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Six Years Later, What Has Meaningful Use Accomplished?

In Atlanta we are recovering from one of worst winter storms in many years. Weather events are financially devastating for a medical practice.  Revenue completely stops while expenses continue without interruption.   Today for the first time we saw patients in the office on a Saturday to recover a little.

During our 3 snow days this past week I decided to take on John Lynn’s challenge regarding what I would do if the Meaningful Use (MU) incentive money disappeared.  There has been a range of responses including one person who wouldn’t change a thing about MU.  However, recent data continue to support my long-held opinion that MU has been harmful to health IT and the EMR cause.

Think about where we were before MU was conceived.  Six years ago the NEJM study cited by the designers of MU showed a 4% EMR adoption rate.  Among EMR users the vast majority (72%-96%) reported a positive effect of EMR on patient care.  Among EMR users physician satisfaction was 93%.  Among EMR non-users, the major reasons for not getting an EMR included cost (66%), uncertainty regarding the return on investment (50%), and loss of productivity during implementation (41%).

Six years later, what has MU done for EMRs?  Medical Economics recently released an EHR survey of 967 physicians polled in late 2013 with very disturbing results:

  • 70% did not feel their EHR investment was worth the cost and the effort
  • 73% would not re-purchase their current system
  • 69% report coordination of care has not improved
  • 65% do not believe EHR has improved quality of care.  45% believe EHR has made patient care worse
  • 66% report financial losses resulting from EHR.  38% report significant losses.
  • Lack of system functionality was the most common complaint among EHR users (67%)
  • 45% of all physicians spent over $100,000 on EHR and 77% of the “largest” practices spent over $200,000.  It is unclear whether this is the total practice cost or cost per physician.  Increased staff costs and loss of productivity were also cited as major issues.

Also telling are data reported by CMS last May that a staggering 17% of all providers who attested for the 90 day period required for MU Stage 1 / Year 1 (2011) did not participate the following year.  A CMS survey of these “non-returning providers” (NRPs) showed many of them gave up for reasons related to the MU program as well as reasons related to dissatisfaction with their EMRs.

Analysis of these 3 studies suggests that the satisfaction rate among EMR users has fallen from over 90% to about 30% over the past 6 years.  The proportion of providers that believe EMR improves quality of care has fallen from 82% in 2008 to 35% in the 2013 ME survey.  The misgivings of non-EMR-users in the NEJM 2008 study were proven valid among the dissatisfied EMR-users in the ME 2013 survey: high cost, poor return on investment and loss of productivity.  Even 5 figure financial incentives can’t get MU / EMR participation beyond a very short time of 90 days.

How could EMR’s reputation among EMR users fall so far?  The Meaningful Use program is solely responsible.

Go back to 2008 for a moment.  Had the health IT market been left undisturbed, EMR vendors would have engaged their existing base of satisfied customers in order to improve their products and sell to new customers.  This base of early EMR adopters was unique and special.  Our practice was among those that had a fully functional EMR in 2007-2008.  We shared a vision and saw the potential for information technology to improve health care.   We had both the IT resources and the will to work hundreds of extra hours to build effective EMR systems from products that were almost useless as they came “out of the box.”  We willingly accepted that proposition.

In 2008 the early adopters would have gladly offered their own practices as examples to demonstrate the value of EMR and help their vendors sell to new customers.  This slow, evolutionary growth would have created a stable environment that allowed the health care system to safely assimilate the cultural and operational changes that EMR brings.  This environment would have also supported stable evolution and improvement of EMR products.  The result would have been modest but steady growth in the EMR market for decades to come.

But thanks to MU this never happened.  Replacement of stable, natural market forces with MU incentives drove immediate, explosive short-term growth in the EMR market.  But these MU-driven EMR purchasers are not like the practices before 2008 that freely chose to purchase a system. These practices had decided against EMR initially, at least partly because they lacked the IT resources to make EMR work for them.   MU coerced them to purchase EMR against their better judgment.

I have spoken with many of these physicians.  They do not share the inspiration and vision of the early adopters.  They are rightly unhappy and cynical, forced by MU to spend huge amounts of money on unproven, underdeveloped EMR products that they did not want and were not prepared to properly use. To these practices the question of EMR’s potential is irrelevant.  In their minds MU (and by association EMRs) lives next to HIPAA, SGR and RAC audits as another method for the government to intimidate doctors and intrude upon their practices.

