The Health IT Scandal the NY Times Didn’t Cover

Below, a guest-post by Michael L. Millenson, president of Health Quality Advisors LLC.  An early, and vocal quality-of-care evangelical, Millenson is the author of the critically acclaimed book, Demanding Medical Excellence: Doctors and Accountability in the Information Age.

As health information technology honchos gather for the annual HIMSS trade show and schmoozefest, it’s a safe bet the industry “scandal” the New York Times placed on page one recently will breed more bored yawns than buzz. The real scandal in health IT involves the customers, not just the vendors, but that’s a topic for quiet conversations journalists can’t cover.

In case you missed it, the shocking news was that health IT companies that stood to profit from billions of dollars in federal subsidies to potential customers poured in ­– well, actually, poured in not that much money at all when you think about it ­– lobbying for passage of the HITECH Act in 2009. This, putatively, explains why electronic health records (EHRs) have thus far failed to dramatically improve quality and lower cost, with a secondary explanation from athenahealth CEO Jonathan Bush that everything would be much better if the HITECH rules had been written by Jonathan Bush of athenahealth.

Next up: corporate lobbying for passage of the 1862 Pacific Railroad Bill is blamed for Amtrak’s dismal on-time record in 2013.

The actual scandal is more complicated and scary.  It has to do with the adamant refusal by hospitals and doctors to adopt electronic records no matter what the evidence. Way back in 1971, for example, when Intel was a mere fledgling and Microsoft and Apple weren’t even gleams in their founders’ eyes, a study in a high-profile medical journal found that doctors missed up to 35 percent of the data in a paper chart. Thirty-seven years later, when Intel, Microsoft and Apple were all corporate giants, a study in the same journal of severely ill coronary syndrome patients found virtually the same problem: “essential” elements to quality care missing in the paper record.

That clinical evidence and the way in which the world outside medicine had been transformed by computers did almost nothing to change health care. Computerized medical records were available: before there was “Watson,” the IBM computer helping doctors make decisions, there was “Watson,” the IBM chairman, vainly trying to sell electronic records to doctors as early as 1965. But well into the 21st century, most providers only trusted computers to send out the bills.
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The Electronic Medical Record and the Disappearance of Patients’ Stories

Below, a guest post by Christopher Johnson, a physician who has practiced pediatric critical care for more than three decades. For many years, Johnson served as the Director of the Pediatric Critical Care Service at the Mayo Clinic and Professor of Pediatrics at Mayo Medical School. Today, he devotes his time to practicing pediatric critical care as President of Pediatric Intensive Care Associates, P.C., i n St. Cloud, Minnesota, and as Medical Director of the PICU for CentraCare Health Systems.

In addition, Johnson writes about medicine for general readers, both on his blog  and in books such as HowYour Child Heals: An Inside Look at Common Childhood Ailments  and How to Talk To Your Child’s Doctor: A Handbook for Parents

Not a few doctors complain that, too often, electronic medical records seem designed to improve billing, rather than to improve care. Johnson suggests that today’s EMRs are trying to serve too many masters—not just doctors, but payers and lawyers who want to see information laid out in easy-to-read “templates.” 

With a single keystroke, one can “drag and drop” information from previous notes into these templates, Johnson observes. But when physicians use them to record their progress notes, something important is lost: the patient’s story. Traditionally, progress notes set out to “tell, from day to day, what physicians did to a patient and why,” Johnson explains. They are a narrative that fleshes out the patient’s history in a way that helps other doctors treating the same patient.

Johnson uses and appreciates the many ways that EMRS can help him. But when writing out his progress notes, he ignores those smart templates, and tells the story the old-fashioned way, typing out his progress notes, just the way he did when he used pen and paper. Not only does this help other doctors, but Johnson says, it gives him a chance to “think things through.”

Narrative connects the dots.

MM

The Electronic Medical Record and the Disappearance of Patients’ Stories   

By Chris Johnson, M.D.

The electronic medical record (EMR) is here to stay. Its adoption was initially slow, but over the past decade those hospitals that do not already have it are making plans for implementing it. On the whole this represents progress: the EMR has the ability to greatly improve patient care. Physicians, as well as all other caregivers, no longer have to puzzle over barely legible handwritten notes or flip through pages and pages of a patient’s paper chart to find important information.

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Hospitals Under Scrutiny For Billing Practices That Cost Medicare $11 Billion

Below, a guest-post from Naomi Freundlich. This post originally appeared earlier this week, on Reforming Health , Naomi’s new  blog. (Many Health Beat readers will remember Naomi as Health Beat’s associate editor back when we were both working for The Century Foundation.)  

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If you or a loved one has been to the emergency room lately you might want to request an itemized bill. The highest charge will likely be for what is known in billing parlance as “evaluation and management” services. These services include taking a patient history, performing an initial exam and directing treatment. How much the hospital charges will depend on an all-important choice of billing code—there are a range of codes that coincide with factors like the severity of the problem, underlying health issues of the patient and in some cases, time spent managing this care.

Why take a close look at these charges? According to a new investigative report from teh center for Public Integrity  providers have been increasing their use of billing codes that correspond with care for the most seriously ill or injured patients, adding $11 billion or more to the fees they receive from Medicare over the last decade.

According to the CPI report; “Use of the top two most expensive codes for emergency room care nationwide nearly doubled, from 25 percent to 45 percent of all claims, during the time period examined. In many cases, these claims were not for treating patients with life-threatening injuries. Instead, the claims the Center analyzed included only patients who were sent home from the emergency room without being admitted to the hospital. Often, they were treated for seemingly minor injuries and complaints.”
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Healthcare IT Is Not a Done Deal—Even in Theory

In a previous post, I briefly mentioned how the U.S. Department of Health and Human Services has started developing regional networks of electronic health information. Eventually, these networks will merge into a “network of networks,” thus working toward a nationwide, compatible system of electronic health records by 2014.

