Trendspotter: Computer-Assisted Coding Is Coming

By Ken Terry


Are you ready for computer-assisted coding (CAC)? So far, it’s being used mainly in hospital outpatient departments, emergency rooms, imaging centers, and ambulatory surgery centers. But it’s starting to move into inpatient settings and ambulatory-care clinics, as well. So you might soon be receiving solicitations from CAC vendors such as CodeRyte, A-Life Medical, AMI and 3M Healthcare Solutions. Whether or not your practice can benefit may depend on such factors as EHR adoption, the types of work you and your colleagues do, and whether you employ professional coders.

There are at least two different forms of CAC. One is similar to the E&M code checkers found in many EHRs. Products from companies like IMO are integrated with EHRs and map the medical terms used in those records to diagnosis and procedure codes. So if you use drop-downs and pick lists for most of your documentation, the program can identify many of the codes you should be using, based on the discrete data in the EHR.
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A more common approach to CAC uses what is known as “natural language processing” to identify relevant terms in electronic text and analyze them in the context of coding logic. By using this kind of software, some radiology departments have been able to code up to 60 percent of their claims automatically and send them directly to the billing system. Radiology and a few other specialties are especially suited to CAC because they have so many repetitive cases. Because these are easy to code, CAC is fairly accurate in these areas.

In more complex care settings, CAC helps increase productivity by doing some of the basic coding work, while allowing human coders to make the final decisions. These programs reduce the amount of time that coders have to spend searching through documents to find relevant information. CAC software does not work with paper or scanned documents; it’s designed for electronic text, such as transcribed notes or reports. But since that’s all that the majority of practices have online right now, CAC might be useful to some groups in which physicians don’t code their own claims.CodeRyte, which has been around for a decade, claims that it “automates medical coding for leading multi-specialty clinics around the country.” It also automates coding for about 70 single-specialty, hospital-based practices. Most of them are radiology, pathology and ER groups, but their customers also include some cardiology practices. CodeRyte avers that its product can increase coder productivity by up to 200-300 percent.

A-Life Medical, another CAC leader, also says that it improves coder productivity and integrates with hundreds of billing, hospital and document management systems. According to the company, it assists coding operations for more than 40,000 physicians.

There are a few reasons why CAC is likely to become more prevalent. First, experienced coders are in short supply, which means that practices need to maximize the productivity of those who are available. Second, hospitals are using these products, and more and more physicians are working for hospitals. And third, the industry is on the verge of moving to ICD-10 diagnostic coding. When that happens, there will be a big expansion of codes, with an accompanying rise in the complexity of coding. Some observers believe that computer-assisted coding can help physicians and hospitals cope with this challenge.

One thing is for certain: physicians and their staffs spend far too much time on administrative tasks that take time away from patient care. If CAC can remove some of that burden, while helping practices code more appropriately, it will be welcomed in physician groups of all kinds.

Trendspotter: Many ED Visits Reflect Poor Access to Primary Care

By Ken Terry

In Voltaire’s book “Candide,” he lampooned a contemporary philosopher’s assertion that “this is the best of all possible worlds.” Now a pair of emergency department physicians argue in a Slate article that we don’t need to reform our system of emergency care because most ED visits are necessary and, besides, they don’t cost that much. Apparently, these doctors never read “Candide.”

Zachary F. Meisel and Jesse M. Pines state that just 12 percent of ED visits are “not urgent.” However, the National Health Statistics Report they cite says that 16 percent of visits are emergent, 36 percent are urgent, and 22 percent are “semi-urgent,” which leaves a lot of latitude for defining “non-urgent.” Moreover, during the period covered by the study (1996-2006), there was a 32 percent increase in ED visits, while the number of ED visits per 100 people increased 18 percent. So a growing number of people are coming to the ED more often. That suggests that more people are using the ER for primary care.
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The National Health Statistics report points out that 11 percent of all ambulatory-care visits are made to EDs, although those departments have only 3 percent of physicians in the U.S. “EDs provide unscheduled care for a wide variety of persons for reasons that range from sudden cardiac arrest or severe injury to minor acute problems that occur after business hours, or for which the patient is unable to access a primary care provider in a timely fashion. In 2005, approximately one-fifth of the U.S. population had made one or more ED visits within the past 12 months and some subgroups, such as infants, persons 75 years of age and older, Medicaid beneficiaries, and African Americans, had higher utilization rates than others.”

Another key part of Meisel and Pines’ argument is that because ED visits are only a small fraction of total health spending, they’re nothing to worry about. In fact, because EDs are open 24/7, they maintain, "the marginal cost of treating less acute patients in the ER is lower than paying off-hours primary care doctors.” I don’t know how they calculate that, but other research contradicts it
In a large-scale study of the cost of non-urgent visits to Minute Clinics (retail clinics in pharmacies), primary-care offices, urgent-care centers, and emergency departments, researchers found that, for treating five common conditions, the adjusted mean pharmacy and medical costs per episode totalled $383 in the ED, versus $159 in the primary-care doctor’s office. Even if the primary-care physicians were paid a bit more for treating patients in off-hours—a rather odd scenario—the ED visit would cost twice as much.

The biggest flaw in Meisel and Pines’ theory is that they don’t consider how many of the emergent and urgent visits to the ED result from a lack of access to primary care. Sure, the majority of ED visitors are insured, but how many of them have comprehensive insurance, and how many shun doctors’ offices because of high copays and/or deductibles? Much has been made of the fact that roughly 20,000 people a year die because of lack of insurance. But people who have skimpy insurance and low wages may also avoid necessary care until it’s too late or until they’re compelled to seek aid in the emergency room.

