Don McDaniel: Why certify EHRs?

I was recently at the eHealth Initiative’s annual meeting in Washington, DC. eHealth Initiative is the organization focused on building bridges in healthcare by and between all of the disparate information systems in healthcare — in short, they are promoting the development of a truly interoperable information ecosystem in healthcare.

The promise of this concept is significant to many stakeholders in healthcare for many reasons, not the least of which is the significant benefit that might be offered to patients that won’t be victimized by the various and sundry errors prevalent in our dysfunctional domestic healthcare system. It’s been well chronicled that tens of thousands of patients per year are harmed or even killed as a result of something as innocuous as an adverse drug reaction.

Anyway, at lunch I struck up a conversation with an especially bright CIO from an integrated delivery system in Eastern North Carolina. We were discussing the recent pronouncements of CMS and ONC on the topic of meaningful use and I mentioned certification of vendors. He quickly replied that there’s no reason to certify vendors of electronic health records because the market will take care of that. I was simultaneously impressed and upset that I didn’t suggest the very same thoughts; I am, after all the free enterprise guy!
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My new acquaintance was right. Meaningful use is a process/outcome achievement scheme. Providers will not be incentivized to simply implement electronic health records, but rather to achieve a (nirvana-like) “state of meaningful use” – which will require appropriate data collection, fidelity to certain clinical treatment protocols, monitoring of patient status and intervention when necessary, and finally, reporting that one has mastered all of the above.

If someone is stupid enough to buy an appliance that doesn’t support their achievement of these goals, shame on them. Is their protection really worth all the money that will be spent — and passed onto purchasers in the form of higher prices — to achieve and maintain certification status? As with every market transaction – caveat emptor – buyers need to educated and ask the right questions.

For instance, I can’t imagine advising one of my clients to purchase clinical decision support technology from a vendor that won’t guarantee that their product will be completely meaningful use-compatible. But do we need a regulator to ensure our protection?

Then again maybe if we were all much better, more demanding consumers of healthcare services, we wouldn’t need the government to carrot and stick our way through meaningful use!

How to make your patients smile

You're busy running a medical practice, so it can sometimes be hard to remember why you went into medicine - let alone spend extra energy keeping all your patients happy. But smiling patients is good for your wallet and your pscyhe. So for the February column The List, we outlined seven ways to make your patients smile. Here are a few:
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1. Be on time.
Nothing makes patients feel more frustrated than still being in your waiting room 30 minutes after their appointment time or spending 15 extra minutes waiting in a thin gown in an exam room. Feeling like you respect their time by keeping on schedule is sure to please your patients. Plus, for you and your staff, it relieves the stress of constantly apologizing to irritated patients for your lateness.

2. Enter the exam room prepared.
It is comforting for patients to feel like they are not a number, that they will be heard and cared for. That comfort is lost when you come into the exam room and have to look in the chart or laptop for the patient’s name and reason for the visit. Take that extra minute before you walk into the exam room to review the chart so you can greet the patient by name and show awareness of his symptoms.

3. Follow-up and communicate.
If your patient has had lab work or testing, was referred to a specialist, or presented with significant symptoms, make time to call her to follow up. See how she’s doing and report on any lab or test results. This helps patients feel secure that your practice is concerned about their health and didn’t forget them as soon as they left the office. Your staff can help with follow-up calls as well.

For the rest of the ways, check out the list online. And let us know in the comments here what other ways you keep patients smiling.

Randall Wong, MD: Go on and say it!

Perhaps you would like to start a Web site or blog, but you are not sure you want to because...you don't have anything to say or are not sure anyone cares. There's an easy remedy: start commenting on blogs that you read.

One unique aspect of blogs (versus the old fashioned Web page) is that the reader may leave a comment. Comments serve several purposes and may be a useful way for you to get started on the Web.

Here are five reasons why you should start commenting:
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1. Feedback - If you read an article and you have something worthwhile and relevant to say, leave a comment. Everyone loves feedback, especially bloggers. (I think even ER docs must love feedback!)

When I write, I have no idea if I got my message across, or more specifically if my writing was clear and cohesive. I can indirectly check by looking at the article's stats the next day, i.e. how many people read the article. I can also tell if my article was popular by seeing how many people "tweeted" about my article. But these are indirect methods.

It is rewarding to have someone leave a comment. This is direct evidence that my message was well received. It is a nice way to say "thank-you."

2. Web Presence - Starting to comment on blogs will start your Web 2.0 presence. Most blogs ask for your name, e-mail and Web address. The name and e-mail usually have to be legit and really function to block spammers.

On the other hand, your name will start your Web presence (in case you are hesitant). The search engines will actually start to keep track of you.

3. Web Traffic - Leaving a Web address with your comment will create, in the Web 2.0 world, an external link from the site you were just reading to your own Web site. External links are an important way to build traffic and increase your Web ranking.

By the way, the web address you provide can also be your Facebook page, LinkedIn site, etc.

Readers of your comment can also click directly on your Web site/Facebook page/Twitter page/etc. and read all about you. Some blogs, however, don't actually list these addresses.

4. People Do Care - As physicians we tend to trivialize our own knowledge and assume everyone shares the same information and that we have nothing special to say. Every one's ideas and interpretations are different. Web sites attract readers from various backgrounds.

Not everyone reading is a doctor!

Even if you have nothing different to say, it is worthwhile to validate the author's opinion with your own. Perhaps you disagree with the author; you might choose to compose a nice comment outlining your counterpoint. You are just creating a constructive conversation using your expertise! Web 2.0 is all about creating "conversations" and sharing information.

5. Get Used To It - Writing comments may be just the way to get used to writing on the Web. It should not be a bad experience. Contributing, especially as physicians, may be one way to improve the quality of health information on the Internet.

Commenting will let you experience, and get over, the anxiety of writing. You'll find people won't poke fun at you, snicker, or call you stupid. Instead, you'll find a whole world that is appreciative of your time and expertise. Just like in the office.

Obama's mention of healthcare reform

Where is that healthcare reform bill?

In his State of the Union address last night, President Obama waited more than half an hour in before mentioning healthcare, and as the NT Times puts it, it was then “wedged into a catalog of presidential priorities, which included jobs, the economy, education, bank regulation, energy independence, deficit reduction and the war in Afghanistan.” This suggests the outlook is grim for the legislation.
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In fact, about seven paragraphs of the 70-minute speech was dedicated to healthcare, Politico reports. That's after spending a year on it.

Obama did call on Congress not to give up the effort, the Hill reports. “Don’t walk away from reform. Let us find a way to come together and finish the job for the American people.”

But he didn’t offer much guidance on how to break the impasse, and meanwhile Democrats have been debating the best approach for the stalled legislation. House Speaker Nancy Pelosi said yesterday that the Senate would have to make changes to the bill before the House would act again, the NY Times reports.

So once again, the fate of the reform effort remains unclear, but grim.

Trendspotter: When doctors and patients think more is better

By Ken Terry

A post on MedPage Today by my former colleague, Marianne Mattera, made me think about how much medicine has changed in the past few decades and why it costs so much more than it used to.

Back when I was in high school (long, long ago), I sprained my ankle playing basketball, and I was taken to the emergency room. After an X-ray showed that there were no broken bones, the ED doctor put a plaster cast on my ankle and recommended that I use crutches until it healed. It did heal completely in about six weeks, and I’ve never had any trouble with it since.

Mattera took her college-student son, who had also sprained his ankle, to an orthopedic surgeon on the recommendation of an ED physician. Because none of the orthopedists suggested by that doctor had an immediate opening, she went to another physician who was on the health-plan list. His office was so ragged, his receptionists so unfriendly, and his examination so cursory that when Mattera left with her son, she decided never to return. She then made an appointment with one of the doctors the ED physician had recommended. The second orthopedist had a much more patient-friendly office and seemed more competent. But, like the first one, he wanted to order an MRI.
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Why? It wasn’t because Mattera had asked for it; she said she questioned the first doctor when he suggested an MRI. Perhaps the expensive test was justified because of her son’s symptoms. Maybe the orthopedists wanted to protect themselves against liability in case surgery was indicated. Or maybe, because they’re specialists, they were hunting zebras. But whatever the reason, most sprained ankles got better on their own before MRIs were invented.

There is even some question about whether X-rays are normally required. A test known as the Ottawa Ankle Rule reliably determines whether an ankle is broken without the use of X-rays. But most doctors still order X-rays of sprained ankles to reassure patients and guard themselves against even the remote chance of a lawsuit.

When asked about the Ottawa Ankle Rule, an old country doctor whom I know was fond of telling medical students: “My radiographic dictum is, ‘It’s the patient’s ankle, but it’s my ass.’ I would rather X-ray 100 sprained ankles than go through the hassle of defending a single missed fracture in a malpractice suit.”

