Why Doctors Will Never Ever Like EMRs and How to Change That

EMRs are not designed for patient care. Is there anyone working in health IT who can honestly say that he or she never heard this statement being made hundreds or thousands of times? Is there any clinician actually working with patients and EMRs who can state that such thought never crossed his or her mind? This includes health IT evangelists and physicians spearheading IT initiatives at the most excellent of centers of excellence. People complained that EMRs are not designed for patient care seven years ago, when the first EMR certification body was created. They said the same thing four years ago when billions of dollars were made available for the purchase of EMRs. They kept insisting even as use of EMRs was becoming widespread two years ago, and the chorus remains unchanged today: EMRs are not designed for patient care.

Seven years is an eternity in the world of computer technology. Seven years ago Motorola and Blackberry ruled the world and the iPhone was getting ready to be born. Seven years ago something called Twttr was released and Facebook launched a high-school version of itself. Seven years ago Ken Jennings was undisputed king of Jeopardy and IBM’s Watson was wrong 85% of the time. We’ve come a long way, baby, but EMRs are still not designed for patient care. Why is that? The most common explanation is that EMRs were designed for billing and cannot be changed. But if a program designed to play Jeopardy can be expanded to practice medicine, surely seven years is more than enough to refocus EMRs on something other than billing. The second most common reason given for the inadequacy of EMRs is the inadequacy of those who build them; because we all know that all great programmers work at Apple, unless of course, they work at Twitter or IBM or somewhere in Verona, Wisconsin. More seriously, the third explanation for EMRs failure to help with patient care is the onslaught of government regulations for EMR design.

Many, including yours truly, are arguing that EMR vendors are so busy meeting regulatory mandates that there are no resources available to make customers happy. On second thought though, are we saying that giants like GE that owns half the planet, or McKesson with its astronomic CEO compensation, or that one place in Verona, are unable to spring a few bucks for half a dozen developers to make EMRs better for patient care? Are we saying that a market chockfull of very wealthy customers railing for a solution cannot attract even one manufacturer willing to solve the problem and collect billions of dollars in return? Surely we are not saying that seven years is not enough time for writing an EMR that is designed for patient care. On September 12, 1962, President John F. Kennedy, in a speech at Rice University, officially launched the race to the moon. On July 20, 1969, Neil Armstrong and Buzz Aldrin walked on the moon. It took seven years.

EMRs are not designed for patient care because our medical system is no longer designed for patient care. Our medical system is being redesigned to provide health services to consumers, and EMRs are morphing into superb tools for a service industry.

• EMRs are designed to collect increasingly detailed customer information.
• EMRs are designed to facilitate market research.
• EMRs are designed to standardize and automate transactional complexity.
• EMRs are designed to smooth handoffs across the supply chain.
• EMRs are designed to orchestrate and monitor production lines.
• EMRs are designed to minimize production costs and maximize revenues.
• EMRs are designed to provide quality assurance based on exact specifications.
• EMRs are designed to prevent and quickly detect malfunction and non-compliance with specifications.

To be clear, most EMRs can’t do all these things just yet, but they are being redesigned along these lines, because these new EMRs are foundational to what David Cutler, a Harvard Applied Economics Professor and one of the most influential health care policy makers, calls the “information technology revolution”. In a surprisingly candid article Prof. Cutler is describing the future health care system as designed by him and his distinguished colleagues, and as currently implemented by our government. The title of his article is self-explanatory: “Why Medicine Will Be More Like Walmart”. It is very possible that as EMRs are being carefully repurposed, they will also be made more intuitive, more iPhone like, glossier, faster, more colorful, and generally more appealing, because it is imperative right now that physicians use them consistently, and preferably without much turmoil. Why? Let’s hear from Prof. Cutler: “The introduction of information technology into the core operations of hospitals and doctors’ offices is likely to make health care much more like the retail sector or financial services. Health care will be provided by big institutions, in a more standardized fashion, with less overall cost, but less of a personal touch”. And, if I may respectfully add, increased convenience and instant consumer gratification to be balanced by lower quality, lower wages, rampant fraud and mass exploitation of both workers and customers. A veritable paradise for well-adjusted proletariat.

Yes, physicians will be using EMRs in larger and larger numbers, but there is zero probability that today’s doctors will ever like using EMRs, because nobody goes to medical school (or any school) hoping one day to land a job at a Walmart lookalike. So the logical remedy for doctors’ dislike of emerging Walmart EMRs is very simple: get rid of doctors. Right now we are told that there is a looming shortage of physicians, so we must find ways to deliver medical services without doctors, and hence we must automate, computerize and delegate medical care. Very clever idea, because once we downgrade services and have people accept this new paradigm, we can make the circular argument that we need even fewer doctors. Indeed Prof. Cutler goes on to prophesize the demise of small independent practice and small hospitals along with most conventional doctoring, which will be replaced by computer-aided self-diagnosis and crowd sourced clinical advice (something to do with Amazon, I think…). He still sees a need for a few doctors here and there, mainly “to direct patients to the right specialized resources, to reassure those in need, and to comfort the terminally ill”, which we are told “is a noble calling nonetheless”.  Noble calling indeed, but it should not require an MD or fifteen years of preparation, and hence it will not command much attention or compensation. The Walmart “doctors” in David Cutler’s future of health care will be happy to like their EMRs, or whatever else they are told to like.

