The Cost Cutting EHR

Healthcare Information Technology (HIT) and Electronic Health Records (EHR) are at the heart of health care transformation. Everything we want to change and improve upon, hinges on the availability of EHRs in every hospital and every physician practice. We all know that EHRs can improve quality of care by providing evidence-based, patient-centered clinical decision support at the point of care, while measuring outcomes and customer satisfaction, so we can monitor and reward providers for their efforts. But this is not nearly enough. After all, our current health care crisis is not due to hundreds of thousands of citizens succumbing en masse to shoddy medical practices as much as it is due to having to squander 17% of GDP on pampering Americans with unnecessary, excessive and way too technologically advanced diagnostics and therapies. We must cut health care costs or perish. There could be an EHR for that. The following is a blueprint for transforming any EHR into a cost-cutting machine guaranteed to chop health care costs in half in less than one year of use.

Cost Awareness - There’s been much discussion lately revolving around small studies showing that when physicians are made aware of costs, they order fewer tests and save the system money, and it was suggested that EHRs can help place costs of everything in front of ordering providers. Absolutely. There is a tiny problem with obtaining true costs, as opposed to arbitrary prices, but in this era of Data Liberacion, surely we can summon the liberation of all insurance negotiated fee schedules. The innovative computer geeks can take it from there, and if we are missing some numbers here and there, we can make them up just as well as hospitals do. Armed with these data, the CPOE module will display the cost for every test about to be ordered, in a very patient-centered way, since we know what insurance the patient has. This in itself should also reduce disparities since Medicaid pays so much less for everything that we can easily order twice as many tests for Medicaid patients, for the same cost to society. Just so patients don’t feel disempowered, patient portals should clearly display tests and procedures costs as well. We could show the costs to their insurer, but a more deterring shock value would come from displaying the hospital list price, so patients can be better prepared in case the insurer decides to deny payments.

Subliminal Messaging – Well, yes this is illegal for advertising, but it should be acceptable for the public good. For providers, we should have two types of subliminal messaging in the EHR. Prospective messaging would flash inducements to order generic drugs for example. A more sophisticated and patient-centered strategy would be to tailor the message to the individual patient. So if, say, the EHR knows that the patient is there to discuss his PSA test results, and the EHR knows what the results are, it could flash “wait and see” all through the visit. Careful programming is required here to ensure that messaging occurs only on provider screens. Retrospective messaging could be used to create feelings of guilt and regret if providers order an MRI. It is likely that they would want to avoid these feelings in the future. We could integrate subliminal messaging into patient portals to help reduce utilization. For example, in the scheduling module, we could flash the word “NP” for consumers attempting to make an appointment, so they are guided to less extravagantly priced resources. Although this particular feature must be written from scratch, the potential for code reuse is obviously enormous. I’m sure pharmaceutical and device companies can come up with great ideas as well, but please remember that for marketing purposes, this is illegal, and no, this is not an infringement on commercial free speech.

Spending Counter – In the olden days when EHRs were mainly good for billing, some used to have funny little counters that showed physicians (there were no providers in those days) how much they made so far today based on selected E&M and CPT codes. Those widgets were not very accurate, and not widely used. Well, here’s a chance to reuse that old code or write new one if we must. As providers go through their daily work, the counters will add up how much health care money each particular provider has spent, in real time, and display the cumulative amount on every EHR screen (much like those page visit counters on the web).  As we gain more experience with value based benchmarking, the spending counters can become interactive. Each day spending limits could be preset per provider, adjusted to reflect schedule complexity, and the counter will run down all through the day as patients are seen and orders are placed. As the counter approaches zero, we could implement popup alerts to notify providers that the end is near. When the spending counter hits rock-bottom, the CPOE module is disabled and no further orders can be placed without administrative override. We can reduce spending limits by a few dollars every week and like Milo of Croton, providers won’t even notice the gradual cost efficiency achieved over time. To foster healthy competition, we could display other providers’ spending status too. The larger the group practice, the more competition we can foster.

Patient Centered Spending Counter – Upscale EHR vendors who are marketing their products to Accountable Care Organizations (ACO) may want to personalize the above counters for each patient. These widgets should display on the summary page for every chart and on each screen where the patient is in context and be represented by an hourglass graphic image. Since the ACO will be receiving claims data from other providers, we could easily calculate how much was spend on each patient during the current fiscal year and compare to what the ACO projects that should be spent to maximize shared savings. To assist providers at the point of care, an info button should be added that will provide clinical decision support when the hourglass gets low on sand. For example if the patient already had six office visits this year, the software may suggest sticking to e-visits and secure messaging for the rest of the year. It is very important to display this counter in patient portals as soon as the consumers log in, so they can judiciously manage their personal flow of sand. The ACO may wish to offer small, Sand Savings rewards to consumers who end the fiscal year with a surplus of sand in their hourglass.