Finally, Meisel and Pines make an outrageous statement about primary care that I cannot let pass. They say, “Most ‘frequent flyers’—a pejorative term used to describe patients who stop by ERs a lot—tend to be the very sick, those with severe asthma, heart failure, or diabetes. When these conditions flare up, patients do, and should,come to the ER. ERs are designed to take care of acutely ill patients, while doctors' offices are not [emphasis added].”

Now, it’s possible to interpret this statement as meaning that, in a true emergency, these patients should go to the ED. If so, I would not disagree with it. But if the ED physicians mean that primary-care doctors are not equipped to care for very sick patients, I think most generalist physicians would beg to differ.

The fact is that we need more and better primary care so that patients who have chronic conditions are properly cared for, and those who are at risk of developing chronic diseases do not get sick. While we need other kinds of prevention, as well, including better eating habits and smoking cessation, those are not a substitute for universal access to good primary care.

Trendspotter: Safety Procedures Known to Save Lives Are Not Being Used

By Ken Terry

Safety and quality checklists can save lives in hospitals, as a new British Medical Journal study reiterates. Yet only a fraction of U.S. hospitals are using the World Health Organization (WHO) surgical safety checklist, which was introduced here 15 months ago. And the Leapfrog Group, a public-private consortium that presses for quality improvement in hospitals, has found that a minority of hospitals adhere to nationally endorsed process measures that have been shown to reduce mortality.

Interestingly, the checklist approach does not require electronic health records. Both the WHO surgical safety checklist and the “care bundle” approach used in three London hospitals rely on paper documentation. So, while there are indications that EHR use can save lives, much can be done even without information technology.

In the BMJ study, the care bundle method—which requires doctors to check off certain treatment steps—was associated with a major drop in patient deaths. While there were 255 fewer deaths in these hospitals during the study year than in the previous 12 months, 174 of those were related to the 13 targeted diagnoses. Despite a 5.7 percent increase in admissions, the mortality rate fell 14.5 percent. Both the drop in overall deaths and the decreased mortality among patients with the targeted conditions were statistically significant.
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The eight checklists addressed these diagnoses: peritonitis and intestinal abscess, senility and organic mental disorders, pleurisy pneumothorax pulmonary collapse, aspiration pneumonitis food/vomitus, skin and subcutaneous tissue infections, acute bronchitis, urinary tract infections, acute cerebrovascular disease, other gastrointestinal disorders, septicemia (except in labor), pneumonia, chronic obstructive pulmonary disease and bronchiectasis, and congestive heart failure (non-hypertensive).

The clinical areas covered by the checklists, which were introduced in April 2007, included central venous catheter/line sepsis, diarrhea and vomiting, stroke, ventilator acquired pneumonia, methicillin resistant Staphylococcus aureus infections, heart failure, surgical site infections, and chronic obstructive pulmonary disease.

Nearly 700 hospitals were using the WHO surgical safety checklist a year ago, and 300 more had committed to trying it, but there have been no updates since then from the Institute for Healthcare Improvement, which is spearheading the checklist campaign. The WHO checklist goes beyond the Joint Commission’s patient and site identification requirements by ensuring that everything is ready for an operation, that everybody on the team knows the safety procedures, and that there’s good communication among team members. A multinational WHO study showed the use of the checklist decreased mortality by nearly half. While it’s expected to have a much smaller impact in the U.S., where surgical mortality is fairly low, it could have a marked impact on reducing complications.

The Leapfrog survey, using 2008 data, found that relatively small percentages of U.S. hospitals were adhering to evidence-based guidelines that are known to save lives. Among the areas where compliance was poor: heart bypass surgery (43 percent), angioplasty (35 percent), high-risk deliveries (32 percent), pancreatic resection (23 percent), bariatric surgery (16 percent), esophagectomy (15 percent), aortic valve replacement (7 percent), and aortic abdominal aneurysm repair (5 percet). Moreover, 65 percent of Leapfrog’s participating hospitals lacked policies to prevent common hospital-acquired infections.

Now, it’s possible that the evidence is poor for some of the surgical protocols, and reducing infection rates poses a number of challenges, both human and technical. But physicians and hospitals that aim to be accountable and form “accountable care organizations” owe us all a better effort to improve patient safety. There’s no excuse for not trying to save lives when we know how to do it.

Trendspotter: Do We Want Hospitals to Run Health Care?

By Ken Terry

Major changes in the healthcare delivery system are coming, and they will affect every physician. The question is whether those changes will have the effect we all want or whether they will lead to unintended consequences that we don’t want.

Back in the 1990s, during the debate over the Clinton plan and in the period following its rejection, hospitals and physicians began preparing for what they assumed was going to be a massive shift to prepaid managed care. While that never happened, many physicians joined larger single-specialty and multispecialty groups, and hospitals purchased many practices, some of which they later returned to their owners. Something similar is happening now as hospitals snap up practices right and left in anticipation of a reform-driven shift to various types of financial risk. According to one estimate, around half of the doctors in the country are already working for hospitals, and there are some markets where hardly any private practices still exist.

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Some experts believe that the fragmentation of our delivery system is responsible for much of our out-of-control spending and the poor quality of care, especially at the primary level. In that view, the disorganization of American medicine, coupled with fee for service and overspecialization, encourages redundant, wasteful, and even harmful care. But I question whether hospitals and healthcare systems are the right agents to reduce this fragmentation by employing more and more physicians.

