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Sunday, July 27, 2014


Will we have an ICD-10 code for that?
"The quality of healthcare has decreased with the implementation of EHRs and core measure/meaningful use requirements."
From MedPage Today.
Questioning Medicine: EHRs and Attention Deficit
Published: Jul 27, 2014

EHR-Acquired Attention Deficit Healthcare Disorder

"How are you today sir?" I ask a patient.

"Pretty good, I've been doing what you asked me to do. But I have this problem ... ," the patient replies.

And there I am. One moment, focusing on the patient, and then another hunting for the right series of key strokes to bring up a normal, 10-point review of systems.

The patient trails off into nonpoetic prose, and I am focused on the meaningful use requirements for this visit. One question into the exam, and I have failed my patient. Patient-centric care is a thing of the past.

A mentor of mine once said "Nobody truly can multitask in healthcare. You simply shift focus and attention rapidly from one thing to another." Our attention is being manipulated and stolen by the machine that is modern medicine.

The quality of healthcare has decreased with the implementation of EHRs and core measure/meaningful use requirements.

As we focus on EHR compliance, we miss the very core of what makes a consummate physician in any field. Time. We are blinded by the need to meet coding criteria, fulfill an antiquated guideline, or be compliant with the corporate demands of documentation.

These obstacles have stolen the 15 to 20 minutes a doctor would spend asking "The Question" and listening with ears aged with wisdom. Our time is torn from the patient by these healthcare distractions...
Meaningful Use is gettin' little love these days.
"As we focus on EHR compliance, we miss the very core of what makes a consummate physician in any field. Time. We are blinded by the need to meet coding criteria, fulfill an antiquated guideline, or be compliant with the corporate demands of documentation."
Notwithstanding that, until I retired last year, I worked with the Nevada REC doing Meaningful Use implementations, my iconoclastic views are well-known, and I repeat what I've said before more than once: serious and rational  Health IT critics need to be taken seriously. I would count these physicians among them.
"Medicine is becoming increasingly more regimented and standardized, and I fear the "art of medicine" has been reduced to attempts at navigating the new EHR faster than ever and not the skill sets that made primary care the most respected field in medicine."
But, every time I hear or read that "art of medicine" beg-off, my hand slides inexorably over my wallet.

When I am ailing, I want dx's and tx's that are scientific. apropos, see my December 2013 post "Philosophia sana in ars medica sana," specifically my cites of Mario Bunge's book "Medical Philosophy."

It bears repeating that the etymological roots of "philosophy" are "philo" (love of, devotion to) "sophia" (knowledge, truth). Properly, "science," not long-winded, obtuse, fifty-dollar-word speculations about arcane, unprovable matters.

The "Art of Medicine" goes to the creative use of intuition and heuristics, and making (frequently iterative and/or recursive) "leaps of faith" guided by them. Given the loose, multivariate coupling of cause and effect in biological dynamics, it often "works," saving time over algorithmic "cookbook medicine."

The engineer designing a suspension bridge is accorded no such luxury.

The real beef here, IMO, is not health IT per se or the Meaningful Use requirements, but with the rushed workflows demanded by the payment paradigm, the "Tyranny of the 99213."

What if we could have a Mayo model, writ large? Insulate clinicians from the "productivity treadmill"? Naive?

See my prior post "There is no more wasteful entity in medicine than a rushed doctor."

A personal observation in support of these critics. I "retired" last year from my REC/HIE, sold the house in Vegas, and relocated to the Bay Area, where my wife works. I am now in the Muir healthcare system, with a new Primary, a pleasant, bright young doc with whom I've hit it off pretty well.

I've seen him twice now, and seen a Muir system specialist to whom he's referred me (also twice). 

Muir is on Epic. The day of my first visit (to their new facility in Walnut Creek), they were on Shakedown Cruise in a beautiful new facility on Treat Blvd, and I had to have my visit with an Epic IT guy in the exam room (there were bugs). 

The M.A. had trouble logging on. In and out, in and out...

She then put me through what I knew to be a Meaningful Use-driven workup: FH, SH, PMH, vitals, active dx's active meds, CC (despite my having uploaded to the portal the most recent progress note export dump my former Primary had given me from his EHR).

She took my BP using a stethoscope -- through my shirt sleeve, using my right arm. "Jeez...seriously? How about a digital cuff, on my bare left arm, hooked up directly into the EHR?"

So, OK, whatever. This was a "Moderately Complex Patient Initial Visit" meet 'n greet. It went well, except that I could feel the doc's productivity treadmill time pressure intruding toward the end.

I later looked up my referral in the Muir patient portal. Didn't see it.

I called the specialist's office.

They're on NextGen. They're a recent Muir acquisition (something I didn't know at the outset), and they remain on a different EHR. Zero "interop" here. The specialist doesn't have a patient portal.

I was handed a clipboard when I first showed up. The usual Overprocessing.

I had to get a lab draw. Went to a "MuirLab" close to my house. Notwithstanding it had the same name on the strip mall front, Muir had sold it off (I forget the new vendor). They take your insurance information and require that you give them a credit card number for anything that doesn't get covered. Revenue Cycle, baby.