Break the Plastic – Many EHRs, particularly those designed for inpatient care, have a “break the glass” feature which, in an emergency, allows physicians to access medical records of people who are not their patients. Physicians are given explicit warning that such access will be logged and audited and often these events are indeed audited by administration. The EHR code used to implement this functionality can be easily modified to support adherence to evidence based medicine and assist providers in keeping unreasonable consumer demands at bay. For example, if a provider caves in and attempts to prescribe an antibiotic for a documented diagnosis of common cold, the EHR will pop up a dialog screen with a red stop sign icon saying that this action cannot be completed. The provider may then show this screen to the consumer and hopefully he/she will just go away. If the consumer insists and the provider is talked into changing the diagnosis and trying to prescribe the antibiotic again, the EHR will pop up a different alert stating that the documented positives do not match the new diagnosis, but if the provider wishes to proceed and “break the plastic”, the event will be logged and audited by the committee to discover the reason for changing a diagnosis after trying to prescribe. Hopefully the consumer will take pity on the provider by now and go spend his own money on a Theraflu generic at Walgreens.

Consumer Digital Signature – Most EHRs today have nifty little checkboxes that allow physicians to acknowledge that they provided counseling to patients on a variety of issues. Since we know that a lot of money can be saved by providing consumers with counseling on smoking cessation and weight management, for example, we need to be certain that such counseling was indeed provided in earnest. Who better than the consumer to attest that sufficient counseling took place? All we need to do here is implement existing code for digital signature, usually written for the provider e-prescribing module, and add it to the progress note page. If satisfied, consumers will enter their special credentials, a simple PIN should suffice, at the end of the encounter. Other than saving money by improving lifestyle behaviors, the EHR can keep count of counseling sessions and automatically deliver a small punishment to consumers who show no positive changes in behavior. For example, a smoker who digitally signs 3 cessation counseling sessions, but is still documented as a smoker on his fourth visit, may see his Sand Savings reward disappear. Small rewards and punishments have been shown to consistently improve wellness and save money.

As outlandish as these features may seem, they really are quite easy to implement in a robust EHR. The only complex development consists of the various real time interfaces with insurers to bring claim data into the EHR, which is really nothing more than reversing the current interfaces that send claim data out to payers. As health information exchange matures in the next couple of years, and more and more data is liberated, many different cost cutting, personalized features could be added. Unlike the first generation of EHRs, widespread adoption should not be a major problem since most providers will be employees of large systems and accustomed to following policies and procedures. Judging by the growing spirit of innovation in Health IT, it may also be easy to find young entrepreneurial companies to quickly build this type of widgets and integrate them into existing EHRs for a fraction of the cost of proprietary development. These are exciting times.

NPfIT Blazing the Trail

The National Audit Office (NAO) in the UK has recently published a report evaluating the status of “The National Programme for IT in the NHS” (NPfIT). The program is a very ambitious top down initiative to deploy Health Information Technology across all NHS facilities in an attempt to provide an electronic care record for every patient in the UK. The blunt conclusion of the report states that “The original vision for the National Programme for IT in the NHS will not be realized” and “This is yet another example of a department fundamentally underestimating the scale and complexity of a major IT-enabled change programme”. Is this gloom ridden report in any way pertinent to our own quest for an EHR for every patient by 2014? Of course not. We don’t have a Socialist system where the government can decide on a particular EHR product, buy it, contract billions of dollars in services, and force all hospitals and doctors to install it and use it in their facilities on a government dictated schedule.

Instead, the United States Government is building a National EHR, and I find the business model fascinating. No, the Feds did not hire a team of software developers, did not set up a business entity and didn’t even hire a defense contractor to do all these things. Instead, they legislate and engage in a flurry of rule makings which are then applied in quick succession, like giant levers, to the delivery side of our health care system. This is nothing short of brilliant.

While NPfIT engaged in the purchase of two EHR products, defined future releases and paid for implementing those in medical facilities, the US government is skipping the capital investment in EHR products, replacing it with a complex incentives and penalties scheme intended to ensure that all health care entities invest their own money in implementing technology which is designed to government specifications. The initial lever is commonly known as Meaningful Use (MU). There is a secondary and smaller lever embedded in the definition of Patient Centered Medical Homes (PCMH), and the final gigantic lever will be pulled along with the advent of Accountable Care Organizations (ACO). The holy grail of both NPfIT and the US government program is, of course, interoperability which will allow the creation of that elusive EHR for every patient and the global reporting of health care indicators to government agencies. At first glance, it seems that the uniformity and mandatory nature of NPfIT would better serve this goal. But NPfIT is failing miserably, so perhaps our way is the better way. If we can achieve universal health care by mandating that millions of people purchase government defined insurance policies from private corporations, subject to minor penalties, why can’t we achieve universal health records by mandating that a few thousand health care providers buy government designed EHRs from private vendors, subject to equally minor penalties?

We probably can, but only if government is thoughtful enough to allow meaningful customer choices and humble enough to admit that customers are not stupid (excuse the harshness). In the case of EHRs, the customer is the clinician. Yes, hospitals, integrated systems and probably even health plans, may be buying these products, but as many have discovered the hard way, if physicians don’t like the technology, nothing will be accomplished. Industry publications are overflowing with indictments against EHR products being designed for administrative purposes instead of patient care and designed by engineers with no regard to, and no input from, practicing clinicians. That’s the past. The present is witnessing the top down design of all EHRs by government committees of experts in health policy, academic research, business, insurance, technology, and a myriad other special interests, with the expressed goal of advancing current health reform policy.

