The current status of our free market economy and the healthcare industry is a cross between âoeFlip This Houseâ and X to the Z's âoePimp My Rideâ. The government insists (with sticks, ie penalties) that all physicians and hospitals start using IT for health records, but sets extremely minimal standards for its IT infrastructure roll out. With carrots (short term incentives) any startup can literally throw crap products together that barely meet the minimal requirements of the government requirements for that given year and contra-spray-gun sell them across the country with a 1-800 number to a clueless India call bank for any sort of support or training or installation.
This has resulted in a cacophony of Pimp-My-Ride EHR (Electronic Health Records) brands lipsticked up by the VC sector with the only intention to lock clients into a known garbage product they are going to flip anyways. For the low low price of $100,000 (they never tell you that up front) and $500/month maintenance contract, you literally get a CD or download, license key and phone number to India. The code, keys and clients are usually sold or merged with another organization within 2 years. Once flipped, clients (physician offices) are at the mercy of the new owner who just bought the code to the old, now sunset and unsupported product. Clients are now forced into buying the next product because it is the only way to preserve/extract their patient data, which physician offices have a legal obligation to maintain for 10 years. The new owners / mergers will never support a sunset product and always force a conversion that takes no less than two years for full roll out and the worthless support they all offer. Then that product gets bought, flipped and sunset... and clients are at the mercy of a new buyer and yet another costly conversion again. They do this every two years. None of these products are ever compatible or have any consistency to easily crosswalk data from one to the other; itâ(TM)s a custom migration solution for each client based on what they were package they were sold by the last owner of their EHR product. Itâ(TM)s a tough pill to swallow for any small business eating hand to mouth on dwindling Medicaid / Medicare reimbursements (another lecture all together). Each migration/ conversion is a fresh start, with usually a 20%-50% decrease in income for at least one year during the training / learning phase for each conversion and implementation of a new product they have just been forced into.
Clients have long spent the government carrots that forced them into this mess, two conversions ago. If you don't continue to ride the conversion wave and continue to go further into debt, government gets out the sticks slowly reduces your income or essentially closes your facility all together with poor quality measures and sanctions for non-compliance. Even if someone threw their hands in the air and said fuck it and closed up shop to become a Wal-Mart greeter, as stated above, physician offices have a legal obligation to maintain medical records for 10 years in an extractable, usable format or migrate to a new âoesupportedâ EHR. The new proud owner of that code and keys are the only people who can extract your data, and there is a fee for that. Itâ(TM)s yet another form legal extortion, or creating indentured servants out of independent physician offices across the country. Many people have tried to sue their EHR vendor, but when a small physicianâ(TM)s office is already in debt $250,000 to the banks for various EHR licensing scams and failed installations that India canâ(TM)t figure out, who could possibly afford years of attorneys fees and litigation?
Healthcare systems need to be able to talk to each other and report/extract meaningful data. There are no two ways about that, and I don't think anyone can argue any legitimate point as to why this isnâ(TM)t mission critical. Government had a great idea and stepped in, but not all the way in like it should have... and left it up to the free market to fuck it up. the free market gobbled up all the fast money and left an entire nation broke, and still without any sort of product or solution that comes close to what the initial intention of spending billions of tax payer dollars was... to streamline the nationâ(TM)s healthcare IT infrastructure as a whole, reduce cost and improve the quality of care and safety to the patient.
Itâ(TM)s not just a waste for the little guys and entrepreneurs, in the Milwaukee market, Aurora spent $200 million and 5 years installing Cerner to scrap it for another $200 million install of Epic two years later. ProHealth did the same thing. The country has spent hundreds of billions of dollars (largely tax payer funded) on this never ending cycle so far. As it stands, if a patient shows up at a hospital unconscious, the staff has no way of knowing or obtaining what the patient is allergic to or medications they are taking. This lack of information sharing causes staff to run an entire gamut of unnecessary tests to find out what they need to know. Three different rounding nephrologists ordered three ultrasounds on the same patient simply because their computers are not talking to each other and they didnâ(TM)t know what the other guy did. Albeit exaggerated, other than saving some trees, we are no better off now than when we were writing on endless piles of paper.
