The Pluses And Minuses Of Electronic Medical Records
http://thedianerehmshow.org/shows/2012-09-25/pluses-and-minuses-electronic-medical-records
As part of the 2009 stimulus package, doctors and hospitals in the U.S. were offered financial incentives to switch to electronic medical records. Three years later, more than one-third have moved to digital. While the change has improved efficiencies and patient safety, there is rising concern about the vulnerability of the system to fraud. One recent study found that hospitals received billions more in Medicare reimbursements following the switch to digital records. And patient privacy concerns remain. Guest host Tom Gjelten and a panel of experts discuss the positives and negatives of electronic health records.
Guests
Dr. Don Detmer
professor of medical education at the University of Virginia.
Fred Schulte
senior reporter at The Center for Public Integrity.
Dr. David Levin
chief medical information officer at Cleveland Clinic.
Dr. Farzad Mostashari
national coordinator for health information technology at the Department of Health and Human Services.
Dr. John Dooley
internist at Foxhall Group in Washington, D.C.
Comments
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Re: the person that wrote in that they only go to doctors with electronic records. As I said earlier, computers aren't magical, nothing about records being electronic makes care inherently better.
Just ask the multiple patients of our orthopedic surgeon that have had life threating conditions (that should have been caught by their primary care provider) discovered in our "backward" non-electronic record office.
Electronic records don't in any way stop a doctor from "backing in the door"
My wife is a family practice physician who is being moved by her group to a different office about ten minutes further up the road. The new office uses a different system of EMR. Because the distance of the move is so minimal, most, if not all, of her patients will be following her to the new location. She is now in the process of having to manually re-enter all of her patients into the new system -- because of patient confidentiality she must do this herself -- since there is no simple way to have the two EMR programs "talk" to one another. Her IT department tells us it would cost thousands just to write a custom program so that the two systems can interface. All of which leads me to question the value of the EMR system in the first place: If the doctor I am visiting cannot access my records because his or her system is incompatible with the system my primary care physician uses, what good is it? And I won't even address the issues of what happens when there's a power failure, when the servers are down, etc.
I am a employed family physcian with 30+ yr.s of experience. WE were placed on EHR 1 1/2 yr ago. It has been a huge amount of work with little actual benefit. True- no one at another location can benefit from my records and I cannot access their's. Wasn't that the point ? So, testing is repeated and costs go up.
In fact the EHR sellers do promote their product with the idea that more data entered into the record permits higher billing codes. Now, I must scan consultations through a maze of boilerplate to get to the actual conclusion of what is wrong and what we are going to do about it. This E/M system of coding is biazarre and ripe for abuse. Still, even a honest difference of interpetation can be called fraud. A much fairer system of payment would be based on time spent seeing a patient as well as review of the patient lab, xray, consultations. All this is not addressed by the current system.
Honest Abe - adequate medical records are important, however hospitalists and consultants often don't read them because of time constraints. A consultant almost killed one of my husband's patients because he didn't take the time to read the chart.
For the first time in the 13 years that I have been their patient,, the Women's Health Center at the Cleveland Clinic coded my annual gynecological exam as my annual physical exam. As a result, when I had my annual physical with my internist one month later, our insurance would not cover it because the record showed that I had already had a physical within the calendar year. Our insurance is Medicare and a major carrier for supplemental. I can no longer afford to be a patient for gynecology at the Clinic!
One recent study found that hospitals received billions more in Medicare reimbursements following the switch to digital records.
my phone app died during the beginning of this so forgive me if this was addressed. What happened to the overpayments? Was the money sent back to Medicare? What are the steps that are being taken to ensure that errors like this don't continue to happen?
there are numerous negative consequences with the use of EHRs. they are not regulated or tested for safety. they are "hold harmless" clauses protecting the vendors and harming the patients. That should also be discussed and addressed.
I'm not frustrated with filling out patient information forms over and over because I keep a copy of all my medical information on the computer and print it out when I go to a new doctor. I simply note on their forms to see my form. I can update it and keep it accurate. I don't want a doctor who I haven't seen in a while to sent outdated information to a new doctor I'm seeing. Chances are the new doctor will read the record and not listen to me. Also, unless I take the time to read every line of the EMR, I don't know how many mistakes are in there.
EHR are a very important step in advancing health care and managing cost. Medical Billing is broken down into two basics, procedures and cognitive services. Claims data collection is lagging behind and Physician Claim form needs more data to establish the medical necessity and reasonableness of what is billed. Physician Claims need to add differential diagnoses to the claim that are not today allowed. Comorbidities, chronic illnesses, conditions that needed to be ruled out or considered during the visit need to appear on the claim to ascertain if the services billed were appropriate. This is a very complex issue that will sooner or later affect every person. Thank you for addressing this issue. Mark Owen
@ Carissa Roper
Where's the proof that there were overpayments? Payments increased <> overpayments.