At least this primary-care physician, who hailed from North Carolina, treated sprained ankles. In some areas, including parts of the Northeast, primary-care physicians are not expected to handle anything that complex. If a patient has a serious condition, the assumption is that he or she will be referred to a specialist. In California and Minnesota, on the other hand, primary-care doctors tend to do much more for their patients before referring them out. The reason for those regional differences is not entirely clear, but it probably has to do with local physician cultures and business environments.

Over the past 40 years, U.S. medicine has increasingly emphasized the intervention of specialists and the use of expensive technology. In some cases, this has been a change for the better; but in other cases, doctors may be calling in the heavy artillery when a little judicious medical-decision making is called for. Unfortunately, when physicians try to do the right thing, they may find themselves being lambasted by patients who would rather leave no stone unturned and by a medical establishment that has convinced itself — and patients — that more is better.

There’s a lot of talk these days about shifting to a new reimbursement approach variously called “pay for value” or “pay for outcomes.” But until attitudes among doctors and patients change, that will be a very difficult transition to make.

Gerald O'Malley, DO: I can't help you, part 2

Some days in the ER, I just can’t seem to help anyone.

Here's the story of another patient, this one about 25 years old with chronic back pain who showed up requesting that I provide him with several different narcotics. He said he had recently moved to Philadelphia from another state and he had run out of his pain medication prescriptions.

You’d be surprised how many people show up in the ED complaining of chronic painful conditions that they had been suffering with for a long time that “suddenly run out of pain medications” and want refills. I never want to deny a patient pain medication if they are truly having pain, but my prescriptions have been forged and stolen and diverted to schoolyards. I have to be careful. My normal practice is that I require the patient to show me something to work with.
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It’s not fair to me for a patient to show up empty-handed and say: “I normally go to a doctor in New Jersey, but I lost my doctor’s phone number and I can’t remember his name but you couldn’t contact him anyway because it is 9:30 on a Saturday night and the office is closed and I don’t have any documentation of my chronic painful condition and I don’t have any empty pill bottles so can I have 120 oxycontin tablets please?” If you think I’m exaggerating, spend one Saturday night in any ER in this country and prove me wrong.

My patient today was a little more savvy than most. He showed up with a DVD containing all his X-rays and MRIs. They were all five years old, but at least he had the decency (or is it chutzpah?) to bring them with him. I contacted the last pain clinic that he had attended and, with his permission, they faxed over several pages of records including a letter from the director of the pain clinic discharging the patient from their care because he had broken the pain management contract numerous times. The receptionist at the out-of-state pain clinic told me that she gets several phone calls each week regarding this patient.

When I confronted the patient with this information, he became quite upset and defensive. He insisted that he could “barely stand up” and he needed to take several different types of narcotics, plus muscle relaxers every day in addition to an occasional percocet tablet just to enable him to do his job.

“What kind of work do you do?” I asked.
“I’m a roofer,” he said.

I called the pain center at my own hospital and they offered to see him and evaluate him in one hour. The patient declined and became testy. “I wasted two hours here, and you won’t help me at all. What did I gain from all this?”

“You got to eat lunch, watch Jerry Springer, and got a referral to the pain clinic. What more do you want? I’m sorry I can’t help you.” He muttered something under his breath and haughtily strode out of the ER.

It used to really bother me when guys like this would present themselves to my ER, but over the past 15 years, I’ve come to accept the fact that we are limited in our capacity to help certain patients because the system simply isn’t designed to accommodate their particular problem. It’s not my fault, it’s at least partially the patient’s fault, but it is primarily the fault of an increasingly inefficient system that is overburdened, overregulated, and unable to provide timely help for non-emergent but urgent problems.

Jennifer Frank, MD: Paperwork

Of all the things that do dual duty by assaulting me both at home and work, none is as annoying, overwhelming, and constantly present as paperwork. As an academic physician, I manage not only the clinical paperwork that threatens to overtake all physicians, but also grant requests, manuscripts, resident evaluations, medical student applications, faculty schedules, and professional journals.

At home, there are the inevitable bills, catalogs, junk mail, pleas for urgent end-of-year, beginning-of-year, and mid-year contributions to charities both noble and questionable, endless brightly colored announcements about a school roller-skating event, book sale, or popcorn day sent home with frightening regularity from my children’s school, and numerous, precious art projects generated constantly by my prolific kids.
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As I write this, I am in a pretty good place with paper control at home and on my desk at work. This is unusual – manifestations of a pretty quiet weekend at home (clearing off the kitchen table is one thing I can do while holding a baby on one hip) and a Friday afternoon frenzy at work trying to get my desk cleared off so that I wouldn’t come in to chaos on Monday morning.

Most days, my desk is piled high with a random assortment of papers – in reverse order of what I have been working on. The references for my article in progress are on the bottom of the pile, followed by the overdue medical student evaluations, an article on placental abruption, a recipe I requested from a co-worker, notes from the last staff meeting, and a letter from a local health plan. It seems impossible to keep it all under control.

Sitting at our kitchen table eating dinner, I am amazed at how quickly my family members undid my good work of the weekend. Papers have taken over once again. The Wall Street Journal, homework assignments, holiday cards, receipts, random scraps of paper for future art projects, and the grocery list compete with the dishes for space. The paper battle feels endless and hopeless. Paper is generated more quickly than I can recycle it. What to do?

- Toss as you go. It is only four feet from the in-box on my office door to my desk, but if I don’t cull out the job offers, CME brochures, and throw-away journals before I get there, they claim space on my desk and make it less likely that they will be recycled quickly.

- Buy a label-maker. It is so much more inviting to file papers in a colorful, clearly marked file folder.

- Periodically purge. Take some time to get rid of papers that you once needed but no longer use. For some of us, it is the article on hyponatremia our internal medicine attending gave us in 1995. For others it may be the pile of Christmas cards littering the dining room table.

- Use electronic media frequently and comprehensively. With electronic access available nearly everywhere, it is getting easier to store things virtually – perfect, no clutter. (Actually it is possible to clutter up your electronic storage but it is not as unsightly).

Do you use patient satisfaction surveys?

I received an e-mail last week, a couple days after a dentist appointment, asking me if I would participate in a survey about my visit. I gladly answered the few questions online, pleased that they cared how my experience was – just another thing I love about my dentist (which uses an EHR, e-mails and texts appointment reminders, and has some of the friendliest staff of any office I’ve been to).
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The questions included:
- Did you have to wait past your appointment time and if so how long?
- Did staff greet you properly?
- Would you refer us?
There was also a field to enter suggestions, and an option to participate anonymously.

It made me really appreciate that the office wanted to know what they were doing well and what could be improved. It would be nice if all my doctors solicited feedback. (Of course, I loved that I could answer the survey online, but I won’t get into my Web site rant again.)

It also made me wonder how many physician practices conduct patient surveys – and why or why not? We do offer a sample patient satisfaction survey for practices, and I am interested to hear from practices using such surveys, online or on paper.

Melissa Young, MD: The day the network went down

I don’t know why I didn’t immediately write about this on the day it happened. I must have blocked the painful memories, but somehow they resurfaced today.

It was an ordinary day. I saw patients in the office in the morning. Everything was running smoothly. I entered all my notes in the EMR. We had Internet. Nothing extraordinary.

I went to do rounds at the hospital at around 2 p.m. At 3 p.m., I get a text from my receptionist: “The computers are down.” Down? What does she mean “down?” They were fine an hour ago. And computers? Plural? Oh, no, no. This can’t be good.

So I texted her back (I do love texting): “Just the EMR or Internet, too?”
“EVERYTHING”
Good mother of all that is good and pure, what happened?!
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I ran back to the office. Sure enough, the computers were on, but none of them could connect to the network. Therefore, none of them had an Internet connection, none of them could run the EMR. And there in the waiting room was my next patient. I tried rebooting each computer. Nothing. I checked the server. That was on, had Internet, and could run the EMR. Now if I could see my patient in the computer closet that it was in, I would have been fine.

I called my IT company. They couldn’t “see” my computers. I was offline. Oh, sweet baby James, I was this close to having a stroke. OK, they said, unplug the switch, then plug it back in. Unplug the modem and plug it back in. I really hate that unplugging and replugging things just seems to be the way to fix things. Still nothing. My IT guy says he’ll send someone out immediately. Nothing could have been immediate enough for me at that point.

Meantime, I remember the patient in the waiting room. She fortunately had a good sense of humor and was rather amused at my agita. I took a step back. She’s a new patient, so it’s not like there was really anything in the EMR that I needed that second. I’ve seen patients for years without templates, and I’ve written notes on paper before. So, I forged ahead.

