What Does it Feel Like to be a Physician Right Now?

I have the pleasure of visiting with dozens of physicians of all types every week. Especially in primary care, the system continues to pile on burdens that increasingly interfere with doctors doing what they do. I have no doubts the loads will increase. It is our mission at SOAPware, Inc. to lighten the load of physicians deserving of their patient’s trust. How can we best facilitate their efforts to detach and offload? Does all of the burden really need to be carried by physicians, or can they transfer much of it? What does that transfer involve?
What does it mean to work smarter rather than harder?

EMR De-Installations - A Growing Trend?

Study: Deinstallation of EMRs in Phoenix could be a trend


The report said de-installation due to financial issues is not unique to physician groups or to Arizona. For example, in areas like Miami, where the economic downturn is threatening the profitability of hospitals, adoption of EMRs has been slow because of a lack of funding for such capital projects.

In the past 2 years, surveys have revealed a high rate of EMR failures with complete de-installations (i.e. a return to paper) between 20-30%. Before our nation spends billions of dollars on flawed approaches promoting EMR use, let's hope there will be an increased focus on implementation. Implementation has to be planned and budgeted. This cost is $2,000 to $20,000 per clinician and is not included in the price of EMR software purchases. And, it is above and beyond training.
The current norm is for non-clinical representatives to be the primary decision-makers with EMR purchases, and the norm is for them to spend money on software that would have been more wisely allocated to implementation.
Almost any major EMR software can be successfully implemented if enough is budgeted for implementation. However, no comprehensive EMR will be successfully implemented if the implementation budget is inadequate.
The most common, alternative approach is to implement a less than comprehensive EMR that does not require as much implementation guidance/services. This will likely only delay the realization of failure until the need to measure and report quality arises (1-3 years?).
Additionally, the evidence is that, currently, over 90% of EMR implementations are not achieving comprehensive use even when they are capable. There are many, additional system reasons for this including the fact that there are little to no financial/economic rewards for using an EMR comprehensively. This makes today's purchase of free-text based EMR systems appear to be wise because they are faster/easier to use, and can template bulky information (often garbage) that satisfies current payment rules. As the rewards shift from medical record bulk/garbage to an ability to report outcomes, there will be many frustrated EMR users.
Final purchasing decisions should be solely made by clinicians based on the clinical usefulness of the system. However, the current norm is for salespersons and consultants (who usually have inherent biases) to convince decision-makers other than the clinicians. Too often, the clinician involvement is either token, is not representative of typical end-users, or the involved clinicians have distractions that prevent them from being adequately involved in the decision process.

HHS panel charts ambitious course for health IT adoption

HHS panel charts ambitious course for health IT adoption


...The American Recovery and Reinvestment Act of 2009 allows such bonuses to be paid to medical providers and organizations that make meaningful use of health IT. ...

Note that the bonuses are for meaningful use and are not going to be available to purchase electronic medical record systems.

...David Blumenthal, the committee’s chairman and national health IT coordinator at HHS, took note of several members’ suggestions that requirements for health IT adoption be moved up from 2013 to 2011. He termed the shorter timeline “perfectly reasonable.”

The workgroup then described a trajectory for achieving that vision through three sets of criteria: data capture and sharing, which should be ready for implementation in 2011; advanced clinical processes, required in 2013; and improved outcomes, to be demonstrated by 2015.

The 2011 objectives include capturing data such as medication lists, allergies, and vital signs in coded format and electronically prescribing drugs. Performance measures at this stage would include the achievement of unspecified percentages of lab results captured in electronic records in coded format and computerized physician order entries entered by physicians.

The 2013 objectives include access to clinical decision support at the point of care and receiving electronic public health alerts....

...“Decision support would be derived from clinical data and would be standardized,” said Dr. Paul Tang, the workgroup’s co-chairman and vice president and chief medical information officer at the Palo Alto Medical Foundation. “These objectives are pushing more toward outcome improvements.”...

...The 2015 objectives include achieving “minimal levels of performance on quality, safety and efficiency measures,” Tang said. “This moves toward implementing a clinical dashboard at the point of care for the physician.”...


...The committee expects to see a revised presentation on meaningful use at its next meeting in July. Eventually, a definition will be promulgated as part of a formal rulemaking process that will include the release of a proposed rule, a period for public comment and the adoption of a final interim rule. That process is scheduled to be completed by the end of this year....

The goals are ambitious but achievable if practices get started by early 2010.
More to come as to how to achieve the goals and not go bankrupt or destroy medical practices in the process.

How Could the Health Industry Actually Block Interoperable Medical Records By Promoting Them?

