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Saturday, February 23, 2013

Countdown to HIMSS13 in NOLA

WASHINGTON [Los Angeles Times] — The Obama administration issued a travel advisory Friday: Because of a budget standoff in Washington, flights will be delayed.

That was the message Transportation Secretary Ray LaHood delivered at the daily White House briefing as he outlined the impact that across-the-board budget cuts would have on air travel, a drumbeat he acknowledged was aimed by the administration at Republicans in Congress.

"I would describe my presence here with one word — Republican," LaHood said of the White House. "They're hoping that maybe I can influence some of the people in my own party."

LaHood described a nettlesome set of potential problems if, as scheduled, $600 million is eliminated from the Federal Aviation Administration's budget this year as part of the so-called sequester cuts set to kick in March 1...
Lovely to be pawns in all of this, ja?


HIMSS library stocked with must-reads
NEW ORLEANS | February 22, 2013

Knowledge is the best tool for IT professionals hoping to weather the turbulence of healthcare initiatives. And as a vital part of its role as the industry’s chief information resource, HIMSS has produced some of the most essential reading materials to address these vital topics.

Written by some of healthcare’s brightest minds, the HIMSS 2013 library lineup addresses some of the key issues facing healthcare IT professionals today, such as accountable care organizations, patient privacy and security, interoperability and data warehousing. Most selections are available in print and electronic editions...

Medicare Officials Raise Issue of Fraud as Greater Use of Electronic Health Records Increases the Number of Claims Upcoded to More Complex CPT Codes

Could increased use of electronic health records (EHR) systems be causing more hospitals and physicians to commit fraud because of upcoding? That’s the assertion of certain federal health officials. They attribute the increased proportion of Medicare claims for more complex and more expensive services by some providers to be, in some part, acts of fraud.

Most pathologists and clinical laboratory managers will notice the irony in these allegations that providers are upcoding services to Medicare patients in fraudulent ways. After all, the federal government is currently paying billions of dollars in financial incentives to encourage providers to implement and use certified EHR systems with the goal of lowering healthcare costs, while improving patient outcomes.

OIG Audit Findings Are Source of Fraud Allegations
Insinuations of provider fraud came after the public learned of findings of an audit done by Health and Human Services’ Office of Inspector General (OIG). The OIG determined that payments for more complex Level 5 E/M services increased by 21% between 2001 and 2010. During that same period, payments for medium-complexity patient services decreased by 11%...

The excellent Skeptical Scalpel Blog ran a good post on this issue back in December.
Electronic medical records: Documentation of care and upcoding
Wednesday, December 19, 2012
Electronic medical records make documentation easier and that may be a problem.

There are many interesting unintended consequences of electronic medical records (EMRs). I was reminded of this by a recent blog I wrote about what interns really do when they are on call. According to a study from a VA hospital using trained time-motion observers, interns spend 40% of their time on a computer and only 12% of their time taking care of patients. This meshes well with other reports noting that doctors are staring at screens instead of talking to patients.

Here’s the problem. The system actually rewards extensive documentation which may result in less patient contact. The saying “If you didn’t document it, you didn’t do it” has morphed into “Document it, and you can use a higher billing code.”

Here are some CPT billing codes for hospital visits.

99221 Initial Hospital Care, Physician spends 30 minutes at the bedside
99222 Initial Hospital Care, Physician spends 50 minutes at the bedside
99223 Initial Hospital Care, Physician spends 70 minutes at the bedside

Sources tell me that they know of physicians who never bill for less than 99223 or 70 minutes for a history and physical (H&P) examination. In order to do this the doctor must document such things as having reviewed at least 10 different systems (e.g., respiratory, GI, musculoskeletal etc.). This is easy to document without having actually done it. The EMR may have popup windows with lists of systems and symptoms that can be checked off as reviewed...

Now that it is so easy to write a very detailed H&P, it must be tempting to bill every encounter at the maximum level. However, this may come back to bite those who try it. Medicare has been known to audit hospital charts and office records. They have profiles of what the distribution of the various levels of care should be.