The MU program gave EMR vendors what they wanted – legislation requiring hundreds of thousands of providers to buy EMR products, with no need to prove that those products do anything useful.  But here’s the bad news: the Feds got what they wanted as well.  Through MU they created an EMR industry that is dependent on government incentives and penalties to maintain a stream of new customers.  This gives them complete control of the EMR market.  There is more bad news.  MU also destroyed the base of satisfied EMR customers from 2008, replacing it with a much larger base of unhappy, resentful customers.

So what happens as MU payments decrease with each passing year as MU requirements go up?  Who can argue that the market won’t collapse without another EMR stimulus package?  John Lynn’s question is appropriate and timely.  MU incentives will indeed disappear over the next couple of years.  How the EMR market will survive is not clear.

February 15, 2014 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Web Portal Use by the Numbers

With our first year of web portal use well behind us I started looking for practical ways to begin mining some data to get some basic statistical observations regarding patient use of web portal.  As with all new undertakings in health IT this was far more difficult and cumbersome than it should have been.  Nonetheless I got a few interesting observations documented over the past couple of days.  I did not do an exhausting review but I don’t think data like this exist anywhere else.

I was curious about what proportion of our network’s new patients have used the web portal over the past 6 months.  Overall 22% of our new patients used the web portal for clinical data entry.  This differs significantly from my subjective observation that about half of my new patients were using the portal; this data includes all 19 of our network physicians, not just my own.  I am in the process of looking at my patients only.

 

The breakdown by age is here - the first table  – web portal figure 1

 

Portal use is very steady at around 25% through age 65 years.  Use among pediatric patients shows parents are just as willing to use the portal for their children as they are for themselves.  It is reasonable to expect portal use to drop with increasing age but I didn’t expect 65 year olds to be using the portal as much as 25 year olds.  Portal use among patients in their 70’s and 80’s is quite respectable.  The bump in use in patients over 90 years of age is interesting but likely to be a statistical illusion due to the very small absolute numbers in those age brackets.

 

The second table shows the same data expressed as raw numbers rather than percentages.  All our new patients, regardless of portal use, tend to be from age 40 to 70 years.

 

 

October 7, 2013 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Our First Year with a Patient Portal

Last month marked the end of our first year with our web portal.  It has been a steep but worthwhile learning curve.  Similar to every other component of our IT system there were many bumps along the way.  Here are some observations worth sharing:

  1. If you build it – and promote it – they will come.  There is no question that patients in our North Atlanta market like the portal.  Over the first 12 months 12,518 patients have signed up and completed over 130,000 health, demographic and general consent forms.  Participation has increased steadily as we have refined web page usability and improved the reliability of the system.  Subjectively I think about 2/3 of my new patients are using the portal to enter their demographic and personal health information prior to their initial appointment.
  2. Overpromotion backfires.  Our telephone-greeting message says, “To schedule an appointment, dial 0 or go to www.entofga.com.”  Sounds reasonable enough, but patients have misinterpreted this message as meaning that we don’t want to talk to them.
  3. If it doesn’t work, patients get angry – with good reason.  Nothing is more frustrating than spending 45 minutes filling out all your information at home and then getting handed the same forms on paper at the office because your online data was lost.  The IT folks seem to think if the explanation for the failure is fancy enough that will make everything OK.  It doesn’t.
  4. Patients who choose not to use the portal at home don’t want to use it in the waiting room, either.  We have tried iPads, laptops and desktop kiosks.  We have trained our front office folks to promote it and even “walk patients through” the portal.  Nothing has worked.  We have considered recruiting those patients with a different technology such as scanned #2 lead pencil bubble forms, at least for the discrete data.
  5. Patients have little interest in using the portal as an ongoing tool.  After the initial creation of the account, data entry and first appointment, they rarely use the portal again.  Last month with over 12,000 patients enrolled we got only 6 prescription refill requests and 24 “ask the doctor” questions.   Appointment requests were slightly better at 134.  Our telephone appointment schedulers tell me they frequently get calls from folks who made an appointment request online but then immediately call for the same appointment because they were not comfortable with the online appointment concept.  One could argue that this is unique to our specialty practice or that the online forms and workflow need improving.  That may be true, but I am convinced that at least a part of this phenomenon represents cultural pushback from patients.
  6. The ROI on the web portal is in some ways an all-or-nothing situation.  For a while the portal was passing to EMR only about 15 of the 20 data fields required to complete our demographic database.  Intuitively one would think the portal was therefore “75% useful”.  The problem is if I have to pay staff to open the patient’s file to manually enter the 5 remaining fields, I may as well have them manually enter all 20 fields.  That makes the portal 0% useful.  I can’t reassign staff to better things until the portal passes 100% of the data to the EMR.  This also relates to the reliability issues described above.  Until we reach near 100% reliability the return on investment is limited.
  7. As with every health IT product we have ever tried, it doesn’t work completely as advertised.  Although the new patient workflow is going fairly well other features remain severely compromised.  In our vendor’s defense this is partly because our parent EMR has had some upgrades which in turn requires our vendor to update the portal to adapt to the EMR changes.  The point is that none of these products is “plug and play” and the industry has a long way to go before these products become easy to use and practical for everyone.
  8. There are unintended consequences of a web portal.  Unbeknownst to us our portal was directing patients to the vendor’s personal health record product.  The transition is apparently pretty seamless so patients often still thought they were still inside our portal when they encountered very personal questions (i.e., sexual history) that had no relevance to their ear / nose  / throat appointment.

