So reviewing this morning's news a couple of interesting articles caught my attention. One, a discussion of Foursquare which provides a social networking app tying into their GPS devices that quickly allow people to "check in" to bars, restaurants, shops and other venues ostensibly to share tips and receive points. The complete article by Rob Pegoraro can be read in his Fast Forward column on the Washington Post.
The second, another release from Duke on a "New smoking cessation therapy proves promising."
And then this add on 7A of this morning's USA Today about a GPS enabled ESCORT radar detector.
What if you put all of these together in a medical application? A GPS enabled, location specific inhaled glucose delivery system for insulin dependent diabetics. Would know what restaurant you walked into, calculate the average carbohydrate load of the items on the menu, adjust the inhaled insulin device so that you could eat or drink your fill without raising your blood sugar and then guide you safely around any police checks?
It's getting pretty freaky but let's take it one step farther and have all of this available as an implant. Now go back and remember the Cyborgs from the old Startrek shows?
Are we there yet?
Monday, March 1, 2010
Sunday, February 28, 2010
We are the problem ... and the solution
We Are the Problem ... and the Solution
An article by Reed Ablelson in this morning's New York Times illustrates clearly why no matter what happens in Congress over the next few weeks our Health Care will never be the same. Our current system is simply unsustainable and incremental changes have done nothing to curb the escalation in health care costs. It is apparent that large changes are coming. The question is not if but when and by whom?
I was struck by how much blame each of us carries in this dilemma. Most physicians in this country are payed by what they do, not what they produce. As a result we are all under pressure to bring in enough income to pay our nurses and staff. Estimates vary but most primary care physicians (of which I am one) need to post at least $400,000 - $600,000 a year in order to make ends meet (staff, malpractice, lease, equipment, supplies, etc.) and even then profit margins are very slim.
In large multispecialty groups where salaries are often calculated by Relative Value Units (RVUs), physicians need to crank out 5-6,000 units just to break even. What’s insidious is that a physician will tally up more RVU’s for procedures than brain work. So it’s much simpler to do something to a patient than work with the patient ... a lot simpler and a lot more profitable.
This has led to serious shortages of primary care physicians and an abundance of specialty physicians partially due to the high cost of medical school, the need for repayment of student loans and prestige that comes with disciplines with high revenue potential.
We physicians have lobbied heavily to keep our costs from dropping, forcing Congress to delay each year the implementation of the Sustainable Growth Rate formula that was voted into law in 1992. These small, yearly decreases in payment have gradually accumulated to where a massive 21% cut in Medicare payments is scheduled to go into effect this coming Monday, March 1, 2010. The AMA is confident that emergent legislation will prevent these cuts from taking effect and forestall them yet another year. Eventually, the system will collapse and the results will be catastrophic not only for physicians, their offices and staff but for Medicare patients who may not be able to get in to see a physician at any costs because doors will be shut to them as it is to many Medicaid patients around the country.
Physicians can still afford to do this because there are enough privately insured patients to generate the revenue needed to keep their doors open for now. At some point this house of cards crumbles.
We patients are also to blame. In the last 20 years we’ve seen an ever increasing cost of health care diverted towards chronic diseases that are in large measure preventable. Obesity, diabetes, high blood pressure, coronary artery disease and many forms of cancer can be directly linked to lifestyle choices.
In addition we choose ignore “natural” ways of preventing diseases through immunizations and dietary changes.
When we hurt our backs we refuse to go to physical therapy and instead insist on medications, MRI’s and even surgery when the evidence points to better results with simple physical therapy.
We patients insist on antibiotics when we feel bad even though repeated studies have shown for many of these conditions we will get better faster without them.
It is infinitely cheaper to stop smoking and avoid lung and heart disease than to pay for cigarettes, medicine and procedures. Yet we complain about the cost and effort involved in smoking cessation programs (even though they are less expensive than the monthly cost of a pack-a-day cigarette habit).
And it’s worse when we’re healthy! We often choose not to purchase health insurance, which only drives up the cost of health insurance for everyone. If only sick people purchased health insurance it would be more costly than medical care (providers of health insurance have the cost of medical care, their own business and profits to shareholders to address). Insurance only works when a critical mass of enrollees never utilize their insurance.
And then there’s politics. The cost of being a politician by its vary nature will prevent the politician from making the hard choices. It’s simply much easier and less costly for supporters to pull funds from anyone making a hard decision since most hard decisions adversely affect a critical mass of supporters in the short term.