Also, there are only so many hours in a day. Let’s say you are working a 12-hour shift and bill for eight 75 minute H&Ps and ten 25 minute subsequent visits. That’s 600 + 250 = 850 minutes or over 14 hours. If you are audited, you will have some explaining to do...
I keep saying it: an EHR audit trail log is a workflow log, insofar as it must (by §170.210) date/time stamp the creation, viewing, updating, transmitting, or deletion of ePHI ("electronic Protected Health Information"). From those data we can elicit a chronology of the flow of user-PHI, which, when coupled with a thorough examination and intersplicing of of the concomitant physical tasks during work hours, comprises a complete workflow record.

I could wreak forensic havoc in a lot of HIT audit logs.


Bitter Pill: Why Medical Bills Are Killing Us
By Steven Brill, Feb. 20, 2013

...Although it is officially a nonprofit unit of the University of Texas, MD Anderson has revenue that exceeds the cost of the world-class care it provides by so much that its operating profit for the fiscal year 2010, the most recent annual report it filed with the U.S. Department of Health and Human Services, was $531 million. That’s a profit margin of 26% on revenue of $2.05 billion, an astounding result for such a service-intensive enterprise.

The president of MD Anderson is paid like someone running a prosperous business. Ronald DePinho’s total compensation last year was $1,845,000. That does not count outside earnings derived from a much publicized waiver he received from the university that, according to the Houston Chronicle, allows him to maintain unspecified “financial ties with his three principal pharmaceutical companies.”

DePinho’s salary is nearly triple the $674,350 paid to William Powers Jr., the president of the entire University of Texas system, of which MD Anderson is a part. This pay structure is emblematic of American medical economics and is reflected on campuses across the U.S., where the president of a hospital or hospital system associated with a university — whether it’s Texas, Stanford, Duke or Yale — is invariably paid much more than the person in charge of the university.

I got the idea for this article when I was visiting Rice University last year. As I was leaving the campus, which is just outside the central business district of Houston, I noticed a group of glass skyscrapers about a mile away lighting up the evening sky. The scene looked like Dubai. I was looking at the Texas Medical Center, a nearly 1,300-acre, 280-building complex of hospitals and related medical facilities, of which MD Anderson is the lead brand name. Medicine had obviously become a huge business. In fact, of Houston’s top 10 employers, five are hospitals, including MD Anderson with 19,000 employees; three, led by ExxonMobil with 14,000 employees, are energy companies. How did that happen, I wondered. Where’s all that money coming from? And where is it going? I have spent the past seven months trying to find out by analyzing a variety of bills from hospitals like MD Anderson, doctors, drug companies and every other player in the American health care ecosystem.

When you look behind the bills that Sean Recchi and other patients receive, you see nothing rational — no rhyme or reason — about the costs they faced in a marketplace they enter through no choice of their own. The only constant is the sticker shock for the patients who are asked to pay.

Yet those who work in the health care industry and those who argue over health care policy seem inured to the shock. When we debate health care policy, we seem to jump right to the issue of who should pay the bills, blowing past what should be the first question: Why exactly are the bills so high?

What are the reasons, good or bad, that cancer means a half-million- or million-dollar tab? Why should a trip to the emergency room for chest pains that turn out to be indigestion bring a bill that can exceed the cost of a semester of college? What makes a single dose of even the most wonderful wonder drug cost thousands of dollars? Why does simple lab work done during a few days in a hospital cost more than a car? And what is so different about the medical ecosystem that causes technology advances to drive bills up instead of down?

Recchi’s bill and six others examined line by line for this article offer a closeup window into what happens when powerless buyers — whether they are people like Recchi or big health-insurance companies — meet sellers in what is the ultimate seller’s market.

