Archive for category Electronic health record
Bernie Sanders popularized the idea of US national healthcare during his 2016 campaign. He described the idea as “Medicare For All”. That was a genius idea since most Americans have a family member with that program for seniors. In fact, with its 44 million participants it represents a very large, although incomplete, national healthcare program. It is very popular among seniors since it reduces insurance premiums dramatically.
There are two major versions of Medicare: Standard and Advantage.
- It sets the allowed price for hospital and medical provider services
- It pays 80% of the “allowed” price leaving 20% for the individual or a “medical supplement”.
- Limits participants to one insurance company or organization
- Has lower premiums
- Wraps Medicare and a supplement together
What about Medicare For All
- What about premiums or supplements or services? (the specifics need to be chosen, not guessed at.) It’s like a dream house, but without a drawing or a list of deliverables.
This is really the nuts and bolts of a national plan no matter what you call it. And, if the current providers sense they will make less money, the self-serving complaints will be very loud. Who will complain if patients don’t get a better deal — not very many people. That’s because not very many people understand healthcare. So, what do you as a consumer want?
☐ Same old insurance, high drug prices and poor quality
☐ Premiums paid via payroll deduction
☐ Premiums paid via annual income tax
☐ Allow supplemental insurance for non-covered items (like plastic surgery or special drugs)
☐ Profits for drug companies limited to 5%
☐ All covered medications available for $10/month
☐ All approved hospital days available for $400/day
☐ Out of pocket annual expenses limited to $5000/year
☐ Approved child medical care is free
☐ 0.5% of premiums for research
☐ Regional claim processing (by current insurance carriers, limited to 5% profit)
☐ Limited list of available medications, generics are required where available, brand name drugs are selected by the plan
☐ 30% of provider payments linked to quality and quantity measurements
☐ Medical school tuition paid in exchange for 5 years of service in designated (poorly served) areas
☐ Mental health service included same as other health care (includes PhD psychologists)
☐ Maternity care, including midwife care at home when safe
☐ Primary care provider available for all persons
☐ Physicians and surgeons are salaried (not paid by number of services)
☐ Same day service for urgent problems
☐ Clinics open nights and weekends
☐ Massive increase in numbers of physician assistants and nurse practitioners with tuition paid in exchange for service
☐ Video visits with providers via Internet if desired
☐ Hospitals paid according to diagnosis (DRGs)
☐ Regional specialty hospitals (5% for growth and development)
☐ Local general hospitals (5% for growth and development)
☐ Providers all use the same secure medical record
☐ Annual adjustment of payment levels based on a budget
☐ Ongoing and up-to-date quality measurements on all services
☐ No need for malpractice suits — immediate compensation for injuries instead
☐ Strong quality system capable of sanctioning administrators and providers (important!! may need lawyers here)
Patient’s who have minor surgery at an ambulatory surgery center (ASC) don’t really know what to expect. And, after the experience they often wonder whether they received high quality care. The basis for thinking the quality was good is usually the perception the staff was friendly and the fact the patient indeed survived to ride home in a car with a friend or relative.
There are more than just those 2 dimensions of quality. What should an informed consumer watch for? Or, more likely, what should family members who accompany the patient look for? After all, the patient is a little anxious before surgery and often sleepy after surgery, mostly concerned about getting to the car.
Here is how a smooth high quality ASO interaction works:
- Primary care physician contacts the surgeon about the patient by phone or secure email to see what steps need to be taken for a possible outpatient surgery — like treatment of carpal tunnel syndrome. And, the surgeon gets information about the patient’s other health problems. Appropriate tests are ordered and an appointment with the surgeon is made within about a week. All records are electronic and made available to the surgeon.
- The surgeon has a clinic visit with the patient. The nature of the surgery is explained to the patient both verbally and with diagrams. The surgeon states whether they feel the proposed surgery is reasonable under the circumstances and describes what the surgery entails from their standpoint. But, no decision is made by the patient at that point. The surgeon uses a shared decision making technique. Meaning, the patient is given literature and internet links to review. Also, a link to all previous patient satisfaction surveys about the same surgery are provided to the patient. Plus, a packet with all the documents that must be signed. Staff review the patient’s insurance and estimate for the patient ALL the out of pocket costs of the surgery (surgeons fees, ASC fees, devices, and drugs).