Funny, after only three months, it seemed almost foreign, but I went forth. And it was fine until I asked her if she had had recent labs. She said yes, and her doctor had faxed them to me. I slapped myself in the forehead. Of course, she had. But I couldn’t look at them, because all that would be in the EMR. She looked bemused again, “You don’t keep a hard copy?”

“We don’t get a hard copy. All faxes go directly into the computer.” So I go out to tell my staff to call the patient’s PCP to have them re-fax the labs, this time to our “old-fashioned” fax machine.

While they do this, I get a call from IT, “Turn off the server, then turn it back on.” Really, seriously? Fine. Now, a regular computer takes but a minute or two to reboot. “A server has a lot more going on” I’m told as I stand there impatiently. Then after what seemed like an eternity, it was back on. And, lo and behold! One by one the other computers on the network came alive. Hallelujah! We were back in business.

This happened about a week or two ago. It has not happened again. I have no explanation for what happened. Just the new-found wisdom that if it happens again to reboot the server. And a bill from IT for “minimum service – 2 hours” plus tax.

EHR stimulus update

Do you have meaningful use on the brain? In a follow up to the primer on EHR stimulus incentives, Ken Terry's EHR Incentives Update in the February journal digs deeper into the meaningful use criteria.

There's a good chance you've got some confusion or anxiety about acquiring and learning to use an EHR. But if you want to get the maximum federal dollars, you can't really hesitate. Ken's article will help clear up some confusions and get you on the right path for the EHR incentives.

I also welcome your comments here about what you're doing to acquire and meaningfully use an EHR.

Randall Wong, MD: Ease into social media using PowerPoint

Using the Internet, Web 2.0 and social media can be as easy as using PowerPoint. Want to try? Web 2.0 and social media are pretty hefty terms to define in just one post, but let's chip away at it by using the example of a PowerPoint presentation.

Most docs are used to giving presentations. We give them to our colleagues, staff (in-service), patients, etc. More formal lectures are given at our medical and scientific meetings. Most of the time we use PowerPoint.

Web 2.0 is about sharing and collaboration. Take one of your PowerPoint lectures and upload to the Internet. There is a social media site call Slideshare. As YouTube is for videos, Slideshare is for presentations; Adobe, text, and PowerPoint.
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Signing up for Slideshare is easy and free. Create your own user name and password, and upload your presentation. You need to type in your title and description. "Tags" are similar to keywords. It helps interested readers find you, both within Slideshare, and outside. You will also choose a category and then decide if viewers can download your presentation.

That's it! You are done! You are now using social media to contribute to the Internet. Using Web 2.0 philosophies, you are sharing your information, inviting others to review it and contribute.

Instead of giving your lecture to a few or hundreds, your lecture is now available for an unlimited number of people to view. You can also choose who is able to view your presentation by keeping the presentation private. If you want collaboration, you can allow people to download your file.

I created the presentation "Social Media: Why Not?" for medical practices. The presentation was uploaded several months ago. My social media for medical practices presentation was created on PowerPoint, and the SlideShare presentation is exactly how I formatted the lecture on my computer and works as easily as PowerPoint. The web site tracks all kinds of stats, such as the number of views, etc.

People interested in social media will search within the SlideShare.net website and might discover my presentation. Similarly, as the files are indexed by Google and other search engines, the lecture may appear if you were to Google about social media.

Best of all, people may share or tell others about your lecture by e-mail or social media. How?

By using a link to your presentation, people can use e-mail to share the link and your presentation. E-mail has its limits. Generally e-mails are shared between only two people; the sender and the receiver.

Instead, you or others that find your presentation interesting could post the link on Facebook, Twitter, LinkedIn, and other social networks to broadcast or share with others. Using these media, many can see your presentation simultaneously as all people subscribing/following/friends of the sender will be able to view the link.

Your message can become viral — and all you did was use PowerPoint.

Gerald O'Malley, DO: I can't help you, part 1

When I enter a patient’s room, I make it a point to demonstrate to the patient that I wash my hands or I squirt some hand sanitizer on before I touch them and my introduction is the same for every patient; “Hi, I’m Dr. O’Malley. How can I help you today?” I got into this line of work because I genuinely enjoy helping people. Today, I felt like I didn’t do such a good job helping anyone.

The first patient I saw today was a young lady that told me that she was losing weight. She wasn’t trying to lose weight and her appetite was good, but her mother and sisters told her she was losing weight. At one time she weighed 122 lbs.
“How much do you weigh now?” I asked.
“I don’t know,” she replied.
“Well then how do you know you are losing weight?”
“Because everyone tells me I am.”
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The patient wanted to be tested for a variety of different disease including but not limited to cancer and lupus. I told her that the ER isn’t really the place to begin a workup for any of these chronic diseases and I could provide her with a list of excellent primary-care providers that might help her. She was unconvinced and wanted something other than my reassurance. Having no insurance or source of income limited her ability to access a doctor that might help her.

“Well, let’s talk about this,” I offered. “How long have you been losing weight?”
“About five days.”
“You don’t need any testing. You need to go home and find a scale and try to figure out if you are actually losing weight or not. If you are losing weight, you need to make an appointment with a primary care doctor and get a check-up. If you like, I can have you talk with our social workers in order to begin your application for Medicaid. I’m sorry but I can’t help you.”

The patient became upset, called me a racial epithet under her breath and stomped out of the ER.

The ER has always been the great dumping ground for patients with no place else to go. Most ER doctors pride themselves as being strong patient advocates. I have argued, bullied, pleaded and bargained with other doctors to help my patients. Most doctors, when push comes to shove, will do the right thing for the patient even though it means that they will lose sleep, not be paid and increase their malpractice risk.

One recent case that comes to mind was the illegal immigrant that accidentally put his hand through a circular saw while at a worksite. He had presented to another ER (located on the “Main Line” – the southwestern suburbs of Philadelphia famous for the gorgeous old staid mansions and outrageously overpriced condos), was bandaged up, and given a map with directions to my hospital. He showed up in my ER with an injury that might have required an amputation had it not been for some gentle arm twisting on my part and a heroic effort on the surgeon’s part – all without compensation and with the shadow of the trial lawyer bribing OR nurses and techs for leads on possible malpractice cases. (I personally know ER nurses and techs that have been offered money from trial lawyers to “keep your eyes open” for information on any potential malpractice cases.)

Some days, I just can’t seem to help anyone.

Help for Haiti

Hundreds of medical personnel have descended upon Haiti in the wake of last week’s devastating earthquake. HHS’s medical teams are providing emergency care at several locations in Haiti, and nearly 20 permanent and temporary health facilities are operating, according to the Pan American Health Organization.

The need for medical support and supplies continues. So what can you do?

- Medical personnel who wish to assist can register here (link provided by HHS).
- For situation reports, see the PAHO’s Web site.
- The AMA has a list of organizations accepting financial donations.

What are you doing to help? Please join the conversation here.

Trendspotter: EHR vendors peg financing deals to incentives

By Ken Terry


The deals from EHR vendors are getting better.

Among the latest offers to be announced is Ingenix’s for its Care Tracker EHR. Ingenix is offering an interest-free loan through OptumHealth Bank, a fellow UnitedHealth subsidiary, to cover implementation and subscription costs until Nov. 30, 2015. Qualifying physicians can repay the loans with annual government payments for meaningful use, which can total up to $44,000 over five years if they’re from Medicare, more if from Medicaid. Physicians who buy a Care Tracker EHR this year would pay nothing out of pocket for use of the remotely served, Web-based software. They’d have to repay the first installment of the loan after they received their government check next year; for the rest of 2011 and part of 2012, they’d pay nothing until they got their next government payment.

Like many other vendors, Ingenix is offering a meaningful use guarantee: If a practice doesn’t qualify for the annual government incentive, it doesn’t have to pay back the previous year’s loan.

Allscripts is offering practices deferred payments for the first six months on loans that are available through “preferred banks.” After that, they have to pay back the loans over 54 months. At the end of that term, they own the software. “Unlike some of the subscription models in the market, where you continue to pay on an annual basis even after that 60-month period, our solution is rent to own,” says Allscripts President Lee Shapiro. “And the loan payments are very competitive with any subscription services in the marketplace.”
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Allscripts offers its MyWay software on a subscription basis, too, and many small practices prefer that arrangement. But Shapiro notes that if a practice wants to purchase the Web-based EHR and have Allscripts remotely host and manage it, that is also an option. Allscripts guarantees that its software will meet HHS’ EHR certification criteria. If it doesn’t, it will wave up to 12 months of a client’s monthly support fees.