The result is a uniquely American gold rush for those who provide everything from wonder drugs to canes to high-tech implants to CT scans to hospital bill-coding and collection services. In hundreds of small and midsize cities across the country — from Stamford, Conn., to Marlton, N.J., to Oklahoma City — the American health care market has transformed tax-exempt “nonprofit” hospitals into the towns’ most profitable businesses and largest employers, often presided over by the regions’ most richly compensated executives. And in our largest cities, the system offers lavish paychecks even to midlevel hospital managers, like the 14 administrators at New York City’s Memorial Sloan-Kettering Cancer Center who are paid over $500,000 a year, including six who make over $1 million...
If you care about anything beyond your own job in health IT, you should closely read and re-read this long article. Draw your own conclusions, but draw them with due consideration. I've been involved with the health care field for 20 years now -- professionally, academically, as a next-of-kin caregiver, and now as a Medicare bene.

Things have not clarified for me.

Niacin is available at Walgreen's (or your supermarket) for 3 to 5 cents per 500 mg tablet. $24 per tablet in the hospital is an average 600% markup.

I would put people in jail for doing this. Particularly those pulling down 7-8 figure annual comp packages.

Read the Brill article.


Health Technology’s ‘Essential Critic’ Warns Of Medical Mistakes
By Jay Hancock KHN Staff Writer FEB 18, 2013
Produced in collaboration with the Philadelphia Enquirer

Computer mistakes like the one that produced incorrect prescriptions for thousands of Rhode Island patients are probably far more common and dangerous than the Obama administration wants you to believe, says Drexel University’s Dr. Scot Silverstein.

Flawed software at Lifespan hospital group printed orders for low-dose, short-acting pills when patients should have been taking stronger, time-release ones, the Providence-based system disclosed in 2011. Lifespan says nobody was harmed.

But Silverstein, a physician and adjunct professor of healthcare informatics who is making a name for himself as a strident critic of electronic health records, says the Lifespan breakdown is part of a much larger problem.

“We’re in the midst of a mania right now” as traditional patient charts are switched to computers, he said in an interview in his Lansdale home. “We know it causes harm, and we don’t even know the level of magnitude. That statement alone should be the basis for the greatest of caution and slowing down.”
Use of electronic medical records is speeding up, thanks to $10-billion-and-counting in bounties the federal government is paying to caregivers who adopt them. The consensus among government officials and researchers is that computers will cut mistakes and promote efficiency. So some 4,000 hospitals have or are installing digital records, the Department of Health and Human Services said last month.

Seventy percent of doctors surveyed in September  by research firm CapSite said they had switched to digital data.

But the notion that electronic charts prevent more mistakes than they cause just isn’t proven, Silverstein says. Government doesn’t require caregivers to report problems, he points out, so many computer-induced mistakes may never surface.

He doesn’t discount the potential of digital records to eliminate duplicate scans and alert doctors to drug interactions and unsuspected dangers.

But the rush to implementation has produced badly designed products that may be more likely to confound doctors than enlighten them, he says. Electronic health records, Silverstein believes, should be rigorously tested under government supervision before being launched into life-and-death situations, much like medical hardware or airplanes.

Silverstein “is an essential critic of the field,” said Dr. George Lundberg, editor at large for MedPage Today and former editor of the Journal of the American Medical Association. “It’s too easy for those of us in medicine to get excessively enthusiastic about things that look like they’re going to work out really well. Sometimes we go too far and don’t see the downside of things.”

A growing collection of evidence suggests that poorly designed software can obscure clinical data, generate incorrect treatment orders and cause other problems. Cases include the Lifespan glitch; a data-entry error that led to the 2010 death of a baby at Advocate Lutheran General Hospital in Illinois; and computers at Trinity Health System, a major Midwest chain, that logged doctors’ orders on the wrong patients’ charts.

Computer mistakes voluntarily reported to the Food and Drug Administration include those that researchers said were linked to 44 injuries and six deaths at unidentified institutions. Those problems included tiny fonts causing caregivers to click on the wrong medication; flipped images that led a surgeon to operate on the wrong side of a patient’s head; and lost or misdated test results that caused unnecessary surgery or delayed treatment.

The FDA’s Dr. Jeffrey Shuren has said that such cases “likely reflect a small percentage of the actual events that do occur.”

At conferences and working from home on the Health Care Renewal blog, Silverstein chronicles digital failures and criticizes hospitals in the same dogged way that he applied himself to building the 1970s-era Heathkit computers he still keeps in his home, say people who know him.