- Later, perhaps a couple of days later, the surgeon calls the patient, questions are answered and a joint decision is made about whether to proceed with the surgery. Also, at some later time the patient talks to the anesthesiologist on the phone and can ask questions about anesthesia issues.
- If the patient wishes to proceed the necessary documents are signed (on paper or electronically) and an appointment for surgery is made. The patient takes or sends the documents, including operative consent, HIPPA forms, etc, to the doctors office. The primary care records, the surgeons records and the documents are made available to the ASC. No additional forms need to be signed or completed at the ASC.
- If there are questions about medication management or other medical issues another phone call or email is exchanged with the primary care provider. The patient should never be a messenger asked to get information or ask questions about medications from the primary care provider.
- Required pre-operative examinations are performed by the surgeon or assigned physician assistants in a timely manner.
- The patient arrives at the ASC at the appointed time, no additional paperwork is needed.
- The patient is taken to a personal pre-operative room, not to a public waiting area — privacy of outpatient surgery is important. All patient charting is done with a computerized system.
- The nurses, anesthesiologist and surgeon meet with the patient and family. Any last minute questions are answered and post-operative instructions are discussed with the patient and persons taking the patient home.
- After appropriate preparation the patient is taken to the operating room and after surgery returned to a recovery room, hopefully the same room they started in. The surgeon and anesthesiologist meet with the patient and persons taking the patient home to relate the outcome of the surgery and to repeat the post-operative instructions. Written instructions with a follow up appointment date and time are given to the patient. A phone number answered 24 hours per day is given to the patient for any problems or questions that arise at home. Telling the patient to go to the ER for all problems is not acceptable.
- No patient should feel they are the last patient of the day and must leave because the ASC is closing. The ASC must stay open for several hours to accommodate all needs of that last patient of the day. Minor complications, like urinary retention, should be resolved by the ASC, not an ambulance transfer to the ER.
- The surgeon sends the operative report electronically to the primary care provider and sends a letter to the patient about the diagnosis and results of surgery.
- Later in the day or the following morning someone at the surgeons office contacts the patient to see how they are getting along, to answer questions and prescribe additional medications or treatments if needed. The date and time of the follow-up appointment are again reviewed. The patient is asked to participate in a patient satisfaction survey.
- The patient fills out the satisfaction survey on paper or on-line.
- The patient returns for the post-op visit with the surgeon as scheduled. The final diagnosis is discussed with the patient and further instructions are provided.
Well, is that how your outpatient surgery went? If yes or if no, leave a comment. What was good at your ASC and what was bad?
Physicians scoff at rules requiring them to use electronic records and now they must pay the penalty.
Melinda Beck reported in the Wall Street Journal 12/18/14 “Medicare to Cut Payments to Some Doctors, Hospitals”. Of the 893,851 physicians in the US, Ms. Beck reports 257,000 will be fined 1% of their Medicare fees for failure to adequately use an electronic medical record.
For example, the technically challenged doctors have failed to use electronic prescriptions, favoring instead marginally-legible hand-written prescriptions. And, they undoubtedly harmed patients by not taking advantage of allergy and interaction checks that are part of electronic prescribing.
AMA president-elect Steven J. Stack is reported as saying he was “appalled” by the government action. Every physician, obviously excluding Mr. Stack, was informed 5 years ago that fines would be imposed in 2014 by Medicare if physicians that bill Medicare fail to use electronic records in a meaningful way.
Why would a rational physician choose not to use an electronic record…?
- Because North Korea might hack the system
- Because the government told them to use an EMR (they give orders, not take them)
- Because they will be retiring soon and won’t need to learn about computers (the real reason)
- Because they will need to pay for a system to help patients
- Because young physicians want the systems, older physicians say no to all this newfangled stuff.
- Because a an electronic record might be used in court against them.
There you have it — a detailed explanation. Appalling, don’t you agree?
A good patient portal is wonderful; a bad patient portal is a waste of time. A recent post by Dr. Yul Ejnes suggested portals may not be patient centered and don’t get much use.
An alternative view is that all patient portals NOT are the same. Some have great features and are supported by the providers offering them. Other portals are not much more than advertising — generally something a patient does not revisit. Sadly, many businesses have the latter type of portal — no wonder people don’t flock to medical portals.