On the subject of medicare paying hospitals. Everyone needs to be aware that those of us not on medicare are paying a secret, hidden tax.
Medicare fails to reimburse hospitals for the cost of care - it actually costs the hospital to care for patients on medicare. This shortfall has to be made up by getting more money from the rest of the patients; higher reimbursements naturally lead to higher insurance premiums. These premiums go to subsidizing medicare (and with higher expenses, even more money in the pockets of the insurance carriers).
I can vouch as former Cleveland Clinic physician, the notion put forth by David Levin that all Cleveland Clinic employees are salaried and that the institution does not "care" for the number of procedures performed, tests ordered, etc. is just not true. If anything this institution "hyper monitors" every move of every physician and every patient with the only motive to improve "billing and net proceeds". This culture is so omnipresent in the Cleveland Clinic management that it is stifling and so heavily skewed towards procedures even in situations were procedures are totally unnecessary. This institution is so driven by the "bottom line" that they even have "business models" for each disease entity, how many tests can be ordered, how many referrals can be made within the institution, what procedures can be performed, etc., etc. To claim that Cleveland Clinic uses EMR to add "value" and to improve efficiency and quality of care is simply NOT TRUE. There is no objective evidence for this claim and is simply a "talking point/marketing" sold by the Cleveland Clinic. A direct comparison of patient care quality for "value" between Cleveland Clinic and an institution of similar size will "reveal" the truth about this matter. But, of course why would the Cleveland Clinic agree to any such unbiased evidence based study?
I would like to comment on Dr. Levin's comment that the shift to electronic medical records has lead to better care and a switch from volume based to quality care. I live in Cleveland and have received medical care at the Cleveland Clinic for much of my life (I am 42). Over the last few years the Cleveland Clinic has dramatically reduced the quality of their care, primarily through overbooking their doctors which results in patients waiting 3 or more hours to see the doctor and doctors being overworked and exhausted.
Sarah
I am the wife of a critical care physician. I only know what I see and hear. The number of patients my husband has been able to see in a day has been cut by 2/3rds. He comes home every day more discouraged and exhausted. Because his patients are in dire need, he can't just schedule them farther out; he has to see them. There are just not enough hours in the day. It won't let him write a decent, useable note. He can't trust the notes he reads; they are either cut and pasted or just wrong. He feels like his only option is to quit because he just can't figure out a way to be a good doctor and use this system. It was designed for billing and it sounds like it is doing that part well. His concerns fall on deaf ears. The problem is not that he is not computer savvy; this is a man who builds his own computers and can write code. The system is flawed.
How funny that the call of "fraud" raises concerns but not patient care. It was also designed to "work" with another local hospital system; now they are told that that interface will cost more millions. For the those who became physicians to help people, this is the end of humanity. But for the new docs who only care about billing rates, it's great. One of his younger colleagues actually said, "Who cares about decent notes in the ICU, it doesn't matter. The patient is going to die anyway." This is the future of medicine.
I pray every night for him to quit. Shame on the administrators who lie and turn a blind eye and the politicians who are promoting this system. This is the biggest sham of all time; the only people benefiting are the computer software companies and the hospital administrators. The public has been duped.
Some reality on electronic medical records:
See "Common examples of health IT difficulties" at http://www.ischool.drexel.edu/faculty/ssilverstein/cases/
and a reading list on the issues at:
http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it....
On upcoding:
http://hcrenewal.blogspot.com/2011/02/does-emr-facilitated-upcoding-form...
Scot Silverstein, MD
Institute for Healthcare Informatics
Drexel University
Philadelphia.
Is it overbooking, or does it take longer for the physicians to see a patient due to mission-hostile EHR systems?
See http://www.tinyurl.com/hostileuserexper for some eye opening examples.
I am a medical provider and have used 3 different EMR. They are wasting my time and taking me away from actually doing medicine. The coding up is not because we are "evil" and try to defraud the public, IT IS YOUR EMR. It take so long to do it and the EMR CODES itself. a 15 minute visit takes me 15 minutes to document. My partners and I are thinking of going to fee only services. We are the only clinic in our town taking medicare medicaid . I don't know who the person is who is taking, however we have to use templates or you cannot get done any other way. The State has us now doing all kinds of junk not necessary for care. And judging us on how well our diabetics get there A1C under control is silly. Most of you probably smoke, eat too much and I cannot control what another person does. Thank you I am on a day off finishing 50 charts.