Oh, by the way, no need for panic... I am fairly certain that they will have separate little venues serving Dom Perignon and Beluga caviar with Harvard Medical School educated physicians on the side.

The Passion of the Health Care Fixer

The first President to take a shot at fixing health care was a Bull Moose trying to become President one more time. Unfortunately Teddy Roosevelt failed to win those elections and instead of providing “protection of home life against the hazards of sickness, irregular employment and old age through the adoption of a system of social insurance”, America took the low road leading to the Great Depression. Fixing health care was on the minds of all subsequent occupants of the White House, from FDR to Barack Obama, to varying degrees, but as America’s circumstances and character evolved over many decades, so did the understanding of why and how health care should be fixed.

For Franklin D. Roosevelt “[t]he right to adequate medical care and the opportunity to achieve and enjoy good health” were part of a second Bill of Rights to provide security at home for all Americans. It was a lofty attempt to “assure us equality in the pursuit of happiness".  FDR failed to implement his progressive fix for health care, and Harry Truman although even more passionate than his predecessor, achieved little in his own health care fixing attempts. It fell to Lyndon B. Johnson, a southern democrat, to create Medicare and Medicaid, taking the first step towards Truman’s vision of a “national system of payment for medical care”. Although much tinkering and heated rhetoric followed, the second step was never taken. Until now.

As our President expanded Medicaid to include a larger fraction of the growing masses of poor people, and created federal subsidies for unofficially poor people to purchase the now mandatory health insurance, an army of experts at everything from Toyota manufacturing systems to silicon chips design are professing their passion for fixing health care. But the passion of today’s health care fixers is different. When Harry Truman spoke of health care, he spoke of those who “suffer needlessly from the lack of proper medical care”. And FDR spoke of the dangers of being content when “some fraction of our people—whether it be one-third or one-fifth or one-tenth- is ill-fed, ill-clothed, ill housed, and insecure”.  John F. Kennedy spoke of “working men and women” subjected to the indignity of “being forced to beg for help from public charity once they are old and ill”.

Today, we speak of the imperative to cut health care expenditures and the need to balance budgets and reduce deficits. Our sympathies are with employers who are contributing too much towards workers’ health care, and we argue that freeloaders must be prevented from getting health care at our expense, and that the poor must be diverted from seeking care at expensive medical venues. The passion of contemporary health care fixers is not about human pain and suffering. It’s not about humiliation and social injustice. It’s not about preserving freedom and democracy or pursuing happiness. It’s not about the people at all. It’s about money.

It was a late evening sports injury resulting in a swollen ankle in fifty shades of purple. After nipping the ER idea in the bud, and dutifully waiting until the next morning, I made a same-day appointment with a reputable orthopedic practice and a doctor we never met before. There was no waiting and the sweet and friendly nurse breezed through all the meaningful use nonsense, which was not pertinent to this visit in any way, and then she and her laptop left the room. The doctor walked in thirty seconds later, with no laptop, no chart and nothing else in his hands. Soft spoken and businesslike, he examined the ankle, ordered the obligatory x-rays, walked out and several minutes later walked back in telling us that nothing is broken, but we’ll be getting a boot to help the healing process, and then walked out again. Exactly what I expected from a specialty visit. But then something strange happened. The nurse could not find a proper Ace bandage and while she was fumbling in the hallway, the doctor walked back in, pulled a little package from some drawer, sat down on the low stool and slowly and methodically bandaged the swollen ankle, making small talk about bandages always being the wrong size. So here was this distinguished orthopedic surgeon, specializing in knee and hip replacements, wrapping an elastic bandage around a little girl’s mildly sprained ankle. He was definitely not practicing at the top of his license, and neither was his nurse, and during those 30 seconds of pure waste, the aloof stranger became my daughter’s doctor. She would keep the boot on although it looked yucky, and she would make an effort to put weight on that foot, and she’ll come back in two weeks to see him, and the doc was smiling faintly as he was leaning against the door before we left.

If FDR had his way, fixing health care would extend the best health care in the world to all people “regardless of station, race, or creed”. If we have our way, and we will, this type of health care will cease to exist for most Americans, because there is no ROI for highly trained surgeons to tend to children’s falls and bruises, unless of course the child happens to live in the ruler’s palace, or Bel-Air, or Alpine NJ. Fixing health care today means learning from India or Nepal, or any random third world country mired in corruption or despotism. Fixing health care means spread of innovation where people who can barely afford breakfast dispense medical advice from mobile vans parked on street corners to those who are immobile in many ways, while calculating the exact dollar amounts of savings realized by such bold innovation. And fixing health care means cool technology.

Technology of the type recommended to fix health care is manufactured for pennies a day, by children existing in those countries we are supposed to learn from; children who were not lucky enough to be born in the greatest country in the world. Harnessing the wonders of technology to fix health care means giving all poor people a shiny blue button to click on, so they can see how well the mobile van driver cared for them, and perhaps share the information with the next mobile van that will be tending to their needs. I can’t begin to tell you how distraught my daughter was when realizing, that unlike the 60,000 former soldiers residing on park benches across the country, she had no blue button to click on. There were no open-notes for us to peruse the next day, and neither the doctor nor his team of people searching for Ace bandages, made any attempts at partnering with us, and we were not empowered to choose wisely. Nobody suggested that the follow up visit be with some “other care giver”, or be conducted electronically from the comfort of our home. I guess, my daughter’s orthopedic surgeon is not a passionate health care fixer, so he forgot to flip his clinic.