NextGen is offering three options. Along with a six-month deferred payment option, it is also allowing doctors to defer payments for four months, followed by incrementally increasing payments (four months at half payments, eight at three-quarter payments, and 44 months at full payments). The third possibility, available only to practices of three physicians or more, is a no-money-down purchase with 12 months of deferred payments, followed by a standard five-year loan.

Mark Anderson, a health IT consultant based in Montgomery, Texas, points out that most leading vendors are offering zero-interest or deferred-payment arrangements in expectation of the government incentives. “In reality, the cost ends up being the same,” he says. “If your payments are deferred, then the interest rate is higher later. If they’re zero interest, the practice ends up paying more for the solution.”

Shapiro, however, says that Allscripts is offering “very attractive programs” through its banking partners. The vendor is using its buying power, he says, to obtain loans at better rates than most practices could get on their own.

The other thing to bear in mind is that the software cost is only part of the total cost of ownership, which also includes outlays for hardware, training, and implementation. Steven Tolle, senior vice president of Ingenix’s Physician Solutions Group, says that, especially in the small-practice space, vendors must minimize these expenses to get physicians onboard.

Still, the five-year cost of subscribing to Care Tracker is $7,000 per physician, and Ingenix estimates that the total five-year cost for the EHR system is $23,500. That is less than the $44,000 maximum payment from Medicare, but a significant portion of that amount must be laid out upfront, despite the zero-interest software financing.

Ingenix and other vendors are aiming their new offers squarely at small-practice physicians who have notoriously resistant to EHRs. To what degree the software vendors will succeed is uncertain. Certainly, many physicians remain hesitant to buy, even with the government incentives. Some doctors fear they will lose productivity, and some have heard horror stories about failed EHR implementations. On the other hand, Allscripts just reported a 30 percent hike in revenues for the quarter ended Nov. 30, 2009.

The real deal lies somewhere between these viewpoints. Many physicians will adopt EHRs and show meaningful use in 2011, but some will need help that goes beyond what their vendors can provide to do that. What could make a big difference are the government’s plans to launch 70 health IT regional extension centers and have community colleges train thousands of EHR technicians. The sooner that happens, the better for everyone.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." In his weekly Trendspotter column, Ken is looking out for trends and changes that may affect your practice.

After Mass. race, is healthcare reform dead?

Republicans took the Massachusetts Senate seat last night, reducing the majority the Democrats needed to blog GOP filibusters and signaling a bumpy road ahead for Obama’s agenda.

So what does Scott Brown’s win mean for the healthcare reform efforts?
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Brown campaigned on his opposition to the legislation and he promised to kill the bill when he got to Washington. His vote as the 41st Republican senator was just the number the GOP needs to blog the legislation, the LA Times reports.

It’s not entirely clear yet what will happen with the bill. Speaker Nancy Pelosi tried to be optimistic about it, but other Dems said it’s back to the drawing board for healthcare reform, according to the Washington Post.

Perhaps the most obvious option is for the House to pass the bill cleared by the Senate, because the chances are slim that they can salvage “the full scope of the current legislation.” The Democrats could also start over in the Senate with a scaled-back bill, or they could shelve it entirely and only try to pass a few of the popular initiatives in the existing bills. Either way, what looked like a sure-thing to pass is now hanging by a thread.

Perhaps that’s not a bad thing. Even those who want healthcare reform and were at one time very optimistic of real reform will be glad to start over. The legislation has surely been watered down over the months of debate, and in many ways fails to achieve meaningful reform. Sure, it was a step – but maybe it wasn’t the best way to go about healthcare reform? Maybe starting over will yeild a better result in the end?

Jennifer Frank, MD: Looking out for each other

Last spring, in a state of somewhat over-worked frenzy, our faculty group got together for a “work-life balance” retreat. We hashed out schedules, expectations, demands, priorities, and realities to come up with a mission statement. This statement outlines a respect for a “healthy balance between personal and professional responsibilities,” “healthy limit setting,” and “open and transparent communication.”

We also discussed the different needs that lead one of my colleagues to round at 5 a.m. in order to fit in all of the items she needs to do in a day and leads another colleague to work part-time so that her balance is not upset.

One thing that recently came to mind was the need to help each other achieve this elusive balance.
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This is a foreign concept in medicine, where workaholism, perfectionism, and all other kinds of unhealthy –isms abound. I don’t remember any residents I worked with as a student or any attendings I worked with as a resident tell me that I looked tired and should go home early to rest. In fact, I remember an attending on my pediatric cardiology rotation reminiscing about his intern days, when he took call every other night. He was told (by his attending) that “if you are only on call every other night, you miss 50 percent of your learning.”

I have been blessed with great colleagues who actually do look out for each other. When I returned to work after a three-month maternity leave, they were understanding of the demands of a new baby, offering to help with rounds or other responsibilities if needed. When one of my colleagues is struggling to complete a paper or presentation, I hope that I am responsive and step up to help out. Why is this so unusual in medicine, where health is our supposed goal?

My husband and I also try to look out for each other. We are both going about 100 mph during an average day. It is essential for us to occasionally look at the other to evaluate for signs of near-collapse or exhaustion. At times like these, my husband may encourage me to head out to the gym or I may send him down to the basement to play video games. This is why my obligation to be at home one Wednesday evening a month while my husband goes out for his “guys’ dinner” is sacrosanct.

Very demanding roles — such as physician or mother — rarely are accompanied by other people looking out for your wellbeing. My kids love me but are inherently egocentric, as is the norm when you are young. My patients appreciate me (most of the time) but are appropriately focused on their own myriad needs instead of on their doctor’s. Therefore it is essential that colleagues or partners look out for each other. Check in with each other to see how things are going, protect each other from self-imposed craziness, and help each other to be healthy in the way they fulfill the demands of their roles.

Melissa Young, MD: Planning for a partner... already?

So I opened my practice four months ago. The influx of patients has been steady. The schedule is pretty full each day. The wait time for a new patient appointment is a manageable two to three weeks. The no-show rate is fair, roughly one patient out of 15. I get about one new in-patient consult (oh, yeah, there are no consults, just “new patients”) a day on average, and the hospital census is relatively small.

So why think of bringing in another physician?
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Before I answer that, let me say that I am not planning on having anyone start before the practice’s first anniversary. But it takes so long to get a license in New Jersey. And then there is applying for a Medicare number, credentialing with the insurance companies, and getting hospital privileges. Plus, the new physician may have to move and look for a house, etc., etc.

I am hopefully optimistic (is that redundant?) that by the time the practice is a year old, that I will have a sufficient number of follow-up patients and a decent sized in-patient population to justify having a second person on board.

I have visions of being able to make the office even more accessible to patients by having more office hours, maybe even the occasional Saturday. I also look forward to having my first day off — no office, no rounds, no phone calls. Sigh. Eight months is a long way to go.

My original business plan called for hiring a nurse practitioner at the six-month mark. I loved my nurse practitioner at my old office and feel she was an invaluable resource.

Having said that, I’ve gotten a lot of feedback from my old patients, as well as from patients of other offices that have an NP. While most of them (but not all) respect NPs, and many were quite fond of mine, they really prefer to be seen by a physician. Their physician. Some of them have said that they are glad that I went solo because they want to see me every visit and not alternate with an NP.

So while hiring a nurse practitioner may make more business sense than hiring another doc, it seems that from a patient satisfaction standpoint, hiring another doc is the way to go.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

New Tip of the Week

For the latest Tip of the Week, endocrinologist Medhavi Jogi advises practices to not accept the one-time training from their EHR vendor.

How did your EHR training stack up? Do you have ongoing support?

Don McDaniel: Health reform death spiral

I gave a speech in early January 2010 to a group of bankers and accountants to discuss the impact of proposed health reform on business. Everyone is nervous about what’s coming down the pike, and the average business owner (or even the average business advisor) doesn’t have the time or the proclivity to dig into reform legislation to understand how it might affect them — it seems our legislative process is geared to obfuscation.

As I thought about health reform and how it might affect business, I started to focus on the impact on one of my favorite small businesses: the physician practice. It seems that even without reform in the offing, the physician-entrepreneur is moving toward extinction — how many businesses can, or want, to operate in an environment where revenue is largely fixed, heavily regulated — sort of like a utility — and highly dependent mostly upon factors outside the control of the entrepreneur, and operating and capital expenses are rising every year.
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So, cash flow is being squeezed from every conceivable angle, the government is mandating purchase of expensive information technology (which mostly benefits others that aren’t contributing to the purchase), and practicing physicians in many states deliver services every day under the specter of being sued.

What else could happen to make things even peachier? How about health reform, which is really insurance reform, which is really focused on expanding coverage for the uninsured?