As an “early adopter” practice we are pleased overall with the portal but I’m not sure how a more typical practice would feel.

August 11, 2013 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

The Naiveté of mHealth

Last week I attended a seminar on mHealth sponsored by the Technology Association of Georgia (TAG).  The presenter was Arthur Lane, Director of Mobile Health Solutions at Verizon Wireless.  He gave a nice presentation and video of a system Verizon is designing to improve care of congestive heart failure (CHF) patients after hospital discharge.  CHF patients are treated effectively in the hospital setting with closely monitored vital signs and carefully administered medications / diet.  The problem is that once the patient goes home it is difficult to maintain the same level of monitoring and precision of the medication / diet regimen.  As a result re-admission rates for CHF are high, adding to the cost of care.

The Verizon system claims to correct this problem with smart phone technology.  The video showed a smart phone reminding a CHF patient to weigh himself before bed.  He has gained ½ pound since the morning.  When he wakes up the next morning the phone again reminds him to weigh himself.  He has gained another pound.  Weight gain day-to-day is an indication that CHF is getting worse.  The phone sends the weight data to a server, which in turn notifies a provider to call the patient and somehow prevent him from getting worse and showing up in the ER.   It was never clear to me how the provider was going to fix worsening CHF over the phone.

After Mr. Lane completed his presentation he joined 3 other panelists for a lively discussion moderated by a local physician whom I know.  Some of these panelists described their devotion to mHealth with near breathless excitement.  The physician moderator posed the ever-present question to the panel:  “How do we get doctors interested in this system (and mHealth overall)?”  The answers ranged from good – “Give doctors a product that is cost-effective” – to the ridiculous – “Align incentives by making physicians join ACOs.”  The silliest thought of the night was the suggestion from one panelist that health care is no different from banking.  I left the meeting with some concerns about who would pay for the Verizon system but decided to hold my reaction until I did a literature review.  After all, I am no cardiologist and have not treated a patient for CHF since med school.

 My review did not yield good news for Verizon or mHealth.

Turns out physicians have been working on home monitoring for CHF patients for years.  Unfortunately their studies do not support remote home monitoring for CHF to reduce hospital admissions.  A study from Yale Medical School published in the New England Journal of Medicine in 2011 randomized over 1600 CHF patients to either a control group or a remote monitoring group for outpatient care following admission for CHF.  There were no differences in readmission rates for CHF or for any other cause over the 6-month study.  Several other studies, including comprehensive reviews of existing literature, reach similar conclusions.

So what would a more realistic mHealth video look like?

Our CHF patient is discharged from the hospital all tuned up with appropriate medications, diet and smart phone remote monitoring using a CHF app.  The monitoring app works well at first, feeding him periodic words of encouragement and reminders to take his meds, record his vital signs, weigh himself, etc.  After several days of his phone going off constantly with all the reminders, alert fatigue sets in.   After ignoring the alarms for a few days he gets fed up and shuts the CHF application off.  The monitoring network detects the data interruption, and a provider calls the patient.  At first the contact with a real human helps, but after several calls alert fatigue strikes again.  Our patient recognizes the caller ID and stops answering.