Inorder for the clinic to make enough money to pay for all the ancillary employees, their benefits etc and ours (and we are not the highest paid professionals) we have to see at least 20+ patients per day--To get to actually know a person and what their problems is to help them under stand what it means and what they need to do takes time--then there is the intellegent exam. Everyone is trying to keep up a good spirit about this and realize that it is here for ever. I want to ask, when did we stop actually practicing medicine. EMR is good in the sense, you can find information and labs, you can read your partner's notes--however I would like to spend alot less time typing in the stupid ROS and PE--it takes too long. And being paid for time spent is useless. My patient do not like the computer between me and them, and they tell me. I tell my provider to put it away--I like to talk with a person who actually looks at me.
The medical establishment is in love with technology because it provides instant information. Unfortunately, like the national security establishment, users soon find they are awash in data and much energy is then spent trying to identify and relate significant data.
I am not a Luddite. But we are replicating in the medical environment the same issue we have with driver licenses. Rather than confront the real issue of creating a national identity card system that would be used for all travel and official personal identification, we left it to 50 states to come up with 50 different verification standards and formats. In the end we still have a hodge podge and the underlying issue remains.
If electronic records are so obviously beneficial why has the medical establishment been left to develop a myriad of systems that may or may not cross-communicate, that have varying security protocols, and are continually modified. There are no prescriptive national standards and it is buyer beware in the marketplace. Within ten years legislative action and judicial review will be establishing standards that will have to be retrofitted at great cost.
As to archiving, how many of us have electronic files they created 12 years ago and can still read them today. With medicine there will also be the issue of image files not just text and numbers. The storage requirements will be huge.
We will move to electronic medical records because the momentum is to shift all data to digital formats. But the process will be expensive, will be fraught with complications and in the end its efficiency and efficacy in healthcare will be no better than the medical provider who know and listens to the patient.
i am a physicist, and what often strikes me talking to medical researchers is that the non-electronic nature of medical records seems to constitute large obstacle to advancing research. now most science fields are seeing a huge influx of data, while medicine is still data starved. i think electronic records will open doors to great changes and improvements in the medical research front
I was a pioneer in medical office automation starting in 1983 using MEDICAL MANAGER until my company was purchased in 1995. Medical records were a natural outgrowth of automated billing and the linkage between diagnostic and procedure codes. I should point out that Mickey Singer who developed Medical Manager, also perfected data links that also grew to include lab work, film and other scans and specialist workups in both written and audio formats.
I am puzzled why something which was fairly well perfected in 1995 is still a 'hot topic'. Perhaps, I was spoiled by my client practices who were run by technologically proficient doc's who would 'max' out the features of this and other software.
The issue of a surge of coding is an old discussion and stemmed from the breakdown of coding into smaller elements under Medicare. Some of my practices, i.e. urology, started with 10 codes and were soon over 100. A surgeon who specialized in nervous systems has several thousand codes, one would use n E.R. computer to plot the path of greatest reimbursement.
The Fed's. thought they would save money by fragmenting procedures and linking them to relevant codes; the doc's used the computer to collect all the small procedures that were previously ignored....my fav. were skin pops for a dermatologist, sometimes over 100 at 50 cents a pop; or bandages, or? I designed intake forms which included many of these, all coded into a check off format for inclusion into the billing system as per CMS requirements.
Physicians and esp. practice managers suddenly discovered how much money they were losing the old way and embraced this kind of billing; as did solo doc's whose wives handled the bookkeeping and billing.
Under my way, the practice ran their billing at close of business, transmitted it electronically directly to the carriers, and had their bank accounts credited electronically or a file of rejects to process the next morning.
Information is power and the larger the entity collecting the data, the more likely your record will be 'shared' with researchers, interns, residents and others with an interest in aggregated health information.
Your wishes are irrelevant; especially under Obamacare which has stressed integrated medical records in share-able formats.
Prior to passage, practices and third party payors could restrict and control access; but not any more.
Remember this adage....the Government which can give you every health care benefit; can take away every protection.
Two years ago, my pacemaker got swapped out in an outpatient procedure that took about 15 min. I spent an hour beforehand filling out 22 sep. forms and I wondered if all of it was scanned or keyed into the hospital's system or my cardiologists and eventually my Internists.
It's a monster I helped create...the procedure was a friendly breezy event; I drove my self home.
The big problem with charges is the way that they compensate and that they decide on the amount after the fact. I should be able to ask "how much will this visit cost" and get a straightforward answer. The pricing should be known and simple. Yes I know that people may not choose to do somethings they need. At least they would be in control of when they are charged.
For example, I know that if I get lab tests from a Duke, despite the fact that my allergist was going to read the test, they tacked on another doctor in the lab to "read the test". By the current system, I have no knowledge that it will occur or ability to challenge that. This is one of the biggest problems
So medical records are not the problem but rather the way that charges and prices are determined... after the fact and through a convoluted system. If they had no incentive to game the system, maybe the doctors could just go ahead and practice medicine.