Here’s one scenario from a particularly contrarian observer (me) that nonetheless has legs. As health reform will be paid for largely on the back of reductions in the Medicare program — almost $700 billion in cuts over the next 10 years — it seems an inevitability that the Medicare program will continue devolving into one of the poorest payers for physicians and hospitals, second only to the Medicaid program.

And, oh by the way, a lot of the proposed coverage expansion in the Senate bill will manifest as new Medicaid enrollees — yes, that’s right, the program that is busting the budgets in states all across the country, will be expanded. So, we’ll have growing public sector programs, at the expense of commercial insurance enrollment, which is today subsidizing the underpayments from Medicare and Medicaid.

Anyway as FFS reimbursement for Medicare (and Medicaid) continues to degrade, physicians, especially primary care physicians, will vote with their pocket books and decide to, in the short run, drop out of public sector programs, and in the longer term, those historically groomed to practice medicine are going to start deciding to choose another career path — one without frivolous malpractice risk, crazy student loans, ever-growing expenses and fixed revenue.

That seismic workforce shift will further drive structural physician shortages, creating a lot of upward pressure on prices (i.e. outsize growth in expenditures) forcing the dreaded r-word – explicit rationing. Get ready to queue-up for that procedure!

Don McDaniel, president and CEO of Sage Growth Partners LLC, is an entrepreneur, economist, technologist, educator, speaker, and writer. He is a skeptical contrarian who writes about the power of free markets, disruption, innovation, and technology in healthcare.

Randall Wong, MD: What's in a URL name?

The Uniform Resource Locator (URL) is the fancy name for a Web site address. The URL should be composed of keywords that describe your business or practice. It used to be that you’d just want to take your business name and add “.com,” but that won’t gain you much Web presence these days.

Carefully selecting a few keywords to construct your URL can give you a big jump on your competitors in terms of gaining a higher listing with the search engines. A smartly chosen URL is the first step to good search engine optimization.

For example, suppose Joe Smith, M.D., a pulmonary specialist living in Bedrock wants a Web page. It would be smarter for Joe to choose a URL such as "BedrockPulmonaryCare.com" instead of "JoeSmithMD.com."
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Most people looking for a pulmonary doc in the Bedrock area will most likely choose words like "pulmonary," "doctor," and "Bedrock." Because these search terms are already in the URL, it will be noticed by the search engines and yield a higher listing. Joe Smith, M.D., may never come up on the listing. Easy?

Suppose the law firm of Wong, Wong, and Wong has a URL www.WeSueDocs.com. Can you guess what they do?

Once you have selected a few keywords, check out their strength using a keyword search tool. There are plenty of Web sites that will analyze your keywords and give you an idea of how popular, or how often, people use them for searches. And it's free.

I would suggest using ones generated by Google. The results are based on actual Google search queries.

Once you have chosen a few strong keywords, construct the URL and then test it. The search engines naturally break down any URL into useable words, so don't worry about confusing the search engines.

Test the URL at a place such as GoDaddy.com. Enter your new URL and see if it is available. If not, you may change a word, the order of the words, make a word plural, etc. Most of the time, the URL will be cheap since it is unlikely you will be using any "branded" keywords in the URL. Basically, certain keywords may cost more and this will be reflected in the price of the URL.

If you buy now, you own it. Rest assured, you don't have to do anything with the URL, but you have come up with a Web address!

Randall Wong, MD, is a retinal specialist in private practice in Fairfax, Va. Wong has a strong interest in Web 2.0, the Internet, and social media, and will write regularly about how social media can help build your practice and even improve healthcare.

Trendspotter: What health reform will mean for you

By Ken Terry


While congressional leaders dicker over the details of healthcare reform legislation, this is a good time for physicians to take stock of how reform will affect them and what they can do to help repair the system.

On the issue of Medicare reimbursement, don’t expect the Senate to follow the House’s example and restore projected Medicare cuts to physicians for the next 10 years. The Senate earlier rejected this permanent fix, and it is unlikely to reverse its position. Instead, the final reform package will probably eliminate the planned cuts this year and perhaps next year, according to consultant Julius Hobson, former lobbying chief for the AMA. After that, the issue will again come up for debate.

However, I do not believe that we will see Congress continue to do its annual dance with the AMA over these cuts, giving back the money at the last minute without solving anything. The direction of Medicare reimbursement will be increasingly tied to approaches like the value-based purchasing and payment bundling proposals in the Senate bill, as well as to the accountable care organizations (ACOs) that the measure encourages providers to form. These aggregations of hospitals and physicians, similar to the Mayo Clinic or the Cleveland Clinic, but perhaps more loosely organized, will deliver care within some kind of budget and will be able to keep a portion of any savings they achieve. If Medicare starts doing this, look for private payers to follow suit.
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So how will all of this affect you if you don’t belong to an ACO and are not involved in a CMS demonstration project? It won’t affect you immediately, but eventually the tsunami of change will reach your practice. When it does, you may find that what worries you now is no longer relevant. In fact, the issue that medical societies have emphasized during this reform season — how much the government will pay doctors for each unit of service — will eventually become moot, because fee for service is on its way out. In five or 10 years, you’ll be paid on an entirely different basis.

This is going to happen because fee for service is one of the key drivers of healthcare inflation in the U.S. Don’t be fooled by the recent announcement that health cost growth in 2008 dropped to its lowest level in decades: That was largely due to the recession, and the growth in spending was still far higher than general inflation or the rise in GDP. Costs are still out of control; the number of uninsured is rising; and more and more employers will drop coverage of their workers unless something is done. If you think that won’t affect your business, you’re living under a rock.

The current reform legislation is a step in the right direction: by expanding coverage and making it easier to afford insurance, it should result in more timely and comprehensive care that will keep many out of the ER and the hospital. But the measure will also create a couple of problems for physicians and patients. First, it is going to produce a tremendous demand for services from the previously uninsured without increasing the number of doctors. (This has already become a problem in Massachusetts, which enacted similar reforms.) And second, it does too little to restructure healthcare financing and delivery. So in essence, the reform is going to pile more volume on a system that is outmoded, wasteful, and inefficient.

What can you do about it? To begin with, recognize the simple fact that, despite your belief that payers control the game, physicians actually have the power to effect meaningful change. After all, your medical decisions determine how about 80 percent of the money in the system is spent. So if you start changing how you practice, you can have a surprisingly large impact. Of course, that might reduce your income, because the system is not yet set up to reward quality or nonvisit care.

The medical home movement is trying to show physicians how to do this without losing money, but it’s still a daunting challenge, especially for small practices. So another thing to consider is how you and your colleagues can start to change the equation in your own community, perhaps through your IPA, your PHO, or your hospital.

While I don’t have the space to discuss this in detail, I’d heartily recommend an article in The New England Journal of Medicine by Elliott Fisher, MD, a Dartmouth professor who has done important research on regional variations in Medicare costs; Donald Berwick, MD, president and CEO of the Institute for Healthcare Improvement; and Karen Davis, president of the Commonwealth Fund, a New York think tank. Entitled “Achieving Healthcare Reform — How Physicians Can Help,” the essay argues that physicians should join integrated delivery systems, which could be “virtual,” to achieve the aims of the Institute of Medicine report “Crossing The Quality Chasm.”

ACOs are already being formed across the country on a de facto basis, as more and more physicians go to work for hospitals. Already, more than a third of all doctors are employed by healthcare systems. But you don’t necessarily have to give up private practice to get involved in some kind of physician organization. The important thing to recognize is that the small, unaffiliated practice is a dinosaur. Only by connecting with your colleagues can you hope to have a voice in the changes that are going to remake medicine in the coming years.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." In his weekly Trendspotter column, Ken is looking out for trends and changes that may affect your practice.

Gerald O'Malley, DO: What is wrong with the PMS?

The Pennsylvania Medical Society (PMS) is arguably the most important professional medical society in the Keystone State. So why don’t they do something important to help the medical professionals in this state?

The medical malpractice situation in Pennsylvania is an unmitigated disaster for physicians and patients. The overt trial lawyer patronage on the part of the governor and state legislature at the expense of the citizenry is a model of corruption, cronyism, and racketeering that the rest of the country can study as a model of how not to run healthcare.

Unfortunately the PMS has, for years, tried to negotiate and cooperate with the state government. It took the theft of $808 million from the Mcare medical liability coverage fund last year to wake up the leaders of PMS that physicians can’t play footsie with trial lawyers or the politicians that protect them. As I have explained in previous posts, the Mcare fund is a pile of money collected from taxes applied to physicians, nursing homes, hospitals, and other health care agencies and was created for the specific purpose of compensating victims of medical malpractice.
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Late last year, the state legislature of Pennsylvania voted to take nearly a billion dollars from the Mcare fund to close a hole in the state budget (filling potholes, paying teachers, painting libraries, etc.), creating an unfunded mandate that will be paid by future generations of Pennsylvania physicians.