In the meantime he tires of his medication regimen and diet restrictions and succumbs to the urge to scarf down some pizza and beer with some potato chips for dessert.  His smart phone isn’t smart enough to change his behavior.  The salt and fluid load makes his heart failure worse.  In the middle of the night he wakes up short of breath and calls 911.  Back to the hospital he goes.

The mHealth community is so enamored with their toys they can’t see what is right in front of them:

  1. Peer-reviewed medical literature does not support the use of home monitoring for CHF patients.  Period.  LTE smart phones and glitzy medical apps do nothing to change that.
  2. Without supporting literature no one is going to pay for remote monitoring.
    Who is going to cough up the dough for all those smart phones, Bluetooth connected home monitoring devices, remote servers, and the army of providers that will be required to manage the terabytes of data that such a monitoring network would generate?  Neither ACOs nor any other ill-conceived “alignment of incentives” for physicians solve this issue.
  3. The mHealth folks fail to recognize that monitoring is not the endpoint.  The endpoint is changing patient behavior.  A smart phone constantly shrieking warnings and reminders is rendered useless by alert fatigue.  Patient behavior is a very tough nut to crack.  The Verizon video ends with a nurse talking to the monitored patient about his weight gain.  But that is NOT the end.  It is just the beginning.  No one knows what that nurse is supposed to say to change the patient’s behavior over the phone.
  4. Like many mHealth ideas this system creates unrecognized changes to the standard of care and thus changes medical liability.  What if our CHF patient who stops listening to alerts and stops answering the phone dies while he is in the monitoring program?  Who is liable?

 So it’s the same thing all over again with health IT.  No proof of effectiveness.  No way to pay for it.  No understanding of the medical challenges involved.  Unrecognized changes in standard of care and liability.  Health care is not the same as banking.  Duh.

 Verizon has no business getting into health care beyond the LTE connection itself.  They are going to lose their shirt investing in a treatment the literature says doesn’t work.  Perhaps unwittingly, the physician moderator said it best when he asked the panel, “Where is the app that slaps my hand when I reach for the bag of Oreo cookies?”

Don’t get me wrong, folks.  Our practice has enjoyed great success with EMR in over the past 7+ years.  Our experience just scratches the surface of the awesome potential of health IT.  I want you to succeed.  But the health IT industry is headed in a direction that will guarantee failure.  To succeed you must stop chasing pipe dreams and focus on the one goal that must be met before anything else – HIEs, mHealth or anything else – can succeed:

Find a reliable way for doctors to succeed with EMR in the office setting.  Upgrade EMRs to reflect some understanding of the practice of medicine.  Design patient portals that actually work.  Demonstrate that EMRs are effective at improving care.  Design a business model that shows the path to a return on investment.

Until that goal is met, nothing else matters.

October 5, 2012 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

My Presentation Submission to 2012 mHealth Summit.

I decided to turn my rant on the 2011 mHealth Summit into something productive and submit a talk to the 2012 Summit.  A description of the proposed talk follows, as it appears on the application.

We’ll see what happens…

 

Why are doctors so apparently reluctant to embrace mHealth?

It is easy to appreciate the mHealth community’s frustration regarding this question. Clearly the physician community and the mHealth community do not understand each other very well.  The purpose of this presentation is to establish a mutual understanding and better lines of communication between practicing physicians and the mHealth community.

The first part of the presentation addresses practicing physicians’ concerns about mHealth:

1.  What is mHealth?  Has it been clearly defined?

2.  The safety and efficacy of mHealth / HIT products are not proven.  Technology always has unintended consequences.  In medicine such unintended consequences can increase costs and can harm patients.

3.  There is no widely accepted business model that establishes the return on investment for mHealth / HIT products.

4.  Government regulations and incentives may also have unintended adverse side effects.

Many of these concerns originate from the cultural differences between the physician and HIT communities. Each of these cultures sees the health care system and the role of mHealth / HIT differently.  The second part of the presentation addresses the cultural differences between these two communities and how these differences impede the adoption of mHealth / HIT.  Examples of cultural differences will include e-prescribing, health information exchanges and telemedicine.

The final part will outline the concessions both physicians and the HIT community need to make in order to facilitate communication, promote adoption of mHealth and improve the quality of mHealth products.  This will be difficult but worthwhile for both sides.