So what are we to do? Well, for one we need to act because no one else is going to. For my own part I have resolved to be a role model for my patients. I am trying very hard to make the decisions I ask my patients to do. My diet has changed as have my exercise habits. In addition I have started listening more to my patients (it does adversely affect my income potential for the organization for whom I work). I make sure that each hour an appointment slot is left open for same-day appointments. I have encouraged patients to log into our web portal for routine things that can be treated without a face-to-face visit. We’ve stopped taking samples in our offices and are working with patients to chose generic medications wherever possible.
As patients it is usually less expensive to do the right things. First, change our lifestyles to maximize our genetic potential. We do need to stop smoking. We do need to move rather than sit. There’s no reason we shouldn’t all be at our ideal body weight and should constantly strive to maintain that weight. We do need to be proactive and strengthen ourselves to grow old rather than sit back and let it happen. We do need to leverage our own immune systems and get vaccinated (which is really the best natural approach to preventing diseases) not only for ourselves but for those around us. It is much less costly to get vaccinated than to get sick, no matter how minor that illness is. The complications from vaccinations are infinitely smaller than the complications from any of the diseases.
When we do get sick it is our responsibility to learn about our illness and help the physicians make decisions. It’s my experience that most bad decisions are made from lack of information than from malpractice. It is our responsibility to know what over-the-counter medications, vitamins, herbal supplements and our past medical histories. Make sure the physicians making decisions are aware of this. If the recommendation is something other than medicine we need to follow that advice (physical therapy and counseling are effective and even if they are not “covered” by most plans are the things that will cost you less in the long term). If medicine is prescribed we need to know the medicine and take them as directed along with redoubling our efforts to make the changes necessary in our lives to decrease the need for those medications.
We all need to purchase insurance. Purchase only catastrophic if nothing else so that we don’t wreck our lives, the lives of our loved ones or undermine public budgets when major illness or injury strike.
We all need to wear seat belts, stop driving under the influence of mind-altering drugs, alcohol or texting. We need to wear helmets on bicycles, motorcycles and other vehicles without roll-over protection.
We need to care for others and not be responsible for hurting others.
Finally, we need to begin rewarding those politicians who make hard decisions. We need to counter the fringes and participate in elections. Neither the left or the right are going to be able to solve our problems. The center will and we need to begin rewarding those who work with others and not those who are obstructionists.
The bad news? It’s always easier to do nothing and be a victim than it is to do something positive and avoid being a victim. But that’s what we need to do if we went to lower the cost of health care and become part of the solution, not the problem.
Friday, February 12, 2010
The Ideal Exam Room: A Primary Care Physician's Wet Dream
There's a certain irony in that the more specialized a practice gets the more technology available to help the physician. A retinal subspecialist is a good example where they have in office orbital CT scanners and a host of other extremely expensive tools available for the physician's use at the time of the visit. On the other side of equation the primary care physician who has to deal with the entire body and mind is often left with only with devices that haven't changed much in 100 years. Yet they are expected in the usual 10-15 minute visit to interview, examine the patient, derive a diagnosis and treat the patient.
The stark reality is that it is the primary care physician, with the greatest informational needs that should have most of the tools.
We're all familiar with the tricorder used in Startrek where Bones could scan a person in the field as well as the exam room, view the images and make a diagnosis.
What's silly is that by the time a patient is seen by the subspecialist the diagnoses have already been made (usually by several other physicians who have sequentially seen the patient at an ever increasing cost). By the time the patient gets to the highest technology it is used only to confirm the diagnoses and to complete the definitive treatment.
It's my opinion that if technology was available at the front lines many diseases would be diagnosed, caught and treated long before they require subspecialised therapy or treatment.
There are many devices such as a dermatoscope, tonopen, digital ophthalmoscope, otoscope, not to mention digital scales are available but outside the reach of most primary care physicians. Yet, if each exam room was equipped with these digital devices AND connected to their electronic medical records many diseases that now are missed could be diagnosed earlier, more accurately and treated at a much lower cost than they are now.
On the pure information front, I find the time cost of logging into multiple systems (our own EMR and those of nearby hospitals, reference labs not interfaced without our system, imaging centers, online reference sources such as UpToDate, ePocrates, MDConsult and a host of other tools that I wind up using in the exam room prevents me from exploiting them in the typical 10-15 minute appointment. Even though we’ve equipped the PCs in each exam room with 21” swivel monitors we find there’s a lot of visit time that could be saved if the all of the information needed at the time of the visit didn’t need to be navigated to.
