The first Christmas blizzard ever in Kansas City reminded me why my wife and I chose to live in Overland Park, a suburb of Kansas City on the Kansas Side of the state line Taxes. We chose it because property taxes were significantly higher than just across the border in Missouri. Huh? Doesn’t seem to make sense, you say. Apparently we’re not alone because we’re surrounded by neighbors who frequently get reminded of the benefits of living where taxes are higher and reaping the benefits of those shared expenses. The blizzard? Right. Three hours into the blizzard we saw city snow plows clearing our neighborhood streets. And they came back several times in a 24 hour period. None of us had problems getting out when we needed to. Today we went to Church, 2 days after the snow. The minute we crossed the state line we found ourselves maneuvering snow-packed streets littered with cars stuck in their driveways and communities locked in. Almost all of those who were at the early service lived on the Kansas Side while many on the Missouri side who lived only a few blocks from Church were homebound. Snow plows may never make it to their side streets before the snow melts. In our neighborhood most of us were out shoveling not only our driveways but our sidewalks. Those with snow blowers went from house to house without being asked wishing their neighbors a Merry Christmas. Even teen age school children put aside their Play Stations and cell phones to help. Why? I think a large part of it was that the streets were plowed and therefore the mobility barrier was only our driveways. That wouldn’t be the same if the streets were filled with 10 inches of snow. What good does it do to get out and shovel your driveway when you still can’t go anywhere? So what does this have to do with taxes? When people see their money going to local services like snow plows, good schools and civic government a stronger sense of community and pride exist. Ironically the more selfish people are in the short term the more isolated and costly it becomes for them to live as a community. Communities are made of those who are fortunate and those who are less fortunate. Those who reach out and help each other socially, fiscally, spiritually and neighborly are those who are healthier and live better. I was struck by an Randall Stross editorial by in the NY Times this morning titled, “Sorry, Shoppers, but Why Can’t Amazon Collect More Tax?” (http://www.nytimes.com/2009/12/27/business/27digi.html?_r=1&ref=technology). The article describes the elaborate efforts Mr. Bezos has gone to keep from paying taxes to the states in which they provide services. This gives Amazon a competitive advantage at the expense of teachers, civic services, public roads and a whole host of other tax-based services on which Amazon itself relies. Similar corporate measures are costing states up to $350 billion a year and we’re all suffering for it. Mr. Stross concludes “Amazon’s in-house counsel should help the company meet its civic obligations — and toss “entity isolation” in the trash can. Amazon’s employees are too scattered, its customer base and its sales too large and the states’ fiscal crisis too grave for it to continue to play tax-avoidance games.” Here, here. And the next time it snows, storms or a crisis hits. I’m glad I live in a community that takes it’s taxes seriously.
Sunday, December 27, 2009
Wednesday, December 16, 2009
The Uncertainty of Diagnoses
There was a sentinal event experienced when I matriculated into medical school at the age of 34. The dean of the medical school stood up and quoted a study that showed in 1983 up to 40% of the time the working diagnoses at Johns Hopkins were found to be in error on autopsy results. He then went on to say that by the time we finished residency most of the knowledge we'd memorized in medical school would be obsolete. That's when I went out and spent over $3,500 for a computer only to be crushed that there was very little software that would help me 1) get through medical school and 2) help with diagnosing and treating a patient.
A lot has happened since then but the promise of artificial intelligence, connected health information networks and computerization of health care hasn't really panned out the way I imagined over the last 25 years. But one thing that hasn't changed is the complexity of even simple diseases. Why?
Well, for one we don't practice medicine scientifically. Take a simple sore throat. We don't do viral and bacterial cultures on every one or even a random sample of patients to discover the exact pathogen with which we're dealing. There are probably over 200 viruses and 50 bacteria and a multitude of mechanical and environmental agents that will produce almost identical symptoms. We don't have instant tests with the exception of Rapid Strep, Rapid Influenza and Rapid Mono tests that can help us significantly. Thus for the vast majority of cases we are practicing blind. Fortunately most patient get well from this condition in 2 weeks no matter how we treat. The evidence suggests that with the exception of a very small minority of conditions NOT treating is better than treating but it is really hard to convince patients no treatment is better than treating.
I purchased QMR, Iliad and a subscription to AMANet to access Octo Barnett's DxPlain to help me come to correct diagnoses. What I and my colleagues discovered is that there were about 1,500 signs and symptoms that covered almost all of the known diseases (over 20,000 in the databases). That meant a large number of diseases presented with the same signs and symptoms. There were very few diseases that had pathognomonic signs or symptoms. Consequently we became pretty good at coming up the differential diagnosis (a list of the diseases that shared the same symptoms). Our goal was to rule in or rule out the diseases by ordering tests and procedures.