But more than anything else, today’s highly educated health care fixers are passionate about knowledge, because you cannot cut costs of things you don’t know about. Imagine how much more effective caring for a sprained ankle could be if I only knew exactly what the surgeon got paid for all the knee and hip replacements he performed last year, not to mention the ability to have a list of every prescription he wrote, every test he ordered and every pharmaceutical bagel he ate since the sun began shining. They used to say that knowledge is power, but in our fixed health care, knowledge is also money, and lots of it. As Robert Henley, 1st Earl of Northington and the Lord Chancellor of Great Britain observed in 1762, and as Franklin Delano Roosevelt, the President of the United States of America reiterated in 1945, “[n]ecessitous men are not free men". Since both “necessitous” and “free” are now relative terms, thus open to personal interpretation, perhaps it is unfair to criticize the abundantly necessitous passion of health care fixers yearning to be free. I therefore preemptively apologize.

Alternative Health Information Technology

Say you are a pediatrician in an average middle class lily white suburb and most of your little patients are either sitting stiffly in the pews next to you or are elevating your spirits with angelic voices clad in white robes on a blessed Sunday morning. Say little Johnny trips on his way down the altar and ends up taking a ride to the ER to have his forehead stitched. Does the ER doc need to know that the 13 year old altar boy is not a smoker? Does he need to know that Grandpa Joe died from prostate cancer, but other than that the family history is unremarkable? Does the nurse washing Johnny’s forehead need to be informed that the boy has a history of ear infections and had tubes put in when he was 3 years old? Not a fair example, right? Let’s cross the 8 Mile road and look at another Johnny who shows up at the other ER at 2 am with two gunshot wounds to the chest. Does anybody on his care team gives a damn about Mom suffering from depression and diabetes, or the fact that Johnny is a current smoker of tobacco products and has been counseled on cessation? Yes, I know, sometimes these things are pertinent, and sometimes even more details are needed, but not always, and not always the same details. Unfortunately, we are busy building a one-size-fits-all-circumstances infrastructure, which is destined to be too big for most, too small for some and ill-fitting for all but a random handful.

Leaving aside the troubled business side of medicine, electronic medical records are supposed to ease and simplify the capture, analysis and sharing of clinical information, by utilizing computer software tools. Computers have eased and simplified the capture, analysis and sharing of financial information, supply chain information, manufacturing information, transportation information, and every other type of industrial information you can think of, so why not medical information? Before you go pointing out that clinical information is highly variable and so very unique to the individual, please consider that computers have simplified and eased capture, analysis and sharing of personal information of all sorts from chatting and accessorizing outfits, to making friends and asking a pretty girl out on a date. Surely, nothing is more unique and personal than finding your soul mate. Not even health care.

If a physician practicing medicine in the U.S. today desires to ease and simplify the capture, analysis and sharing of clinical information, he or she can choose from a large assortment of computer software tools, better known as EHRs, all carefully examined and certified by government sanctioned entities to be capable of easing and simplifying these tasks, and as Pete Seeger might have said, “there's a green one and a pink one and a blue one and a yellow one, and they're all made out of ticky tacky and they all look just the same”. To the dismay of regulatory and certifying authorities, most physicians who are willy nilly adopting these tools, under threat of financial fines and penalties, continue to grumble that the capture, analysis and sharing of clinical information is neither eased nor simplified by EHRs, and quite the opposite is true.

This strange situation can be, and often is, dismissed as due to physicians being technophobes or just unwilling to do their share in promoting beneficial health reforms. To support these specious arguments, the regulators are constantly parading a handful of doctors who found happiness and efficiency in their EHRs. Unexplainable? Not really. There are always a few lucky folks for whom one-size tee shirts fit as perfectly as if the rag was tailored just for them, while the rest of us have to tuck it in, tie it in the back, cut it off, or pull at the sides to make it stretch, and in all cases it ends up looking like someone else’s garment. A quick look at what is driving health care costs up reveals that physicians as a group are cheerfully adopting things like magnetic resonance, computed tomography, image guided radiation, proton beam therapy, laser surgery, robotic this or that, and a host of other high tech tools that would terrify the average technophobe into crawling under the first available rock. So why is health information technology so different? Or is it?

• epocrates, the drug reference software boasts 50% of physicians in the U.S. as its users. epocrates has been steadily growing since 1998 and is practically a household name when it comes to medications advice. It is available on iPhones, iPads and mobile Android devices and it has expanded far beyond just lists of indications and contraindications for prescription drugs.
• UpToDate needs no introduction either. The widely used electronic clinical decision support system has been in existence for over 20 years and you would be hard pressed to find an academic institution that is not subscribing to its content and tools, both in the U.S. and the rest of the world. Like epocrates, UpToDate is available on the web and on all fashionable mobile devices.
• Doximity is a relatively new kid on the block, and a very interesting one to boot. Only 3 years old and already claiming to have “crossed the 200,000 member milestone”. Doximity is a communications platform for physicians allowing members to securely exchange messages, including clinical information, and make referrals or obtain ad-hoc consultations from colleagues. Sort of like a social network on steroids, and of course it is available on mobile phones and tablets too.