The basic Meaningful Use lever is now in its second stage of design and according to the government, it is an “escalator to where the country needs to be from a health reform point of view”. As such, it is imposing an ever expanding list of items that physicians must record when seeing patients. You must record patient demographics, of course, but you must be sure to capture a refined definition of race and ethnicity. You already knew to ask each patient if he/she smokes, but now you must phrase the answer in one of several sanctioned formats, and you should also ask about second hand smoking, and even if you are an optometrist, you should ask about these things. There must be someone, somewhere, extremely interested in the type of contact lenses purchased by Native Hawaiian and Other Pacific Islander populations who were exposed to second-hand cigarette smoke (cigars don’t count). You are certainly recording vital signs now, and if you are a pediatrician, you probably have those lovely growth charts to go with it. If your young patient is hospitalized for, say, an appendectomy, you will be pleased to know that the hospital too must maintain growth charts, so we don’t miss even a few days of growth. You will also have to document your response to various drug interaction alerts in a soon to be defined standard format and record family history in another pending standard format. Following a national storm in a teacup, CMS elected not to reimburse physicians for the advance directives “discussion”. Too bad, because you will have to document that discussion now, along with the equally unpaid for, secure messaging with your patients. And the list goes on.

In 1995 and then again in 1997 CMS saw fit to define exactly what physicians must document during a visit in order to get paid. Those guidelines were the foundation for most EHR designs until very recently, and those guidelines are the reason for EHRs being perceived as billing oriented instead of patient care and clinician oriented. Compared to Meaningful Use, the CMS E&M guidelines are child play in their complexity and prescriptiveness. Since every EHR vendor today is busy implementing Meaningful Use designs with the same fervor that they implemented E&M guidelines in the past, it looks like we are going to end up with pretty much the same result – technology that will allow customers to collect money from CMS. One could argue that this is a very pessimistic view. After all, unlike the E&M guidelines, Meaningful Use is supposed to be about improving quality of care, patient centeredness, interoperability and better outcomes for patients. What’s wrong with supporting policy if the policy is good and sound?

Nothing really, except that policy-driven software design, enforced by certification, is minimizing the most important factor in widespread adoption of any product – the voice of the customer. What little influence customers were gaining on EHR software design is now drowned by the relentless grinding sound of vendors trying to keep up with Meaningful Use directives and certification criteria. Substituting committees of experts for actual live customers and their often unexpected wishes has never been proven a successful product strategy, and unlike the NPfIT in the UK, our government is not giving out these soon to become cookie cutter EHRs for free, and is not (yet) in a position to force physicians to use them. Increased market penetration and successful adoption of technology usually hinges on the product’s ability to solve a problem for which the customer is willing to pay. I may be wrong, but I doubt that the majority of physicians in this country are willing to pay for health reform.

The Last Best Hope

According to the recently published CMS Accountable Care Organization (ACO) rules, an ACO needs to care for at least 5000 Medicare beneficiaries. Theoretically, two primary care physicians and a nurse, practicing in a garage, or cottage, in Boonville Missouri (yes, there is such a place), seeing nothing but Medicare folks, could become an ACO. Of course, they would have to set up a business entity with a board of directors, hire a couple of lawyers, several accountants and contract with a hospital or two and a score of specialists, and be ready to accept financial risk for their patients in a couple of years; all this on top of seeing twenty to thirty elderly and complex patients every single day. Nope. Not going to happen.

ACOs are for the big boys, hospitals and/or extra-large multi-specialty groups, to set up, manage and perhaps eventually benefit from. Big systems, as we all know, enjoy economies of scale, are better able to manage and coordinate care, and are therefore uniquely equipped to solve our health care crisis by providing better care at lower costs, and ACOs are just the vehicle by which these systems will be rewarded for all that good work. If you care for people in a small primary care practice, you could bite the bullet and sell out to a large system, or you could retire if you are one of those last standing dinosaurs, or you could become a concierge practice, or you could sit still and watch your practice dwindle and die, or you could buy an EHR, which is the last best hope to keep primary care independent.

Science, the type of science that employs mathematical hypotheses, theorems, proofs and equations, is timidly asserting that the emperor is in need of some serious clothing. A 2009 paper published in a non-medical, non-health care venue, “examines the staffing, division of labor, and resulting profitability of primary care physician practices”. The authors who are researchers from the University of Rochester and Vanderbilt University conclude that “many physicians are gaining little financial benefit from delegating work to support staff. This suggests that small practices with few staff may be viable alternatives to traditional practice designs.” Although I did not check the math, which is extensive, I would have expected that such controversial conclusion would make headline news in health care policy forums for at least two or three days. It did not.

From John Hopkins and the MGMA, we have a 2010 manuscript titled “Size Matters: The Diversity of Physician Practice Production Functions”, also complete with mathematical analysis, which reaches several interesting conclusions. First, it seems that “multispecialty practices gain by size through the creation of an internal referral network among their physicians, and through the capture of ancillary services and control over equipment and facilities”, which identifies one of the reasons why health care costs are steadily increasing. On the other hand, for primary care practices who “have few opportunities to generate production (and revenue) beyond direct patient care and cognitive services”, it seems that “organizational complexities of larger size (and the attendant perception of loss of control by each physician as the practice grows) will rapidly overcome any limited production advantages”. The authors offer two hypotheses for the observation that “[t]he median size of actual physician practices is considerably smaller than expected by estimated production efficiencies”: one is that in addition to maximizing income, physicians may have “non-profit-related goals such as professional autonomy and service to patients”, and the second is that “practice size may not be rewarded in the market”, therefore “health care reform proposals that expect that physician practices must become larger and more integrated will need to identify or create incentives for practices to expand (through internal growth or merger)”. It seems that ACOs have adopted the second hypothesis and rewards are forthcoming.