A good means to actually block interoperable health information would be to encourage the government to adopt an industry specific method/standard for interoperability that allows HIT vendors and enterprises to charge tens of thousands of dollars for each and every single interface to small and/or independent practices or to entities wanting to share health information directly with patients. The brilliance of doing this would be that HIT vendors, enterprises and their “expert” buddy/consultants could publicly claim they are honorably promoting information exchange while covertly blocking exchange almost completely. However, in order to be able to do this, they would have to ignore existing methods of information exchange that would allow for 90% of the needs to be met, today, at less than 10% of the eventual costs of a theoretical exchange mechanism.
But, surely the Health Care Industry and their vendors would not consider such methods, and certainly the government is not that gullible?

Trail Unsafe When Under Water

Most days, I pass this on the path I follow. And, when I go for walks, this is the sign where the Mud Creek Trail passes under College Ave.
The reason this sign even has to exist is symptomatic of some of the the key reasons "meaningful" healthcare reform and practical requirements for "meaningful" use of health information technology are unlikely.
I know, I know, I'm not being very sensitive or politically correct. Sorry if I have offended anyone who would rather not be intimidated by reality.

Patients and their Physicians should Shape Reform, not Vice Versa

Barbara Starfield has best articulated what is so obvious it is consistently ignored.
I have great concern regarding how primary care and the Patient Centered Medical Home (PCMH) are being defined and measured without adequate involvement of patients and their primary physicians. Policymakers, even when well-intended, consistently miss the mark. I see little with current events showing much likelihood of changing this.

It appears patients and physicians will remain pawns within pretty much the same bureaucracies that take advantage of them today. I was hoping for at least some shuffling of the deck. Silly me.

The Cartoon in the Mirror?

You will not need to go to the Comedy Channel if you want mindless humor the next few weeks. Just watch the news as health care “reform” rolls out of Congress. If there is ever going to be a demonstration as to just how corrupt our system is, this will be it. It is beyond amazing how something is made out to be much more complex than it needs to be. But, complexity is necessary to protect all the special interests at the trough of waste.
The consumer is just as much of the problem as payers and providers. Americans have clearly let it be known that we deserve the best health care that money can buy… just as long as it is someone else’s money.

Is it not amazing that the same constituencies that stress the need for drug companies to not give ink pens to doctors (which I support), are the same ones saying little about Congress collecting millions from the same companies? Will we ever get a clue, or will we continue to allow the media and special interests to maintain mind control?

"We have met the enemy and he is us." Pogo

Physician Instructions on How to Plan to Fail with EMR Implementations

Because the majority of EMR implementations taking place today are on a path to failure (i.e. unlikely to meet "meaningful use" criteria), I thought I would add some guidance as to how to be the best at failure...

Budget less for implementation than you do for software.

Continue the anachronism of clinicians creating most of the documentation.

Delegate practice decisions (such as EMR implementation), and don’t delegate documentation tasks.

Have administration or the information system persons be the primary decision makers rather than the clinicians.

Spend years trying to find the perfect vendor-product. Allow a search for perfection to prevent incorporation of the great.

Spend months and thousands of dollars having an administrator, technical person or consultant develop an RFP. Better yet, pay thousands to a consultant to help select a system. (However, implementation consultation/facilitation services are the key to success in over 60% of practices.)

Travel thousands of miles and spend many days out of the clinic doing site visits.

Make site visit to practices that are the exception rather than the norm. Don't ask for full disclosure regarding the rewards the visited site is receiving from the vendor.

Remain stuck in the fallacy of “I can’t afford it.” (It does not need to be expensive. In fact, with higher EMR costs, you usually get what you pay for… EMR advertising, promotion and payola.)

Make decisions based on expecting someone with shiny shoes to come in to stroke egos of the decision makers.

Purchase systems that have limited numbers of installs and lots of venture capital.

Only consider systems offered by "Big Name" vendors thinking this is safer. (More orphaned EMR users have bought from big names than small ones.)

Buy into the notion that the more employees the EMR vendor has, the less the risk.

Plan for “Big Bang” Revolutions instead of Non-Disruptive Evolutions.

Buy systems that lack connectivity or charge exorbitant fees for interfaces. (This is the norm and can only be negotiated at the time of initial purchase. Get specific in writing. The current, minimal, average cost for a simple, one-way interface is $14,000.)

Buy systems that store (i.e. trap) your data in a proprietary database so that you can only get to it through the single vendor’s proprietary software. (This is the norm, and an average cost to be able to get your patient's data out of the system averages $10,000.)

Focus on having a big list of bells and whistles rather than focusing on improving basic practice efficiencies and work flows.

Choose products that either force structured entry or don’t support structured entry. (With few exceptions, you should have both options in all areas.)

Implement a stand-alone electronic prescribing product as a "transition tool" thinking this will make it easier to get to a full EMR. (This is a false assumption leading to more work for clinicians, and secondarily leads to delayed or failed EMR implementations in a majority of settings.)

If you do implementation in the fashion most of the industry advocates, you are more likely to fail than succeed. So, at least fail in style.