epocrates never bothered to obtain Meaningful Use certification for its main product, because what it does and what clinicians find useful is not a certifiable activity. It did however certify its feeble attempt at creating yet another ticky tacky EMR, and then proceeded to quickly dump the resulting stillborn. UpToDate obtained certification only for its peripheral patient education module, and Doximity is nowhere around the target zone of what the government decrees as meaningful use of technology. While both epocrates and UpToDate had ample time to solidify their user base before the advent of Meaningful Use, Doximity experienced its meteoric rise in spite of Meaningful Use and that should give us some hope that any day now, a couple of MIT grads in some basement may launch Patximity and make information sharing between doctors and patients as simple and as easy as apple pie. We can imagine that somewhere far from the limelight a doctor laboring in solitude will come up with the simple and easy to use Charximity to effortlessly capture thought processes at the point of care. And then someone will come up with something better or different or faster or smarter or cheaper…

Sadly, this crescendo of innovation is very unlikely though, because unless the new software is a clone of some primordial EMR, or parts thereof, and unless it conforms to government devised ways of doing things, most prospective customers will be forced to choose between a new and unknown product and the piles of cash thrown at them by regulators. If say, our imaginary Charximity developers come up with a quick and elegant way to record a dynamically defined set of information, and package it in a small, nimble and universal format that lends itself to being securely moved around the private networks of the fabled Patximity and real Doximity, in a most expedient way, chances are great that this cool innovation will fail to thrive because it can’t inform regulators on Johnny’s smoking status or Grandpa Joe’s prostate trouble, in an exhaustive XML format passed around through interminable chains of certified intermediaries on the federally secured national health information network. The good news is that one day checkboxes and dropdown lists will only exist at the Smithsonian, and good technology will prevail in the end. The bad news is that the end is being pushed further and further away with each additional Meaningful Use stage.

Meaningful Use Stage 2 Beta - A Suggestion

It’s that time of year again when Meaningful Use conversations heat up because all sorts of deadlines are approaching, and as expected, nobody is ready. Meaningful Use was originally intended to have 3 stages, each lasting two years. At the end of 2011, Meaningful Use Stage 2, which should have started in 2013, was postponed by one year and reduced to 90 days to allow vendors and providers enough time to build, deploy and implement new functionality required for Stage 2. As 2013 is drawing to a close and Stage 2 is practically upon us, a flurry of organizations is petitioning the Secretary of Health and Human Services (HHS) to delay Stage 2 just a little bit longer.

The College of Healthcare Information Management Executives (CHIME) fired the first shot back in May, asking for one more 12 months extension. Later in July, the American Medical Association (AMA) and the American Hospital Association (AHA), combined forces and jointly requested additional flexibility to be built into Stage 2 and that providers that are still at Stage 1 should not be forced to upgrade their software in 2014 (more on that below). The American Academy of Family Physicians (AAFP) followed with its own sophisticated proposal on how to better stagger the transition to Stage 2. Next, the Medical Group Management Association (MGMA) petitioned the Secretary to place a moratorium on all penalties for providers that achieved Stage 1, and to allow Stage 1 meaningful users to continue attesting for Stage 1 if they cannot obtain a Stage 2 certified product. HIMSS, the EHR vendors association, sent their letter in support of maintaining the current Stage 2 Meaningful Use launch schedule, but extend its first year to be 18 months long. Confused yet? Let’s detangle the mystery.

First and foremost, whether you began your Meaningful Use journey in 2011 or are about to jump in next year, this conundrum affects you directly, because beginning January 1st 2014 all meaningful users must implement and utilize 2014 certified EHR technology (CEHRT). Even if you plan on just attesting to Stage 1 next year, you cannot use just any old 2011 certified EHR. So all 300,000 or so eligible professionals who have previously attested to Meaningful Use Stage 1, plus all late adopters planning to enter the fray in 2014, will be out there trying to wrestle a good place in line for upgrades, training and installations. Most will do so only after January 1st, and all will have to be ready to start clicking the boxes no later than October 1st. That’s over 1,000 clinicians per day, not counting new entrants. Any way you want to look at it, it’s not a very likely scenario.

Much has been said in the various letters to HHS regarding the small number of EHRs that managed to get certified for 2014, compared to the seventeen hundred complete EHRs certified for Stage 1. This is true, and this may pose a completely different type of problem down the road when doctors realize that most of these fly by night products will soon disappear. However, as late as October 2010, we had less than three dozen certified complete EHRs for Stage 1, a number that grew exponentially in the following couple of years. My guess would be that by the end of the year all major, midsize and viable minor players will be 2014 certified. The problem this time around is that Meaningful Use Stage 1 has been rather successful and there are now about 6 times as many providers needing a new EHR as there were in 2011, and unlike 2011, those who fail to get their upgrades in time will not only lose an incentive, but will be financially penalized by CMS. It just doesn’t seem fair.

Delaying Meaningful Use Stage 2 by yet another year will obviously address the time crunch problem, but if we really want to be fair, we have to admit that another delay will look really bad for the program. Putting in place a complicated scheme of who should buy what and when, and who should attest to which Stage at which time, in an attempt to control the flow of upgrades, is bound to create much confusion in an already over specified and (needlessly) complex EHR certification scheme. So what should HHS do? Take another hit to its credibility and further delay Stage 2? Push forward full steam and deal with the consequences at a later date? Perhaps Meaningful Use is more like a Chinese finger trap at this point, and the best strategy would be to relax a little bit, and understand that 5 year plans rarely go as planned and that’s OK. Below is a humble suggestion to that effect. (Note: Here we are discussing the Eligible Professional measures. The Hospital equivalent should be straightforward.)