As early as 2003, researchers in the UK have warned the NHS that quality of chronic disease management in primary care (ischemic heart disease, in this case) is not necessarily associated with practice size. “Although recent developments in the NHS have cast doubt on the future of smaller practices, both patients and the doctors seem happy with smaller practices. Smaller practices are seen as more accessible and achieve higher levels of patient satisfaction. The NHS should reconsider how it can improve the quality of care provided by general practices, without relying on the presumed benefits of consolidating them into larger units”. On the other hand, in the US, acute myocardial infarction seems to be significantly more dangerous to patients of solo practitioners, as reported by a 2007 study published in Health Affairs. The same study notes that “[patients] of solo physicians appear to be less healthy in many of the measures. They also were more likely to have physicians that were female (except those of the largest practices), over age fifty-five, in internal medicine, and with non-U.S. medical training”. I for one, have no idea how to interpret this statement or its implications on the study results. To be sure, other studies, such as “The Relationship between Practice Size and Quality of Care in Medicaid” from the Center for Health Care Strategies, have found that small practice size may have ill effects on some quality measures, less on others and strangely improve access to care for some populations.

Small practices usually score very low on measures that are believed to be indicative of ability to provide better care, such as various preventive care screenings, consistent patient reminders, disease management testing and last, but not least, availability of Health Information Technology (HIT) to facilitate all of the above. It may be that documentation is lacking and it may be that small practices just don’t measure very well. As Dr. Lawrence Casalino told amednews.com in 2007, “[t]here is no question about whether large practices that can invest in it and hire staff to make sure they score well are likely to have higher Pap smear rates than people in small practices. But when you get to things that are perhaps harder to measure, like diagnostic skill, then we don't really know anything about how group size might affect that".  By 2008, Dr. Casalino seems to have reached a different conclusion. A JAMA article he coauthored, and which sets forth the blueprint for the recent CMS ACO rules, states: “At the heart of the challenge is transforming a 19th-century craft-oriented delivery system to provide 21st-century biomedical science and technology. Most physicians still practice alone, in partnerships, or in small groups. Small practices generally have less capacity to implement electronic medical records, less frequently use teams to care for patients with chronic illness, and are less able to provide statistically reliable and valid data on quality and efficiency measures. A more solid foundation of physician organizations is needed to avoid having the system crumble under the increased weight of greater demand for care and technological advances.”  By 2010, in a Roundtable discussion, Dr. Casalino seemed again, less certain, “I don’t think that accountable care organizations will succeed if they don’t make life better for patients and also for physicians. They just won’t. I don’t think you can have a major delivery system reform in this country with physicians actively opposed to it. And I think we found that out in the ‘90s.” and he even acknowledged that small practices may have some merit after all, “So there could be these virtual networks. And the concept is, physicians who want to be in small practices and patients who like to go see physicians in small practices — and there are real distinct advantages, I believe, to that setting for both the patients and physicians — would have the option to remains so.”

Bottom line is that when people are being intellectually honest, they have to admit that practice size is just one of a multitude of factors influencing quality and cost of care, and probably not even a very important factor. However, there are three major roadblocks to small practices being perceived as a viable option for the 21st century: lack of health IT, ineffective collaboration with other entities and the inability to measure performance due to small panel size. The beauty here is that removal of the health IT roadblock will automatically remove the other two, because when using computers, collaboration does not require physical proximity and performing analytics on aggregated data is a trivial task. Since the legendary economies of scale supposedly available in large practices have never been calculated and shown to actually exist, and since the advances in Internet-based training and support tools are driving costs of HIT acquisition and deployment down, particularly for small practices who don’t need many of the enterprise bells and whistles in top-shelf EHRs, the 21st century medical practice is within the reach of any solo practitioner.

So if you are an independent primary care doc in small private practice, and would like to stay that way, the best thing you can do right now is to position your practice to take advantage of things to come, or at least ensure that you are not losing ground while you are waiting to see which way the wind blows, and this unequivocally translates into getting an EHR (a cheap one will do), getting connected to the world, exchanging whatever clinical information you can, getting those clinical decision support rules running and, most important, learning to score well on quality measures.

I know this advice may seem unpalatable to many and I know that EHR may seem just another insult to add to the improper reimbursement injury, but what worked well in the past is not likely to work as well in the future. An EHR may not be enough to preserve some semblance of independent primary care, but it is truly the last best hope, and hope is all it is.

(Over)Simplifying EHR Usability

Dr. P patted the middle aged patient on the back, helped him off the elevated exam table and guided him to the chair by the sink. He picked up the chart and using the exam table as his desk he flipped through the chart, pulling out several pieces of paper, spreading them to his right, while making small talk with his patient. He reached into his pocket and pulled out a battered silver recorder and without any warning started dictating: “Mr. H is a 60 year old mildly obese gentleman presenting with…..“. He had a pen now in his right hand, and as he was talking into his recorder, shuffling the various papers in front of him, he was also writing orders and prescriptions as fast as he was dictating. “….follow up in two weeks” was the last thing he said. He didn’t write that one down, but turned around, handed the patient a bunch of scripts, told him to stop by the front desk and make an appointment two weeks out and stop by the lab on the fourth floor to pick up a container for the urine test. Two minutes, tops, including the small talk. It was my turn now and I was sweating bullets because I knew exactly what he is about to say. “Can I do this in the EMR?”