The problem with the hospital-centric view of the world is that it’s all about hospitals. Whether for-profit or not-for-profit, hospitals seek to maximize their revenues, their market share, and their competitive advantage. In that sense, they’re very much like corporations in any other field. When they employ physicians, they’re thinking about the value of each doctor’s admissions – about $1.5 million per year, on average – and whether they want their competitors to get those referrals. They may also be considering how a particular physician or group can help sustain or grow existing or new service lines and feed new imaging equipment.

Having hospitals run a revamped, better-organized system creates other issues as well. One is related to the mal-distribution of specialists, which is endemic across the country. Some communities are saturated with specialists, while other communities have very few or no specialists in certain key fields. As hospitals control an increasing percentage of physicians, some facilities will not be able to provide certain kinds of care, because the competing hospital in town has locked up all of the specialists who are capable of providing those services.

There is much validity in the concept of “accountable care organizations”--combinations of hospitals and doctors that can provide particular services or types of services for a budgeted payment, with the ability to share in cost savings. ACO supporters say that these organizations might be “virtual” organizations that tie together independent practices and hospitals through information technology. Unfortunately, however, one outcome of the move toward ACOs and payment bundling—both goals of the reform legislation—might be the growth of hospital power in many communities. And I don’t think we should place responsibility for the future of healthcare in the self-interested hands of hospitals.

I’m not predicting that this is the only possible result of current trends. We’re also facing the influx of millions of newly insured patients in 2014, and it’s clear that there won’t be enough primary-care physicians to care for them. That will be true even if every primary-care doctor in the country is working for a hospital by then. So we’re going to see an increasing emphasis on community health centers, which have received a steep increase in funding from the Obama Administration. Those clinics, which now care mostly for poor patients who have little money, will soon be seeing more middle-class patients—just as retail clinics do. So they will be competing with hospitals, but I don’t see them ever having the same power and influence that the healthcare systems do.

What we need now is for policymakers to give some serious thought to the long-term implications of the trends that are now being set in motion. It’s always easier to make course corrections along the way than to deal with unintended consequences later on.

Trendspotter: Health Reform Will Be Mixed Bag for Physicians

By Ken Terry

The historic reform bill that Congress passed on Sunday will immediately affect physicians, but the impact will be much greater in the long term.

First, some expansion of coverage will occur within six months of President Obama’s signature on the bill—whether or not the Senate adopts an accompanying measure that would add House-sponsored changes. The bill will immediately allow parents to cover their young adult children and will prohibit children from being denied insurance because of their health status. Adults can’t have their coverage dropped when they get sick, and people who can’t get coverage because of their health condition will be eligible for beefed-up high risk insurance pools. All of these measures, coupled with small business tax credits for buying insurance, should reduce the number of patients who can’t pay their bills by the end of this year.

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The really major impact, however, will come in 2014, when the big Medicaid expansion and the individual mandate to purchase insurance kick in. By 2019, these provisions will expand coverage to an estimated 32 million people, providing physicians with many more insured patients.

The health insurance exchanges for uninsured individuals and small businesses will also be launched in 2014. Health plans that participate in those exchanges will be required to offer a minimum level of benefits, and catastrophic plans will be available only to those under 30 and those who are exempt from the mandate to buy coverage. Moreover, people who have skimpy plans at work and/or who pay more than 10 percent of their income for it will be able to buy insurance through the exchanges. The plans offered in these government-sponsored markets will also have fairly low out of pocket maximums. All of these provisions, again, will increase the number of patients who are insured and will therefore be able to afford your services—assuming you take Medicaid.

On the other hand, the expansion of coverage will lead to a massive increase in consumer demand that physicians will be expected to handle a few years from now. The legislation does include provisions to increase the supply of primary care, and recent increases in primary-care reimbursement by Medicare—albeit at the expense of specialists—should begin to attract more doctors to the primary-care fields. But much more needs to be done. For one thing, the debt burden of new residency graduates must be reduced if we expect more of them to become, say, internists rather than endocrinologists.

There are also cost control provisions in the bill—mainly pilots of new Medicare payment approaches--that could lead to lower reimbursement for physicians. Whether it’s accountable care organizations, payment bundling, or value-based purchasing, the days of unrestricted fee for service are drawing to a close. Many physicians will be unhappy about this. They don’t want to take financial risk, either alone or in tandem with other physicians and hospitals. But some kind of quality-based or budget-based approach to reimbursement, both by government and private payers, is inevitable, because the current level of cost growth is unsustainable. This will probably mean that more physicians will go to work for hospitals, and that small private practices will become less viable. But market forces are already pushing health care in both of those directions.

Meanwhile, Congressional leaders have promised the AMA that they will enact some kind of “fix” to prevent physician Medicare payments from being cut 21 percent this year and more later on. Presumably, they will find some savings in the overall national budget to cover the $200 billion plus cost of that fix over 10 years. But that is isn’t part of the reform legislation that just passed or the reconciliation bill that is now before the Senate.

Obviously, the payment method that has Medicare has used to reimburse physicians for the past decade is not viable and must be replaced. Congress’s last-minute passage of bills to prevent pay cuts to doctors, year after year, is ample proof of that. But there’s no chance that Congress will simply decide to give physicians what they want under fee-for-service Medicare. So get ready for changes in how you’re paid by both Medicare and private payers. This is no longer going to be your father’s healthcare system.

Trendspotter:Healthcare Reform Is First Step To Shore Up Deteriorating System

By Ken Terry

Many pundits have weighed in on the likely consequences of not passing healthcare reform, which is expected to come to a head within the next few days. But a recent blog post by Matthew Mintz, MD, an internist in Washington, DC, puts things in perspective for physicians.