Meaningful Use Stage 2 Beta

There are three factors affecting the Meaningful Use program trajectory: time frame, requirements definition, software readiness. Unfortunately, we started by defining the time frame and then discovered that requirements definition and software certification did not fit in our predefined schedule and not even in our expanded schedule. Also unfortunately, we cannot control software readiness, since it depends on thousands of independent players that we can motivate, cajole or threaten, but that’s about it. What is left then? The requirements. The definition of Stage 2, or any other Stage, is not immutable even at this late junction. Those who made the rules can change them ever so slightly to allow a hybrid Stage 2 Beta (see figure below) to be inserted between good enough and perfection.

Proposed Meaningful Use Stage 2 Beta vs. Current Meaningful Use Stage 2 (click image to enlarge)

When compared to Stage 1, Meaningful Use Stage 2 introduced 4 types of changes:

1. Higher thresholds for existing measures
2. Transition of optional (Menu) measures to required (Core)
3. New measures (Menu and Core) for existing EHR functionality
4. New measures that require new software to be built (Menu and Core)

The changes in #1 and #2 can be all satisfied with 2011 CEHRT. #3 can be satisfied by most 2011 CEHRT, and even some of the #4 measures are already deployed in the better 2011 CEHRT. Splitting and transitioning portions of a handful of #3 and #4 measures from Core to Menu, will allow the 300,000 providers that already attested to Stage 1, to seamlessly move on to Stage 2 Beta without much turmoil. All in all we are talking about 5 such changes from Core to Menu, plus allowing for the increased number of clinical quality measures to continue to be submitted through attestation if necessary.

1. CPOE for labs and radiology capabilities were present in all good EHRs long before ONC certification came into play.
2. Patients access to health information is, by definition, what patient portals are for, and many 2011 CEHRT used portals to become certified. True, ability to download and transmit information is rarely there if at all, but although this is a 2014 certification requirement, it is not a Meaningful Use actual requirement.
3. Having the EHR suggest education materials based on patient health status has been around for a decade, and the better 2011 CEHRT already have that built in.
4. Secure messaging through a patient portal is part and parcel of any patient portal. More exotic forms of messaging which are required for 2014 certification are optional for users (same as #2).
5. Electronic health information exchange is only available for a minority of users, for reasons other than EHR capabilities, which should have been present in all 2011 CEHRT.
6. Electronic submission of clinical quality measures is possible from 2011 CEHRT that have a CMS approved registry. There aren’t that many and insisting on the methodology here seems a bit petty.

The proposed Meaningful Use Stage 2 Beta is achievable with 2011 CEHRT, and allowing it to be used along with the 2014 CEHRT for an interim Stage 2 Beta, should provide immediate resolution to the problem at hand. Since most 2011 CEHRT contain functionality to meet the problematic measures anyway, my guess would be that these newly designated Menu measures will be very popular with Stage 2 Beta attestations, particularly because many of the current Stage 2 Menu measures are heavily dependent on non-existing third party infrastructure. And just so CMS doesn’t feel that it is giving away too much by allowing 2011 CEHRT to be used for a slightly less stringent Core set, let's up the ante on the Menu measures and require that 5 are satisfied instead of the current three. If I was working on Meaningful Use 2 Beta, I would pick the first 4 items above, plus visit notes or family history from the current Menu items (no decent EHR comes without notes and histories).

The difficulty with this Meaningful Use Stage 2 Beta proposal is that all downgraded measures have something to do with the much debated subject of interoperability, thus Stage 2 Beta could be erroneously construed as a retreat from interoperability in general, and so called patient engagement in particular. It may be so, but to a very small degree, since there is no way to pick 5 Menu items without having at least 3 of them relate to interoperability/engagement. Besides, it is usually better to continue moving ahead at a slightly slower pace than it is to come to a dead stop, or alternatively keep going fast and furious over the impeding cliff. Personally, I would use the Beta period to evaluate the program to a greater degree than just how much money was paid out in incentives, and I would take a hard look at the incredible complexity introduced in the EHR certification program, because this too frequent and too invasive granularity is not sustainable, and is the root cause for the difficulties we are experiencing right now.

How to Hang Out Your Electronic Shingle

(Source: forgotten-ny.com)

When a doctor, a lawyer, an accountant or any other professional graduated from University, or moved to a new town, he or she would most often locate a nice little office, prepare it for the big day and hang out a shingle to let the world know that new services are available. The world back then consisted of the immediate neighborhood in the big city or an entire small town out in the country.  While waiting for the new shingle to do its thing, the new doctor would most likely join the country club, attend the pee-wee league games of his/her children, patronize local eating establishments and slowly the word of mouth would help build a new practice that would become a fixture in the community for years to come.

Fast forward to 2013 when nobody strolls leisurely where shingles are not hanging any more, and doctors rarely live and raise families within walking distance of their medical practice. Word of mouth has been largely replaced by text of iPhone and the enameled dangling shingles are now flashing electronic signs in the clouds. Heck even doctor services are increasingly delivered electronically from somewhere in the clouds. So when you push open the door to the coffee shop in the morning, chances are that nobody is going to ask you about their gout and nobody is going to say “morning Doc”, and neither you nor they will give a damn anyway. So if you are, or aim to be, practicing independently, you will need to upgrade your shingle for the electronic times.  