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EHR usability has finally arrived to Washington as the guest of honor at the most recent ONC HIT Policy Committee hearing. ONC seems to be considering the regulation and certification of EHR usability. NIST has created a testing procedure and just like its Meaningful Use testing procedures, it is superficial and doesn’t really test anything of any consequence. Those who represented “providers” and patients argued for the need to improve usability and those who represented academia and grant funded research argued for more funded research. Predictably, usability experts, argued for hiring more usability experts. Large vendors eloquently stated their objections to government mandating what EHRs should look like and small vendors argued that the more mandates, the better, since this will automatically remove the built-in competitive advantage of those with larger budgets and larger usability departments. As is customary, EHRs were compared to ATM machines, cars, iPhones, Google and a variety of “other industries” that are all so much more advanced than health care when it comes to usability.

When usability, or lack thereof, is discussed, most actual users of EHRs (oddly, there was only one of those at the ONC hearing) think about too many clicks, too many screen changes, convoluted workflows, stilted terminology, finding needles in haystacks, slow and freezing software, crashed servers, disappearing information, mind numbing alerts and lack of functionality. But wait, there is more… There should be out-of-the-box interoperability, ability to customize everything, thousands of templates, no bugs, no need for training, no need to document all that crazy billing stuff, and it wouldn’t hurt if it looked pretty and colorful (as opposed to “dull”), and it should work on the iPhone, iPad, Blackberry, Android, Mac and Windows 98 too.

There are two questions facing all involved: How to measure usability, and who should define and measure usability. The ONC committee is presumably exploring whether government should be the answer to both questions. Before you cheerfully agree that government should indeed regulate EHRs through an FDA approval process, let’s take a minute and explore what it is that we want government to regulate. No doubt, we want government to ensure safety of patients. Since EHRs are part of the clinical process, the FDA has, in my opinion, a clear and definitive role in making sure that EHRs do not endanger people’s lives. Usability, however, is a much larger aspect of a product than safety. To use the completely inappropriate analogy to automobiles (more on that later), it is pretty obvious that government should mandate that cars come with airbags and seatbelts, but it is less clear that government should mandate that all vehicles come with heated seats or automatic transmission, even if manual transmission and freezing bottoms may be tied to some types of accidents, for particular types of users, in particular circumstances, at particular times of day. And here is a trickier question: should the government fund and engage in the design of a preferred seatbelt, and then require that all automobile manufacturers use the exact same design?

Back to the more general question of usability and how it should be measured. ONC is funding projects and the government is paying for contracted work to provide an answer to this question. The initial outcomes as presented at this hearing consist of a rather strange standard form for assessing effectiveness (success/failure), efficiency (time to completion) and satisfaction (subjective) for several use cases based on narrow Meaningful Use criteria as defined by NIST testing procedures for certifying EHRs for Meaningful Use incentives. For example, an evaluator would be asked to prescribe a statin for a patient, or record vital signs, or execute a similarly granular sub-step of real life clinical scenarios. I don’t think I need to belabor why this exceedingly simplistic approach provides no indication for evaluating usability of the EHR. However, as one participant stated during the hearing, it seems that it is better to measure something than nothing. If you are reading this and you are a physician, this way of measuring things out of context, just because we can, would be akin to measuring the percent of patients sitting in your waiting room at a random date and time with a blood pressure under 130/70, and deciding that you are a good doctor if they all do, or a bad one if they don’t, whether you are a pediatrician, a geriatrician, or if you practice in a posh suburb, or tending mainly to indigent and homeless folks, or if it just so happens that this is the time when you do sports physicals for the local boys’ lacrosse team.

To continue on this path to oversimplification, there is a much circulated drawing in the circles of EHR usability experts (created by a former colleague of mine, Eric Burke), depicting three screens: the first shows an Apple screen with one word on it - “touch”, the second shows Google’s famous home page with nothing but a Search button, and the third is a cluttered data entry screen supposedly belonging to an EHR. This drawing is supposed to impress upon us how horrific EHR designs are by comparison to “other industries” and other software products we use in our daily lives. I’m not totally sure what the Apple screen is supposed to symbolize since touching a blank screen does nothing for me (sorry, Eric). I do understand the Google search screen and I agree that if you only want to do one thing, you should only have one button. When you want to do many things, many business and enterprise type things, it would be more meaningful to compare an EHR screen to say, SAP, or Siebel, or Epicor, or Photoshop, or any serious CAD application. The results of such comparison may surprise some usability experts, who seem to have all the answers. EHRs are not leisure applications for consumers and EHRs are not gaming platforms. To use the automobile example one last time, EHR is to iPhone and Facebook what a Ford F-150 is to a Little Tykes Cozy Coupe.

In conclusion, I would like to leave you with a screenshot of a widely used EHR. It indeed defies almost every single usability expert generated opinion on what good design should look like. However, if you look very carefully at the top-left of the screen, you will see that this is a screenshot from VistA, the VA EHR, designed and built by clinicians for clinicians. I have not met a single doctor who used VistA and did not really, really like it.

Click picture to enlarge

So let me ask again, who do you think should decide what a good and usable EHR should look like, a Government usability expert or Dr. P?