June 26, 2012 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

EMR Note Cloning is Scarier than I Thought

The health IT community is well aware of the dangers of cloning notes in an electronic medical record.  I include myself in that group.  Until recently I prided myself for doing a good job, both in our EMR design and in my own personal practice, of using just the right amount of automation in our documentation workflow.  Two recent events showed me that I still have some work to do.

The first event occurred a few weeks ago when I was reviewing some records.  One patient note documented an enlarged salivary gland containing a stone.  That would be fine except for one small detail – I had removed that gland one week prior to the date of the note!  My nurse had created that note.  A conversation with her revealed she thought she was doing the right thing by always clicking the “previous finding” button, which I had programmed myself.  My nurse is extremely bright; this was my fault for not training her on this issue.  I had also signed that note.  So it was my fault twice.  After a 30 second conversation with my nurse it has not happened since.

The second event was when an attorney interviewed me regarding one of my patients.  I was a treating physician in a malpractice case (I am not the defendant thankfully).  The attorney wanted to know if, in my opinion, the physician defendant had met the standard of care in treating the patient despite the adverse outcome.

This was a high-risk case for note cloning; the patient had multiple abnormal neurologic findings that were stable over time.  In reviewing my records I was satisfied that my notes were accurate, complete and original for every visit.  I avoided cloning those abnormal but stable findings by describing the same exam but using slightly different wording at each visit.  How else do you avoid cloning?  But the attorney pounced on my small changes in description, trying to establish a trend in my notes that the patient was getting worse.  I explained the cloning issue to him, and he understood…. I think.  Nonetheless I felt somewhat uncomfortable defending my documentation, and I was not even the defendant.  In trying to avoid cloning notes I had stepped right into another problem.

This issue is huge in my practice.  I have a large volume of head and neck cancer patients.  The essence of caring for them properly is to monitor them for changes in their abnormal – but stable – physical findings.  A recurrence of cancer might manifest as a subtle change in one of these findings.

How do you document that an examination is stable and unchanging, but change your wording enough to document that you actually examined the patient at every visit?  We do not yet have the cloning issue figured out.

June 15, 2012 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

The “Enthusiasm Gap” in Health IT

My next piece is published at Townhall.com:

 

Despite the success of information technology (IT) in transforming many parts of the economy, the health care sector has proven itself immune to the seduction of smart phones and iPads.  This is puzzling at first glance.  It is certainly not due to any shortage of health IT products.  The problem appears to be on the demand side.

A recent article by Olga Khazan in The Washington Post provides some explanation. She reports on the third annual mHealth Summit, held earlier this month in Washington D.C.  The event has attracted such notables as Bill Gates and Ted Turner, according to the mHealth website.  The piece laments the “enthusiasm gap” between Health IT startup companies offering dozens of miracle products and those darn stick-in-the-mud physicians who just can’t get with the program.   But meetings like the mHealth Summit actually hurt the movement of Health IT that they profess to support.

The poster child for Ms. Khazan’s article is Dr. Eric Topol, one of the Summit’s keynote speakers.  HHS Secretary Kathleen Sebelius joined Dr. Topol behind the podium.  Together they offered Health IT Utopia – where “you can take a video of a rash on your foot and get a diagnosis…without making a doctor’s appointment.”  Then they criticized practicing physicians using the same old Obamacare propaganda.  Ms. Sebelius continued, “Americans still live sicker and die sooner than many of the people in other nations…Healthcare has stubbornly held on to its cabinet and hanging files.”  Dr. Topol called the medical community “ossified” regarding the adoption of health information technology.  The author starts the online post-article comment thread herself with the question, “How do we encourage doctors to be more open to these technologies?”

This kind of meeting is common in the Health IT (HIT) community.  A bunch of self-described HIT experts get together, pump each other up about the absolute perfection of their products, and then start bashing physicians because – literally and figuratively – we aren’t buying it.  At similar meetings I have heard HIT people brag about walking out on their doctor the minute he pulled out a paper prescription pad.  Doctors are called fearful, stupid, or rich fat-cats protecting their turf.  Now thanks to our “colleague” Dr. Topol we can add, “ossified” to the list of unflattering terms.  It comes as no surprise that the government is happy to join in the sing-along.  It is a free opportunity to serve Obamacare Kool-Aid.