Judging by his essay, Mintz is neither a Tea Partier nor a single payer advocate like those who belong to Physicians for National Health Program (PNHP). Both the Tea Party and PNHP oppose the reform bill—the former because it would expand government intervention in healthcare, and the latter because it fails to put government in charge of healthcare. Mintz is not concerned that the proposed legislation would give the government too much power; rather, he worries that, in the absence of reform, the healthcare system will continue to deteriorate. In fact, he believes that while the reform bill deserves to pass because it expands insurance coverage, healthcare will decline even if it's adopted. What’s missing, he says, are more stringent cost control measures and a plan to increase the supply of primary care.

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Writes Mintz: “Though our dysfunctional system and plans for reform may not affect you now, things will get worse. Without addressing costs, premiums will continue to go up and even more patients will lack the ability to afford health care coverage. Without addressing the bureaucracy of insurance paperwork and the pay disparity between specialists and primary care physicians, students will continue to go into non-primary care fields and current primary care doctors will retire. In addition, our nation is only getting older and fatter, and thus sicker and more expensive.”

Despite the shortcomings of the reform bill, Mintz views it as an essential step toward providing everyone with high-quality care at an affordable cost. If the legislation is voted down, he points out, Congress will probably not revisit the issue for a long time to come. By then, he says, things will be so bad that everyone will be demanding reform.

I agree with Mintz on the politics of reform, and I also concur that the system’s decline will accelerate unless the federal government takes decisive action. But several elements in the bill could help slow cost growth. One is the proposed Independent Medicare Advisory Board, which would theoretically have more power than the current Medicare Payment Advisory Commission (MedPAC) to make changes in Medicare reimbursement. While the proposal has elicited strong opposition from the healthcare industry, including medical societies, it's needed because Congress is too political to make the required cost-cutting decisions. The problem with the proposal in its current form is that it takes hospitals, physicians, and drug companies off the table for the next decade. So it would not have much practical effect unless later legislation gave the independent board real authority.

Another provision in the bill would encourage the formation of accountable care organizations – combinations of hospitals and physicians that would share in whatever savings they produced for Medicare by improving coordination of care. Most likely, big healthcare systems would take advantage of that opportunity. There are also demonstration projects for payment bundling and enhanced home care for chronically ill seniors. Many hospitals are already preparing for payment bundling—which would provide a single payment for multiple kinds of services, such as acute and post-acute care—by employing more physicians.

Last but not least, the Senate bill that forms the backbone of the final reform legislation places 1 to 2 percent of hospitals’ Medicare reimbursement at risk for meeting quality and efficiency targets. While the bill is not specific about physician incentives, it proposes studying physician utilization patterns before deciding how much of your reimbursement to put at risk.

As for increasing the attractiveness of primary care to young doctors, the bill would shift some Medicare funds from specialists to primary-care physicians—a direction in which CMS has already started moving.

Needless to say, the AMA and many specialty societies oppose most of these initiatives. So if Washington is really interested in cost control, it’s unlikely to get much help from physicians. And yet, if both public and private health spending growth is not restrained, an increasing percentage of patients will no longer be able to afford your services.

Trendspotter: Physicians Remain Leery of EHRs, Despite Government Incentives

By Ken Terry

The results of recent surveys suggest that a majority of physicians intend to buy electronic health record systems within the next few years. But software vendors interviewed at a recent annual meeting of health IT professionals aren’t yet seeing any stampede of doctors to acquire EHRs. And the Medical Group Management Association (MGMA) has expressed reservations about the ability of physician groups to meet the “meaningful use” criteria for government financial incentives. That casts some doubt on the eagerness of doctors to adopt EHRs.

A study by consulting firm Accenture shows that 58 percent of physicians in groups of 10 or fewer doctors who don’t have an EHR plan to get one in the next two years. Four of five non-EHR-using doctors under the age of 55 are gearing up to go digital, according to the survey. Three quarters of the non-users say they’d buy an EHR through a hospital if the facility subsidized it, and the average amount of subsidy these doctors expect is about half of the EHR’s cost.

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Another survey, by EHR vendor athenahealth and physician social network Sermo, finds that 80 percent of Sermo’s online users have a favorable opinion of EHRs and believe that these systems can improve patient care. Seventy-three percent say that the patient benefits of an EHR justify the financial costs. But most respondents agree that EHRs are expensive to purchase and maintain; 54 percent agree with the statement that EHRs slow physicians down; and barely more than 50 percent believe that EHRs have been designed with physicians in mind.

I’m somewhat skeptical of the latter survey, since it was co-sponsored by an EHR vendor. Also, physicians who participate in Sermo’s online network are not necessarily representative of doctors as a whole. I’d guess that a far smaller percentage of physicians view EHRs favorably than this survey indicates. As for the Accenture study, I’m struck by the fact that 61 percent of the non-EHR-users want to adopt because of the threat of Medicare/Medicaid penalties down the line, and only 51 percent are motivated by the federal subsidies for EHR adoption. What that tells me is that physicians are being reluctantly dragged into this deal.

One reason for their reluctance and their skepticism about government incentives is the difficulty of achieving meaningful use. In an MGMA survey, member practices said that the hardest requirements to meet were providing electronic copies of medical records to 80 percent of patients requesting them within 48 hours and providing electronic copies to all requesting patients within 96 hours. The majority of respondents also foresaw problems in using clinical decision support and submitting quality data. More than two-thirds of the respondents said that the use of EHRs would reduce productivity. Thirty-one percent said that productivity would drop more than 10 percent.