As a result of the theft of the Mcare money, the leaders of the PMS finally realized the futility of negotiating with the Pennsylvania state legislature. Recent e-mail communications and a “toolkit” pamphlet that was mailed to all members suggest that the PMS has decided to push back. Sort of.

The toolkit pamphlet is titled “Anatomy of a Raid – Challenge for Action”. Wow! Sounds like PMS got the message! They have finally figured out that there is no negotiating with the politicians in Harrisburg! Finally, our leaders are willing to get a little bloody on this! Let’s go! Let’s fight!

Excitedly I read the action plan to stop the legalized theft of my money and the hemorrhage of young physicians from the state:

Challenge #1: Learn more and pass it along
Challenge #2: Choose how you want to become involved
Challenge #3: Thank your legislators

Huh? Learn more? Thank my legislator? What the heck kind of challenge is that?
PMS joined the Hospital and Healthsystem Association of Pennsylvania to sue the state in October 2009 and challenge the theft of the Mcare funds, but as the Philadelphia Inquirer recently reported, the state judicial system is as corrupt as the legislative branch. The headline from the Inquirer from Dec. 28, 2009, was “Oversight of Pa. judges is wrapped in secrecy. The Judicial Conduct Board, created to protect citizens from errant judges, is criticized as doing just the opposite.” This fight will not be won in the courtroom. It should be fought very loudly and publicly.

How about a few more lawsuits? How about a few press conferences? How about organizing a physician strike, for crying out loud? The PMS is bringing a feather pillow to a gun fight. It should hire a few union bosses to advise them on tough-tactic collective bargaining.

This is war and the PMS is playing junior varsity paintball.

The importance of customer service

In a guest post on KevinMD’s blog, Susan Giurleo writes about “Why I had to fire my primary care doctor.”

She explains her plight trying to get an appointment to see her physician for a sinus infection. When she called the first time, a terse-sounding woman answered the phone and rudely placed her on hold for 20 minutes. Susan finally hung up and called back, only to be treated rudely again by the same person. She was further mistreated by the receptionist when she arrived for her appointment.
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She described her physician as knowledgeable, kind, and efficient, but she fired her because of this experience with her staff. She writes, “While YOU may be a fabulous practitioner, your staff may be undermining your good work and reputation without your knowledge.”

I thought this was an interesting account, because I often hear these stories from friends and colleagues. (On a related note, I had the complete opposite experience with my own primary care physician, whose staff was kind and helpful and who fully uses electronic medical records. So pleasant was my experience that I have referred him to three friends and counting.)

Clearly, customer service from the staff is hugely important, and you might not even be realizing how its reflecting on you.

Jennifer Frank, MD: There's no "I" in "team"

Busyness and stress erode a team’s cohesion. My husband is my primary teammate. Together we are raising four children, managing my career, keeping our home running (even smoothly at times), and occasionally even interacting with each other.

At work, my faculty colleagues are my primary team. We support each other during difficult days, cover each others’ patient care responsibilities, and commiserate about the numerous challenges we all face. Moments of true team cohesion feel really good. We get in a groove, work together towards a mutually important outcome, and smile at each other while doing it. Encouragement, support, understanding, and good will are the undercurrents of the team.

Unfortunately, the team doesn’t always work well.
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Busyness breeds isolation. I run off to take the kids for a haircut while my husband goes in the opposite direction to get groceries. Isolation can foster delusions of persecution. I’m doing all the work around here. Nobody else is as stressed as I am. Good will evaporates, even as logic demands that everyone is busy and stressed. A lack of communication born of too many fires to put out or too many patients to see or too many little people needing a bath inevitably leads to even less communication and that leads to more isolation. You see where I am going with this.

The less connected I am with my teammates — at home or at work — the less connection I tend to seek as I hunker down into an increasingly selfish spiral of what is bothering me, what is important to me, what I have to do, what is on my to-do list. It gets ugly. I also notice that my team members behave similarly. They are less generous in cutting me slack when I don’t get something done. They are not as quick with a smile or a friendly “good morning.” It gets uglier. Sometimes someone is so frustrated and disconnected that they quit the team.

How can I protect against this? Well, for starters, communication is key to the successful running of a team. (When is it ever the case that communication is not key to success?) I force myself to start a conversation with a colleague I have only breezed by during the week on my way to this task or that task. During our chat I discover that he or she is carrying a heavy load and I understand more, am willing to extend myself more for them, and see my own worries in a new light.

Two other ingredients are important. First, I need a margin around myself — a little extra time, energy, understanding, patience — so that I have it available to a team member who may need it. Second, I need to assume the best, instead of the worst. If my feelings were hurt by the fact that my husband has yet to read any of my blog posts, I remember that he is usually too busy to sit down and when he does, he inevitably falls asleep.

Teamwork is just that — work. However, the times when I look up at work or at home and catch a teammate’s eye and smile, knowing that we are in it together energizes me to continue the work.

Jennifer Frank, MD, FAAFP, is an assistant professor in the University of Wisconsin Department of Family Medicine and a faculty family physician at the Fox Valley Family Medicine Residency Program in Appleton, Wis. She is a mother of four, whose husband, also a physician, is a stay-at-home dad.

Bonus podcast: On meaningful use

For a bonus podcast this month, I spoke with Robert Tennant, a senior policy advisor for the MGMA, about the new meaningful use criteria and why the MGMA believes they are "overly complex" and sure to create "significant barriers" for physicians.

Listen to the podcast here, and please feel free to comment below with your thoughts on the meaningful use criteria and what they mean for your practice.

Melissa Young, MD: Patients in transition

I’ve run into a problem with patients who are transitioning from one practice to mine — either from my old practice or from another physician’s office. Who is responsible for a patient’s care when they have indicated to one practice that they are leaving but have not yet been seen in the new office?

I have had some of my old patients ask for lab requests and prescriptions. Now while some of them I know quite well, some have names that only sound vaguely familiar, and quite honestly, some don’t ring a bell at all. Without their records, I haven’t felt comfortable ordering anything. And it’s even worse when they ask for medical advice.
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My old practice washes their hands of my patients once they indicate they are moving. Some patients have had their records sent, and that makes it easier. At least they were my patients, and with their information in front of me, I can make intelligent decisions even though they haven’t been seen in the new office.

Patients from other practices are both simpler and trickier. I had a patient call the other day. He had a new patient appointment to see me in two weeks and had his records sent to me from his prior endocrinologist. But he was nearly out of meds and his old doctor wouldn’t fill his prescription because he wasn’t going to follow up anymore.

While according to his records, it seemed reasonable to simply refill his scrip, it didn’t seem right to me. I didn’t feel comfortable calling in a prescription for someone I had never seen before. What if he never showed up? What if there had been a significant change since his last visit with his endo? Fortunately for this patient, I had a cancellation the next day and I was able to see him and take care of things. But what if I couldn’t?

What about the patient who insists she needs labs done prior to her visit otherwise “it would be a waste of time?” How do I know what labs she needs? “It’s not rocket science, I just have a thyroid condition.” Sure, I could order a TSH and be done. It would probably make her visit more meaningful.

But what if she looks pale or jaundiced when she comes in? Or what if I order a TSH and it’s 50 and she doesn’t show? I don’t know what meds she’s on or what other medical conditions she has. Who would be responsible for following up on that? Me, of course. And without seeing the patient, I don’t want that responsibility.

So what to do with the in-between patient?

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.

The fix is in

I will not sign a health-care bill that “adds one dime to our deficits, either now or in the future, period,” a pledge President Obama has repeated over and over. Unfortunately mass repetition by our very talented Orator-in-Chief can’t solve the biggest obstacle to a deficit-neutral bill: The SGR—not without some political sleight of hand, that is.
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What is the SGR anyway? In short, Federal law requires Medicare payments to physicians to be modified annually using a formula known as the Sustainable Growth Rate (SGR). Because of flaws (what a surprise!) in its methodology, the formula has mandated physician fee cuts almost every year for the past decade.

The SGR formula originally was designed to control Medicare utilization by reducing physician fees. (That’s code for government driven behavior modification.) Then came along PET, MRI, a general shift from inpatient to outpatient care, older, sicker beneficiaries, etc. But the docs are still seen as the bad guys in the cost-containment debate.

So, absent of Congressional action, the SGR will continue to mandate physician fee cuts for the unforeseeable future. Case in point: In July 2008 it took Congress overriding President Bush’s veto of House Resolution 6631, the Medicare Improvements for Patients and Providers Act of 2008 to stop a huge cut of 10.6-percent in fees to docs.

