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Meaningful Use Is Not For Specialists

You know, I’ve been thinking a lot about Meaningful Use lately. I previously I’ve had pretty negative opinions of it, and my thoughts seem to be echoed by a lot of doctors currently in practice.

Rob Lamberts, MD, wrote an interesting post titled Ten Ways to Make the EMR Meaningful and Useful. I have to admit, his suggestions made an awful lot of sense. They started me thinking about how useless much of my own documentation is because of its origination in archaic rules for receiving insurance reimbursement money. Unfortunately, it seems that a lot of these rules stem from the medical profession itself rather than have been having been thought of exclusively by insurance moguls. For example, the family history is usually almost entirely irrelevant to what my scope of practice generally entails. The Review of Systems (ROS), which is the part of the exam where we as doctors ask the patient a myriad of questions regarding their symptoms, is typically exhaustive, unproductive and usually despised by most practicing physicians. Patients are generally very forthcoming about any active symptoms that they are currently experiencing, and a few additional questions around their symptoms typically suffices for a doctor’s purposes.

The majority of old medical records that I get from previous practices in which the patient has been involved are usually either illegible, irrelevant, or not directly related to the reason the patient is coming in to see me. If I am seeing them for the same purpose and they are just transferring their care to me, I generally will ask much of the same questions that have been asked before, rendering the review of records of even more limited value.

I think that getting meaningful use out of our own individual records could be greatly helped by an overhaul of the medical profession’s recommendations to insurance companies on the types of information that needs to be included in medical office notes for the purposes of providing excellent healthcare. In the increasingly complex and technologically-advanced society in which we live, information “noise” really should be kept at a minimum, especially in providing appropriate healthcare recommendations to patients. Medical records should not be in a habit of containing information that does not change or impact the medical management of the patient. We really need to revisit the idea of “gee whiz” type of data and cut out any extraneous documentation.

This would, of course, require that meaningful use become much more personalized and individualized to specific doctors and their specialties. The current state of meaningful use is actually fairly limited in that it applies mostly to primary care providers making recommendations for preventive health care. Preventive health care, unfortunately, is almost never the reason why patients seek the advanced medical knowledge of specialists and subspecialists in specific areas of medicine.

In summary, I agree with Dr. Lamberts that we need to overhaul meaningful use into something that is much more meaningful and usable.

October 1, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

EHR Evolution Can Improve Doctors’ Lives

Or is it the doctor’s evolution with an EHR?  Recently, John Lynn of EMRandHIPAA.com asked me to comment on how the evolution of EHR can improve a phyisicans life.  This was sparked by the announcement by an EMR vendor that their electronic prescribing process was made simpler, moving from a 6 screen click process to a 2 screen process.  Although I think I’ve put this into some of my posts, perhaps in a scattered fashion, it’s a good topic to keep discussing.

More recently, I’ve been trying to pare down my EMR documentation to just the essentials, and it’s surprising after more than two years in private practice working with EMRs (two different vendors) that I can still find places to cut corners and make my life even easier, … ahem, … I mean better.  I wouldn’t want to give anyone the wrong impression that my life is easy.

Most recently, I’m working on fine tuning my templates and cutting out things that don’t seem to matter, like the section for chief complaint.  This has now become just an automatically populated field with the time and date stamp of the appointment and when the patient actually showed up.  Anyone who reads the “History of Present Illness” section will know what the chief complain is anyway since it’s reiterated there.  Ah, I love redundancy!

Although I didn’t mention much about it, my EHR system has evolved and “upgraded” its programming over time, and these changes have mostly been good and needed ones.  Most of these changes, however, are behind the scenes alterations that the end user will never know about unless they get announced.  One comment I can make is that, in 2011, software changes in order to meet Meaningful Use has derailed a lot of the more potentially innovative, dreamy ideas that could be so much more if the EHR vendors weren’t having to jump though creativity-stifling, complex hoops to redo their systems to meet even Stage 1 MU.  This will probably get worse as the hoops become more onerous in Stages 2 and 3.

However, back to my more productive line of thought.  The best part of continually refining one’s strategies for using their EMR system is that it leaves them with even more time to use for other more beneficial things in one’s professional life.  Life is so short, so I highly recommend choosing wisely how to spend it.