The latter MGMA findings and the similar one from the Sermo/athenahealth survey show that physicians remain apprehensive about the financial impact of EHRs on their practices. This impact is related not only to cost, but also to productivity. Dr. Daniel Palestrant, CEO of Sermo, commented, “It is clear from the survey that current EHR solutions are imperfect, with cost, resource allocation, and ease of use being areas that could stand great improvement. Discussion amongst the Sermo physician community supports the survey’s findings of ‘holes’ in current offerings and, more broadly, the notion that EHRs have a long way to go towards delivering on the promise of cost savings, freed resources, and better medicine.”

Nothing exhibited at last week’s conference in Atlanta of the Health Information Management and Systems Society (HIMSS) really represented a breakthrough in EHR design. Some vendors were offering components of EHRs that stressed connectivity more than documentation. That’s important, because the ability of EHRs to exchange data with other information systems remains poor. Also, many physicians find it difficult to document visits in EHRs. There have been some advances in “natural language processing,” which enables computers to parse the meaning of text and sort medical terms into EHR fields. When that’s ready for prime time, many more physicians will be enthusiastic about EHRs, because they won’t be required to enter data. But that’s probably at least 10 years away, and the government incentives for EHRs will be available only from 2011 to 2015.

In the meantime, doctors will have to adjust to the realities of current EHRs if they want to win federal subsidies and avoid later penalties. Let’s hope that as the market expands, EHR vendors will reinvest some of their profits in developing products that are easier to use and that help physicians improve quality and efficiency more than those now on the market.

Trendspotter: AMA To Give Small Practices a Helping Hand in Launching EHRs

By Ken Terry

Small physician practices are less likely than big groups to have electronic medical records—and there’s a reason that goes beyond cost. They lack the resources and the technical knowledge to implement these complex systems. The support and training that vendors offer is frequently inadequate, especially for physicians who aren’t especially computer-savvy. And the vendors freely admit that they don’t have sufficient staff to cope with the expected influx of new EHR buyers who want to show meaningful use by 2011, when the government incentives start flowing.

Under the HITECH provisions of the American Recovery and Reinvestment Act (ARRA), the government is required to create health IT regional extension centers (HITRECs) across the country to help up to 100,000 primary-care physicians install EHRs in their practices. The Office of the National Coordinator for Health IT has allocated nearly $600 million for this purpose, and 60 HITREC grants will be handed out by the end of March.
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Some healthcare systems are taking advantage of the Stark exception to subsidize EHR purchases by non-employed staff physicians, and far more are trying to get their employed practices online. But in either case, the demands of working with a multitude of small practices to implement EHRs exceeds the capacities of most hospital IT staffs. Moreover, the hospital IT people have expertise in inpatient systems but know little about ambulatory-care EHRs.

The AMA is trying to help fill the gap by creating a new web portal that will “provide physicians access to information, products, services, and resources to help facilitate medical practice and ease adoption of health information technology.” While the AMA will give doctors access to e-prescribing and lab ordering applications via the portal, now in beta test mode, AMA’s partner, Dell Perot Health Care Systems, will help physicians implement their EHRs. According to Dell Perot, the AMA will initially offer its member an Allscripts EHR, and it appears that other products will be made available later.

No pricing was available at press time. But, since Dell Perot will host the EHRs on a remote server, upfront and maintenance costs will be lower than they would be if the program and the patient data were hosted on an in-office server.

The big question is how effective Dell Perot can be in working with small physician practices. Both companies have extensive experience in helping hospitals set up and integrate their systems, and Perot—which merged with Dell last year—has also done a lot of outsourcing work for hospitals. The company has also been helping some big healthcare systems, such as Memorial Hermann in Dallas and Tufts Medical Center in Boston, ramp up EHRs in the offices of affiliated physicians. But small independent practices outside the orbit of a healthcare system present a different set of challenges.

In an interview with Physicians Practice, Jamie Coffin, vice president of Dell Healthcare and Life Sciences, pointed out that Dell has helped computerize lots of small businesses in non-medical fields. Of course, that doesn’t mean too much, because EHRs and healthcare are much more complex than, say, a bookkeeping system in a restaurant chain.

Part of the small-practice solution, Coffin indicates, is to use remote training and support tools. Dell Perot will install the hardware, do a “brief touch” in the practice to get the software running, and then follow up online. This does not leave much room for change management or handholding, and practices that cannot figure out how to use the software quickly might drop it, as many have before. But based on Dell Perot’s success to date in working with healthcare systems, they’re hopeful that this approach will also click in private practices.

In any case, Coffin points out, the AMA-Dell venture will fill a need as physicians scramble to show meaningful use. “The real question is whether EHR vendors can scale to the number of installations they have to do over the next 36 months,” he says. “It’s not a cost question for them, it’s an issue of whether they can scale to the demand. They’re going from 1,000 implementations a year to 10,000-20,000 or more. That’s one reason why they’re looking at companies like Dell and Perot.”

Trendspotter: RACs Are Now Encouraged to Search For Fraud

There’s good reason for physicians to be worried about Medicare’s new Recovery Audit Contractors, better known as “the RACs.” Like auditors for Medicare carriers, the RACs seek to recover money for the government by finding evidence of overpayments to hospitals and physicians. What makes these four private companies different from traditional auditors is that they’re being paid a percentage—9 to 12 percent—of whatever they recover from providers. (See “Medicare’s New Bounty Hunters” in the current issue of Physicians Practice.)

While the January 1 launch of the permanent, nationwide RAC program was a wake-up call for providers, there hasn’t been much concern that the RACs would actively seek out fraud. They are supposed to forward fraud cases to CMS, but they have no financial motivation to ferret it out, says Jessica Gustafson, a Southfield, Mich.-based attorney who specializes in Medicare audits. “The financial incentive is for them to do the audit,” she points out, because that’s how they make money.