Unfortunately this “network of networks” approach of regional heath information organizations (RHIOs) has some serious faults. And the alternative system currently favored by many, health record data banks, still poses a lot of unanswered questions.

According to an October report from the Information Technology and Innovation Foundation (ITIF), the major problem with RHIOs is coordination: “multiple, heterogeneous databases” require “the extensive use of middleware—that is, software used to interface between incompatible databases and data formats.” Otherwise it’s like trying to run Mac software on a PC. Other coordination challenges include accurate patient identification (is John Smith in the Bronx the same as John Q. Smith in Cleveland?) and ensuring comparable service quality—each network needs to be as fast and secure as its peers.

With all of these inefficiencies, the ITIF study notes that RHIOs don’t make a very compelling business case to the health care providers who are expected to implement and operate the networks. Most of the system’s savings go to patients (because they can expect better care) and insurers (because mistakes can be avoided) rather than hospitals and doctors, who incur all the costs of transitioning to a new IT platform—a fact of which they’re well aware. A 2006 JAMA study showed that health care providers are worried about IT transitions primarily because of start-up costs (installation, consultation, training, etc), ongoing costs (such as compliance with privacy laws—no small matter, given the ambiguity of HIPPA) and the potential loss of productivity as employees learn the new system.

In lieu of RHIOs, ITIF recommends health record data banks (HRDBs), a model that has gotten a lot of buzz over recent months—including its own bill in Congress last year.

The simplest way to explain HRDBs is via analogy: think of how you engage with a commercial bank account, and you’re on the right track. Just as you choose a bank from a competitive marketplace of financial institutions, so would you pick an HRDB provider from many vying for your business; just as you open a bank account, so would you start a medical record account; and just as you log in to access financial information, make transactions, and monitor your activity with a bank, so would the HRDB service let you sign in online to access to your medical history, test results, and so on.

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Online Doctors, Privacy, and the Almighty Dollar

Last month a
slew of media outlets
caught wind of Jay Parkinson, a 31 year old
Brooklyn-based M.D. who provides care for his patients through the Internet.
Here’s how it works: you get an initial in-person consultation at your home or
office. After that, you can ask Parkinson questions online through instant
message or video chat; e-mail him digital images of minor wounds, rashes, etc.,
that he can then diagnose; have him help contact, call ahead, and inform
specialists when you need their help; and generally fulfill most basic medical
consultation functions online.

Parkinson’s work raises a lot of questions, but first among them may be
this: how come my doctor isn’t
utilizing virtual communication to its fullest potential?

Part of doctors’ technophobia stems from their lack of incentives to engage
with the virtual world: they’re not reimbursed for virtual consultations that
may be deemed “self-management support activities,” or good old fashioned advice
about do-it-yourself care. As little as eight
percent
of patients communicate with their doctors via e-mail—a shame,
considering in the latest issue of JAMA, Tom Delbanco from Harvard Medical
School estimated that 50 percent of visits to the physician are unnecessary and
could probably be dealt with online.

But there are other reasons why doctors are reluctant to take their practice
online. For most doctors, communicating sensitive patient information without
special, government-approved secure platforms is illegal under the Health
Insurance Portability and Accountability Act (HIPAA). HIPAA, originally passed
in 1996, was revised in 2002 by the Bush Administration to incorporate a
privacy rule that came into effect in 2003. The privacy rule regulates the use
and disclosure of private health information (PHI),
which is information about “health status, provision of health care, or payment
for health care that can be linked to an individual.” It’s this privacy rule
that makes so many doctors computer-shy.

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Hospitals & Nurses: Behind the Scenes

Recently I’ve begun reading allnurses.com, a website that offers an eye-opening window on conditions in U.S. hospitals.  (I found the site when allnurses reprinted my post about the nursing shortage).

Clearly nurses and doctors know more than virtually anyone else about what is going on in our hospitals, but they also realize that they risk reprisals if they speak out. When I was writing Money-Driven Medicine, I was surprised by how many physicians returned my phone calls. The great majority did not know me; I expected responses from perhaps 20 percent. Instead four out of five called back. To a man and a woman, they were most passionate about what many saw as the declining quality of healthcare. “We want someone to know what is going on,” explained one prominent Manhattan physician as he described how much care had deteriorated in many of New York City’s major hospitals. “But please don’t use my name,” he added. “You have to promise me that. In this business, the politics are so rough–it would be the end of my career.”

Nurses are in an even more vulnerable position. I could not find any who were willing to be interviewed. I e-mailed quite a few, promising anonymity, but not one responded.

On allnurses.com, however, nurses speak freely, knowing that their identities are protected and that their audience is composed of other nurses.  Here is what I have learned from some of the polls and forums on the site:

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Employers and Healthcare: “Which Frogs A-Leaping?”

At “Healthcare Renewal” (hcrenewal.blogspot.com) Brown University’s Dr. Roy Poses recently posted a thought-provoking piece about the Leapfrog Group, an employer group that has made its reputation pushing for higher quality care.  Poses points out that nearly 30% of the members of Leapfrog are healthcare corporations, and notes that this might skew their view of healthcare’s goals:
 

“One would expect that companies who make money by providing health care goods and services may have different ideas about health care costs and quality than companies who do not do any health care related business” said Poses in his post.

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