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Volume 64, No. 4 April 2008
The current Democrat front-runner for the Presidency has it
in his "Blueprint for America" also: "lowering costs through
investment in electronic health information technology [HIT]
systems." It states that "Obama will invest $10 billion a year
over the next five years" and will "phase in requirements for
full implementation of health IT."
Mandates will be needed. As Chip Kahn of the Federation of
American Hospitals noted, physicians would not achieve even 40%
adoption of e-prescribing without being compelled to do so
(HITS 11/15/07).
IT will be essential for achieving Obama's objectives: Costs and Efficiency
Sen. Edward Kennedy quipped that it would take only "four
hours of savings" from a fully digitized system to free up $50
billion to fund SCHIP (HITS 5/17/07). Congress wants IT
as a "major accomplishment" to show voters before the November
elections. IT will produce "radical change," stated former U.S.
Representative Nancy Johnson, and is the "only way that we
guarantee" state-of-the-art medicine to all Americans, including
the uninsured (PCWorld 2/18/08).
Small physician practices will not be the beneficiaries of
cost savings from electronic medical records (EMRs). Considering
the AMA's estimate that doctors would see only 11 cents of every
dollar saved through IT, Massachusetts BlueCross/BlueShield
decided not to require EMRs for participation in its bonus
program. A hospital computerized order system might pay for
itself in 26 months if it reduced rehospitalizations caused by
errors (AMNews 3/10/08).
At the 2008 meeting of the American College of Legal
Medicine (ACLM), Dr. David Donnersberger reported that a $60,000
grant to his practice covered infrastructure and temporary
staffing, but not the $500,000 loss in revenue, or the $10,000
annual maintenance cost. Productivity is down 15-25%. The VA's
Vista system has cut the number of patients seen per hour from 4-
6 to 1-2. It can take 30 minutes to do a note that typically took
2-3 minutes maximum on paper. Yet the designers "have made clubs
and user groups to praise each other" (Consumer Power
Report #88 7/26/07).
Quality Gains and Evidence Base
The absolute reduction in risk-adjusted in-hospital
mortality between hospitals with the best and poorest performance
measures was a mere 0.005 for myocardial infarction and 0.001 for
heart failure, according to the CMS Hospital Compare study
(JAMA 2006;296:2694-2702).
As the accompanying commentary asks about such minimal
results: "why should clinicians and health centers be required to
collect and submit the data, and why should payers and consumers
want to act on them?"
A study of family medicine practices showed significantly
better diabetes care and outcomes in practices without
EMRs (Crosson et al. Ann Family Med 2007;5:209-215).
Since the randomized controlled trials that are de
rigueur for medical treatments show such poor results for
IT, use of social science methods such as qualitative,
observational, and quasi-experimental designs are recommended
for "strengthening quality improvement research." Leadership must
insist on engagement of all workers, despite needed "radical
change" in their work habits (Boat TF et al. JAMA
2008;299:568-571).
Branding and Grading Doctors
The NPI (National Provider Identifier) at last makes it
possible to track physician-specific outcomes, stated Dr. James
Szalados of Unity Health System at the ACLM meeting.
Modeled on an agreement between NY Attorney General Andrew
Cuomo and insurers, with input from the AMA, insurers nationwide
are constructing tiered networks, based on "true quality
measures" (AMNews 12/7/07).
Elizabeth Kubler-Ross's stages of grief response starting
with shock and denial may occur in clinicians receiving bad news
about their care practices. "It is only through persistent
measurement that clinicians move beyond initial paralysis to
acceptance and action" (JAMA 2005;294:369-371).
Professional autonomy, reinforced by organizational
autonomy, leads to "functional silos." Thus, "shared financial
and regulatory incentives" are needed (JAMA
2008;299:445-447).
The Greater Rochester Independent Practice Association
(GRIPA) requires each physician to contribute $10,000 to the
disease-management protocols and physician performance measures.
"Physicians who repeatedly fail to comply with GRIPA's standards
will face disciplinary action and possible expulsion from the
group" which could end a medical career, cautions Dr. Lawrence
Huntoon.
"Systems-based practice" is part of the new medical
"professionalism" which requires a new "medical-societal
alliance," reinforced by constant relicensure examinations.
If a shortage of physicians develops, no matter. "More
physicians will compete for new resources against already well-
documented health system needs." Patient outcomes are no better
in regions with more doctors (JAMA 2008;299:335-338).
With fewer physicians and less productivity, the investment
in IT could contribute to cost-cutting goals after all.