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But something in that equation changed recently. CMS has decided to provide formal training to the RACs on how to identify fraud and where to refer fraud cases. It is also developing a database to track fraud referrals. Needless to say, this will give the contractors’ personnel an extra incentive—although not yet a financial one—to look for fraud wherever it may lurk.

CMS chose this course after the Office of the Inspector General (OIG) in the Department of Health and Human Services examined what the RACs were doing about fraud—which was not much. During the three-year pilot that preceded the current program, an OIG report says, the RACs turned over evidence of fraud to CMS in only two cases. CMS wasn’t aware of these cases, according to the report, but has now forwarded them to OIG for further development.

OIG’s interest reflects the Obama Administration’s crackdown on fraud and abuse in the Medicare and Medicaid programs. “The government thinks they can whack close to 10 percent of their healthcare spending by nailing people for fraud,” says David Glaser, a healthcare attorney in Minneapolis who defends physicians against Medicare audits. “So concern is warranted, because they’re coming after you and it’s a way of reducing healthcare costs that doesn’t offend anyone except physicians.”

When does a pattern of improper coding become fraud? “The majority of audits involve a pattern of medically unnecessary services,” says attorney Abby Pendleton, one of Gustafson’s colleagues. “That’s a common reason for denial of claims. When does it rise to the level of fraud and abuse? It’s got to be pretty extreme.”

The government’s definition of fraud is vague, says Glaser. If a single claim error is viewed as an honest mistake, but a series of errors is regarded as fraud, he notes, that definition ignores the likelihood that someone who makes one mistake is likely to repeat it. “Say a lab had one code wrong a couple hundred times. Should the false claims law apply?” He has also seen an overpayment of $150,000 to one doctor regarded as evidence of fraud, while another physician who got a $3 million overpayment merely had to refund it.

In any case, the RACs are still less likely to turn up fraud than a Medicare auditor would be. The OIG report notes, “We recognize that RACs are not responsible for identifying potential fraud; however, we believe that there may be a disincentive for RACs to refer cases of potential fraud because they do not receive their contingency fees for cases determined to be fraud.” Let’s hope that it remains that way: the RACs should not have a financial incentive to find fraud and turn in physicians who may have made honest mistakes.

Meanwhile, the government needs to develop a better definition of fraud and a more reliable method of identifying it. Certainly, some providers are cheating the government, and they should be caught and punished. But especially when private contractors are enlisted in this effort, there is a danger that physicians may be wrongly accused unless CMS carefully supervises the anti-fraud effort.

Trendspotter: Where Hospitalist Communications Fall Short

By Ken Terry


One of the persistent problems in our healthcare system is the communication gap between inpatient and outpatient care. The increasing use of electronic health records hasn’t really resolved this problem, because, unless ambulatory-care physicians are using the same EHR that their hospital is, comprehensive information about a patient’s inpatient care is still hard to obtain in a timely manner. Discharge summaries are supposed to contain this data, but they often arrive too late to be helpful; and even if a primary-care doctor receives this document soon after a patient’s discharge, it may be missing key information.

A recent study in the Journal of General Internal Medicine found that tests pending at discharge were mentioned in only a quarter of discharge summaries and that only 13 percent of the summaries stated what those tests were. “We already know that outpatient providers aren’t very good at following up on pending tests documented in the discharge summary,” commented Dr. Martin Were of the Regenstrief Institute, the study’s author, in an article about the study’s findings. “Imagine how much worse the follow-up is when pending tests aren’t even documented.” Were added that the growing use of hospitalists and the tendency to discharge sick patients faster make the situation even more alarming.

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The discontinuity of care between hospitalists and outpatient physicians has been mentioned in a number of studies. Internist Robert Wachter of the University of California San Francisco, one of the hospital movement’s leaders, told me a few years ago that good hospitalists believe it is essential to contact referring doctors when one of their patients is discharged. “They ‘get’ that sending the patient back to the primary-care physician without the right information and without a phone call is a bad thing to do, both for the patient and in terms of the program’s credibility,” he said. But he admitted that some hospitalists in some programs are not very good about calling outpatient physicians; they might have a nurse or house doctor do it.

Even if the hospitalist does call the primary care doctor, he or she might not mention a pending test. The hospitalist might think it’s more important to focus on the most relevant issues in a brief call. There are also reasons why pending tests might not be documented in a discharge summary, Were points out. For example, multiple consultants order tests at different stages during a hospitalization. To find out which were pending, the hospitalist might have to pull information from several different hospital systems. Of course, that would not be the case in a hospital with a computerized physician order entry system—but only about 15 percent of hospitals have CPOE.

Even if hospitalists are aware of all pending tests, Were notes, they must distinguish between which are important enough to include in a discharge summary. Outpatient physicians will be annoyed if they are prompted to follow up unnecessarily on tests such as kidney function or CBC tests if the results had been normal throughout a patient’s hospitalization.

Another major issue is confusion over who has responsibility for following up on pending tests in the hospital, Were notes. Even if a primary-care physician knows about a pending test, he or she may feel that the inpatient physician should follow up. Hospitalists, on the other hand, may believe that, after a patient is discharged, the outpatient physician is responsible for all aspects of that patient’s care. But if a pending test is not documented, Were believes, it should be the responsibility of the hospitalist to follow up on it.

Blogger Kevin Pho observes, “Some hospitals have post-discharge clinics where hospitalists do the follow-up themselves, but that’s not commonplace. We clearly have a ways to go in bridging the communication gap between hospitalist and outpatient physician.”