I got my bill from the Primary visit alone. $416.00. Given that we're on a high-deductible / HSA plan, my cut was $303.77.

Bending The Cost Curve, all right. Significantly upward in my case. With all of the historical data silo impediments still rather firmly in place.

There are three principal players here in the East Bay Area, judging by their respective soothing billboards that litter the Contra Costa County landscape: Kaiser, Sutter, and Muir.

Dunno, man. You can't just change medical providers and systems like changing your shoes. I have to admit to some frustration.


Budding legislation in the Senate Appropriations Committee:
The Committee makes available $61,474,000 to ONC. The Committee provides funding for ONC entirely through budget authority, rather than through both budget authority and transfers available under section 241 of the PHS Act. ONC is responsible for promoting the use of electronic health records in clinical practice, coordinating Federal health information systems, and collaborating with the private sector to develop standards for a nationwide interoperable health information technology infrastructure.

Information Blocking.—The Committee urges ONC to use its certification program judiciously in order to ensure certified electronic health record technology [CEHRT] provides value to eligible hospitals, eligible providers and taxpayers. The Committee believes ONC should use its authority to certify only those products that clearly meet current meaningful use program standards and that do not block health information exchange. ONC should take steps to decertify products that proactively block the sharing of information because those practices frustrate congressional intent, devalue taxpayer investments in CEHRT, and make CEHRT less valuable and more burdensome for eligible hospitals and eligible providers to use. The Committee requests a detailed report from ONC regarding the extent of the information blocking problem, including an estimate on the number of vendors or eligible hospitals or providers who block information. This detailed report should also include a comprehensive strategy on how to address the information blocking issue.

Interoperability.—The Committee directs the Health IT Policy Committee to submit a report to the Senate Committees on Appropriations and Health, Education Labor, and Pensions no later than 12 months after enactment of this act regarding the challenges and barriers to interoperability. The report should cover the technical, operational and financial barriers to interoperability, the role of certification in advancing or hindering interoperability across various providers, as well as any other barriers identified by the Policy Committee [pp 170-171].
Only a committee draft at this point, but, bears watching. Jonathan Bush and Judy Faulkner will no doubt put their people on it to dilute down or eliminate substantive interop language.

More news just in...
Ending debate on EMR effectiveness?
New data is [sic] coming to the fore on EHRs

July 28, 2014

For at least the last decade, the health IT field has seen a scholarly back-and-forth on the effectiveness of electronic medical records. As soon as one study is published that finds technology has little impact on patient outcomes, another emerges that seems to show just the opposite.

These studies are frequently limited by the size of the data set or scope of the analysis. Take, for example, a June 2014 JAMA article that found meaningful users of electronic health records failed to deliver improved care for five chronic diseases. According to one news report, the new study cast “doubt on whether the tens of billions of dollars invested to encourage EHR adoption among healthcare providers is really enhancing patient outcomes.”

The analysis, it turns out, included just three months of data from 818 physicians (about .1 percent of the 834,769 active physicians practicing in the United States) across seven clinical quality measures. By the way, all those physicians were employed by a single hospital or its affiliated practices.

And the variable being studied? It distinguished physicians who qualified for MU1 against those who did not. Considering the low bar set by MU1, the distinction might not signify all that much.

So what if, instead, you had a data set that drew from ALL the hospitals in the United States. And what if that data ranked healthcare IT adoption not on MU1, but on a multi-tiered scale, from no technology use to completely paperless systems? And what if the outcomes studies included 19 patient cohorts in five service lines, from heart failure and pneumonia to sepsis and stroke, with findings adjusted for risk and other differences in patient health status?

That study might be a little more authoritative when it comes to evaluating "whether the tens of billions of dollars invested to encourage EHR adoption among healthcare providers is really enhancing patient outcomes."

And the good news is, that study now exists and it has found that EMRs do have a measurable, positive impact on care as measured by clinical outcomes of risk-adjusted mortality rates..

​Serious patient safety questions raised in Maryland, D.C. hospitals. So what’s the fix?
Tina Reed, BizBeat, Washington Business Journal

Despite billions in spending in the last decade to improve health care quality, patients aren't much safer today from preventable medical errors and complications, a D.C. patient safety expert said.

The reason for the problem? The very thing that the feds long hoped would help fix patient safety in the first place: incentives for health care providers to adopt electronic medical records, a process called "meaningful use'' standards.

So says Dr. David Classen, chief medical information officer of D.C.-based patient safety company Pascal Metrics. In the rush to bring the health care world into the technology age, from mobile apps to digital patient records, providers are losing their focus on patient safety, he said.

“Meaningful use has completely driven what the focus of the industry is,” Classen said. "And you get what you pay for."

The new federal standards for electronic records have spawned a huge industry in the health IT sector, Classen said. But companies in that space are centered on cost savings and faster communications — not necessarily safety.

“We know hospitals and vendors respond to these meaningful use incentives,” he said. "The solution is to rethink meaningful use."...
Contention will no doubt continue. Given the ongoing DC gridlock, I don't expect much progress, congressional hearings notwithstanding.

More to come...

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