Shingle = Website

First and foremost you need to hang your shingle where it can be seen by prospective clients. If you have an established practice with a waiting list from here to Armageddon, you can safely close your browser now, and go take care of your patients, at least for the next couple of years. If you are not exactly in this enviable position, read on. You need a shingle on the web, a.k.a. a website. A Google Maps generic listing doesn’t count. A canned webpage with your name, address and hours of operations won’t do either, because the rules have changed. For the skeptical, harried and alienated modern person, your website should provide the same reassurance that a simple white rectangle with the word Doctor on it provided 50 years ago. You need a nice website with a minimum of four or five pages to keep people looking at your shingle a bit longer. As to content, look around for other doctors’ websites, see which ones you like better, and model yours in a similar fashion. A good place to look for structure is hotel websites. Yes, hotels. Hoteliers are trying to convey to customers that they are each very important and special, that they will be safe and comfortable, that the premises are clean and upscale, that staff is dedicated and highly professional, that booking is easy and extra amenities are abundant. If you have a sudden urge to throw up just about now, hire a kid to do this for you. A professional “medical websites” firm is not necessarily better and it will cost you ten times as much.

Location = Search Engine Optimization (SEO)

It is pointless to hang your shingle on highway H between endless fields of corn and soybeans (although I know at least one such practice that is thriving). Equally useless would be to hang a shingle from a 5th floor window, or by the back door, next to the big trash containers. Unlike physical shingles, electronic websites can be made to appear just where they are most visible to people most likely to need your services. Today, the equivalent of strolling down Main Street is searching for stuff on the Internet. Having your nice and readable shingle appear in just the right place, at the right time, for the right people, is called search engine optimization (SEO) in the Internet age. Frankly, it is a boring subject, even more so than designing your website, but if you want to read about it, here is a beginner’s guide, and then of course, there is the authoritative book written by Dr. Kevin Pho, which covers much of what we are discussing here. You should peruse these references even if you let one of your kids build the website (kids know all about these things), and even more so if you plan to shell out a few thousand dollars for a professional. Your goal, in a nutshell, is that when someone in your service area is searching for a doctor of your specialty, or a condition that you treat (much more tricky), your website will be the first entry on the first page of Google results. It will take time to get there, but you will never get there if you don’t start. And, yes, this is about marketing, and yes, doctors today are supposed to actively market their practice, just like everybody else. Feel free to pour yourself a drink before reading on.

Word of Mouth = Rating Sites

The means by which messages get from one individual to another have obviously changed. Actual “word of mouth” is still a useful communication channel for finding professional services, but most people looking for a doctor will ask Google first, and then proceed to review unsolicited recommendations from perfect strangers. The entire notion of new information being diffused through social networks has been turned on its head, unless you count planet Earth as one social network. You could argue that your practice is local and planet Earth is irrelevant. You could argue that your patients are older, sicker and that they don’t use computers. You could argue that only dumb people would trust anonymous advice on some random website. However, your small universe is now indistinguishable from the whole, and perhaps the patients you have now don’t use computers, but those who influence their decisions most certainly do, and besides we are talking about attracting new patients. As to rating sites, think about your most recent important purchase, and honestly try to remember how much weight you placed on the little yellow stars at Amazon, or their low tech predecessor at Consumer Reports. Not how accurate these turned out to be, but how much they influenced your purchase. Since you are not selling gadgets to the entire world, how can you make those little yellow stars (all 5 of them) appear next to your name? If you search randomly for physicians, you will see that the ones with star ratings have between one and a handful of reviews. This in itself is reason to discard the information as statistically insignificant, but yellow stars are a very powerful visual cue. Let’s get the ball rolling then.

Do you have at least one friend/employee that is/was your patient at least once or twice? Is one of your patients a physician also looking for stars? Did you call in a script for Uncle Joe last Christmas? Find your comfort zone and get yourself one 5 star rating. Since there are many places people can rate doctors, pick the one where you have some ratings and link it to your website (e.g. “Dr. Jones on Health Grades”), so people can easily find your ratings and continue to grow them. Some would go as far as suggesting that you should personally solicit that patients recommend you on the Internet. Meh…. What you should do though, is have social media buttons on your website (e.g. like us on Facebook, recommend us on G+). All people have to do is click a button, which most of us are willing to do, and there is no option to “hate us on Facebook”, so risk is minimal. Yes, it sounds humiliating, rather shallow in nature and a mega waste of your time. It is all of the above, except it shouldn’t take any of your time to get with the times (so to speak).

For completeness sake, we should mention another type of rating site that may be crucial to building a practice and obtaining referrals. Health plans are increasingly publishing “preferred provider” lists, or add some special designation to the preferred ones on their network listings. These preferences are based on much more complicated and time consuming activities (e.g. MU, P4P, PCMH), and we will address them in a future post. For now be aware that payers “recommendations” are coming and that this is not your grandfather’s word of mouth.

Community = Social Media

We cannot complete the electronic shingle discussion without addressing the new community concept, whether community at large such as Twitter, Facebook and blogging, or specific communities and forums for folks with a particular health concern. If you are reading this, then you are pretty familiar with social media, so we will dispense with preaching to the choir. Besides, if your practice is in trouble, there are better ways to spend your time and energy in the short term. Go back to the top and start with that electronic shingle, which is a prerequisite to anything you will ever do in cyberspace. If you are sitting idle waiting for patients to show up, you may want to consider adding a blog section to your website, but don’t even think about venting your frustrations there. If there’s anything left in the bottle, pour yourself another drink, or maybe switch to coffee, and write a short essay with the customary cliché advice on how to eat right and exercise. Your cyberpatients will love you for it. Cheers....