When not seeing patients I usually grab all of the computers to which I have access, splay them up in front of me (including one of the units from the nearest exam room). Productivity increases dramatically. Most information resources are at my fingertips in parallel rather than serially if restricted to a single machine or reduced screen real estate. This is exactly why traders in most brokerage houses sit behind multiple displays in order to work. Time is money and faster, better (well, maybe) are made if one doesn’t have to waste time navigating to that information.
So what am I saying?
I am confident that if we would put the most technology possible into the hands of front line physicians who have to address the broadest spectrum of patient concerns we might be surprised at how much more efficient, productive and cost effective healthcare would be.
So one day I see myself practicing in a room with all of the tools at my and my patient’s fingertips. Any questions could be quickly answered, the record would not have to be populated with vague text but actual images of the pathology observed, sophisticated imaging and testing could be accomplished at the point of care before the patient left the room. The patient and I would have a very good understanding of the next steps rather than waiting for all the ordered tests to come back as the patient is sent across town for them, paying higher and higher prices the closer we get to the definitive diagnosis.
And then I wake up only to have had a wet dream. I have to return to the small, cramped, jail-cell exam room with the one computer and a variety of relatively low-cost analog devices and try to answer difficult questions. Often having to disappoint the patient by sending them on to another person or facility to eventually get to their answers.
The stark reality is that it is the primary care physician, with the greatest informational needs that should have most of the tools.
We're all familiar with the tricorder used in Startrek where Bones could scan a person in the field as well as the exam room, view the images and make a diagnosis.
What's silly is that by the time a patient is seen by the subspecialist the diagnoses have already been made (usually by several other physicians who have sequentially seen the patient at an ever increasing cost). By the time the patient gets to the highest technology it is used only to confirm the diagnoses and to complete the definitive treatment.
It's my opinion that if technology was available at the front lines many diseases would be diagnosed, caught and treated long before they require subspecialised therapy or treatment.
There are many devices such as a dermatoscope, tonopen, digital ophthalmoscope, otoscope, not to mention digital scales are available but outside the reach of most primary care physicians. Yet, if each exam room was equipped with these digital devices AND connected to their electronic medical records many diseases that now are missed could be diagnosed earlier, more accurately and treated at a much lower cost than they are now.
On the pure information front, I find the time cost of logging into multiple systems (our own EMR and those of nearby hospitals, reference labs not interfaced without our system, imaging centers, online reference sources such as UpToDate, ePocrates, MDConsult and a host of other tools that I wind up using in the exam room prevents me from exploiting them in the typical 10-15 minute appointment. Even though we’ve equipped the PCs in each exam room with 21” swivel monitors we find there’s a lot of visit time that could be saved if the all of the information needed at the time of the visit didn’t need to be navigated to.
When not seeing patients I usually grab all of the computers to which I have access, splay them up in front of me (including one of the units from the nearest exam room). Productivity increases dramatically. Most information resources are at my fingertips in parallel rather than serially if restricted to a single machine or reduced screen real estate. This is exactly why traders in most brokerage houses sit behind multiple displays in order to work. Time is money and faster, better (well, maybe) are made if one doesn’t have to waste time navigating to that information.
So what am I saying?
I am confident that if we would put the most technology possible into the hands of front line physicians who have to address the broadest spectrum of patient concerns we might be surprised at how much more efficient, productive and cost effective healthcare would be.
So one day I see myself practicing in a room with all of the tools at my and my patient’s fingertips. Any questions could be quickly answered, the record would not have to be populated with vague text but actual images of the pathology observed, sophisticated imaging and testing could be accomplished at the point of care before the patient left the room. The patient and I would have a very good understanding of the next steps rather than waiting for all the ordered tests to come back as the patient is sent across town for them, paying higher and higher prices the closer we get to the definitive diagnosis.
And then I wake up only to have had a wet dream. I have to return to the small, cramped, jail-cell exam room with the one computer and a variety of relatively low-cost analog devices and try to answer difficult questions. Often having to disappoint the patient by sending them on to another person or facility to eventually get to their answers.
Sunday, December 27, 2009
Why I like taxes
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.
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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