Without a fix to the SGR, doctors’ fees are scheduled to fall by 21.5%, and 40% over the next five years! Of course we can’t let that happen; it would force many doctors to stop seeing Medicare patients. But how do you deliver a budget-neutral bill without cutting fees.

Simple, the D.C. shell game: Rather than include the pricey $247 billion plan known on Capitol Hill as the "doc fix" as part of ObamaCare, the Dems will make this a separate contribution to the deficit, without compensating tax increases or spending cuts.

Doctors just want fair pay for their valuable services. Policy makers in D.C. need to get their collective heads out of the sand and address this issue before we can see real reform to our system.

New feature: Tip of the Week

Today we are introducing a new feature here on Practice Notes: a Tip of the Week. (See the right-hand column of the blog for this week's tip.)

Starting with Houston endocrinologist Medhavi Jogi's tips on implementing an EHR, we'll bring you advice from your peers on a range of topics. Each contributor will offer a new tip each week for a few weeks.

If you have ideas for a Tip of the Week contributor or topic, e-mail me at sara.michael@cmpmedica.com.

Randall Wong, MD: Why blog?

A blog is an interactive Web site — unlike the older, more standard, Web site that remains static.

Back in the day, I started fiddling around with pages on my own using Microsoft's Front Page. I was part of a multispecialty ophthalmic practice. While I was their retina specialist, I couldn't understand why we advertised refractive eye procedures on the radio, etc., without a Web page. My partners didn't understand.

If we offered state-of-the-art eye procedures, shouldn't we have a Web page?

I spent two years creating a 65-page Web site. It included everything about the practice, including information about the hi-tech laser procedures we were offering.
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Back then, any changes to the site were made by me, for free.

Eventually, we turned the site over to some professionals. It cost about $10K to transform the site with fancy artwork and Flash. But the content was the same. It never changed. Never. Any time we had to change the site, it cost us money — a lot. So the page was never updated. It became stale. Back then, Flash was king; content didn't matter.

Google changed the game in 2006. By dominating the Internet search market, Google added relevance to the Internet. In short, that meant that Google would pay attention to Web sites with good, fresh, relevant content. Web pages that became stale would fall in rankings.

Fancy images and Flash no longer mattered. The tricks used to gain high rankings (i.e. meta tags, and now, keywords) became obsolete and worthless.

Content became king. Fresh and relevant content rules.

And now back to blogs.

With the old, static Web sites, it is difficult to add information, or content, to the Web. The traditional Web site requires separate software to design the site. This software generally resides on a specific PC, laptop, or server. It is hard to make changes. For instance, if you wanted to add an article about H1N1, you'd have to contact the Webmaster to make the changes. And it may cost. Web sites that remain static lose ground (i.e. ranking) with Google, and your Web ranking falls.

Ever try making changes to your own Web site?

Blogs became very popular initially because they were interactive. They allowed the reader to become proactive and comment about a particular topic. The blog writer offered a point and the reader could offer the counterpoint.

The Web now became more dynamic. Content was added immediately, without fluff, yet without cost. The reader simply had to leave a comment. There are over 200 million blogs.

Spam and porn artists have ruined the interactive portion of blogs. (Porn and spam artists have used the comment portion of the blogs as portals for advertising. They can leave a link to their sites as a comment. The link is then published for all to view.) But blogs still have remained popular. Why?

Blogs rule because the software is easy to use and simple to add content. All you need is an Internet connection. I use Wordpress.org (Wordpress.com) for my blog. It is free, and offers hundreds of templates - I don't have to design a thing. I can write an article and post in minutes. No cost. If I want to be a little creative, making it look like any other Web page is a breeze. My site costs me less than $10 per month.

Blogs rule because they are dynamic. They are constantly refreshed with new content, which, remember, Google likes. Blogs allow Web sites to be content focused — the basis of high ranking with Google and other search engines.

Randall Wong, MD, is a retinal specialist in private practice in Fairfax, Va. Wong has a strong interest in Web 2.0, the Internet, and social media, and will write regularly about how social media can help build your practice and even improve healthcare.

Trendspotter: Meaningful use criteria may not suffice for care coordination

By Ken Terry
The Department of Health and Human Services (HHS) has released draft regulations on the “meaningful use” of electronic health records that will be required to qualify for government incentives in 2011. The good news is that physicians will not have to enter visit notes electronically to show meaningful use. But you will have to use some other EHR features out of the box, including electronic prescribing and decision support tools such as drug interaction alerts.

Patient demographics, vital signs, and smoking status must be recorded in the EHR, and at least 50 percent of lab results will have to go into the EHR as structured data. That means you will need interfaces with your major labs. In addition, you will have to give patients access to key data from their medical records, and you will have to transfer clinical summaries as part of referrals. In addition, you must either submit quality data based on PQRI measures and other metrics endorsed by the National Quality Forum, or attest that you can do so. In 2012, you will have to send in the data electronically.

All of this, of course, is designed to prove that physicians who apply for up to $44,000 in Medicare incentives ($64,000 for Medicaid) are using their EHRs in a way that will improve the quality, safety, and efficiency of patient care. A key part of that quality improvement is enhanced coordination of care — a major goal not only of the HITECH Act, but also of the public and private medical home pilots that are underway.
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But a new study from the Center for Studying Health System Change casts doubt on whether current EHRs, even if they meet meaningful use criteria, are up to the task of improving care coordination in today’s environment.

Based on their interviews with users of EHRs (which they call EMRs) in 12 markets, the CSHSC researchers conclude:

“There is a gap between policy-makers’ expectation of current EMRs’ role in the coordination of care and clinicians’ real-world experience with them. We found that commercial ambulatory care EMRs facilitate care coordination within a practice by making data available at the point of care, but they are less helpful for exchanging information between practices and settings. EMRs may also have unintended consequences for coordination, such as creating an information overload that complicates providers’ efforts to discern key clinical information.”

There are some non-technological reasons for these shortfalls, including physician culture and a lack of reimbursement for care coordination. But the researchers also delineate some deficiencies that affect some or all EHRs. Among them are these:

• A lack of interoperability between systems used by various physician practices, hospitals, diagnostic testing facilities, and other providers. This results in practices scanning paper documents into the EHR as non-searchable PDF files.
• Problems with problem lists. Few EHRs link specific problems to portions of past notes that address them. Also, the lists often include redundant diagnoses generated by test results.
• Inability to capture the planning component of medical-decision making. EHRs typically do not remind physicians of things that need to be done for patients until the doctor opens that patient’s chart for the next visit.
• Lack of registries or other mechanisms that would facilitate population health management, ensuring that patients with particular conditions receive the preventive and chronic care they need when they need it.
• Inability to track referrals within the EHR.
• Tendency to generate too much information in referral notes, making it difficult for physicians to find the important points about a patient’s care.

The CSHSC researchers suggest that HHS use its meaningful use and EHR certification regulations to prompt vendors to correct these and other deficiencies in their products. The 2011 meaningful use criteria indirectly address some of these issues, such as interoperability, referrals, and population health management. But they are not specific about the technology tools that are needed. Neither are the accompanying standards and EHR certification criteria, which are designed to support the meaningful use requirements.

One reason why the rules are not more specific is that HHS and its advisory committees wanted to avoid requiring certain types of functionality, fearing that that would limit innovation and favor established vendors. In addition, it is clear that the government does not want to require EHRs that might prove too complex for the majority of physicians. In fact, doctors are even allowed to combine several components from different vendors if those enable them to show meaningful use.

This might be an acceptable starting point if the only goal were to persuade the bulk of physicians to adopt some kind of EHR. However, the implementation of any kind of EHR — other than a basic electronic chart — requires a big investment in time and money. If physicians are going to go to all this trouble, the least that the vendors can do is provide them with the tools they need to meet the government’s goals.

Ken Terry is a New Jersey-based freelance writer and the author of the book "Rx for Health Care Reform." In his weekly Trendspotter column, Ken is looking out for trends and changes that may affect your practice.

Merging the two bills

The next step in the healthcare reform legislation path is to merge the House and Senate bills. Right before the holiday, the Senate passed their version of the legislation; the House had already passed theirs.
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Now, to merge the bills, instead of going through a conference committee, lawmakers have agreed to do what’s called “ping-pong” the bill – send the Senate bill to the House to amend and approve, and then send it back again, the Hill reports. The idea here is to avoid Republican delay tactics.

It also looks like without the formal conference committee, the House will basically be accepting much of what is in the Senate bill (and therefore not in the House bill.) For one, the Senate bill does not have a public option, and rather than a national health insurance exchange, states would create their own. For a clear breakdown of the differences between the two bills, check out this NY Times graphic.