The Kübler-Ross Model of EHR Adoption

Elisabeth Kübler-Ross, MD

For over a hundred years the paper chart has been a trusted partner and best friend to many physicians and nurses. The paper chart was born the day a new patient walked into the office, a pristine, crisp and neatly color-coded folder, with just the right markings in carefully shaped calligraphy on its covers. As the years went by, the paper chart grew in size, acquired meaning and wisdom, and like most of us, became a bit tattered around the edges and heftier in the middle. It felt good to hold the elderly paper chart in your hands and its voluminous physical presence inspired confidence and trust. The paper chart is dead. In some places the paper chart’s pages are still turning slowly, but we all know its long, productive life has come to an end and someone should pull the plug and call it. Or do we?

In 1969 Elisabeth Kübler-Ross proposed a 5 stage model for typical grieving behavior. The various reactions from the clinical community to the apparent demise of the paper chart exhibit almost textbook adherence to the Kübler-Ross model, with each clinician advancing through the five stages of grief at his/her own pace*.

Denial – This is a joke. These people don’t understand medicine and this entire Obamacare thing will soon go away and we’ll return to normalcy. My practice is doing just fine on paper and my patients get all this fancy medical home care right here and always had. They actually get better care. Besides, I have patients to see and I am too busy to tinker with these fads that come and go every five years or so.

Anger – This is a cruel joke. This EHR thing is just a government ploy to punish doctors and enslave them. There’s nothing in this for me and you want me to pay for it?? We are all going to stop taking Medicare, Medicaid and all your government plans, which don’t even pay for my receptionist, see what you do then. Heck, why stop there? There will be no doctors left, period, because nobody is going to accept such humiliation and no bright students will choose medicine as a career. We can all do much better doing other things. I didn’t go through ten years of medical school and residency and pissed my entire youth away just so I can become your personal data entry clerk. You want data? Enter it yourself and feel free to treat yourself too. Go Google it, or go to an NP at the grocery store. Not to mention that these EHR contraptions are killing thousands of people every day because nurses are tending to EHRs instead of patients. Is that what you want? Suit yourself. I’m out.

Bargaining – This is not happening to me. This does not have to happen to me. I am a doctor. If I stop playing their game, they’ll have no way to touch me. I will only take cash, at least for a while, until this thing blows over. My patients love me and I will take better care of them than any computer can. They know that. They are willing to pay for a true doctor/patient relationship and my undivided attention. I have friends that switched to concierge practice and they’re doing great. I’ll practice good medicine, and in time everybody will come to their senses and see that this is the right way to care for people. They will see the errors of their way and everything will be back to normal. I just have to make it through the next couple of years.

Depression – What’s the point? Why did I have to sacrifice my entire life and work like a dog for these ungrateful people? There’s no respect any more. There is no gratitude. There’s no money in this either. I should have gone to law school and spent my time ripping everybody off like those shyster lawyers do every day. They want me to be a cog in their Toyota production line for people. I don’t know anything about computers. I can’t even type. Why should I? Doctors don’t type. There is no point. Can’t even give this practice away, let alone sell it; might as well just walk out right now. I have a little money. I don’t need to work. I’ll retire early. I’ll play golf all day. Maybe go into consulting for those thieving insurers. One thing’s for sure: no child of mine is ever going to medical school. It’s over. 

Acceptance – This EHR is really primitive. Costs a fortune, but the hospital kicked in for most of it. They want to measure my performance; fine with me. I’m a good doctor and I take good care of my patients. I don’t like using the computer in the exam room. My nurse does though, but you should see her texting, and my receptionist says it’s better than the old system. I wish I could get the hospital labs, but they’re still faxing them over. They say it will get better. I don’t know. I have an iPhone and it has an app for medications, which is really nice. I have email and some patients use it. Not too many, but it’s nice too. I signed up for this new telehealth program starting in the fall. My father practiced for 40 years down in the valley. He wasn’t home much, but sometimes he took me along on house calls. Saw the first baby born when I was eight. I don’t think you can deliver a baby on telehealth, can you? Well maybe if there’s a midwife out there and you watch just in case… Never mind. I love practicing medicine. It’s hard right now, but I think I have another ten-fifteen years left in the tank, and if it gets much tougher, maybe I’ll just go work for the hospital. They already have my charts anyway.

But here’s the deal, folks: the chart is not really dead. It just underwent major reconstructive surgery. It has new legs and new organs and a new face, because, unlike people, they can do that for charts nowadays. Sure, it looks terrible right now, all stitched up and bruised and so very helpless, hooked up to wires and machines. It can’t do anything for itself. It moves slowly and sometimes just collapses under its own new weight. You will have to teach it how to use its new legs and train it to engage all those brand new bionic organs. It will take time and lots of physical therapy. It is a big commitment and there will be setbacks and more surgeries down the road. You could just walk out and leave it to its fate and to others to nurture it back to a useful life. Or you could take it home and tend to it, and every day be amazed at small miracles and watch it slowly get stronger, better and more beautiful, surpassing your wildest expectations, until it becomes the indispensable, trustworthy  and useful friend it always has been, with a brand new lease on life for you both.

*All first person utterances in this post are fictitious. Any resemblance to what anybody may have said or communicated to the author during times of great frustration is purely coincidental. 

