Self-defeating Regulations
by Tom aka Rusty
Self-defeating Regulations
The Obama administration has made a major commitment to the installation and use of electronics in U.S. medical records.
Obama sees electronic medical records (EMRs) linked into electronic health record (EHRs) networks as a major factor in controlling costs and improving quality in the U.S. health care system.
The administration put money behind the thinking, ARRA ’09 (commonly known as the stimulus act) includes significant funds for physician groups and hospitals to purchase and implement EMRs in the next several years. There are penalties for providers not on board within five (5) years.
In order to qualify providers have to buy “certified” systems and engage in “meaningful use” of those systems. (Most providers will select the Medicare track, others (pediatricians) will select the Medicaid option).
And therein lies a huge problem.
The statute directed the various bureaucracies to write implementing regulations for the certification and meaningful use of EMRs and EHRs. The recently published draft regulations are (not surprisingly) long and wildly complex. Make that very long and very wildly complex.
I have been asked by a major health care association to prepare a monograph as a guide for physician groups working to meet these standards, so have been wading through nearly a thousand pages of new regulatory matter.
Keep in mind we currently have a plethora of medical record systems ranging from purely handwritten to dictated and transcribed to partial EMRs to full blown EMRs.
My preliminary conclusion:
1) many physician practices, especially those with 5 physicians or less, will not be able to comply
2) those practices able to comply will probably not get a positive return on investment (ROI) even with federal funds (practice disruption, training time, system support, etc. are all expensive)
3) some hospitals will be able to fully comply, some partially, some will struggle
(Conspiracy theorists may conclude the Obama administration is trying to drive physicians into larger groups, hospital based MSOs and/or Integrated delivery systems.)
My overall conclusion, the program is so complex and the requirements so complicated the overall objectives of the program will not be achieved. Many billions will be spent for some progress, but not the progress desired by the administration.
For further reading:
Medicare and Medicaid Programs; Electronic Health Record Incentive Program
Federal Register, Vol. 75, No. 8, January 13, 2010, pps. 1844 – 2010
(impacting 45 CFR Parts 412, 413, 422 and 495)
Health Information Technology: Initial Set of Standards, Implementation Criteria Specifications, and Certification Criteria for Electronic Health Records Technology Federal Register, V. 75, No. 8, January 13, 2010, pps. 2014 – 2047
(impacting 45 CFR Part 170)
Proposed Establishment of Certification Program for Health Information
Technology, Federal Register V. 75, No. 46, March 20, 2010, pps. 11,328 – 11,373 (impacting 45 CFR Part 170)
Isn’t it likely that physians will outsource their data base to third party data retrival systems making it more cost effective? Also, the present system requires each physian office to recreate patient records from scratch. Not is the present system costly requiring multiple transcribing of records, it is likely to result in serious omissions and errors.
The problem is the EMRs drop practitioner productivity 20+%. So if a physician or nurse could see 2 patients per hour, now they can only see 1.6
You save money in other ways, but this is a very difficult headwind to overcome
The VA has a best-in-class system (VistA) developed over several decades through open-source methods which has won universal praise. It seems to me adopting this well tested and proven system would be the sensible way to proceed.
***I have been asked by a major health care association to prepare a monograph as a guide for physician groups working to meet these standards, so have been wading through nearly a thousand pages of new regulatory matter. …***
My condolences … you can’t possibly be paid enough to justify taking that job on.
Obama and his advisors are probably right. Uniform Records Management probably is a key element to controlling costs (and to some extent outcomes). However, AFAICS we really have no body of theory and proven practice for designing effective records management systems — medical or non-medical. It’s all ad hoc hidden behind a facade of BS from corporate officers and “marketing excutives”. These systems in all fields are often horribly bungled and only add to the costs and problems.