“His message has been consistent: [health IT]provides far less benefit than is claimed by its proponents and opens new — sometimes potent — routes to failure,” said Dr. Richard I. Cook, a medical error expert at the University of Chicago who sat on a panel examining electronic record safety at the authoritative Institute of Medicine. “No one wants him to be visible. But his message and tone have not wavered.”

The HIMSS Electronic Health Record Association, an industry group, declined to comment on Silverstein. A spokesman for the HHS’s Office of the National Coordinator for Health Information Technology, the administration’s proponent of digital records, said: “It’s important to listen to all the voices” in the discussion of the subject.

Trained as an internist and in medical info-tech as a Yale postdoc, Silverstein, 55, served as Merck’s director of scientific information in the early 2000s and then as a full-time Drexel professor, shifting in recent years to part-time teaching and working on medical liability cases for plaintiff attorneys. His insistent warnings about digital health risks over more than a decade have effectively barred him from a lucrative career at a hospital or software vendor.
Scot Silverstein, one of the most ardent critics of electronic medical records, works on an antique computer. A growing collection of evidence suggests poorly designed medical software can obscure clinical data, generate incorrect treatment orders, and cause other problems. (Photo by Ron Tarver/Philadelphia Inquirer)
“I’m sure Scot would be better off by keeping his mouth shut and getting a job with a hospital that’s just put in a big effing system,” said Matthew Holt, a Silverstein critic and co-chairman of Health 2.0, which organizes health technology conferences.

Many say he comes on too strong. Even admirers cringed when he began blogging about the 2011 death of his mother, which he blames in a lawsuit on a computer error that allegedly caused Abington Memorial Hospital to overlook a key medication. (Both he and the hospital said they couldn’t comment on a pending suit.) Personalizing his campaign, some thought, made him seem less objective.

“His refusal to temper his message makes it sometimes difficult to hear,” said Ross Koppel, a University of Pennsylvania sociologist and digital health record skeptic.

But Silverstein says his position today is the same as it has always been. He believes in the potential power of electronic records for good, he says. But any doctor who feels bound by the Hippocratic oath’s injunction to “first, do no harm,” he adds, should balk at what’s going on.

“Patients are being harmed and killed as a result of disruptions to care caused by bad health IT,” he said. “I’m skeptical of the manner and pace [of implementation], not of the technology itself…. My only bias is against bad medicine. And my bias is against people with complacent attitudes about bad medicine.”
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I've corresponded with Dr. Silverstein a bit. Dude is hardcore. A stickler for facts and logic.

Where they favor his case, to a degree, though. An affliction regarding which we all have to be careful of.


From The Health Care Blog:
...Unfortunately, the increasing popularity of EMR caused increased focus from the government. PQRI, NCQA, HIPAA, and CCHIT all took focus of our vendor from clinical development, instead focusing on regulatory requirements. When the HITECH act passed I was still (delusionally) optimistic that the focus would eventually turn to patient care. But the last update I saw on the product I bought in 1996 showed the truth: the product was certified for “meaningful use,” but it was bad. Really bad. We even nicknamed it “Vista.” Previously simple tasks were difficult, and data was harder to use, and was not moving at all toward better patient care.

My inability to accept mediocre care (and my obnoxious obsession with improving it, from my partners’ perspective) eventually drove me from the world of meaningful use and E/M coding to my current home: a practice that accepts only monthly payments between $30 and $60 a month in exchange for an undiluted attention to patient care. Without the overhead caused by the ridiculous complexity of our payment system, I can finally realize my dream of showing the world what good care actually looks like.

But here’s the hitch: EMR has never left the world of note generation. Yes, it does submit data so the doctor can get the check for (ironically) achieving “meaningful use,” but that data is still very hard to actually use to improve care. My attempts at using other EMR products to accomplish my goal have proven to me once and for all that to truly give good care I’d have to abandon EMR as I knew it. I’ve got to look beyond EMR to something better, more focused on the patient and less on the payment. But it’s really been a hard search. I know what I want to do, but the road to that goal is not yet evident...

More to come...

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