In primary care we see patients every 10-15 minutes. We go through the same process and usually have a relatively short differential list of diagnoses that we think we're treating. We order tests that are returned to us over the next few days. And yet we have to make a diagnosis for that visit at the time of the visit in order to get paid. We usually pick the most probably diagnosis at the visit and that goes on the claims that is processed electronically.
The labs will come back and either rule this diagnosis in or out. Guess what? There isn't a process for us to go back and amend the visit diagnosis with the correct one if a test ruled the original one out and replace it with another one. My guess is that over time up to 40% of the claims based diagnoses are totally bogus.
And then there are complicated diseases like Lupus Erythematosis or Fibromyalgia with no confirmatory tests. A patient may be seen up to 10 times before these "diagnoses of exclusion" are made. There is no systematic way to go back and amend the diagnoses of the previous 10 visits and change them to the final diagnosis made.
That's why most astute people will take claims based data in the ambulatory environment with a huge grain of salt. What may be more valuable is a big picture of all of the diagnoses over time to get an idea of what's going on with a patient. But that data is usually not available as it's hidden in many physician's charts, EMRs and insurance claims data.
We need a national system for experts to go through reams of claims based data, compare it with the symptoms documented and then systematically modify the diagnoses to improve their worth. That's probably not going to happen.
A lot has happened since then but the promise of artificial intelligence, connected health information networks and computerization of health care hasn't really panned out the way I imagined over the last 25 years. But one thing that hasn't changed is the complexity of even simple diseases. Why?
Well, for one we don't practice medicine scientifically. Take a simple sore throat. We don't do viral and bacterial cultures on every one or even a random sample of patients to discover the exact pathogen with which we're dealing. There are probably over 200 viruses and 50 bacteria and a multitude of mechanical and environmental agents that will produce almost identical symptoms. We don't have instant tests with the exception of Rapid Strep, Rapid Influenza and Rapid Mono tests that can help us significantly. Thus for the vast majority of cases we are practicing blind. Fortunately most patient get well from this condition in 2 weeks no matter how we treat. The evidence suggests that with the exception of a very small minority of conditions NOT treating is better than treating but it is really hard to convince patients no treatment is better than treating.
I purchased QMR, Iliad and a subscription to AMANet to access Octo Barnett's DxPlain to help me come to correct diagnoses. What I and my colleagues discovered is that there were about 1,500 signs and symptoms that covered almost all of the known diseases (over 20,000 in the databases). That meant a large number of diseases presented with the same signs and symptoms. There were very few diseases that had pathognomonic signs or symptoms. Consequently we became pretty good at coming up the differential diagnosis (a list of the diseases that shared the same symptoms). Our goal was to rule in or rule out the diseases by ordering tests and procedures.
In primary care we see patients every 10-15 minutes. We go through the same process and usually have a relatively short differential list of diagnoses that we think we're treating. We order tests that are returned to us over the next few days. And yet we have to make a diagnosis for that visit at the time of the visit in order to get paid. We usually pick the most probably diagnosis at the visit and that goes on the claims that is processed electronically.
The labs will come back and either rule this diagnosis in or out. Guess what? There isn't a process for us to go back and amend the visit diagnosis with the correct one if a test ruled the original one out and replace it with another one. My guess is that over time up to 40% of the claims based diagnoses are totally bogus.
And then there are complicated diseases like Lupus Erythematosis or Fibromyalgia with no confirmatory tests. A patient may be seen up to 10 times before these "diagnoses of exclusion" are made. There is no systematic way to go back and amend the diagnoses of the previous 10 visits and change them to the final diagnosis made.
That's why most astute people will take claims based data in the ambulatory environment with a huge grain of salt. What may be more valuable is a big picture of all of the diagnoses over time to get an idea of what's going on with a patient. But that data is usually not available as it's hidden in many physician's charts, EMRs and insurance claims data.
We need a national system for experts to go through reams of claims based data, compare it with the symptoms documented and then systematically modify the diagnoses to improve their worth. That's probably not going to happen.
Saturday, December 12, 2009
Digital sharing of data and compliance conundrum
The Situation
Saw one of my partner’s patients (new to me), a 71 year old woman with a history of hypertension, late in the afternoon with an 8 hour history of abdominal pain. She’d thrown up once but other than the epigastric pain was not that uncomfortable. Vitals were stable, EKG normal and acute abdominal films were unremarkable. Drew basic labs including pancreatic and liver enzymes and discussed with her the broad differential. She elected to go home and wait for the labs to be resulted. We batch our labs at the end of the day and since she was the next to last appointment of the day expediting the labs by ordering STAT would only add expense without improving the turn-around time.