Check out your health care provider’s portal. If it does not really provide a benefit then TELL THE PROVIDER, complain, and say other providers do a better job.
Admittedly, a poorly functioning provider office will likely have a poorly functioning portal. Just because the portal lets you send a message to the nurse or provider is no guarantee the response will be helpful.
Large vertically integrated health systems or ACOs have the best chance of a good patient portal. The portal needs monitoring and rules for providers — rules that require questions to be answered the same day. And, that the portal will display lab results within 48 hours, regardless of whether the provider has or has not seen the results. Responses from nurses need to be monitored for accuracy and timeliness — the lazy but profitable response to just make an appointment is not adequate. Integration of pharmacy functions is essential.
Here is a checklist of possible portal features — how does your provider’s portal stack up?
- Responses to online requests take less than 24 hours
- Ask a medical question
- Ask medication related question
- Make a follow up appointment
- Make a same day urgent care appointment
- Get refills on a chronic medication
- Get a message from your provider about test results
- Report drug side effects or drug allergies
- Send a picture of a skin rash.
- Diabetics can send blood sugar results
- Asthmatics can send peak-flow measurements
- Look at your list of medical diagnoses both active and inactive
- See a list of current medications and the diagnosis for which they are prescribed
- Links to drug information about the drugs on the medication list
- Review the providers notes
- Review any test, x-ray or consultation report
- Your provider can send questions to specialists and forward the response to you
- You can print your lab, pathology and x-ray reports
- See your most recent medical summary including past medical history, social history, family history, medications list allergies — and be able to print the report if needed for consultations or to take on trips.
- Request a summary of billing and payment information — including when bills are sent to insurance and when payment is received.
- Pay your bills on-line
- Links to reliable on-line information sources about tests, treatments, drugs, immunizations and diseases. Include a symptom checker — a computerized diagnosis based on symptoms — something to discuss with your doctor.
- Provider office provides training to use the portal.
A provider might say: “I’m not paid for running a portal or answering questions”. That is very true for many providers in the US health care system. But, in systems without fee-for-service billing then portals are a huge driver of efficiency. If a patient’s questions or problems can be resolved via the portal so much the better for both the provider and the patient. The handwriting is on the wall — fee for service is going to go away — the efficiency of portals will be a strong driving force.
Delinquent, delayed and diverted the electronic health records in the US are missing. According to the Washington Post two Presidents set 2014 as the target for all medical records to be electronic — so has American medicine hit the target?
According to a study by the Robert Woods Johnson Foundation US healthcare has been very slow to adopt the technology. RWJF reports 50% of office practices have a “basic” system and 59% of hospitals have at least a “basic” system (25% of hospitals have a comprehensive system). To give perspective, a “basic” system contains medical reports and medication lists but no physician notes.
Barriers stand in the way of progress:
- Medical data is a very valuable business asset. EHR companies are threatened if such data could be easily transferred to a competitor.
- Fear of losing control. Doctors and hospitals don’t want their data to be too available to insurance companies or regulators. Quality problems could be easily exposed.
- Self-determination. Health care entities want to make their own systems — the CEO would rather manage than cooperate.
- Lack of governmental action. Doctors and hospitals are licensed by States — just putting the license at risk is all that is needed to make EHRs mandatory.
- High cost of building an EHR. Every office practice and hospital needs a financial system. But, really, only one EHR is needed in a State or perhaps only one in the entire US. Hundreds of EHRs across the country is a waste of money — they all do the same thing, and they can’t “talk” to each other.
- Failure to embrace a “cloud” computing solution for a large scale EHR.
Ask your doctor:
- Please show me my chest x-ray on the computer screen in the office exam room.
- Please electronically send all my records to a specialist across town.
- Please show me a record of all the prescriptions I had filled this past year and which pharmacies filled them and how much they cost. (surely you can trust your doctor with that small bit of financial information).
- Can I send you a secure email and expect a response?
- Can you securely send me the results of my tests?
- Can you easily look up the discharge instructions from my recent hospitalization on your office computer?
- Do all the doctors and hospitals and pharmacies in town share the same medical record system — why not? It would be very good from a patient standpoint.
NO answers exemplify the current data problem. The US has a far better tax system than a medical record system and a far better post office than a medical record system. Contrary to the story in the Washington Post this is NOT OK.