I am a dedicated supporter of HIT.   Our practice’s EMR implementation reached a reasonable level of maturity long before Obamacare, HITECH incentives, and Ms. Sebelius came along.  We became Meaningful Use – compliant the first of October.  I believe in the potential of HIT to revolutionize the practice of medicine by reducing costs and improving efficiency and quality of care.  But I do not believe the HIT community is on a course that will take us to that vision.

Read the rest of the article here at Townhall.com

January 5, 2012 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Deep Thoughts from the Meaningful Use Mountain Top

In some ways I am grateful to see 2011 end.  Several extracurricular projects have drained the life out of me, including our Meaningful Use (MU) project.  As near as I can tell we survived.  Our 90 days of compliance for phase 1 / year 1 are completed.  Last night I completed my attestation on line uneventfully.  We will get attestation completed for the rest of our physicians within a couple of weeks.  Then we will join the few (1%) of “eligible providers” that have complied with MU.  One would think that folks would be breaking down the doors of these “one-percenters” to learn the secrets of their success.  Yet a brief Internet search reveals no doctor testimonials on MU success beyond the second hand accounts offered by EMR vendors and consultants.  These are of little value.  So I am writing my testimony.

Over the past several months I have repeatedly criticized MU, with good reason.  But perhaps now that I have climbed the MU Mountain and my check will soon (hopefully) be on its way, I should soften my view a bit.  Sort of like final exam week…exams looked awful before you took them, but when you got done and you were somehow still alive, well, maybe it wasn’t so bad.

Well, sorry, it’s still that bad.  It took about 150 man-hours of work to complete this project.  And our EMR use, our quality of patient care and our practice efficiency is for the most part no better.  In some ways it is worse.  As a result of MU:

  1. We now take blood pressures on children.  This is almost never medically relevant in an ENT practice.  We can’t exempt ourselves from this requirement because of our adult patients, in whom blood pressure is often relevant.
  2. We waste volumes of paper printing clinical visit summaries that no one reads.  While the concept of a visit summary is OK, the document itself must include so much extra data it is useless.  Our web portal, which we are in the process of replacing, does not support this requirement so we have to use paper visit summaries for now.
  3. Patient waiting time is increased while we process data on pneumovax status, smoking status and body mass index on every patient.  In our practice these data are medically relevant for many patients, but not everyone.  Doing it for everybody is a waste.

To be fair, a couple of good things did happen:

  1. Use of EMR-based prescriptions and true e-prescribing (e-Rx) improved with those physicians that were still hanging on to paper scripts and/or were not using e-Rx.
  2. We were not maintaining true ICD-coded problem lists in the EMR before MU.  We had problem lists and diagnoses of course, and we were using ICD codes for billing.  But we had never combined the two processes before.

The entire process is complicated, confusing, and intimidating.  Not only are the guidelines themselves a mess, but also there is a surprising amount of inaccurate and misleading information out there.  Even the CMS publication Attestation User Guide is missing a page compared to the actual attestation web site.  After reading the User Guide I lost an entire night’s sleep thinking that the “children with pharyngitis” quality measure had been deleted because it is missing from that document.  I have 17 years of medical practice experience and 37 years of IT experience.  If I can’t figure this out there is something wrong.

The view from the top of the MU Mountain looking down is no better than the view from the bottom looking up.  Meaningful Use remains an expensive distraction that forces the true benefits of EMR to be overlooked in favor of regulatory compliance.  MU also creates an unhealthy alliance between government and the health IT community.  The government wants to own health IT just like it wants to own the rest of health care.  Don’t fall for it.

December 30, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

The Nitty-Gritty of Meaningful Use – Part 2

This is the second in the series of how our practice is getting the work of MU done.  The first of the series can be found here.

Starting with Core Set Item #7:

7.   Record demographics as structured data.  We have been doing this for a long time but MU requires us to add race and “ethnicity.”  Isn’t ethnicity the same as race but more specific?  If you have the latter you don’t need the former.  Furthermore we have had patients push back on asking this question.  Some find this question offensive.  They shouldn’t; since many diseases are race / ethnicity – specific the question is medically appropriate.  Fortunately MU considers the term “undetermined” as acceptable for this data point.

8.  Record vital signs as structured data.  This conflicts with lower level CPT E/M coding with does not require vital signs.  Once again the left hand of government doesn’t know what the right is doing.  Nobody thought it through.