Gerald O'Malley, DO: Dreams from the 'hood, part 2

Our ER survey of 13- to 18-year-olds was reassuring in that most of the participants had some ambition and many of them were working toward their goals for the future.

The participants (and results) of the second part of our survey weren’t as optimistic as the first. The participants were older, between the ages of 22 and 27 years old. We chose that age range based on our own experiences; we believed that most people have some direction in their lives by the time they reach their early to mid 20s.
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One-third of the young people in our survey were unemployed or disabled, and the rest were employed in the service industry (waitress, limo driver, supermarket checkout-clerk) or were working toward their high school diplomas or technical trade certificate. When asked if there were any obstacles that had prevented or interrupted the goals that they had when they were younger, one-fourth of the respondents replied in the negative; half had children that had slowed the pace of their goal achievement, and the rest gave a variety of reasons for not being where they thought they might be when they were younger (including a war in one subjects’ native African country).

What can be derived from this summertime survey? Not much. It seems that young, primarily black individuals from the inner city have hopes and dreams for achieving success and career satisfaction, but their understanding of the process for realizing those goals is nebulous and unrealistic.

What happened to these young people in the decade from age 15 to age 25? Three-quarters of the respondents in our survey identified some obstacle that delayed or prevented them from being where they wanted to be — why were they not able to circumvent or avoid or overcome that obstacle? Many of the female respondents identified one or more unplanned pregnancies as the single greatest obstacle to their goals, despite all the financial supports that are available through social services monies and networks.

This seems like such an easy fix. Teenage pregnancy is a dream-killer — our respondents told us so. Instead of funneling lots of money on the back end, when the problem already exists, why not apply more resources to preventing unwanted pregnancies through abstinence programs and birth control education and measures? In my opinion, abortion counseling isn’t the answer because, again, the unwanted pregnancy (the problem) already exists.

Beginning at the age of 13, young men and women need to be taught not to impregnate or to allow themselves to be impregnated. Government provision of financial support to pregnant teens discourages families from doing the hard work that is necessary to work through the problems that accompany unwanted pregnancies.

Prevent the problem before it begins. Convince teenagers that getting pregnant when you are still in school is the surest way to not get what you want. Once the pregnancy occurs, the battle is lost.

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.

Podcast: Congressman and physician Michael Burgess

Have you ever wondered how the healthcare reform debate might be different if the lawmakers were themselves physicians? Well, 16 members of Congress are physicians and no doubt bring a unique perspective to the legislation and how it will affect practicing physicians.

I recently spoke with Congressman Michael Burgess, R-Texas, who was an OB/GYN for many years before being elected to Congress. We spoke about the insight his background provides and what he thinks is missing from the legislation.

Rep. Burgess said that, unlike many of his colleagues, he recognizes that medical practices are often small business, and patients still have to be seen, the office still has to stay open. "At the end of the day things have to work," he said.

Listen to our conversation in this month's podcast, and let us know your thoughts about the discussion here.

Patient portals and meaningful use

For the MGMA (and elsewhere, no doubt), concerns with the meaningful use requirements come down to practicality and achievability. Can small- and medium-size practices really meet some of these requirements? In their current form, MGMA says, not easily.

I just spoke with Robert Tennant, senior policy advisor at MGMA, for a podcast to be posted soon. He outlined to me why these requirements are “overly complex” and create “significant barriers to physician efforts.”

Here’s one example of many.
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Among the requirements is that practices be able to provide patients with timely electronic access to their medical records. Meaningful use in this area means that 10 percent of patients must have this timely access.

Sounds fine on the surface, Tennant noted, but this means practices will have to implement a robust patient portal to provide that access. Patient portals are not usually part of your standard EHR, so practices will have to invest in an additional module. The 10 percent then is really irrelevant, Tennant said, “You have to have the patient portal in place. Whether it’s 10 percent or 100 percent, practices will have to incur the costs of development.”

That’s just one area that MGMA noted the requirements are unreasonable – and could be quite costly – for smaller practices. As Tennant noted, the requirement- writing committees really should ask not should, but could.

I welcome your thoughts on the requirements and whether your practice will be able to achieve meaningful use.

Jennifer Frank, MD: The mom in me

As my husband and I lug four tired kids from the YMCA to our minivan after swimming lessons one bitterly cold evening, I think to myself, “This is hard.” In fact, I frequently have that thought. It is hard getting four kids clean simultaneously. It is hard refereeing the continual arguments and fights that abound in our home. It is hard being a working mom.

But, I often think, it could be so much harder.

I see the difficulty many of my patients have with parenting and raising their children. Often, these are young, single moms trying to raise one, two, or more children on minimum wage salaries while battling their own medical problems or addictions.
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They love their children as fiercely as I love my own, but their struggles are multiple. They can’t easily afford children’s Tylenol. Gas money may be scarce. Trusted childcare can’t be found for the price they can pay. Other family members interfere with their attempts to better themselves and protect their children. They have serious medical problems that physically or psychologically impair their ability to be the type of mom they would like to be.

It is difficult not to judge them for the choices they have made that led them to where they find themselves. When I am tempted to form a critical conclusion, I remind myself that I was raised in a stable home by two loving parents, had numerous educational and extra curricular opportunities, enjoy a healthy marriage, have a supportive spouse, am blessed with four healthy children, and appreciate an exceptional standard of living. If it is hard for me, it must be nearly impossible for someone with more barriers and obstacles.

Too often, I have little to offer to help them in their journey. However, I can try to smooth the way rather than being another obstacle. I can forgive the no-show appointment or showing up 20 minutes late for a 15-minute visit. A few simple words such as “you are doing a great job” can lift spirits. I can fill out that paperwork for the social services agency quickly (even though it was just dropped off). I can try to find an extra bottle of children’s Tylenol and not bristle that they spend needed income on a pack of cigarettes.

In short, I can try to be an advocate for these patients. Taking them where they are, I can try to help them and their children by doing everything in my power to make it less hard for them to be successful. From one mom to another, I can extend a hand and lift them up.

Jennifer Frank, MD, FAAFP, is an assistant professor in the University of Wisconsin Department of Family Medicine and a faculty family physician at the Fox Valley Family Medicine Residency Program in Appleton, Wis. She is a mother of four, whose husband, also a physician, is a stay-at-home dad.

Meaningful use reactions

The reactions so far to the meaningful use requirements out late last week are mixed.

Among those who are not so pleased is the MGMA, which in a statement called the requirements “overly burdensome” and that practices will “confront significant challenges trying to meet the program requirements.”
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Among the barriers MGMA sites are:
- Unreasonable thresholds for some of the criteria (such as electronic claim submission and electronic insurance eligibility verification
- Potentially difficult meaningful use attestation after the first year
- A requirement that physician offices provide patients with electronic copies of their health records

The American Hospital Association also had some concerns, according to Modern Healthcare.

CMS and the Office of the National Coordinator for Health IT released two highly-anticipated regulations defining the meaningful use of EHRs and setting the criteria for how to receive federal incentives for EHR use.

The requirements will be phased in over three stages between now and 2013, and the first stage focuses on collecting and sharing electronic health data, reporting quality measures, and using EHR data to track conditions and coordinate care. Providers will also be required to provide patients with electronic copies of their medical records.

Our own Trendspotter, Ken Terry, will be writing about this in his column this week, so stay tuned for more.

Melissa Young, MD: Thoughts for the new year

As the old year ends and the new one begins, I'm sitting here thinking about how much my life, my career, my goals have changed. Opening a new practice — a solo practice no less — in a time of financial trouble and uncertainty was certainly a new and challenging experience.

I'm about to start my fourth month. Patients are steadily coming in, although not in the droves that I had anticipated. I have started having more follow-up patients come back. My no-show rate has been relatively good, infinitely better than at my old practice. Of course, that probably had a lot to do with how far in advance appointments were being made. Hey, if I made an appointment six months ago, I'd probably forget about it, too.
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My schedule is much less hectic than it was at the old practice. That is much better for my family life and overall sense of satisfaction. Not so great on the pocketbook. Still, my kids are getting older and are starting to have more afterschool activities, and I'm glad to be able to leave my office on time, or even early when necessary and with enough notice. And despite the fact that I technically have no weekends off, there are many weekends that I don't have to go to the hospital, or if I do, it's only for an hour or so, as opposed to the five to six hours I had to work two out of every five weekends.

I have learned a lot about the business side of running a practice. Everything from making sure we never run out of supplies, including but not limited to such mundane things as staples, gloves, and toilet paper, to explaining to a patient that an EOB is not a bill.

No, it has not been an easy transition, but it has been a satisfying one. One quarter of a year down, I'm looking forward to the new year.

Melissa G. Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson, and a working suburban mother of two in Freehold, N.J. She is a regular contributor to Practice Notes.