New Medicine – First, Show Me the Money

This is a warning shot across the bow of the mighty health care ship which seems to be changing course in search of calmer waters to carry the riches stowed deep in its rusty hull. I have no arsenal to fire anything more than sporadic warning shots through the descending darkness, but this ship is now on a collision course with the American people, the 47% that Gov. Romney scoffed at and an equal number that is yet to be awakened by the ringing disaster bells. The navigation chart used by the captains of this ship, mapping an America full of dumb and gullible people, too fat and too lazy to make any sudden movements as the corroding ship sails through their bodies, is woefully incorrect. Americans may be slower than most, more forgiving than others, but sooner or later, the health care ship will have to battle the people, and it will be sank, or emerge victorious at the conclusion of the American experiment.

A couple of weeks ago I wrote about Dr. Ezekiel Emanuel’s thinly veiled fury at the medical profession which seems reluctant to accept promotion to the rank of Puppet Captain of the health care ship. That is beginning to change, and this week’s issue of JAMA carries a brief manifesto from three physicians accepting the Captain bars and calling on all colleagues to do the same. The piece, titled “First, Do No (Financial) Harm”, is a succinct summary of health care’s new prime directive: First, Show Me the Money. Before recommending a course of treatment, doctors should first assess the patient’s financial capability. To deflect any remnants of ethical questioning, the authors suggest that assessment of financial status should be undertaken for all patients, not just the obviously poor. This in their learned opinion eliminates the appearance of discriminatory practice, and appearances are the major concern here, because this navigation strategy will have to be packaged by some Mad Men for consumption by the presumed stupid masses. [Note to EMR vendors: Perhaps financial prowess should be another vital sign that the nurse can collect during intake (e.g. how much can you afford to shell out of pocket? Nothing; Up to $100; Up to $1,000; Up to $10,000; Up to $100,000; No Limits), and decision support would be objectively provided by the EMR during Assessment & Plan. This should probably be added to Meaningful Use Stage 4.]

The example provided in the article is of course treatment of mild back pain, which requires no treatment. This, and MRI for headaches, or antibiotics for a cold, are the preferred examples to illustrate the benefits of cost consciousness by both providers and consumers. Nobody dares venture into the conversation that will have to take place with a cancer patient, other than Oregon, of course, which is mandating that this “conversation” takes place before the state will pay for anything. If the “conversation” did not result in the impoverished, sick, depressed and frightened patient asserting his or her “cultural values and preferences” to forgo expensive treatment (as all poor people should), the State will pull the plug anyway, thus empowering those who fail to be empowered on their own.

Let’s go back to MRIs and physical therapy for back pain which is a subject better suited for polite conversation. The authors provide us with a very thoughtful script on how a doctor would go about the difficult conversation of gently avoiding overtreatment of back pain. First you find out if the patient has any money in their wallet, then you proceed with the unrelated task of explaining that an MRI is clinically inappropriate. The latter can probably be skipped if the empowered patient doesn’t know enough to ask for an MRI. The next step is to tell the (poor) patient that beneficial treatment, like physical therapy is too expensive for him/her, and suggest self-care at home (an illustrated sheet of exercises should help). To round it up for those with no money and no real insurance, you could amicably suggest the patient’s “local yoga class”. This is how you “[o]ptimize care plans for individual patients”.  The optimal care plan for someone living on the 10th floor of a housing project is most definitely a “local yoga class”. Marie Antoinette must be smiling in her headless grave.

A couple of years ago, my son’s friend, Kenny, got injured during a football game in his high-school senior year, and needed surgery on his knee. Since Kenny did not have a car, and even if he did he was in no condition to drive after surgery, my son drove him to the downtown clinic for post-op follow-up. Kenny came out of the exam room limping cheerfully since the nurse said that he is all good to go and does not need to come back. My son, having had his own surgical encounter with football’s unintended consequences earlier that year, was a bit surprised and asked where Kenny should go for his physical therapy.  According to the friendly nurse, Kenny didn’t need any fancy PT. The boys walked out, one furious and the other limping and smiling sheepishly. I haven’t seen Kenny since that year and I don’t know if he is still limping, but this formerly bubbly and faster-than-the-wind running back has not shown up at the traditional, and immensely popular, Thanksgiving high-school reunion football games ever since.

From the dawn of civilization to the current day and most likely well into the future, the rich and powerful in all social orders enjoyed better access to better medicine than members of the human species who are poor and powerless.  Similar to disparities in other life-sustaining goods and services, enlightened governance systems have attempted to minimize (not eradicate) these differences in medical service provision due to an emerging sense of social justice and also because prosperity seemed to accrue to better nourished, better educated and healthier societies. A nation founded on the premise that individuals have an inalienable right to pursue happiness cannot weave social injustice into the very fabric of its existence, and expect to thrive. We know this, because we tried similar schemes before, and failed in what were arguably the darkest and most perilous moments in U.S. history. 