January 31, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

My Failure of Attesting for Meaningful Use

Truthfully, when I opted out of Medicare (and seeing those patients) in July 2011, I kind of sealed my fate in not being able to go for the Meaningful Use EHR incentives.  I did however, as an experiment, try to attest to see how far I could get using data from the first six months of the year.  Let me just say that the chart reviews, mouse clicks and calculations got so involved that I was glad when I found out, after only reviewing the charts of 55 qualifying Medicare patients, that my numbers and percentages weren’t sufficient for qualifying for meaningful use.

Nevertheless, I forged ahead to the end of my “experiment”.  CMS’ EHR incentive portal is a funny and bass-ackwards system, in a way, because it lets you get to the painful end of the long data entry process without telling you, “Hey wait, stop now since you’ve already failed on this one measure (by percentage).”  Half of the time I was guessing at what I thought they wanted, being that the specific questions involved in attsting are so poorly worded that they leave a lot of roof for creative interpretation. How the people in charge at CMS figure that they will get accurate research data in such a context is beyond me, but then this is a typical government-run system — dysfunctional is par for the course.  You can honestly attest that your numbers are true “to the best of your knowledge” in the end because you didn’t really know what some questions were asking for.  Apparently, your best guess is okay.

Nope.  Rather than warning you of your demise early, they let you get to the bitter end and then they tell you in a summary page all the points along the way that you actually failed at in meeting the MU requirements.  I have to admit that they had me going there for a while.  I really was thinking, “Well, they let me get this far, so maybe I can just submit and report the measures and the government will honor all my hard work and time spent.  Maybe the goal for a partcular measure X is 50%, but they just want any numbers this time around, being that this is only Stage 1 of MU.”

I have heard stories of MU attesters/doctors who said they were so exhausted by the time they finally finished the process that I suspected, going in, this wasn’t going to be a cake walk.  However, in fairness, our EMR system had not yet put into action its “MU Dashboard” function during the first part of 2011, when I actually saw the patients.  The dashboard function/page now allows convenient tracking of all measures and calculates the numbers for you… after, of course, you go through the time-sucking process of checking off all the measures that are required to qualify.  And I only had around 70 Medicare patients.  Imagine those doctors with hundreds or…. gulp… thousands.  Just to give you a sample of the pain, last week I tried entering allergies for 20 random (non-Medicare) patients the next day after I saw them.  The dashboard function doesn’t do this for you, after all, and my patients’ allergies are recorded as free text (unstructured data) using my template system.  By the time all clicks were done, it took me 10 minutes of solid mouse clicking time at a brisk pace.  Pages have to load up, after all.  I could have done so much else with that 10 minutes of my life that I’ll never get back.  Talk about frustrating.

I did a crude calculation and took $44,000/(5 yr x 365 days/yr) and came up with $24/day for a heck of a lot of work.  In doctor-speak, it ain’t worth it.  Now I’m not poo-pooing the do-gooders out there who want to give their time to this process and try to make the world a better place through being meaningful users of health IT.  Just please don’t hate the business-oriented group of doctors out there who have done the math and dabbled in it enough to choose otherwise.

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine and opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.  He blogs at HappyEMRDoctor.com and EHROutlook.com.

November 21, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Are More Doctors Leaving Medicare?

Today’s blog is a bit of a departure from my usual EMR and EHR focus, but I think that Medicare is pretty intricately intertwined with the EMR incentives via Meaningful Use, and so I thought I would share some perspective on a recent article that set my mind’s hamster wheel spinning.

Bob Keaveney’s article at Physicians Practice, With Friends Like These… paints a powerful summary to the reason doctors are running from Medicare and Medicaid — left and right — these days and how the New World Order coming in the form a ACOs may put a strain on the relationships between physicians and patients.

Last Tuesday evening, my practice manager was visiting with a freindly neighborhood PCP and her practice manager from down the road.  They are literally a block up as a matter of fact.  My manager was helping them understand how we use our EMR system, Practice Fusion, and how they could do the same.

The conversation at one point turned to why we were seeing a lot of Medicare patient referrals for diabetes care from the PCP’s father earlier this year.  Her father is also a PCP in the same practice here in DC.  She had an interesting answer.  “Oh, he left Medicare and had to find a home for them.  I’m also planning to leave Medicare in January 2012,” she said.  And to think that we just dumped Medicare ourselves on July 1!

