Is it time to drag private physicians out of the paper age?

Editorial

Our Pen-and-Paper Doctors 

Published: June 24, 2008 

If this country does not accelerate the conversion from paper to electronic health records, many health care reform promises will become irrelevant. 

Yes. So? 

American physicians are still paid on piece-work; productivity matters to them and their families. Seeing patients pays the mortgage and feeds the family. 

I've successfully implemented an electronic medical record that has served more than one-half million patients since 2002, yet I know that we've accomplished this only by sacrificing physician productivity even as we've improved overall productivity in our emergency department. Optimizing an entire system often requires that components of the system operate at less than optimum in some fashion. 

We can do this at my hospital because our physician staff is only partially compensated by piece-work and the alternative subsidies could be adjusted. 

The NY Times got it wrong this time. Private physicians behave as they do in response to the totally distorted payment system--even the term "reimbursement" so common in this context is evidence of this distortion. 

My Dad, an internist, used to say that the head-bone is connected to the foot-bone. He practiced internal medicine and gastroenterology and empirically experienced connectedness of the head-bone and the gut long before we had the science proving it. 

It's not the private physicians who must be dragged out of the paper age. It's the payment system and the financing of healthcare in 21st century America. 

The NY Times should castigate our policymakers, not our practitioners.

Mobile Lawyer and "ER" the TV show

ER: Season 11, Episode 177861, 1/20/2005

[ . . . ]

A personal injury lawyer sets up a mobile office outside the ER, infuriating Lewis as he tries to turn dissatisfied patients into clients.

[ . . . ]

It turns out that the post on the Mobile Lawyer who showed up at our hospital and ER last spring caught some notice in the blogosphere. Overlawyered picked up the post and I had thousands of hits in a few days. A colleague referred another contact and somehow the story reached the writing staff at the ER production company to appear in the fictionalized version on tomorrow's show. Imagine that.

Could CMS demand only delayed reads of imaging studies and take Ultrasound billing away from EM?

An Influential Federal advisory panel has voted to recommend lower 2006 Medicare payments than expected by physicians and hospitals, as well as other policy actions affecting both. (emphasis added)

While reimbursement levels are a concern, it's the other "policy proposals" that really scare me.

The Medicare Payment Advisory Commission voted to recommend a 2.7 percent increase in Medicare payments to doctors, which is less than the expected increase in doctors' costs, but substantially more than doctors would get under current law, under which payments would be cut five percent next year if Congress takes no action, reported the New York Times.

[. . . ]

The commission expressed concern about the proliferation of imaging equipment and services in doctors' offices, and urged Congress to direct the secretary of health and human services to set national standards for doctors who perform or interpret diagnostic imaging studies billed to Medicare - a move which would alter the historical role of states and medical specialty boards in physician licensing and certification, the Times noted. The standards would cover the training and education of doctors who bill Medicare for X-rays, CAT scans, PET scans, magnetic resonance imaging, ultrasound, (emphasis added) echocardiography and other imaging. The panel maintained that poor quality diagnostic imaging can lead to repeat tests, misdiagnoses and improper treatment, the Times added.

[. . . ]

So this proposal could entrench delayed reads as the standard for all radiography as a consequence of the requirement that only those meeting federal standards for "training and education" interpreted imaging studies. Also CMS could easily decide that bedside ultrasound imaging was merely a component of the evaluation and management (E&M) service and not separately compensable.

http://www.nytimes.com/2005/01/18/politics/18medicare.html?oref=login&pagewanted=print&position=

WSJ.com - California Hospitals Open Books, Showing Huge Price Differences

Link: WSJ.com - California Hospitals Open Books, Showing Huge Price Differences. (subscription required)

A new law in California mandates that hospitals there do what few hospitals in America will: open up their "chargemasters," books that show thousands of list prices for medical goods and services. An examination of chargemasters at several hospitals shows that pricing strategies fluctuate wildly -- on everything from brain scans to painkillers to leeches. Depending on a hospital's pricing method, the charge for the same commodity or service, such as a blood test, can vary by as much as 17-fold from one institution to another.

Horrors! People will now learn that the respected institution in their community, "their hospital" behaves entirely irrationally in order to make a buck. There's merit to exposing this and other practices to daylight, but the real irrationality derives from the continuing skirmishes and overall lack of coherent information about what it takes to make a successful hospital work and serve its community. (I'll leave the justification for what it takes to serve hospital company investors for others to explain.

VA Chief, Prinipi, Quits with Budget Cuts Looming

So the VA Chief, Prinipi, is quitting. It probably doesn't have much to do with the $900 Million plus cut anticipated in the DVA budget which will mostly fall on healthcare since that's the largest part of the DVA budget. This at the time when our military men and women will be returning from Iraq. Just a small precursor of the coming cuts in Medicare. Stay tuned.

Bloomberg Dec 9 2004 1:24AM GMT [Moreover - moreover...]

iHealthBeat.org

I don't know why they picked this one article out of the entire November 2004 issue of Academic Emergency Medicine devoted to Healthcare Technology and IT in the ED, but  it's very cool that we made the California Healthcare Foundation's iHealthBeat.

Link: iHealthBeat.org.

Recommended Reading: Suggestions for ED Clinical Documentation Systems

November 10, 2004

An article in the current issue of Academic Emergency Medicine outlined eight recommendations for improving emergency department clinical documentation systems.

. . .

"As technology is implemented, standards and requirements for documentation systems need to be established," according to the article. Electronic clinical documentation eventually will "improve immediate care, promote efficiency, and permit ready communication of critical patient information" (Davidson, Academic Emergency Medicine, November 2004).

Lower Nurse Staffing Proposed

Link: Lower Nurse Staffing Proposed. Well it appears as though California is re-thinking nurse staffing. I like the comment from Sandra Shewry, California's director of health services, "These changes provide common-sense flexibility for hospital emergency departments and clarify language in current regulations."