One of medicine's most underutilized tools is the medical
warning bracelet or necklace; Medic-Alert has only 4 million
patients participating worldwide. For $15, the subscriber gets
the bracelet, and for $35 plus $20 annually, a 24-hour toll-free
hotline from which doctors can get contacts and medical records
in an emergency. The fashion conscious can get a 18-K $1,050
solid gold version from Tiffany's (WSJ 4/5/05).
If illegible handwritten prescriptions are a problem, Stuart
Gitlow, M.D., suggests a typewriter. His community mental health
center bought a self-correcting IBM Selectric III on e-Bay for
about $100. "It may be retro, but it gets the job done
efficiently, effectively, and accurately." The center stopped
using eRx because it increased the time needed for each patient,
and there was no observable improvement in error rate, just a
change in the types of errors.
According to a study of 26,092 errors related to look-
alike/sound-alike drugs submitted through the Medmarx database
from 2003 to 2006, two-thirds had an additional error. Unclear
handwriting accounted for only 6.2% of these, while errors in
computer entry explained 15.1%. Performance deficit in the
practitioner topped the list of co-causes at 52.4% (www.modernhealthcare.com
1/30/08).
Where do doctors start if they are to be penalized for not
giving preventive health and safety advice to patients? The
American Academy of Pediatrics has 192 published discrete
advisories that doctors are expected to deliver none of which
include an evidence-based discussion of efficacy. Tobacco use and
smoke exposure are to be covered at every single visit (www.pediatrics.org
11/15/06).
If the relevant clinical practice guidelines were followed,
older individuals with several comorbidities would be on an
average of 12 drugs costing $406/mo (JAMA 2005;294:716-
724).
Boeing decided to use ratings by Regence Blue Shield to kick
doctors out of the network; 593 were excluded, one for not doing
a Pap smear on a woman who had no cervix. After union objections
and lawsuits, Regence decided not to implement the performance-
based network, without admitting to flaws in data or method (www.workforce.com
2/26/07).
Dr. Steven Petak got the dreaded grey ribbon from BCBS of
Texas BlueCompare program, which uses "massive ...computer power
and algorithms beyond the understanding of mortal man to
distill...a lifetime of medical achievement down to a single
consumer-friendly rating." He didn't meet the requirements for
diabetes care his practice specifically excludes diabetics.
After many complaints the program was suspended (First
Messenger January/February 2007).
"When Mary steps on a weight scale, she will be able to see
both her weight and basal metabolism index. The scale will then
upload this information to the PHR [personal health record] on
her computer so the PHR can determine if her caloric intake
matches her health goals" (California HealthCare Foundation,
ihealthreports, June 2007).
All Massachusetts taxpayers must file Schedule HC this year,
including their insurers' federal tax ID number and their
subscriber number. Being without coverage on Dec 31, 2007, will
cost them their personal tax exemption, worth $219. Next year,
the penalty will be half the premium for the lowest cost coverage
available through the Connector, or $912. A person who lived in
Dallas, TX, could probably buy coverage for the price of the
penalty (Consumer Power Report 3/6/08).
Several initiatives are proposed for making federal grants
and low-interest loans available to purchase IT in exchange for
providing free or low-cost medical care to low-revenue patients
("Who Is Accountable for Racial Equity in Health Care?"
JAMA 2008;299:814-816).
After spending $60 million, New York City is ready to equip
doctors with software to track patients' records to improve
preventive care, as by alerts for overdue prescription refills or
cholesterol checks. Some 200 doctors with 200,000 patients have
signed up. Government programs can compare outcomes, preparing
the way for drastic changes in payment, such as compensating
doctors by outcomes. A six-month decrease in productivity is
anticipated (NY Times 2/26/08).
Massachusetts is considering a bill that would require the
use of EMRs and force doctors to show competency in the
technology for medical board registration (AP 3/8/08).
During the era of systematic prescription data mining, costs
have quadrupled, writes Benjamin Schaefer, M.D. (letter,
Modern Healthcareonline 11/30/07). "Data-mining is the
tool with which the most expensive medications are best promoted
to the highest prescribers."
The Blue Health Initiative was designed to sell data on
79 million Blues enrollees to employers, without consent. The
greatest use of electronic health data is by the data-mining
industry for profit. "[N]ot a single dime of this money...goes to
improve the health of a single sick person," writes Deborah Peel,
M.D., of the Patient Privacy Rights Foundation (www.modernhealthcare.com
6/27/07).
EBMs are to be integrated with EBMgt, in a system in which
"organizations and individuals should be held accountable for not
using evidence-based approaches." A federal agency for compiling
the guidelines is suggested (JAMA 2007;298:670-679): a
"medical-societal alliance" or public-private partnership.
"At present, the financial ties between guidelines panels
and industry are extensive," writes Robert Steinbrook, M.D.