Has anyone looked at what the Canadians do for record management? Despite the mindless drivel from the political right, the Canadian medical system seems to differ only slightly from our own with the major exception of actually providing health insurance and being about 30% cheaper. We really ought to be trying to learn from them rather than misrepresenting the quality of their medical care. (The Canadians outlive Americans by 2.5 years on average BTW, but that might be due to exogenous factors such as the greater availability of Labatts and Molson North of the border rather than to superior healthcare)
The problem with third party is HIPAA regulations. Major security issues in developing a system. The idea of EMR is that the paper office goes away regarding the medical record. Thus all notes, labs, tests, treatment and results are recorded under a universalized structure of organization in a universal digital language. This will have to include any imaging and maybe in the future voice. The extreme logical extrapolation could mean video. All of this has to be tied into the billing system as the billing will be supported by what is in the record.
The only 3rd party system that would work would be a web based system that would create a virtual group practice and thus cost sharing for the doc. The problem is coming up with a system that if flexible enough to cover all practice specialties. Again, a web solution would help.
The cost is an issue. A big issue. The government money is dependent on how much medicare one bills. The minimum cut off leaves many providers out of the money.
I have not seen any reports of such productivity drop other than in initial introduction to a new system. Any EMR is going to change the way the office flows, however, a good system (and I have seen them) once learned makes recording data very automatic and is even intuitive as to next step and where else in the record data needs to be plugged in.
The issue I see with the doc’s and billing will be in coding for higher services than the record shows time avalible in a day. That is, the total hours billed vs the actual hours the office is open. Up coding will be a thing of the past at best and a thing of contention for the provider at worst.
Most clinics already have some kind of computer system, so it’ll be easier to get their existing systems to interface with a national database instead of making everyone replace their old system. With today’s technology, you do not even need a standardized format!!
http://www.emrandhipaa.com/emr-and-hipaa/2007/10/24/boston-health-network-requires-all-physicians-to-adopt-ehrs-by-2009/ Boston 2007 institutes EMR
http://healthtrain.blogspot.com/2007/10/economic-advantage.html the start of the mandate
http://www.healthcareitnews.com/news/hospitals-vendors-not-washington-drive-emr-use 2010
North Shore Long Island Jewish Health System in New York is offering subsidies of up to $40,000 over five years to its affiliated (not employed) physicians who implement EMR systems. This does not stop any physician from collecting funds from CMS as well. Tufts Medical Center and Beth Israel Deaconess in Boston also have their own EMR incentive programs
Not true in this case. More onthat later.
No, it is not just a data base matter, it is a practice flow, security, privacy and interoperability matter.
Current technology demands periodic re-implementation which is expensive, ie not modular in nature, and not standardized nationally nor even regionally.
I’m guessing that there are dozens of medical record managment systems and that what they record and how they are indexed is different in every system.
In the case of K-8 schools where I have some familiarity with the records management software, it is safe to say that it all sucks. This is exacerbated in the schools by different methods of reporting used in different jurisdictions — often with force of law. How, for example, is a part day absence handled? What’s the unique identifier for each student (not just name, you WILL have two students with the same name)? What do you do with a student with no street address? What if the student actually resides in a different state with different reporting requirements (there’s a school district in the Connecticut Valley that includes towns in both VT and NH) and there is a county on the other side of the state where many of the students are tuitioned to a high school in NY.
I can only imagine that the situation in medicine is orders of magnitude worse.
I have been told that many older doctors on the verge of retirement are going ahead and retiring early to avoid the problems associated with establishing new record systems.
well, here’s where i join the lunatic fringe
given the post above this one re taking away the due process protections of american citizens, i have to look at the medical records initiative as just another data base to provide the information to big brother that he needs for total control.
see me at a tea party near you.
btw, it’s been a few years, but watching the people i work for install a computer system that totally destroyed the initiative and creativity of the field offices so that downtown could control every detail
makes me think this is a bad idea even without the eye in the sky feature.
if i were a doctor, i’d keep records in a folder in my handwriting, and any other doctor would have to start from scratch if he took over the patient. far less likely to mindlessly repeat my mistakes.