Epic (Wisconsin based firm) will effectively be health ITâ(TM)s (HITâ(TM)s) Roman Empire: establishing the laws and the language for âoeknown worldâ, as well as the underlying infrastructure, and ends up shaping information flows, IT architecture and â" potentially â" the eventual configuration of provider systems. It will be the Apple of healthcare IT moving forwrard. Epic won't talk to you unless you see a minimum of 400,000 patients, or a hospital with a minimum of 400 beds. (i just talked to their sales people). Epic's code is a proprietary version of MUMPS, so in a lot of ways it is like Apple. Epic custom builds an EHR solution for each client. So often Epic to Epic systems will not even talk to each other, unless you pay Epic for a custom solution to make that happen.
The only consistent healthcare IT solution I have ever seen in the US that is actually "functional" and works across the board is the VA Hospitals' and VA clinics' OSEHRA system (I think its called "VistA" now). Some of you elephants in the crowd will be shocked to find out that one of the best IT infrastructure in our country comes from the only completely socialized healthcare system we currently have. The VHA manages the largest medical system in the United States, where Medical records are actually talking to each other anywhere you go in the country. (Sorry about the dude who said they lost his stuff.). The loveliest part about OSEHRA is that it is foss, albeit late MUMPS / M turned variations of other code, has been winning awards since the 1990's.
ah yes, wikipedia. "For its development of VistA, the United States Department of Veterans Affairs (VA) / Veterans Health Administration (VHA) was named the recipient of the prestigious Innovations in American Government Award presented by the Ash Institute of the John F. Kennedy School of Government at Harvard University in July, 2006. The VistA electronic medical records system is estimated to improve efficiency by 6% per year, and the monthly support cost of the EHR is offset by eliminating the cost of even a few unnecessary tests or admissions.
The adoption of VistA has allowed the VA to achieve a pharmacy prescription accuracy rate of 99.997%, and the VA outperforms most public sector hospitals on a variety of criteria, enabled by the implementation of VistA.
VA hospitals using VistA are one of only thirteen hospital systems nationwide that have achieved the qualifications for HIMSS stage 7, the highest level of electronic health record integration,while a non-VA hospital using VistA is one of only 42 US hospitals that has achieved HIMSS stage 6."
I guess it's kind of like our two party political system. They make you to believe there are only two choices for independent physicians and healthcare entrepreneurs. You either get "swallowed up" and sell your practice to a hospital system because you need to get on EPIC so bad... or keep running the rat race of sub-par installs, licensing scams, and conversions every two years... All while taking out massive loans and sinking your business in the never ending debt cycle so Wall Street can continue to make money off of you every time they merge and acquire a few corporations. (Citigroup and the likes broker these deals).
Albeit unity v. CLI fights are internet hilarity, everyone forgets that open source is always there for you with open source armsâ¦ kind of like the Ron Paul kids, or any other 3rd option of anything for that matter. Most of the worldâ(TM)s health systems run extremely well on open source or Linux based Electronic Health Records. Why is it that the United States Government, White House, entire US Military is run on open source? â¦yet leaves welfare and health of its entire population to figure-it-out in the proprietary code, licensing rat race of the free market? Seems extremely backwards to use it for evil (bombing other nations), yet donâ(TM)t allow it to be put it on the table as even an option to be used for good.
The basis of my lecture / rant stemmed from several recent incidents, but mostly the sadness I see when what was supposed to be a good intentioned national rollout has left thousands of thriving independent physician offices broke, hundreds of thousands of dollars in debt whereas they may have had a debt free practice for 20 years prior to this free market scam that afflicted the entire industry. After a physicians second or third attempt at a usable solution flops, they have no choice but to close their practice penniless, or become swallowed up by a large firm or hospital complex and work for someone else.