Another interesting part in considering this PCP’s story of leaving Medicare in January is that she is probably not planning on going after Meaningful Use incentive money, an idea that I’ve nearly given up on as well given the complexities involved, in particular, to my current situation.  But that’s a completely different story for a different day.  At any rate, read Bob’s article above.  It’s food for a hungry mind as the year in Meaningful Use progresses.

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine and opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.  Some of his blogs also appear at EHROutlook.com.

October 3, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Do EMR and EHR Registries Equal Better Care?

Meaningful Use includes the creation and transmission of patient registries for reporting various medical data such as vaccinations, medications, lab results and vital signs including weight, body mass index (BMI) and blood pressure.  To be honest, I don’t know any real practicing doctors out there who worry about their EHR’s ability to perform registry generation, but non-doctors with more time on their hands seem to think it’s the Holy Grail.  As it turns out, a recent post by Ken Terry EHRs Give Docs Analytics Tools They May Ignore sparked my interest.  

It was pretty intriguing that an insurance company like Blue Cross Blue Shield would be sponsoring a pilot experiment to correlate doctors’ access to EMR and EHR technology with doctors’ ability to generate patient registries.  Clearly, this is the first step in making searchable databases that will enable users to ask more detailed questions.  Since the pilot study was not clear on what or how much information was shared with the insurance company by the administrating body for the study, the Massachusetts eHealth Collaborative, there’s an interesting closed door there that the public can’t see behind right now.  Why does an insurance company want such information?  Let’s be honest:  it’s got to be money, plain and simple.  Insurance companies are for-profit entities after all.  Assigning report cards and pay-grades to doctors based on performance?  Stratifying out “good” and “bad” doctors?  Door #3?  If they just want to study problem areas for public health improvement, then it would be preferable to define their end goals publicly ahead of time — which has been one of my big beefs with Meaningful Use.

I loved the comment by Jane Metzger, a CSC consultant who is an expert in registries.  Most of today’s EHRs can do a registry-like function, but it takes work to do that… Not every practice that adopts an EHR is committed to care management–having guidelines for care, knowing who your diabetic patients are, and deciding you should see them at least once a year and so forth.”  Wow — what a negative connotation of docs who might have other ways to benefit their patients.  However, Metzger did mention something I agree with in the end:  ” it’s extra work to do it.”

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

August 9, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

CMS to cut healthcare payments by 30% in January 2012

You knew it was coming folks.   I did, too, as a matter of fact.  And so, as of July 1st, I famously exited Medicare, stage right.  Earlier in the spring, I enjoyed a lunch here in DC at Lauriol Plaza — my favorite Mexican resuarant in the District — with a personal friend of mine fairly high up in HHS who works on MU rules.  At one point, when we were discussing the highly cliche will-they-or-won’t-they cut Medicare/Medicaid payments, he rhetorically stated with eyebrows raised, “Think about it, the money’s got to come from somewhere.”  The clear implication being that it will logically come from cutting from doctors’ payments.

Now, the New York Times reports this post, discussing the compromises that the Obama administration is proposing to make by cutting CMS payments for services to seniors in exchange for the Republicans allowing them to raise taxes to solve the budget crisis.

Suddenly the $44k incentive money for using EHRs is looking quite pale.  E-prescribing for 2%?  Pee-shaw!

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

July 7, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Idealism and Motashari’s politics

I just waded through a description of Dr. Farzad Motashari’s speech to providers recently at a session of the National Health IT and Delivery System Transformation Summit in Washington.  Dr. Mostashari, MD, ScM, is the national coordinator for health IT.  Although he appears to have a lot of degrees and certificates behind his name — most, it seems, in public health and epidemiology — it’s not clear how much actual time in a private practice office Dr. Motashari has spent, beyond his internal medicine residency.

Residencies are great at teaching you the ideal, textbook way medical practice is supposed to take place.  But, unfortunately, the real world of private practice doesn’t start educating you until you are out in the real world, with pressures and requirements that are not discussed or taught in medical school or residency.

More than a career in data crunching and writing research papers would give me confidence that Dr. Motashari really understands how many hoops –which he insists that meaningful use is not about — are actually entailed by MU and how much it has the potential to side track doctors’ abilities to self-direct patient care as they see fit.  It’s one thing to make eloquent public health speeches and have public health research as your personal goal in life .  It’s another to get practicing doctors to buy in up to the point that they are willing to change their own goals and work flows in providing excellent patient care in order to support someone else’s plans of collecting a ton of data for research use.