Not to jump the gun on Rusty, but as Vtcodger notes what currently exists are privately developed software office management systems that are unique to the software company. Proprietary is the word. It is a problem for a practice when they change from one company to another for what ever reason. Most of these systems are billing systems with some type of electronic note keeping. Electronic note keeping is not the same as a totally digitized medical record. Note systems replace a hand written note, some may even keep the imaging. None allow you to digitally send the record from one brand of software to another without an interface specific for those two brands of software.
The new requirements are such that every system will have to have the same data structure which can talk in the same language. So, if you have an existing system, it would have to be able to convert all the data to the new structure and code, plus add any data that it does not currently have and it all has to do it in a Fort Knox secure way. It also has to show that it can do this without hiccups in order to be “certified”. If it is not certified, it is not worth anything.
Not to mention making people figure out if they are Latino or Hispanic.
I know nothing about the healthcare biz, but I did have a mini career as a corporate IT computer programmer. I can guarantee if the government thinks they can issue a few thousand pages of “standards” and push down the system software development to physician level, that this will fail and consume many, many billions on the way.
Not that it couldn’t be done. The network model would be intranet, which is the secure internet deployment that large multi-departmental, multi-site, corporations (and government) use.
There are database systems that can handle text info and images. Things that don’t enter well into standard forms can be scanned and indexed with search words. The mortgage industry has to do this because documents have to be signed, by law, digital signitures are not allowed yet, and they must scan all loan docs into the database.
Also, whenever the states want to come up with a system to use to manage any of their social services, they go to someone like ACS or other IT contractor for system design and then they typically also run and maintain the system. The Federal government including the IRS does that as well. How can they think it could work any different with medical records?
Then, once and a while I would go on a contracting interview with one of the myriad of companies involved in our healthcare delivery and billing industry. The first interview question was not what programming languages and databases I knew. It was did I know HIPAA code. I stopped going on interviews like that.
There go my multiple posts again.
There is certainly potential for 1984 stuff regarding digitizing the medical record. Just look at what we have done with communications. However, there are major reasons regarding the practice and delivery of health and healing for having universal exchange of medical info for those providing the care. One is simply duplication of costs.
As to doctor’s taking a fresh perspective, well…that is suppose to be part of the job. Maybe, being able to see what has already been done, more of this will happen. As it is now, without seeing what has been done, it is easy for the doctor to just do what they always do and thus we get assembly line delivery of health care with each new doctor seen putting the patient on the doctor’s own unique assembly line. With the EMR, all providers are standing on the one and only assmebly line that the patient if riding on.
Yes, it is a problem.
Larry Ellison used to famously say that someday there would be only one database in the world, it would contain all information, be located in Washington DC, and it would be Oracle.
I think he was sort of kidding, but that would work with medical records , I think.
Also, I did contract work for a company that administers Blue Cross for a state. The way it works in that case is the software is not owned by any particular company. To keep people honest, the administration contract goes up for bid every couple years. Whoever wins the bid gets the existing software as part of the contract award.
But at any rate, it seems to me (not knowing anything about it) that the insurance companies need to standardize on a system, then open it up via intranet to practitioners.
Offices and clinics will have internal accounting systems and whatnot that would like some of the info of course, and that is where to make the interface of importing/exporting data.
Larry Ellison used to famously say that someday there would be only one database in the world, it would contain all information, be located in Washington DC, and it would be Oracle.
I think he was sort of kidding, but that would work with medical records , I think.
Also, I did contract work for a company that administers Blue Cross for a state. The way it works in that case is the software is not owned by any particular company. To keep people honest, the administration contract goes up for bid every couple years. Whoever wins the bid gets the existing software as part of the contract award.
But at any rate, it seems to me (not knowing anything about it) that the insurance companies need to standardize on a system, then open it up via intranet to practitioners.
Offices and clinics will have internal accounting systems and whatnot that would like some of the info of course, and that is where to make the interface of importing/exporting data.
Larry Ellison used to famously say that someday there would be only one database in the world, it would contain all information, be located in Washington DC, and it would be Oracle.
I think he was sort of kidding, but that would work with medical records , I think.
Also, I did contract work for a company that administers Blue Cross for a state. The way it works in that case is the software is not owned by any particular company. To keep people honest, the administration contract goes up for bid every couple years. Whoever wins the bid gets the existing software as part of the contract award.