Shared Sacrifice

The Internet is abuzz with Attestation fever. CMS has officially opened its website service for physicians and Hospitals to attest to achievement of Meaningful Use for 2011. It is expected that stimulus incentives, as mandated by ARRA’s HITECH Act, will soon be flowing out to the new Meaningful Users to the tune of $20 Billion (or more) over the next five years. Meaningful Users are a very diverse population and range in scope from a solo practice in the middle of nowhere with a rickety EHR purpose bought for these incentives, to Kaiser Permanente with thousands of employed physicians, dozens of hospitals and gold-plated enterprise technology worth many billions of dollars, purchased and implemented years before HITECH saw the light of day.

Last year Becker’s Hospital Review published a list of “52 Not-for-Profit Hospital Systems to Know”. Those are the largest and most excellent integrated health delivery systems in the country. Between them these 52 leaders in health care delivery have about 900 hospitals of various sizes and most have hundreds and thousands of employed physicians, both in inpatient and outpatient practice. Many of these organizations are faith based and were founded years ago with the goal of providing care and comfort to the sick. Today, these non-profit systems are leading the way in quality improvements, adoption of health care information technology and innovative ways to provide better and more cost-effective medical care, and most, if not all, have healthy and profitable bottom lines, while actively engaging in charitable contributions to their communities.

As CMS is gearing up to disburse the ARRA stimulus incentives, it stands to reason that a significant portion of the money would go to these non-profit leaders of our health care system. As anyone trying to figure out the exact amount of incentives for any given hospital knows, the exact calculations are rather cumbersome. HIMSS estimated that the Medicare incentives for a hospital could range from $3.5 million for a 75 bed facility to over $11 million for a 750 bed hospital, over the entire stimulus period. It is worth noting that, unlike physicians, hospitals can qualify for both Medicare and Medicaid incentives, significantly increasing the estimated amounts for Hospitals with a large enough Medicaid population. What follows is a very conservative attempt to estimate the percentage of the proposed $20 Billion ARRA incentive that will more than likely flow to these 52 non-profit Hospital systems.

Let’s assume that the average hospital in this group will collect only $5 Million from both Medicare and Medicaid, which puts the average hospital at about 200 beds and accounts for some hospitals that will not be able to qualify for incentives. Let’s also assume that an outpatient physician has 5000 patient visits per year (which is very high), and when encounter data is not available, let’s assume that only half of employed or affiliated physicians qualify for incentives under Medicare, and none qualify for the higher Medicaid stimulus. For very large systems, where data is not readily available, let’s assume that there are no eligible professionals and all incentives will come from the Hospital side of the house. Based on these very conservative assumptions and any 2010 annual report data found on various systems websites, here is how some numbers shape up:

• Kaiser Permanente – 35 hospitals and 36.6 million doctor visits – is looking at about $0.5 Billion total incentive payments.
• Trinity Health – 45 hospitals and about 8000 physicians – will collect around $0.3 Billion in the next five years
• Sutter Health – 25 hospitals and 3500 physicians – comes in at around $0.17 Billion in incentives
• Providence Health – 26 hospitals and 7 million visits – will qualify for almost $0.2 Billion
• North Shore LLJ – 14 hospitals and 7500 physicians – should obtain over $0.2 Billion in stimulus payments
• Intermountain – 23 hospitals and 750 physicians in their medical group – will receive well over $0.1 Billion

All in all, if we just consider the 900 hospitals these systems have in common, and ignore the outpatient payments, the total incentives due are around $4.5 Billion total. This number will go up significantly if we account for the various eligible professionals payments, running at $44,000 per physician under Medicare.

In the large scheme of things, a few Billion dollars is not that much money. Withholding those billions will not fix the deficit and will not put a visible dent in our health care expenditures. No single act of savings will solve the dire problems present in our health care system and the country in general. President Obama is calling for us all to contribute to a solution and share the sacrifices needed to rectify the situation. In a perfect world, Shared Sacrifice is not something that should be imposed by government. It should be a grassroots effort where everybody agrees to give up a little and come together in one unified force for the public good, but someone has to go first, someone has to step forward and make the first sacrifice. Today is Good Friday.

To these 52 benevolent paragons of health care, in the spirit of the selfless and saintly men and women who, many years ago, founded your organizations with the single mission of aiding and comforting the sick: Don’t take the money. 

And if you must take the money, because of irrelevant legislative technicalities, turn around and give it all to the poor and sick and needy people in your community. A few billion dollars will not solve the big problems, but a few dollars may be enough to provide a sick elderly person one more hot meal, or buy one more pair of glasses for a child so he can stay in school, or provide one more bottle of prenatal vitamins to a pregnant woman and maybe even allow for one more hospice day for a dying man. And above all, you will set an example for us all, and maybe even change the spirit of this country, so we can all do better by doing good first.

The Health Insurance EHR

Kaiser Health News recently published excerpts of an interview with the CEO of Aetna, Mark Bertolini. Interesting article and interesting subject, but one thing Mr. Bertolini said in connection with Aetna’s acquisition of Medicity, a vendor of Health Information Exchange (HIE) platforms, caught my attention: “We are as much a health information technology company as an insurer”. United Healthcare has also been engaged in significant HIT acquisitions for quite some time. They bought an EHR, Care Tracker, and an HIE vendor, Axolotl, amongst other things. According to the Aetna CEO, in order to create a system that functions properly, insurers “have to be able to provide an infrastructure”.  So is this the future? Will health insurance giants be providing insurance coverage to customers, and HIT infrastructure, including EHR software, to physicians and hospitals?