Utilizing inherently trusted individuals to prevail upon the unfortunate that what seems like injustice is actually good for them in the long run, is not a novel idea. Substituting betrayal by physical healers in clinics, for indoctrination by spiritual leaders in churches, is a minor innovation. Internalizing and institutionalizing pure evil wrapped in misleadingly kind and gentle rhetoric, while inflicting much pain and suffering on countless human beings, is also a sure recipe for the ultimate destruction of the perpetrators no matter how righteous they believe they are. Doctors, who are tempted to accept compliance with the newly created Captain positions on the misguided health care ship, without questioning its opiate laden navigation route, are simultaneously terminating the medical profession’s days of glory.  There will be no joy. There will be no trust. There will be no prestige. There will be no respect. And there will be no financial privilege. Captains of this doomed ship are a dime a dozen and they all reside below deck.

In order to protect privacy, names and locations mentioned in this post have been changed, as have certain physical characteristics, quotations and other descriptive details.

Cost Effectiveness of Health Information Exchange

At some point it was decided that the exchange of clinical information between facilities of care is lacking in both quantity and quality, and it was further decided that a drastic increase in frequency of such exchange will improve the health of people and the quality of care they received, while reducing costs of health care. The idea, which is almost as old as medicine itself, has been perfected by physicians over centuries of evolving documentation standards and sharing of knowledge in general. As medicine became a service provided by a bewildering array of entities in parallel and/or in sequence over one lifetime, the need for clinical information exchange increased exponentially, making this particular activity a perfect candidate for computerization in the Internet age. Since all computerized functions are better and cheaper than their manual predecessors, it was decided that the Nation must engage in sophisticated exchange of health information to the point where one’s medical records are omnipresent wherever one may need or want to perform, or have performed, a health related function. That’s nice, a bit creepy perhaps, but nice nevertheless, possibly useful, and certainly very convenient.

The Department of Health and Human Services (HHS) is the government agency in charge of making Health Information Exchange (HIE) a reality in this country. A recent HHS pamphlet published in Health Affairs provides an update on the state of HIE for the first term of the current administration (2008 to 2012), spanning the first four years of legislation, rulemaking and financial incentives in support of computerizing medical records and their exchange across facilities of care. The results are based on a survey of hospitals that were asked if they “electronically exchange/share” any one of four types of clinical information (clinical summaries, medication lists, lab results, radiology reports) with other hospitals or ambulatory providers inside or outside their own system. The study shows (see below) that the rates of hospital exchange/sharing of information with any other entity, which stood at 41% in 2008, jumped to 58% by 2012. That’s a whopping 17% over 4 years or slightly over 4% per year on average, although there is a clear acceleration after 2010 when financial incentives became a reality.

(source Health Affairs)

According to CMS reported numbers, the government paid out roughly $14.5 Billion in incentives to hospitals and health professionals by the end of 2012, or approximately $850 Million for each 1% increase in self-reported electronic exchange/sharing of health information by hospitals.  The survey did not inquire about the levels of such exchange, so there is no way to ascertain if hospitals with affirmative responses are exchanging all clinical information of the types listed, most of it, some of it, or occasionally some things here and there. A quick back of the napkin calculation indicates that upwards of $27 Billion will be needed to sustain the current growth rate for the next 8 years or so, in order to achieve universal exchange, and that’s without counting the startup costs of State HIE organizations, Regional Extension Centers and other grant making activities for this purpose, not to mention privately funded infrastructure and operational expenses. And here I have to make a confession: these dollar amounts are in a realm of finance where I cannot tell if these are reasonable expenditures, an incredible bang for the buck, or outrageous waste.

It makes perfect sense that making pertinent information electronically available at the point of care is helpful, and test results, clinical summaries and medication lists are obviously pertinent in most cases. But then, it also makes perfect sense that propping a clogged artery open with a stent should be very helpful in most cases. What is not obvious without additional research is whether there are cheaper and less invasive methods to achieve the same results. Does the most cost effective method of making clinical data available at the point of care consist of a nationwide network of big-iron servers and Federal protocols, continuously fed by hundreds of thousands of clinicians furiously typing and clicking away at hostile terminals? Maybe. Maybe not.

Unencumbered by any doubts, HHS is proposing to forge ahead with “Principles and Strategy for Accelerating Health Information Exchange (HIE)”, because “real-time interoperable HIE” is critical to the success of the Affordable Care Act and its various programs. Note that HIE just got a couple of extra qualifiers prepended to it. Interoperable exchange implies that the exchange is taking place between machines (not people), and that those machines can both exchange information, and understand it well enough to put it to some use. Interoperability is all about the exchange of computable data elements and their analysis. So having a piece of paper (or a PDF) containing all pertinent information, magically appear in the hands of a hospitalist or other care provider, on-demand, does not qualify as interoperability. It doesn’t qualify as real-time either, because real-time in computer language means just as it happens, with no delays and no waiting, so when the doctor updates something in his computer, the hospital computer knows right away, and vice versa.

And how does HHS propose to reach this ubiquitous HIE state? There are lots of steps to accelerate, strengthen, advance, enable, align, support, educate and other operative actions, involving standards, stakeholders, committees, agencies, States, ecosystems, policies, guidance, regulations, incentives, rewards and such, all meshed together in a “multi-year approach that is consistent, incremental, yet comprehensive”, culminating with HIE becoming “standard business practice for providers”. If you are tempted to discard this as fluff, think again because “HHS’ approach to accelerating HIE among health care providers is expected generally to follow a natural lifecycle of incentives followed by payment adjustments and finally through conditions of participation in Medicare and Medicaid programs”. A natural lifecycle indeed...