After creating a practice from nothing and working the American entrepreneurial dream for 20-30 years, many of these guys are now forced to be employees of another corporation, but in the same office they built from the ground up. Some of my sadness stems from seeing the entrepreneurial flame die within so many that I also see through the Independent Physician Network of SE Wisconsin. In a roundabout way, they appear to be up against a make it or break it challenge implemented by CMS to see who gets the future of healthcare, gigantic hospital systems or independent doctors. They are tasked with gathering extremely basic data on the patient population of the physicians within their network. The information they need to obtain is buried inside EHR's from over 44 different vendors, all in various stages of conversions from previous EHR's that all had happen to them what I was explaining above. Those that didnâ(TM)t want to go into massive debt or the computer illiterate population still write on old fashioned paper. So data extraction is a near impossible task. IPN is essentially a "union" that independent physicians are able to join to be able to negotiate slightly better deals from insurance companies. The powers that be know Epic can produce this information with three clicks, but it will take an entire year to obtain it from the myriad of systems and failed installs or simply non-functional emr's all these offices have been scammed into. If IPN can't produce it, it essentially dies, and the entire concept of an independently owned family doctor, staff and nurses is wiped out like that. Itâ(TM)s union busting.
If any of these systems actually produced half of what they packaged and sold and resold asâ¦ or if there were more regulation for the rollout, nobody would be in this mess. Another option would have been more strict government regulations on companies that sell themâ¦ or quite honestly mandating everyone install a specific flavor of free beer/speech OSS to be cms certified. The free market can still be free because everyone needs support and the never ending supply of hardware. The free market would drive a support consultant to actually do their job knowing your clients (physicians) can go anywhere else for support. Many million dollar systems get scrapped under the current structure because clients simply canâ(TM)t get anywhere with Indiaâ(TM)s rolodex canned responses. Iâ(TM)ll admit to throwing a wrench in the spokes to flag it as a life threatening emergency a time or two
... to bypass 3 days of Indiaâ(TM)s rolodex and actually get the one guy in the U.S. paged who knows anything about anything.
To add insult to injury, the intent of bettering health care by forcing the entire nation to invest heavily in IT was derailed even further by the software design within the rollout. This was packaged and sold as a way to reduce endless charting/documentation time, reduce make-work staffing, âoeassistâ the provider and streamline workflow in a medical facility. Almost all of the software that is currently on the market has only one purpose, and that is to increase charge capture. The administrators and billers only wanted a tool to capture as much revenue as possible from each visit, and missed procedures that didnâ(TM)t get billed out from the days of using a paper format. What you get is software that is extremely clumsy for a medical provider and staff to work withâ¦ un-patient friendly, and not user friendly. Most of these new âoecertifiedâ EHRâ(TM)s take 20 clicks to get where you should be able to get with 1 or 2. The average time to chart a progress note has increased threefold, which means doctors are clumsily clicking through menu after menu rather than spending face time with their patient. The other side of this sword is that they are seeing half the amount of patients they were able to see before, which means administration needs to try to make up for this pay reduction in higher chargesâ¦ so they create more menus for doctors to click through and thatâ(TM)s where we are. An example of some of the new requirements, are to associate a diagnosis code with each lab ordered and Rx written â¦ clicky clicky clicky click. Many physicians complain that just the lab and Rx portion of the note takes longer than the time space allotted for the office visit. Let alone answering the patientâ(TM)s questions, education, or clicking through the note itself.
This has since created and epidemic of doctors trying to âoediagnose the computerâ rather than talking and listening to the needs of their patient. Eye contact with the patient is crucial, yet destroyed by the doctor being forced to complete all of the clicks by the time the patient leaves, to comply with CMSâ(TM)s new requirement of giving the patient a printed summary of their visit at checkout.