This is an area that deserves much more attention, especially given the shockingly high readmission rate of Medicare patients. Part of the solution is to give hospitalists better tools and incentives for communicating all key inpatient data to primary care physicians, whether on the phone or in the discharge summary. In addition, as we build electronic health record systems in hospitals and physician offices, national health IT policy should prioritize the creation of electronic connectivity between inpatient and outpatient care settings.

Trendspotter: Apple iPad is already attracting physician attention

By Ken Terry


The new Apple iPad is causing a stir in the medical world, even though no electronic medical record software has yet been designed specifically for it. One indication of this interest comes from a physician survey by Epocrates, a leading vendor of software for mobile devices. Of the respondents to this poll, conducted just before the iPad’s launch, nine percent said they would buy one immediately. Another 13 percent said they would get an iPad within a year, and 38 percent said they were interested in the product but needed more information to make a decision.

One reason for physicians’ curiosity about the iPad is that it uses the same operating system and has the same finger-activated pressure screen as the iPhone and the iPod Touch. According to Epocrates, which has just announced its compatibility with the iPad, more than one of five physicians is using its applications on either of those devices. The fact that the iPad’s screen size is almost as big as a full-size tablet’s doesn’t hurt, nor does its svelte weight (just 1.5 pounds).

Moreover, the basic features of the iPad—web access, e-mail, photos, video and music playback, electronic books, and access to 140,000 applications—probably appeal to tech-savvy docs. But many physicians are also intrigued by the idea that the iPad might someday be used for EMRs and various modes of inpatient documentation and ordering.

According to Satish Misra at iMedicalApps:

“Rumors abound that Apple is already pitching the iPad in LA-area hospitals as the replacement for the old physician clipboard. For outpatient practices already running a Mac-based EMR, MacPractice has already announced development plans for an iPad interface. According to their press release, they plan to develop apps that will allow patients to fill out registration, medical history, and other forms on the iPad. For physicians, it will integrate with the MacPractice EMR to manage schedules, view patient records, and even enter clinical notes.”
Read moreHowever, Misra notes, most EMRs run on the Windows operating system; while there’s already a Citrix application that allows an iPad to use Windows as a dumb terminal, that would eliminate the cool interface that is the iPad’s biggest selling point. Also, the iPad has no digital handwriting capability. And its handwriting recognition probably has to be better than that of the “digital ink” in tablet PCs, which some physicians find too slow and clunky, Misra says.

I’d also point that there’s a problem with the iPad’s lack of a keyboard. Although many physicians like pressure screens and the ability to scroll or select with their fingers, a certain amount of typing (or, alternatively, dictation with voice recognition software) is inevitable when documenting visits in an EMR. The iPad features an onscreen keyboard, but physicians have found such keyboards to be only marginally usable in other computer tablets. You can also tap on an external keyboard when the iPad is in its docking station, but that is not a portable feature.

A few other drawbacks should also be mentioned: While the iPad contains a rechargeable battery, it cannot be removed and exchanged with a fresh battery. If you believe that the iPad battery will go 10 hours without a charge, as Apple claims, that’s probably sufficient for daily use with an EMR. But some observers are skeptical about that. And a survey of physicians conducted by Software Advice about the features physicians desire in a tablet shows that the iPad falls short in several areas:

“It lacks a large number of features that healthcare professionals deemed important, such as resistance to dust and hospital fluids and disinfectants (the iPad does not have sealed ports); fingerprint access to the system (HIPAA compliance); barcode scanning (patient safety); and an integrated camera (documenting diagnosis). In fact, you could argue that the iPad’s difficulty in being disinfected or kept clean of hospital fluids is a deal breaker for healthcare workers.”

Of course, conventional tablets also have problems, including the fact that most are heavier and have a shorter battery life than the iPad does. But many physicians like tablets and have had success in using them with their EMRs. Whether or not the iPad becomes a major competitor in the EMR space will probably depend on whether Apple adds some new physician-friendly features and on the willingness of EMR vendors to write applications for the Apple operating system.

Trendspotter: Making patients pay when the insurance company won't

By Ken Terry


Imagine you’re a patient in a hospital and you need an emergency procedure such as a CABG or an appendectomy. You have insurance, but the surgeon, who’s in a rush to perform the procedure, neglects to inform you (or doesn’t know) that the anesthesiologist she has chosen is not in your plan’s network. The anesthesiologist doesn’t tell you, either.

As a result, you might get stuck with a bill far higher than what you would pay if had you known — or perhaps not. After all, if you’ve had a heart attack, you’re not likely to demand an in-network anesthesiologist. Nevertheless, you will probably be angry when you receive a bill for what seems like an astronomical amount, representing the difference between the doctor’s charges and the insurance payment.

A Texas law that went into effect last year allows patients who get stuck with big, unexpected medical bills to request mediation in certain situations. The legislation applies only to people who are in fully insured PPOs and who owe an out-of-network provider more than $1,000 after deductibles, coinsurance, and copayments. Patients in self-insured plans, indemnity plans, Medicare, or Medicaid are not covered. Neither are the uninsured. The only providers affected are hospital-based physicians such as anesthesiologists, radiologists, pathologists, neonatologists, and ED specialists.
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An eligible patient may ask for mediation if the hospital-based physician did not disclose that he or she was not under contract to the patient’s health plan and did not disclose his or her charges in advance for the services to be provided. The State Office of Administrative Hearings may select a mediator, or the parties may agree to use a particular mediator.