But at any rate, it seems to me (not knowing anything about it) that the insurance companies need to standardize on a system, then open it up via intranet to practitioners.
Offices and clinics will have internal accounting systems and whatnot that would like some of the info of course, and that is where to make the interface of importing/exporting data.
Yes.
There are major privacy and security issues with an EHS network.
Physicians really, really hate the input devices, in general they have not found an input device (tablet computer, regular keyboard, dication software) that really flows well as they move from room to room.
Also, different specialties have different needs.
VISTA is available for any doc to use for free, it does not seem to work very well outside the VA environment.
The Candians and Europeans do better with this.
Problem is, we are not starting from scratch, we are trying to computerize and integrate tens of thousands of providers, all of whom do something a little different.
Most practices have “practice management software” which is directed at 1) appointments and 2) billing.
Some of these systems can integrate EMR. Many cannot. Some are very old.
Most are a pain in the ass to set up, train up and keep running (one reason many docs are not enthusiastic about going to a new platform).
The cynic in me says the new healthcare plan “fails” and is repealed in 2016. By then all of our problems have been recorded in the public domain and insurance companies will know exactly who to deny coverage to.
Divorced one
yes. i know. but looking at the Brave New World, I don’t like what I see. I’m trying to meet your legitimate need for transferable records and still preserve the independence of the doctor, and the privacy of the citizens. I wonder if it would be too much for the doctor to keep his records on some sort of computer which he could email to a new doctor in response to a request. i think this would take care of the medical need. Billing is a cat of another bag. And I think that’s where the problem lies. As long as everyone expects someone else to pay for his health care, we are going to end up sending pictures of our private parts to both big business and big government. I think that ultimately big government is more dangerous, but big business is not as people friendly as they are always telling us they are.
That’s why it should be what is lately called “cloud computing”. You buy it as a service.
Fixed.
Hiccups??? Like Cedric Regula’s?
Perhaps our proposed biometric social security cards can serve as a clearinghouse for our medical records. Wouldn’t that be efficient ?
Why can’t someone develop a data input system so that I don’t have to fill out stupid intake forms at every doctor’s office ? Why can’t I give them an insurance card or flash drive from which the doctor’s office can download the customary information (name, address, insurance policy #, etc.) — it doesn’t have to contain medical records/information and privacy issues are reduced since I possess the data. It would save a lot of wasted time and data entry errors.
How is this new stuff? Didn’t Ross Perot earn his billions doing just this kind of thing for Medicare about thirty-five years ago? So what’s new?
Good old Social Security provides a peek into the future for this massive effort. What happens is that one or more big IT providers will get a huge contract to set up an “architecture” into which various kinds of records coming from different sources can be transmitted electronically. There will be time to set up only a few initial input formats, with only a limited processing capability in the short term. With promises of future systems’ enhancements.
The data base capacity will be severely limited due to equipment and networking installation costs and the multiple layers of interconnectivity involved. Microsoft (or the selected provider) will need to invent a whole new real-time online LAN/WAN software configuration. All kinds of additional apps will be needed to fill out the projected scope of the online system. And, so on. Thirty years from now, the system thus created (kinda) will sorta kinda work for most of a limited number of things and no one will be willing to give up paper records. Which, incidentally, are still required for most district court cases, including those at the federal level.
Surely the new EMRS will be better than any existing system!, you exclaim. Well, I wouldn’t bet on it. And, as Thai points out, decreased productivity will inevitably lead to greater per patient expense per visit. And, physicians have to want to do this stuff. They have to want to pay for it, maintain it locally, buy more equipment with greater output capacity, train, train, train and train again. Pay higher salaries for people who can do IT just like any outfit does. And, do all this while dealing with our old friends, the HI carriers.