In today's NY Times is a letter written by HHS Secretary Sebelius and US Attorney General Holder in which they warned hospitals and others to be honest.
What shocks me is that they act as though they did not know of the EMR upcoding project.
It is a program promulgated by the same vendors who influenced HHS and Congress to spend $ billions to entice doctors to use systems that waste time, promote errors, delay care, and cause neglect.
As a pharmacist who has worked on Ohio’s Health Information Partnership’s E-Prescribing Taskforce, I can tell you that EMR and electronic prescribing has NOT reduced prescribing errors.
I like to say that prescription errors are still present, but now I can just read them easier.
Sloppy handwriting has been replaced with errors in choosing from drop-down menus. Two sets of directions are often attached to one prescription- one the provider could pick from a pre-populated field, and another set of directions free-typed. Dosage forms are mismatched; I see prescriptions where the directions say “Take One Capsule By Mouth Daily,” but where the drug is a suppository.
Also, pharmacies receive duplicate prescriptions. Doctors’ offices will send multiple copies of the same e-prescription, or call in the same prescription “just because they wanted to make sure the prescription made it to the pharmacy.” This is a safety issue, as the patient may receive double dosing.
Electronic prescribing has NOT made prescribing safer. Yes, it has eliminated the worry from handwriting interpretation, but it also has created many more problems.
One important issue that wasn't raised is that even though the US govt is investing $22 billion in tax payer dollars to encourage the meaningful use of EHR"s one of the "fastest growing" EHR's Practice Fusion is a "free" EHR's. Their CEO is very clear that his business model the delivery of ads right on the screen itself and the sales of your data (de-identified) to the highest bidder.
This is like having a drug rep sitting right in the exam room with the patient.. If you want to see the provider you can't opt out of this happening - in the contract the EHR company owns your data.
The doctors get the EHR for free, they also get money from CMS (medicare/medicaid) $44,000 or more and pharma gets access in the exam room to deliver their advertising.
There is no clear evidence that EHR model benefits the patient but we are paying for it.
We're "CRAZY" you know..
It's apparent we're still making the most basic mistake of predicting economic results. When you provide **increased value at lower cost** it INVARIABLY *increases* costs.
Why? It's because the way improved services are designed is to increase revenue... They don't tell you that, but that is the whole purpose of business innovation, and "more product at lower (unit) cost" is one of the most reliable ways to increase the cost of your demand for increased services, and profit....
http://synapse9.com/pub/EffMultiplies.htm
Farzad Moshateri stated that meaningful use criteria will improve safety. FALSE. Meaningful use is meaningfully devoid of safety and efficacy criteria. There is not any search function on these systems.
A robust search function was to be drafted but the vendor Epic and its wealthiest CEO J. Faulkner organized a write in canpaign to deep six it.
The HIT programme in the US is one of the greatest scams in the modern era. THEFT. The devices are no damn good.
The software of electronic medical records such as Epic and Allscripts is extremely inefficient and worse, time consuming. The people who promote it do not use it. The clerical work of medicine has been transferred to the doctor. There is simply much less time to spend with patients and much more time with the computer.
Having all notes typed is an advantage but does not require EHR. The complexity of the system leads to more medical errors. Communication is much worse than before because there is so much garbage and the system is so impersonal.
How can you not see that the mandated EHR has been a categorical disaster?
However it may be good public policy. More old and sick people no longer productive in society will die and so no longer be an economic burden for the country. It will help balance the budget and reduce national debt.
I have not heard the entire program, however, one of the primary end users of EHR's are bedside nurses. I have been a bedside nurse in an ICU for 17 years. There are many advantages and disadvantageous of the EHR. Perhaps your show could present the end users side of the issues related to the use of EHR. In my opinion, one of the primary weaknesses to EHR is that they were developed by engineers who have no concept of what an end user nurse does or what they need to chart in an EHR. One of the driving forces of why we have to chart certain things in certain ways on certain screens is for "auditing" and "reimbursement". This lends itself to more time in front of a computer and less time at the bedside and more "double" charting, again, which leads to more time in front of the computer and less time at the bedside. The usability of the software is in need of extreme overhaul and to ensure "seamlessness", we should all be using the same thing. I also believe that the "increase" in costs is directly related to people deferring care until they end up in the ED or ICU very sick. Also with technology, we can do alot more and people are demanding alot more. So when you evaluate higher quality at lower costs, that is an oxymoron. Of course costs are going to go up. Our society and healthcare system does no practice nor promote preventative healthcare. Making behavior changes and being "compliant" is much harder for most individuals. Perhaps audits should be used to evaluate those individuals who have repeat admissions for the same thing. That is not a reflection on poor care by the hospital, that is mot likely poor care of the patient by themselves.
Thanks for having this program! I plan to listen to the rest soon.