(NEJM 2007;356;331-333). Disclosure statements by
authors reveal that 35% have a potential financial conflict of
interest. Some guidelines such as the Infectious Diseases
Society of America's guidelines for diagnosing and treating Lyme
disease are used to deny insurance coverage.
Guidelines may be voluntary, but the federal government has
its methods. "Quality" initiatives may indeed "save" or
recoup money for government programs.
Survey Fees. CMS announced "revisit user fees" to
facilities cited for failure to comply with federal quality-of-
care standards, authorized by the 2007 continuing resolution.
The Social Security Act otherwise forbids user fees for
compliance surveys. The estimated revenue of $37.3 million
annually is expected to cover the cost of revisits (HCFR
7/4/07).
Nonpayment. If CMS refuses to pay for services that
don't meet standards, billions of dollars in revenue could be
denied to providers. The Office of Inspector General (OIG) found
that Medicare paid $4.5 billion in 2004 for consecutive inpatient
and skilled nursing facility stays that were associated with
"quality-of-care problems and fragmentation of services" (ibid.).
Criminal Prosecution. Most concerning is that billing
for services deemed substandard could increasingly be considered
fraud or abuse.
The Health Care Fraud and Abuse Control (HCFAC) program will
get an additional $200 million in discretionary funding in FY
2009, bringing its total funding to $1.3 billion (HCFR
2/13/08). As Prof. Ron Libby notes, HCFAC is a self-perpetuating,
unaccountable bureaucracy, whose existence depends on a continued
stream of prosecutions (The Criminalization of Medicine:
America's War on Doctors, Praeger 2008).
Public-Private Partnership. Government efforts are now
augmented by private contractors (called recovery audit
contractors, or bounty hunters), who are paid a percentage of any
improperly billed Medicare payments. Appeals generally take 2
years, and even if the provider is eventually proved right, the
RAC gets to keep its contingency fee. Such an audit was a key
factor in the $28 million loss posted by Boca Raton Community
Hospital in 2007 (Palm Beach Post 1/9/08). The 2006
pilot program will gradually be expanded, encompassing 19 states
by October (Kevin Freking, AP 3/1/08).
Higher Penalties. Provisions in the Indian Health Care
Act Amendments of 2007, if passed, would double civil monetary
penalties for Medicare fraud, and quadruple criminal penalties.
The highest criminal fines would be $100,000 per claim, up from
$25,000. Additionally, the bill would increase jail time for
false statements or Stark anti-kickback violations from 5 to 10
years (HCFR 2/27/08).
Clinicians who use EMRs may come to rely on them for
automatic alerts. However, physicians ignore or override 75% of
the electronic reminders (Sacramento Bee 1/20/07).
Imagine the clear well-formatted screen blown up to display for a
jury.
Guidelines may come to define the standard of care and even
to substitute for expert testimony in professional liability
cases, noted Dr. James Szalados at the ACLM meeting. Patients who
are researching physician performance data may be influenced in
their decision to pursue litigation. It is not clear whether
issuance of guidelines or monitoring compliance with them is
considered a peer-review function, he said.
In an ACLM talk titled "The Curse of the Black Pearl and Be
Careful What You Ask for," Dr. Frank Battaglia explored some of
the unintended consequences of tort reform in Texas.
Plaintiffs' attorneys, unwilling to bring a case because
they can't recover a large enough award, are providing would-be
clients with an 800-number and instructions for filing a
complaint with the Texas Medical Board (TMB).
Limits on tort liability were exchanged for increased power
and resources for the TMB. The number of investigations has
doubled (increasing from 1,158 in 1999 to 2,593 in 2007), and the
number of disciplinary actions has tripled (99 v. 311)
(www.tmb.state.tx.us/agency/statistics/enforce/mbdphp).
In 2006, the TMB collected $480,000 in penalties.
Szalados named 10 reasons why defending a lawsuit was
preferable to enduring a TMB procedure, including:
Concerning the October 2007 legislative hearings on the
TMB, Szalados said that the allegations were shocking if true,
and highly embarrassing if even partly true.
A deposition of former chief disciplinarian Keith Miller,
M.D., in AAPS v. TMB is scheduled for March 14.
On the basis of charges originating from a white suburban
hospital, Monica Applegate, M.D., a black obstetrician/
gynecologist certified in high-risk obstetrics, had her medical
license summarily suspended by the State of New York, without a
hearing. She had practiced without malpractice claims from 1986-
2000, mostly in city hospitals. She was the only black woman
practicing her specialty in the Buffalo area, but has been unable
to work in medicine since the license suspension. The Second
Circuit dismissed her appeal on the basis of absolute judicial
immunity.