I wish someone could help me understand why I should be helping support an already way-overpriced program for researching what doctors already do all the time.  Do we have not trust in our nation’s doctors to do such basic healthcare as addressing blood pressure, obesity, and smoking cessation?  Somehow, I don’t buy that we need such a program at such a high price.

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

July 6, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Lack of motivation of private payers to incentivize EHRs

In his June 30, 2011 post “Private Payers Need to Join Humana, CMS With EHR Subsidies”, Neil Versel wonders where all the private payers are when it comes to providing incentives to doctors for implementing meaningful use of EHRs.  Apparently, Humana is now one company slated to start following CMS’ lead.

This reminded me of an interesting story involving an insider I knew who previously worked for insurance companies.  He once told me an interesting story about the conversations that happen behind closed doors of private health insurance corporate boardrooms.  Alas, it was so long ago, that I honestly don’t remember who it was, or who they previosuly worked for, but it put such an indelible mark on my memory that I couldn’t resist the chance to share it here.  This may be a bit graphic to some, so turn back now if you have a faint heart.

I told my contact that I just couldn’t understand why preventive office visits such as counseling by registered dieticians dealing with weight loss for patients with obesity weren’t ever covered.   Did these patients really need to develop diabetes first before any coverage for such services would be provided by the insurance companies? It just didn’t make any sense to me or others that I had discussed it with.

My contact told me about an example of how insurance companies employ actuaries to mathematically predict odds of a bad outcome.  [For those of you who worship the movie Fight Club, you might find some similarity here to a particular dialog in that film.]  Because the odds are very good that a particular patient will change insurance companies within a few years –happens all the time — there is much less of a chance that insurance company A will have to end up paying for their leg amputation by the time it happens.   Therefore, insurance company A doesn’t provide much in the way of preventive care and counseling visits today.   The odds are with the insurance company that they’ll never have to pay for that operation in the future because the patient’s out the door by then and on to insurance company B.  I know, what a callous and disgustingly money-grubbing view!  Gee, you don’t say.

Now, getting back to this private insurance company incentive plan idea …

Dr. West is an endocrinologist in private practice in Washington, DC.  He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

July 5, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Quantity vs quality: keeping America’s doctors back with MU regulations

I read the following post on Saturday over at TheHill.com.  I have to quote from the article here because it’s such a perfect setup for what so many doctors feel about meaningful use/MU.  Warning:  possible ravings of a complete lunatic coming at the end.

“Small medical practices warned Congress on Thursday that health information technology risks being less than useless if it’s designed to meet bureaucrats’ arbitrary standards rather than the needs of doctors and patients.

Testifying at a House Small Business healthcare subcommittee hearing, the CEO of HIT Services company Ingenix said cost isn’t the main reason physician’s offices are struggling to make the switch to paperless. Rather, Andy Slavitt testified, the “purchase and design of technology (…) have taken a back burner to all of the compliance reporting requirements” needed to qualify for federal incentive payments.

“Today,” Slavitt said in written testimony, “the end-users, doctors and patients, are further away than ever from system design, because new product development is focused on satisfying those regulatory hurdles, rather than on simple innovations that improve productivity.”

I could not agree more.  The U.S. federal government, in the form of HHS and CMS, is basically hijacking the doctor-patient relationship by giving doctors extra steps to do during office visits.  The way I see it, if CMS and HHS are so hellbent on puppetmastering the show and making doctors into mere data-reporting automatons — which, I have to tell you, PQRI reporting felt an aweful lot like — then I suggest that they take an even fuller responsibility for providing the healthcare to the patient themselves.  After all, what do they need doctors for if they can practically write the script for the visit?  With the increasing number of MU requirements that have to be incorporated into each visit — to basically “help” doctors “do a better job” — it begs the question “Where will it end?”.  Is it much different from an organized crime boss telling me, “Do this… or we’ll hurt you?”    As MU progresses into stages 2 and 3 — I’ve said it before and I’ll say it again — I can’t wait to find out what my CMS-participating peers will end up dealing with.

It all reminds me that I didn’t go to medical school because I wanted to become a data collector for Uncle Sam.  Call me old fashioned, but I actually like having enough time to to listen to why the patient really came to see me today.  However, for the government, apparently, the numbers are more important.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.  He can be reached at doctorwestindc@gmail.com.

June 7, 2011 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.