And, don’t forget, a lot of providers don’t take Medicare patients. Hmm. No, no chance of problems there! And, thousandso of existing systems to integrate. Nope, not a chance it won’t work like a charm. Right. 😎 Nancy Ortiz
Oh, Purple. WHAT biometric Social Security card would that be? We don’t have one now and many efforts to establish one have been blocked in Congress. Conservatives won’t have it and Progressives aren’t wild about it either. The idea that people in this country would be required to have a biometric, counterfeit proof/resistant SSN card makes lots of people go nuts. Why? The phrase “Big Brother” comes to mind. The idea that citizens have the right to freedom of movement runs contrary to the notion of having people be ready to identify themselves on demand. Never mind that the phrase “freedom of movement” doesn’t exist in the Consitution. The idea that the cops can take you to jail if you don’t have your papers.
Oh, and SSN’s by law cannot be used as an identifier for anything but Social Security earnings and other record keeping purposes. This is a federal effort. No attempt has ever been made to enforce this law of course, but never mind, you can’t do it without changing the law. Highly unlikely to work. In general, without a system unconnected to the internet, the information stored in the EMR system would be on the street in 15 minutes to anyone who was willing to pay the going rate. And, all those thousands of medical offices, with thousands of inquiring minds, and low pay, well–there is no way that information would stay secure. HIPAA or no HIPAA. Too many ways to get and steal information.
Me, I think it’s a bad idea. We’ll see. Nancy Ortiz
Perot (EDS) did batch claims processing for payers – whole different animal, very little in common with clinical record keeping.
I recommend Java applets for the front end data screens. From a programmers standpoint, programming anything complicated in HTML is like going back in time 30 or 40 years and using a powerless, spaghetti code language.
With Java applets you can relatively easily and inexpensively write complex, window-like front ends to a server based system in an object oriented, easier to maintain language.
Yep.
Somepractices take medical history on-line through their web site, minority though.
It would be good for medical history, but entering current clinical data is very difficult.
It’s not new. Been around as long as IBM. Now even Indians do it. They question is why did the government get amnesia?
Another common mistake in system design is to start out with the assumption that “everything needs to be connected together”.
Maybe the scope just needs to be centralized storage and retrieval of medical records.
For the billing part of the biz, centralized and standardized billing.
My mother worked as an senior ER nurse. And lots of nurses are retiring if they can rather than learn the new system also. Just another anedote…
2012…
Yes, physicians are not unlike anyone else who has to make a change to new tech or in their life. However, where EMR has been implemented well, the doc’s come around. Input devices are an issue. Some love a tablet, some hate carrying it around and prefer a key pad/typing. Problem comes with talking to the patient and inputting at the same time. You have to learn how to converse and then record without loosing the patient contact.
The biggest problem with flow, is doc’s waiting until the end of the day to do all their recording. Makes it easy for the doc, but will not work with EMR that is keyed to billing.
I noted different specialties have different needs. Thus, a web based system where the practice does not buy a program that carries all the specialties. It’s would be like using one platform for multiple vehicle types.
The major problem with billing is data not avalible to support the service code used. This is the big canyon that EMR is trying to cross and thus create savings.
Billing currently is easy. I personally bill direct into BC’s and MC’s systems. No middle man. However, when there is a question regarding support for the service charged, we’re back to copy and fax or mail.
It is the tying of billing with the medical record that the payment side of the health care problem is trying to solve. The other issue is related to doctoring. The hope is the EMR will produce better doctoring via reduced duplication, compliance with guidelines including showing where the need was outside the guidelines, communication on referrals, etc.
Remember, nothing happens in health care, no charges are created until the doctor say so and puts their name on it.
Some practices are cloud computing, but most of the issues are the same – conversion, training, privacy and security, accuracy, etc. etc. Still a burden to the practice.
One thing I have been wondering about is if this concept of “Electronic Medical Record” really is a cost saving. Sometimes ideas take hold, but don’t hold up under serious study.
Usually when we first started design on a new system, cognizant managers were sequestered in room for as long as it takes and do goal setting and define how those goals should be implemented.
If you were lucky, this process was completed before programmers found out there was a new project.
strb:
Why doesn’t VISTA work well outside of the VA. Just curious.
strb:
You are discussing net change or instantaneous change to records rather than batch updates. Has anyone looked at a “sharepoint” style of system?
