this information directly (like marital or smoking status) or notify the office of changes (like medication lists).
If the patient doesn’t update it online, then they can do so when they come into the office (while sitting in the waiting room). Some people will undoubtedly not want to do this, but a significant percent will, decreasing the workload on the office while maximizing the quality of information.
Patients should be able to communicate important information to the office online. If they go to the ER or see a specialist, if their blood pressure or sugars are high, they should be able to send that information directly to the physician.
Another area of potential gain is the gathering of information for a visit. When a person comes to the office, they have to answer a series of questions related to the visit:
what are the symptoms the are having?
Are there any other symptoms?
How have they been since the last visit?
Gathering this information is essential, but it is one of the main causes of delays. Here is how we want to employ technology to improve this process:
Put kiosks in our waiting room where patients can provide information, such as:
History of their present illness. If they are sick, then what are the symptoms and how long have they gone on?
Review of systems. What other things are going on in their health?
Medication and demographic review (if not done already online).
If patients fill out information online before coming to the office, the staff will bring them to see the doctor immediately (or at least as soon as possible).
Even 50% participation by patients in this process will have a huge impact on our office workflow. The end result is a win-win: the patient is seen sooner, the information is more accurate, and the workload of the staff is reduced. Will there be problems? There always are; but the advent of ATM machines, airport kiosks, and online shopping are a few examples of process automation that have greatly improved the customer experience. Why should medicine be different?
I am going to stop here, as I don’t want to lose you (if you haven’t already whacked the keyboard with your forehead). Hopefully you can see that the use of technology applied smartly can help patients and medical offices at the same time.
Electronic Medical Records are coming. The economic stimulus bill (furious spinning kittens notwithstanding) assured this.
Under the terms of the bill, CMS will offer incentives to medical practices that adopt and use electronic medical records technology. Beginning in 2011, physicians will get $44,000 to $64,000 over five years for implementing and using a certified EMR. The Congressional Budget Office projects that such incentives will push up to 90 percent of U.S. physicians to use EMRs over the next 10 years.
Practices that don’t adopt CCHIT-certified EMR systems by 2014 will have their Medicare reimbursement rates cut by up to 3 percent beginning in 2015.
There will be even more money for implementation. We look forward to our checks (and are not counting on them yet).
Now it is time for the flies to start gathering. Wherever there is lots of money, “experts” pop up and new products become available that hope to cash in. Doctors, who are never lauded for their business acumen, will be especially susceptible to hucksters pushing their wares. It seems from the outside to be an simple thing: put medical records on computers and watch the cash fly in.
Anyone who has implemented EMR, however, can attest that the use of the word “simple” is a dead giveaway that the person uttering the word in relation to EMR is either totally clueless or running a scam. It’s like saying “easy solution to the Mideast unrest,” “obvious way to bring world peace,” or “makes exercise easy and fun.”
Run away quickly when you hear this type of thing.
Just like becoming a doctor is a long-term arduous process, EMR implementation happens with time, planning, and effort. It’s not impossible to become a doctor, but it isn’t easy. With EMR adoption, the most important factor in success is the implementation process. A poorly implemented EMR isn’t simply non-functional, it makes medical practice harder. A well implemented EMR doesn’t just function, it improves quality and profitability.
How do I know? Our practice ranks very high for quality (NCQA certified for diabetes, physicians are consistently ranked high for quality by insurers), and we out-earn 95% of other primary care physicians. EMR allows us to practice good medicine in a manner that is much more efficient.
So how’s a doc to know who to trust? What product should he/she buy and whose advice about implementation should they follow? There are many resources out there. Here are a few I think are especially worthwhile:
Buy a product that is certified by Certification Commission for Health Information Technology. CCHIT is a government task force established to set standards for EMR products. Its goal is to allow systems to communicate with each other and enable more interfaces in the future. The bonuses for docs on EMR are contingent on the system being CCHIT certified (think of it as something like the WiFi standard).
Several professional IT organizations have programs to improve EMR adoption, including HIMSS and TEPR.
Austin Merritt has written a good article of advice on his website Software Advice that underlines the importance of implementation.
The best advice I can give, however, is to visit a doctor’s office who is using an EMR successfully. This office should be as close in make-up to your office as is possible. You should be able to look at how they do it and see yourself in that situation. Never buy a product before visiting at least one office like this (no matter how good the sales pitch). When you visit, make sure you ask them about the implementation process. How did they do it and how hard was it?
Which EMR do I recommend? Remember, I have been on EMR for over 12 years, so haven’t had much of a chance to shop around. You hear raves and horror stories with every product. Here is some basic advice:
Get a solid CCHIT-approved brand that has been around for a while
Don’t pay as much attention to price as you do function. Since the EMR will be absolutely central to the function of your office, it is a dumb mistake to overly-emphasize cost.
Realize you are paying for a company, not just a product. It is not like buying a car, it is more like having a child or getting married. REALLY research that side of things. A good EMR with a bad company behind it should be avoided like the plague.
See how connected the user-base is as well. A solid user group will do much to make up any deficiencies in the product and/or company.
So much time is spent shopping over EMR products, but buying an EMR is like being accepted into Medical School; your work is just beginning. That’s OK, because like medical school, the effort put in gives a very worthwhile product.
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