Drove home, had a cocktail and enjoyed a meal with my family and then logged in to review that day’s labs (which by now were being resulted). To my dismay her liver and pancreatic enzymes were in the thousands. Called her cell phone to advise her to go to the emergency room right away. The patient’s choices were many including the hospital with whom I share an EMR. However, she was at her daughter’s home and there were two other hospitals very close by and she elected one of them rather than drive an hour to my own hospital.
Called the ER to discuss the case with the attending who said this was a “slam dunk” admission and transferred me to the Transfer Team so that the hospitalist could be notified. The hospitalist accepted the patient and asked if I could fax my visit note, recent labs, patient’s Face Sheet and summary to expedite care. No problem, I quickly gathered that information together, assembled them into a document while the physician was on the phone and was about to click the SEND on our e-mail and paused ...
The Problem
Was I doing HIPAA compliant? Probably not.
Even though I had the patient’s verbal consent to do “whatever was required” to get her into the hospital I doubted whether that would pass not only our own internal compliance officers but any state and federal regulator’s judgement.
Our system does have a HIPAA compliant Medical Record Printing (MRP) function that gathers all of the HIPAA variables (who, what, to whom and why) but only allows us to FAX to those devices that have been tested and validated. It doesn’t allow an end user to key in a new fax number. The MRP function has 2 options: Print and FAX. And then only to defined printers and fax numbers. There isn’t a way to generate a password protected PDF file that can be sent to where it’s needed. Nor can it generate HTML documents that could be sent to a secure web server into which anybody downstream who is given the correct password could log in to retrieve it.
Our system also comes with a patient portal allowing patients to access and then do whatever they want with their own information including a function that lets them share the record with another physician who can then log in as a new user and view that record. Over 80% of my patients are taking advantage of this but this was an elderly patient of my partner who is less aggressive in enrolling her patients. This patient didn’t have an account and therefore the other option of sharing her record with the next physician wasn’t available to her.
This information would significantly speed up the admission and workup process on this patient and it was needed in a matter of minutes, not hours or days. I had everything ready to go to the physician with one click of the SEND button. Should I? Which is more important? Compliance with old paper-based regulations or patient care?
Damn the torpedoes
I clicked the SEND button with only a little hesitation and felt good as the hospitalist thanked me profusely, complimented me on the thoroughness of the note which included the patient’s picture, all of the labs, radiologist’s preliminary interpretation and an image of the EKG. She wanted to know why more referring physicians weren’t more accommodating and suddenly realized how important leveraging technology was.
Solution?
There have been years of discussion in Healthcare Information Technology circles about standardizing communications between Health Information Systems, numerous detailed proposals and countless arguments on how Patient identifiable Health Information (PHI) should be transferred from one system to another. In the meantime these types of situations happen thousands of times each day. The overwhelming majority of them are accomplished by Medical Records department personnel locating a paper chart, scanning and faxing the appropriate material to another provider’s fax machine and then taken to the requesting physician. This process take time, often many hours transpire between the request and the fulfillment of that request and often involves many people and supplies. The process is at the mercy of the resolution of the scanner and fax machines so many times the data in the hands of the requesting physician is barely legible. All this time there are low cost solutions using everyday tools that enable the transfer of this information directly between the two physicians who are involved in the care of the patient.
Surely we can come up with better regulations to let us care for the patient without having to worry whether some compliance officer or regulatory will spank us after the fact.
Any ideas would be welcome and passed on to our vendor and our compliance officers. Uh, we’ll keep the regulators out of this one for the time being.
Saw one of my partner’s patients (new to me), a 71 year old woman with a history of hypertension, late in the afternoon with an 8 hour history of abdominal pain. She’d thrown up once but other than the epigastric pain was not that uncomfortable. Vitals were stable, EKG normal and acute abdominal films were unremarkable. Drew basic labs including pancreatic and liver enzymes and discussed with her the broad differential. She elected to go home and wait for the labs to be resulted. We batch our labs at the end of the day and since she was the next to last appointment of the day expediting the labs by ordering STAT would only add expense without improving the turn-around time.
Drove home, had a cocktail and enjoyed a meal with my family and then logged in to review that day’s labs (which by now were being resulted). To my dismay her liver and pancreatic enzymes were in the thousands. Called her cell phone to advise her to go to the emergency room right away. The patient’s choices were many including the hospital with whom I share an EMR. However, she was at her daughter’s home and there were two other hospitals very close by and she elected one of them rather than drive an hour to my own hospital.
