Managing Managed Care

Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

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The EHR's Costly and Currently Not Collaborative

The adoption and implementation of digital communication in health care is accelerating, but in ways that are worlds apart from the transformation we are witnessing in social media.  After all, in healthcare, cost control is at issue and an important part of the enabling legislation–the "American Recovery and Reinvestment Act" ("Recovery Act" in short), Health Information Exchanges (HIE) and in transformative health information technology (HIT) developments.

Not surprisingly, the Recovery Act is actually adding to the costs of care by allowing practitioners to code for services not rendered, examinations not competed and practitioners charging more for a service than it is worth (i.e., up-coding), or not justified.  The "Recovery Act" provided $19 Billion and up to $44,000 per doc to purchase and use the computer system and have it perform in a "meaningful" way. This may seem straightforward, but that incentive is really adding to the costs of care in that it is being used to  "document" or justify unnecessary care or or a level of complexity that simply isn't there. 

* See "In 2nd Look, Few Savings from Digital Health Records," by Reed Ableson and Julie Oreswell, NY TImes, Jan. 10 2013; it speaks to a RAND Corporation study, the "2005 Report," which grossly overstated expected savings.

* Contrast the above mentioned NYTmes piece with the Consensus Document, which got the imprimatur of the AARP, American Academy of Family Physicians, Joint Commission, America's Health Insurance Plans, and the National Committee for Quality Assurance.

Background from Medical Economics' publication, "Premium Content Preview | EHR Improvements After the AMA's 'Hateful 8'" an AdvancedMD PDF

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The “'Hateful 8' signs of a poorly functioning EHR: 1. Interfering with patient care 2. Poor team communication 3. Lack of care coordination 4. Adding to the workload 5. No custom options 6. Unwieldy data 7. Few mobile options 8. No product reviews or feedback"

Miliard M. "CIOs target population health, patient engagement in 2016." Healthcare IT News. 12/14/15

The AMA’s EHR Usability Wishlist 2014 • Enhance physicians’ ability to provide high-quality patient care • Support team-based care • Promote care coordination • Offer product modularity & configurability • Reduce cognitive workload • Promote data liquidity • Facilitate digital & mobile patient engagement • Expedite user input into product design & implementation feedback

 "AMA calls for design overhaul of electronic health records to improve usability." American Medical Association. 9/16/14

Note also, the Act could be a Trojan Horse....

In "EHR Financial Incentives Tied to 'Meaningful Use'" [Pediatric News. June 2009;43(6):34], "Dr. John Halamka defined this phase of health care information technology as “processes and workflows that facilitate improved quality and increased efficiency.” The same article also spoke to the Markle Foundation's “simple” definition of patient-centered "meaningful use"–“The provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs.” [Here I have to make a distinction - the Foundation is really talking about sharing "data," not "information," per se.  They could be one and the same, however you need analytics to translate data into information, and, currently, health care analytic expertise and real-time, point of contact heuristics is in short supply.]

Surely there will efficiencies gained by digitalizing the patient registry, appointment scheduling, the medical record, tests, orders, plan, prescriptions and patient education.  However, I find myself documenting what "should be," not "what was." And don't even think I am being dishonest, either. Yes! I want what should be for my patients, but what I think is medically necessary in the office, may not be on the patient's priority list of things to do when they have left it–After all, what I recommend may not be affordable; the family may have competing interests; they're nervous, not hearing and they simply don't understand. They've got 'better' or more pressing things to do then take the medicine 4 times a day, get the X-ray for an ankle sprain or apply the hot soaks, as directed.
We now have HIPPA "protections," but with it I am often finding it difficult to get the other doctor's or hospital's records or labs. And who can blame them?–We don't have a collaborative relationship, after all. (So much for "meaningful use," which assumes there will be good communication and let turf issues be damned).  And then there's Big Brother-1984, looking over my shoulder–​could the EHR be an entry to governmental oversight?  I have no problem with unobtrusive feedback into my practice (and I know the value of acuity indexing, a longitudinal patient record and an "episode of care" kind of picture), but 'been there; done that.' Indeed, one of the reasons, HMOs lost favor was they became judgmental; you know, "Monday Morning Quarterbacking."—"Doc, I'm really on your side; I'm here to help ya."
  • Oh, Dr. Kaplan: We see you've not immunized X patients. (Could it be that I'm not their PCP?)
  • Dr. D. Mellitus: Your Hgb A1c levels? (Could it be that some of these patients lost their coverage or are non-compliant?)
  • Dr. C.A.P.: Too many of your patients are being admitted to the hospital. (Could it be that many of them continue to polute their lungs?)
  • Etc., Etc.