I sort of suspected the primary reason was for the payer to verify charges, but wasn’t really sure.
But with a client-server, intranet system the doctor then is required to input what he did into a record. Xrays, lab test results are scanned and are uploaded (or maybe the lab did it and that’s how the doctor got them). Any datatype can be handled by the database nowadays. This can be date stamped in the database. So it’s there, and when the payer wants to verify billing, they retrieve the record. Management reports can be designed to data-mine any info in the database.
This all needs a way to identify the patient of course, which I’ve heard has caused problems for doctoring now and then too.
So that all can be done, and it is “separate” from other systems but serves the purpose. It’s just if that’s an improvement or not.
I sort of suspected the primary reason was for the payer to verify charges, but wasn’t really sure.
But with a client-server, intranet system the doctor then is required to input what he did into a record. Xrays, lab test results are scanned and are uploaded (or maybe the lab did it and that’s how the doctor got them). Any datatype can be handled by the database nowadays. This can be date stamped in the database. So it’s there, and when the payer wants to verify billing, they retrieve the record. Management reports can be designed to data-mine any info in the database.
This all needs a way to identify the patient of course, which I’ve heard has caused problems for doctoring now and then too.
So that all can be done, and it is “separate” from other systems but serves the purpose. It’s just if that’s an improvement or not.
I sort of suspected the primary reason was for the payer to verify charges, but wasn’t really sure.
But with a client-server, intranet system the doctor then is required to input what he did into a record. Xrays, lab test results are scanned and are uploaded (or maybe the lab did it and that’s how the doctor got them). Any datatype can be handled by the database nowadays. This can be date stamped in the database. So it’s there, and when the payer wants to verify billing, they retrieve the record. Management reports can be designed to data-mine any info in the database.
This all needs a way to identify the patient of course, which I’ve heard has caused problems for doctoring now and then too.
So that all can be done, and it is “separate” from other systems but serves the purpose. It’s just if that’s an improvement or not.
Clinical records have to updated almost instantaneously with the service in order to capture data and facilitate billing – otherwise we depend on the doc’s memory or double handling of data.
Then information dribbles into the chart from mutiple sources – labs, MRI, therapists, phone calls, etc.
Billing, once the data is in, is somewhat simpler than maintaining the clinical record.
As note at least the Belgian have a working system of
EMR (from interactions with an exchange student). Now as noted what has to happen is to have small practices affiliate with a larger org perhaps just for medical records. If Europe and theVA can do it, why can’t the us. Unless this is seen as a conspiracy to go to single payer. Perhaps the simplest way is to give a smart card to the patient, and the non billing records can only be unlocked using the card.
None of the comments have engaged the question of why the VA VISTA system won’t work outside the VA. By the way, the Armed Services Active Duty ID card now has a chip with all medical info just like in France. It is updated each time the patient sees a doc. This is not rocket science.
The VA has a limited patient population and tends to provide comprehensive services to that population.
General medical practice has wide populations and numerous providers may be involved in any one case (doc, lab, pharmacy, etc.).
I think it could be as simple as having everyone create a MySpace account with their picture and the family’s picture. Then the doc, clinic, hospital, lab, and pharmacy posts copies of visits, notes and transactions, uploads x-rays, cat scans, MRIs, blood tests. std panels, etc…
Then the payer can verify charges, or emergency healthcare practitioner can find medical records. Data mining studies can be done to find out if a particular doctor calls for a $5000 MRI to be done on every patient, or constantly refers them to the wrong specialist.
The only thing left to do would be designing the security layers and controlling access, for people that don’t believe everyone is our friend.
Then there should also be the ability to create local storage of the medical record. Right now when you access a web page it is downloaded to a temp file, but we have designed system where that is automatically copied to a permanent storage directory. This would be so the data is available in case of power outages, Internet glitches, etc, during a critical time like during surgery.
Or at least use this model when working thru thought experiments about if we want something like this as a system.
Google is trying a form of this on a consumer voluntary basis.