Called the ER to discuss the case with the attending who said this was a “slam dunk” admission and transferred me to the Transfer Team so that the hospitalist could be notified. The hospitalist accepted the patient and asked if I could fax my visit note, recent labs, patient’s Face Sheet and summary to expedite care. No problem, I quickly gathered that information together, assembled them into a document while the physician was on the phone and was about to click the SEND on our e-mail and paused ...
The Problem
Was I doing HIPAA compliant? Probably not.
Even though I had the patient’s verbal consent to do “whatever was required” to get her into the hospital I doubted whether that would pass not only our own internal compliance officers but any state and federal regulator’s judgement.
Our system does have a HIPAA compliant Medical Record Printing (MRP) function that gathers all of the HIPAA variables (who, what, to whom and why) but only allows us to FAX to those devices that have been tested and validated. It doesn’t allow an end user to key in a new fax number. The MRP function has 2 options: Print and FAX. And then only to defined printers and fax numbers. There isn’t a way to generate a password protected PDF file that can be sent to where it’s needed. Nor can it generate HTML documents that could be sent to a secure web server into which anybody downstream who is given the correct password could log in to retrieve it.
Our system also comes with a patient portal allowing patients to access and then do whatever they want with their own information including a function that lets them share the record with another physician who can then log in as a new user and view that record. Over 80% of my patients are taking advantage of this but this was an elderly patient of my partner who is less aggressive in enrolling her patients. This patient didn’t have an account and therefore the other option of sharing her record with the next physician wasn’t available to her.
This information would significantly speed up the admission and workup process on this patient and it was needed in a matter of minutes, not hours or days. I had everything ready to go to the physician with one click of the SEND button. Should I? Which is more important? Compliance with old paper-based regulations or patient care?
Damn the torpedoes
I clicked the SEND button with only a little hesitation and felt good as the hospitalist thanked me profusely, complimented me on the thoroughness of the note which included the patient’s picture, all of the labs, radiologist’s preliminary interpretation and an image of the EKG. She wanted to know why more referring physicians weren’t more accommodating and suddenly realized how important leveraging technology was.
Solution?
There have been years of discussion in Healthcare Information Technology circles about standardizing communications between Health Information Systems, numerous detailed proposals and countless arguments on how Patient identifiable Health Information (PHI) should be transferred from one system to another. In the meantime these types of situations happen thousands of times each day. The overwhelming majority of them are accomplished by Medical Records department personnel locating a paper chart, scanning and faxing the appropriate material to another provider’s fax machine and then taken to the requesting physician. This process take time, often many hours transpire between the request and the fulfillment of that request and often involves many people and supplies. The process is at the mercy of the resolution of the scanner and fax machines so many times the data in the hands of the requesting physician is barely legible. All this time there are low cost solutions using everyday tools that enable the transfer of this information directly between the two physicians who are involved in the care of the patient.
Surely we can come up with better regulations to let us care for the patient without having to worry whether some compliance officer or regulatory will spank us after the fact.
Any ideas would be welcome and passed on to our vendor and our compliance officers. Uh, we’ll keep the regulators out of this one for the time being.
Wednesday, December 2, 2009
What I believe about EMRs and Medical Information
I matriculated into medical school relatively late in life (at the age of 34) back in '84. Purchased my first computer with all of our savings (more than $5,000 - can you believe they cost that much then?). My wife threatened to do nasty things to my gonads unless that investment paid off. Twenty five years later it has (thank goodness). Here's what I've learned in the interim:
Now there are equally several big lessons that I've learned in other areas of my life but I'm not sure I want to share those with the world now.
- First and foremost, unless information systems are aligned with human, bacterial and viral interactions they will never fulfill their promise of providing the "RIGHT information at the RIGHT time to the RIGHT people.
- Second, unless the patient is the primary user of the information system it will have trouble delivering a return on investiment. This is what is meant by patient centered approach to care.
- Third, the power of any electronic health or medical record is proportional to the number of other clinical information systems (hospitals, other doctor's offices, pharmacies, etc.) to which it is seamlessly linked.
- Fourth; until physicians begin to think like patients they will have trouble communicating and improving the health of their patients.
- Fifth; until we change the reimbursement formulas, we will never bend the cost-curve of medical care in the United States.
- Incidentally, this is a corollary of #4
Now there are equally several big lessons that I've learned in other areas of my life but I'm not sure I want to share those with the world now.
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