Math time â" average primary physician salary is supposed to be around $150,000. Thatâ(TM)s roughly $75 per hour. To keep the lights on in the building and pay for support staff (nurses, billing, receptionists, etc), each provider has to generate $250 per hour that they work (7 hours in a work day). The average office visit pays around $65, so a provider would need to see 4 patients per hour, every hour, for the facility to break even. Seeing 28 patients per day was quite common in the paper days because documentation was generally a snap. With the clumsiness of clicking through the new EHRâ(TM)s, it is physically impossible to see 28 patients and be able to document all of it in the same day or âoereal timeâ. It takes about 10-15 minutes to document an encounter, in addition to the time meeting and talking to the patients. Most physiciansâ(TM) production ability is about half of what it used to be, 2 patients per hour or 10-14 patients per day. So thatâ(TM)s an additional 4 hours of documentation time, after an 8 hour day of work. With static expenses (like salaried physicians, rent, etc), facilities are seeing their income slashed in half. To survive, the only alternative would be to make more clicky clicks in the computer program to try and fluff each office visit note up try to charge insurance companies more for each visit. This is the cycle we are in now.
Ironically, CMS is whining that the cost of healthcare is up, because physicians (mostly hospitals) are charging more for their visits because of all the automation set into place with all the clicky clicks the providers have to do to account for the lost production.
My argument to that is that physicians have always done the work, and lack of time to document all of it resulted in a lot of work not getting paid. An example is a patient needing a cerumen impaction removal. Historically, the provider would tell their nurse to do the procedure in the hallway or do it themselves while in the room. Getting behind on their schedule or starring down the barrel of a 16 hour day, they might not spend the extra minutes documenting everything about that procedure and just send it out the door (to the claims clearinghouse) with a 99214 and call it a day, not wanting to look up the 380.4 or the procedure codes to go along with it. Most EHRâ(TM)s have spent all of their R&D dollars on perfecting the SO/SP (services ordered / services performed) section of their systems to make sure this never happens, and all cerumen impaction removals get accounted for, documented and billed. CMS is in an uproar. Their genius idea now is to tie up the nation in monetary recovery audits to try and recoup some of this money.
The reduction of paper was also a sham. The cost benefit analysis of just not buying and printing and shuffling as much paper pays for most of these EHRâ(TM)s alone. CMSâ(TM)s MU Stage 1 requirement to provide the patient with arm loads of printed educational material, visit summary and medical history summary at each office visit is just as much or more printing than before purchasing a âoepaperlessâ medical record system.
College economics taught me this thing called âoelinear expressionâ that where the more you spend the better product you get. In this industry, the more you spend doesnâ(TM)t get you a more patient friendly, or workflow friendly system, it simply accounts for more charge capture. The behemoth that is Epic systems (mentioned previously) creates a product that Administration, IT departments and the billing offices love, but the boots on the ground (providers, nurses) find unusable, inefficient and clumsy.
Everything I talked about here and the inability for our government move beyond party line votes and fix anything in any fashion other than turning it over to the drooling free market that ruined it in the first placeâ¦ is sadâ¦ and exactly why we spend the most but have the worst results, and most uninsured population of any developed nation.
I will punch anyone who tries to bring up death panels or any other Limbaugh-esque rhetoric. That stuff is already in everyoneâ(TM)s free market purchased over-priced policies if anyone actually took the time to read them. Paying for your doctorâ(TM)s visit is called a âoelossâ to your insurance carrier, so they are never going to be on your side. It is a business first and foremost. The only thing I can remember from business school was that they drilled into us that stockholders and executives come first and everything else comes after that.
Eliminate the 400 middle-men confusion and endless paperwork between a patient and the one on one relationship they have with their personal doctor. Open source, single-payer, universal healthcare, or just scrap the whole fuckin thing and let everyone google how to manage their renal failure and insert a central line.