Most HIT experts are forecasting consolidation in the EHR market, which is currently fragmented into hundreds of less than optimal disparate software products, but is anybody seriously contemplating that the emerging forces in health care technology will be the payers? If you think about this for a moment, and if you remember doctors’ plight that EHRs mostly benefit payers, this outcome doesn’t seem so far-fetched. After all, selling health insurance and selling EHRs follows pretty much the same paradigm.

• Company Website – Health insurance companies have beautiful websites loaded with pictures of happy people and the cutest babies. EHR vendors have equally high-gloss websites with lots of Flash banners, happy doctors holding shiny tablets in pristine clinics, and, strangely, some also have the cutest babies and toddlers bouncing on every page. Neither one has any useful information for someone shopping for a product unless, of course, you provide them with your contact information, in which case you will be getting a very energetic sales call.
• Price Transparency – When you buy an insurance policy, all you know for sure is what premium you will have to pay every month. Most folks don’t realize until it is too late that they will have to pay for all sorts of other things that are “not covered”. Similarly, when you buy an EHR for $399 per month, little do you know that there is at least the same amount of hidden charges, and unexpected “upgrade” fees imposed whenever the vendor feels that it needs to improve its top line.
• Contracts and Policies – Health plans have notoriously long and convoluted policy documents aimed at confusing the buyer. I don’t know too many people who are competent enough to read and understand their content. EHR vendors are a bit ahead of the game here since they also have carefully staged vaporware demos and their contracts, although shorter, are as good as the payers’ policies in obfuscating real terms and conditions, which become painfully evident only when disaster strikes.
• Freedom of Choice – Most people, including the vast majority of employed citizens, has increasingly little to say about which health insurance plan they end up with. Employers, who pay a large portion of the cost, either pick a plan based on business considerations, or just self-insure. Employees are forced to do the best they can with whatever they were dealt. As more and more independent physicians are being acquired, and salaried, by large systems, they too have very little to say about what EHR will end up in their exam room. Those who are still somewhat independent, but herded into various affiliations, are rarely able to check a gift horse in the mouth and end up taking whatever the large system is providing under Stark law relaxations.
• Rationing – Health insurance is expensive. The wealthy and those with large and conscientious employers are able to gain access to fairly decent insurance coverage. Some may even have so called Cadillac plans. The poor and unemployed must shop for insurance with no bargaining power and their dollar usually buys a lot less coverage. Large hospitals and specialty medical groups can afford to buy the fancy gold-plated EHRs and they often do. Small and rural primary care practices can’t even come close to being able to afford an EHR from an industry leader. And similar to the private insurance market, a solo doc, with no bargaining power, will end up paying more than a physician in a large practice for the exact same EHR.
• Government – Unless you live on a deserted island, you know that by 2014 the individual mandate will be kicking in and everybody will have to buy insurance or pay a penalty. Also by 2014, every American is supposed to have an EHR, which means that every physician will have to buy EHR software, or pay a penalty in the form of reduced Medicare reimbursement down the road. Both regulations may be viewed as voluntary since you could choose to pay the penalty, which is much lower than the price of the mandated products. And in both cases Government proposes to determine the minimum requirements for what you can buy to avoid penalties.
• Product Design – We all know that health insurance policies are designed by bureaucrats and bean-counters to maximize payer profits, with complete disregard for patients’ lives and doctors’ advice (or at least that seems to be the common wisdom). The parallel mythology asserts that EHRs and HIT products are created by “programmers” and other “geeks” with no knowledge of, and no respect for, established clinical workflows and with the same disregard for patients’ lives and safety.
• Good Ole’ Days – Ah, those days gone by, days of beautiful simplicity, when Government minded its own business, and everybody paid for medical care out of their own pocket, except those who had nothing in their pocket. Those days of wonder when the most medicine could offer was lancing boils and mustard plasters in return for a hefty slice of rhubarb pie, and an amputation went for a couple of chickens. The olden days with hospitals run by selfless nuns in full habit, doing God’s work on earth, where the very sick were freely admitted, but nobody was ever discharged. A gentler era when people died at home from romantic ailments like consumption, surrounded by family and friends, or succumbed en-masse to plagues with mysterious “putrid” origins. The days of golden fountain pens and neatly stacked notecards in little clinics manned by workaholic doctors and spinster nurses clad in white starched uniforms.  Yeah, well, that’s over now.

We are entering the Big is Beautiful era in health care. Big government with big regulations, created in deference to big corporations, will only allow big insurers and big health care delivery systems to thrive. They will be using big computer programs with big algorithms simulating big artificial knowledge and intelligence, administering to the big needs of big populations with big risks and big payoffs. Not to worry though, big insurance has figured this all out, as evident from Mr. Bertolini’s big vision:

“We will shift risk (financial responsibility for medical costs) to the provider system. We’ll provide them cover with capital as re-insurers. We will be the Intel-inside, if you will. We have dozens of these conversations going on with major systems. We spend $400 million a year on new developments: We are as much a health information technology company as an insurer. Our U.S. health system is not really a system as much as a bunch of independent players. How do we create a system that functions properly? When my dry cleaner knows more about the whereabouts of my shirts than my doctor knows about the whereabouts of my X-rays, we have a problem. We have to be able to provide an infrastructure. ”

Yes, just like dry cleaning. We find the X-rays and we’re all good. Brilliant!