In her petition to the U.S. Supreme Court for Writ of
Certiori, the question starkly presented by attorney Andrew
Schlafly is this: "Are members of a state agency entitled to
absolute judicial immunity for racial discrimination in
investigating and disciplining a licensee?"
Once a medical board has publicized a summary suspension, as
here, it "has every political reason to strain to justify its
decision, made without due process, and to avoid admitting
publicly that it made a mistake," the petition argues.
Serious flaws in the post-deprivation hearing included
denying Dr. Applegate access to needed medical records; use of
unqualified participants on the hearing panel; use of hearsay;
withholding exculpatory evidence; intimidation of prospective
supportive witnesses; and biased adjudicators.
"Not even a criminal prosecutor enjoys the sweeping absolute
immunity granted below to the New York medical board officials,
despite the claim of racial discrimination."
Veterans Lose Benefits Because of Paperwork Errors.
Returning disabled veterans are finding themselves destitute and
without medical benefits because of faulty discharge papers.
Veterans are responsible for correcting errors on their own
DD214, but are not familiar with the codes. One Marine who saw
combat was miscoded as a "conscientious objector"; she ended up
living in her car for a time. The Army alone has a backlog of
1,890 veterans asking for corrections (Buffalo News
2/24/08). Some have been waiting for 3 years.
Much like CMS, the military blames private contractors,
evading its responsibility for hiring and supervising
contractors.
"Universal coverage" means universal incompetence of
bureaucrats running the system, which means universal suffering
for patients who are "covered" by the socialized system with no
means of escape.
The Primacy of Data. I had a conversation with the
evidence-based medicine advocate and state data maven, who said
it is OK to require all breast cancer patients to participate in
randomized controlled trials because that is how we get data.
When I asked what gave her the right to use patients as lab rats,
she replied that that is how we progress.
Lost: the Medical Record. My charting system consists
of sheets of blank white paper, for notes, and lined file cards,
for collection information. It works very well. Any simple
database program can emulate that system. But every stakeholder
wants to convert the medical record into something else: quality
control, liability control, cost tracking, prescription tracking,
E&M and CPT codes. All the information we doctors use to remember
the important stuff from visit to visit, or to provide
consultative information to one another, is gone, because we
can't write narrative after we've wasted all our time keeping
track of things we never had to bother with in the past.
Electronic Efficiency. Electronic technology is
supposed to save money by "cutting through the mountain of
bureaucratic paperwork and improving worker productivity." Before
1985, we submitted all claims manually. This required one worker
for three physicians, and claims were paid promptly and
correctly. With the addition of practice management software, we
have increased this molehill of paperwork to a mountain of paper,
electronic entry, appeals, bundling, more appeals, denials,
automated downcoding and need four or five staff members.
The Real Motive. In my opinion, the
government/corporate push for EMRs is merely a way for Big
Brother to get our clinical practice data so they can call us
names and pay us less. When EMRs benefit my patients and don't
cost too much for my solo practice, I'll get them.
EMR Results. IT gurus have long concurred that EMRs
will not allow us to treat patients more quickly. The hope was
that we would be more thorough and score higher on "quality
measures." This hope was dashed by a study showing no significant
difference on 14 of 17 quality indicators. There was improvement
on two: avoiding benzodiazepines in depressed patients (91% with
EMRs v. 84% without) and avoiding routine urinalysis during
general medical exams (94% v. 91%) (Arch Intern Med
2007;167:1400-1405).
More Can Be Less. Computers give us the ability to scan
more and more data. That is both good and bad. Bureaucrats have
no recognition that someone has to collect and record the data.
Then when I get reams of paper produced by an "efficient" EMR I
have a printout of garbage plus a little bit of data that I need,
which is lost in the mess. The rationale behind the note is lost
in a sea of paper. Return EMR to physicians!
Security Checklist for EMRs. Is all of your patient
data encrypted on secure servers and backed up daily, with the
backup kept off-site in a secured place? Is the backup moved to
storage via secured transport? Do any employees have laptops with
sensitive information on them? If so, how are they secured? Are
emails containing sensitive information encrypted? What sort of
physical security does your office have? Could someone walk off
with your server? What sort of disaster recovery responses do you
have in place? Are all employees trained in security and privacy?
Have they signed security agreements? Is there a published
security policy? Different levels of password access?....
Payment for Data. The Secretary of HHS has advised
Congress that physicians should have to spend at least $10,000-
$20,000 to implement an EMR system to qualify for a small pay
raise not enough to cover the costs. The ultimate irony is that
the EMR would be used to gather data that would rate doctors on
"quality" and "efficiency" as determined by bureaucrats to see
whether they qualify for future pay increases. Will HHS ever
learn that people don't pay to work?
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