9.  Record smoking status.   No problem here.  Medically appropriate for all specialties.

10.  Quality measures.  These are poorly designed and confusing.  There are 2 redundant measures both dealing with tobacco use and cessation, and these are both redundant (but not identical) to core set #9.  Weight screening is reasonable enough but the follow-up requirements are ambiguous and burdensome.  Are we really supposed to bombard our local dietician with weight loss consultations?

11.  Decision support rule.  We will configure our EMR to prompt for hearing loss screenings in patients over 50 years old.  Fair enough.

12.  Provide an electronic copy of health information to the patient upon request.  Who are they kidding?  This should have been delayed to Phase two.  Qualified EMRs can do this easily enough but the product is exported to your remote server desktop; it is cumbersome to copy from there.  We have had few such requests from patients; I wonder if those few are asking just to prove a point.  I don’t know that for sure.

13.  Provide clinical visit summaries.  Again should have been delayed to Phase two.

14.  Exchange key clinical information between systems.  This one is unbelievable.  Fortunately, as I understand it, you only have to do it once.  You are supposed to upload all or part of someone’s chart (or perhaps a test chart or other hypothetical data) to portable media, go to someone else’s EMR and try to upload the data.  Doesn’t matter if you succeed or not.  Am I misunderstanding this one?  If anybody has a better handle on this one please leave a comment.

15.  HIPAA security risk analysis.  Although I hate paying for it I must admit that is a good idea.

 

The last installment will cover the Menu Set Measures.

September 18, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

Meaningful Use Will be on Life Support by the End of 2012.

Earlier this week I attended the annual meeting of the primary professional organization for my specialty, the American Academy of Otolaryngology – Head and Neck Surgery.  As you might expect the first thing I did was attend a mini-seminar on strategies to meet Meaningful Use (MU) requirements.  These “mini-seminars” typically include 3-4 speakers presenting various viewpoints regarding the subject at hand.  Presenting the supporting viewpoint on MU was Dr. K.J. Lee, who has been an icon in our specialty for decades.  He had distilled MU requirements for Otolaryngology down to a few typed pages and reviewed each requirement, emphasizing how easy it should be.

The most interesting part of the presentation was the reaction of the audience.  Presumably based on his professional reputation the audience initially bought into Dr. Lee’s enthusiasm for MU, hopeful that he was right.  However, as he continued through the list of MU requirements his point of view became less credible, and the enthusiasm began to fade.  When he suggested that it was no problem for ENT docs to ask and counsel patients about mammograms and colonoscopies, audience members began to stare at the floor and shake their heads.  By the end of his presentation he had lost just about everyone.  I have seen this happen before at MU meetings.

Later that morning in a different mini-seminar I gave my own brief presentation, a MU update.  I was asked to give an update on how MU payments were going, presumably specific to our specialty.  The August CMS report shows MU payments given to about 1100 providers so far (as of 7/31/11) totaling about $18 million.  For the 6 weeks leading up to the meeting I tried, without success, to get MU payment data from CMS for ENT doctors.  The best I could infer from the data available is that more than 1 but less than 28 individual ENT docs have been paid for year 1 MU.  In any case the conclusion is clear:  only about 0.1% of all eligible providers – and essentially no ENT docs – have met MU so far.

But isn’t it too early to draw conclusions?  After all, the program just got started a few months ago.  And the number of payments going out is increasing month to month.  And providers still have a year to get the full payment.

My opinion is that the situation is worse than it looks, not better.  I believe even this tiny number of payments represents an early peak of MU payments to providers who implemented EMR long before MU came along.  Our practice is in this group, and we will begin our 90 day attestation period October 1.  MU is achievable only for those providers that have already acquired several years worth of EMR skills.  Once these early adopters are paid, no one else will be left.  If I am right we should see MU payments plateau in Spring 2012 and start declining in the summer and fall.

MU remains a bad idea, especially for surgical specialties.  It is not possible for a paper-based medical practice to complete the long process of selecting, installing and implementing EMR on the schedule imposed by MU.  The provider skill set required to meet MU requirements takes at least 2-3 years to develop, and providers can’t even begin to acquire those skills until the EMR is chosen and installed.  The MU schedule forces providers to rush the process, raising the risk of making catastrophic mistakes in the EMR selection and implementation process.

September 15, 2011 I Written By

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery. After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations. Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia. With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.