According to a Dallas Morning News story, mediators are not sure whether they want to participate, because the law requires them to determine whether anybody is acting in “bad faith” during the mediation process. That might represent a hospital administrator not showing up for a hearing or a party withholding material information, for example. The mediators say they are afraid they would never be hired again if they told the Texas Medical Board that a doctor was acting in bad faith.

More troubling is the implication that some providers charge disproportionate amounts to plans they do not contract with and then bill patients for the balance. The newspaper piece notes that most facility-based physicians in North Texas work for one of a few companies that hold contracts with hospitals. Without much competition, they are in a good position to charge whatever they want. But the hospital-contracted firms say that they are in the networks of most major health plans in the area and that 90 percent of their patients are covered by Medicare, which does not allow balance billing.

The Texas law is much more circumscribed than some other states’ limits on balance billing. California has banned all balance billing for emergency care at the urging of the state Department of Managed Health Care. The California Supreme Court last year upheld the legislation in the case of out-of-network ED physicians, who have to accept the patient’s insurance as payment in full. Connecticut, Pennsylvania, and Alabama also prohibit balance billing.

Some observers say that the core of the dispute over balance billing is how much insurance companies should pay out-of-network providers. The use of an Ingenix database to determine the proper amounts that plans should pay non-contracted physicians has been challenged both by New York Attorney General Andrew Cuomo and by medical societies in New York, New Jersey, Connecticut, North Carolina, and Texas. Cuomo won a settlement from UnitedHealth Group, Ingenix’s owner, which has agreed to fund a new, independent database, and Aetna has agreed to do the same. These moves should lead to fairer reimbursement of out-of-network providers. But they are unlikely to end the controversy over balance billing, especially in hospitals and emergency rooms.

As long as physicians feel they’re being underpaid by health plans, most of them will balance-bill insured patients where they can. But not all. One Texas doctor responded to the Dallas Morning News article in these terms: “What is wrong with the anesthesiologist [who balance-bills patients]? Is that why she/he became a doctor? To put people into bankruptcy? Cases like this make me sick. Who am I? I'm a private physician who routinely writes off whatever my patients can't pay.”

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.

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.

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.

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.

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.

Trendspotter: Health information exchange raises new liability issues

By Ken Terry


When physicians are asked how an EHR might affect their malpractice risk, they usually think about their own documentation and orders. More comprehensive records, better access to those records, and automatic alerts might help them avoid an error that could result in a suit, they say. System crashes, diversion of their attention from the patient, and “charting by exception” could increase the possibilities for liability.

But what you do with your own EHR is not the only source of potential difficulties. As EHRs become increasingly interlinked with outside information systems, including those of other practices, hospitals, labs, pharmacies, and health information exchanges, the greater availability of data from these other sources could also raise malpractice risks, say some experts.
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In a recent Dr. Kevin blog post, attorney Robert J. Mintz points out that, as access to data on patient treatment outside your practice grows, you might also be held accountable for a higher standard of care. “Even as quality increases, the legal standard of care will keep rising too, so that rather than fewer mistakes and fewer lawsuits, there are more of each since the information you ‘should have known’ is now right at your fingertips,” Mintz writes.

Mintz cites a case involving a pharmacist who was sued after a patient to whom he dispensed a painkilling drug caused a fatal car accident. Because the pharmacist had access to records showing that this patient had gotten prescriptions for a large number of similar drugs before, the plaintiff alleged that he should have known the patient was abusing these medications. Mintz believes that similar suits could be brought against physicians who have access to the records of other physicians, as well as to community medication histories.

Other observers are concerned about the unintended effects of the information revolution on physician liability. Gerald “Jud” DeLoss, a healthcare and malpractice defense attorney in Fairmont, Minn., notes that when one physician’s EHR is interlinked with those of other doctors, “faulty information that may have been inputted into the system by a physician or staff member outside their facility could result in some type of incorrect treatment or an allergic reaction that could injure the patient.”

Steve Waldren, a family physician who is director of the AAFP’s Center for Health Information Technology, is concerned that if a physician has access to lab results in a colleague’s EHR and doesn’t integrate those results into his own record, he might be held liable.

And Washington, D.C., internist Peter Basch, a leading health IT expert, says that if you even open a colleague’s e-mail that contains information about a patient and don’t file it in your EHR, you could be held accountable because the audit trail would show that you had opened the e-mail.

Electronic prescribing is another can of liability worms. First, as mentioned earlier, physicians who prescribe online to pharmacies, either through an EHR or a standalone e-prescribing system, have access to Surescripts’ community medication history, based on claims data from pharmacy benefit managers and health plans. In some areas, prescribers may also be able to access a point-of-sale database that shows all of the medications, both prescription and OTC, that a patient has purchased in participating pharmacies.

What this means is that the e-prescribing physician either knows or should know what other medications a patient is taking when he prescribes a drug that might have an adverse interaction with one of those other pills. If everybody looked up this information, it would be a great leap forward for patient safety. But Surescripts says that in 2008, only 16 million prescription histories were routed to physicians who ordered 68 million prescriptions online. So doctors were checking their prescriptions against community records less than a quarter of the time.

The other liability risk associated with e-prescribing comes from the new ability to find out whether a patient has filled his prescription. (Surescripts includes the fill status as part of the medication history.) If a physician does not check on whether a patient has filled his prescription, is he liable if the patient doesn’t get the medication and has an adverse event as a result? If the doctor does know that the patient isn’t taking or refilling his meds, should he follow up immediately or wait until the next visit, and what responsibility does that entail?

The list of possibilities is endless. But, perhaps because legal experience in this area is sketchy, relatively little attention has been paid to the liability implications of health information exchange. That is likely to change, however, as more physicians acquire EHRs and as HIEs emerge across the country.

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.