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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.

The Secure Texting Scam

I fondly remember going deer hunting with my father and grandfather in Pennsylvania where I grew up.  We hardly ever actually killed anything.  One deer hunting technique we never used was called “putting on a drive.”   You start with a group of hunters at each end of the woods.  The first group does the “driving” by walking through the woods making lots of noise.  The other group lies hidden at the other end.  The first group scares the deer towards the second group for an easy blindside kill.  Even if you like hunting it’s not very sportsmanlike.  The deer don’t stand a chance.

Recent developments in health information technology convince me that Washington politicians and health IT vendors are putting a drive on physicians. Together they coerce physicians into technology purchases that may be redundant and unnecessary.  One such example is all the noise health IT vendors make about secure texting.

In November 2011 JCAHO posted a notice deeming the use of texting to communicate physician orders as unacceptable.   This very short statement offered two supporting arguments:  1.  The sender’s identity could not be verified, and 2.  There is no way to preserve the text message for the medical record.  The statement did NOT mention any potential for hacking, eavesdropping or any other privacy / security issue.

The following April a small (5 physician) cardiology practice was fined $100,000 for a number of HIPAA violations.  The worst of these was putting appointment and surgical schedules on a publicly accessible online calendar.  Other violations included failure to appoint a privacy officer and failure to conduct a risk analysis.  The HHS press release for this settlement does not list texting protected health information (PHI) as one of the violations.  Nonetheless many secure texting vendors have cited this settlement as evidence that the Feds are prosecuting providers for texting PHI.  My inbox has been inundated with ads: “Don’t get caught texting PHI!  Buy our secure texting product today!”

Many providers have drunk the Kool-Aid, succumbing also to strong intuitive – but unverified – arguments regarding SMS texting.  It is widely accepted that every text has at least 3 copies:  the sender phone, the receiver phone, and one or more copies on the telecom servers involved in the transmission.  The first 2 clearly exist.  But has anyone verified current practices among telecom providers regarding server storage of text messages?  There is no credible source that clearly documents what those practices are.  Many providers and IT folks also intuitively believe that text messages can be easily monitored / intercepted remotely.

One secure text vendor I reviewed offers secure texting for the “bargain” price of $10 per user per month.  For our practice that totals $12,000 per year.   The app requires installation on both sending and receiving ends, so even after all that money is spent I can text “securely” only to employees inside my practice.  Too bad I don’t need secure communication inside my practice.  My EMR already does that.  So the product is both expensive and useless.  Most secure text products are structured similarly.

The argument for secure texting products fails in several ways:

  1. The November 2011 JCAHO directive regarding texting of physician orders does not mention privacy as an issue.  The two issues it does raise, identity verification and documentation in the medical record, are not solved by secure text products.  Furthermore, the JCAHO arguments should apply to voice conversations as well.  The voice of a caller cannot be objectively identified, and voice conversations are not preserved for the record either.   Telephone orders have been the standard of care for decades.  We have tolerated those “shortcomings” without difficulty.
  2. No federal agency has investigated anyone for texting PHI – although the secure texting vendors would like you to believe otherwise.
  3. There have been no documented PHI security breaches related to texting.
  4. The biggest security issue for texting is the smart phones themselves, where stored text messages are just waiting to be lost or stolen with the phone.  Secure text products don’t solve that problem either.  This is more appropriately handled by password protecting phones and remote-erasing technology for lost or stolen phones.  There are lots of other ways to address the problem, such as storing text messages in the cloud rather than on the phone.
  5. Physicians have been using text communications for almost 20 years, since the advent of text-enabled pagers.  This far predates SMS technology.  We contacted our answering service regarding the security of the text-pages that they send to our smart phones.  We were assured that their secure server adequately addresses the issue.  Really?  Don’t their messages pass through the same telecom servers as other texts to reach our smart phones?  Am I missing something?
  6. Smart phones can be eavesdropped for both voice conversations and text using the same methods.  If the eavesdropping argument is used to outlaw unsecured text, then voice communications should be treated similarly.
  7. How exactly do the wireless carriers handle text messages?   Why isn’t anyone grilling them about securing their servers?  Current practice across the IT community is that the owner of a database is responsible for its security.  Verizon Wireless, starting last April, has expressed great interest in health care and has declared its intention to establish a role in the management of chronic diseases.  How about something simpler and much more useful…like secure texting for health care providers?

The “logical” conclusion – ignoring common sense – is that PHI would be prohibited in all wireless communications.  Doctors would have to return to 1980’s era pagers that only emit a tone.  You call the answering service – on a landline – to get the message.  The privacy policies made necessary by the Information Age would force us back to the Stone Age.

Instead consider the following plan that would serve PHI privacy needs without all the hysteria and expense of add-on products:

-       Establish a set of practices for texting medical information that avoids or minimizes the creation of PHI.  This would include referring to patients by initials and avoiding the use of identity-establishing information.  I have done this for the past few months and it works well.  You can include all the medical information you want in a text, but if the patient is identified only by initials then it is not PHI.

-       Engage telecom providers to establish adequate security measures for its servers.  They should be doing this anyway.  There would be many users willing to pay a reasonable amount to cover the expense.  This would be much better than add-on products since it would be compatible across all users.

-       Aggressively implement protection for smart phones, starting with mandatory password protection and remote erasing, and implementing more sophisticated technologies as they become practical and widely available.

How do you get a marginal product to sell?  Either have the government make people buy it (Meaningful Use) or use marketing sleight of hand to create the illusion of a legal imperative.  Secure text marketing strategy works just like the deer drive.  The “drivers” are the secure texting vendors.  They leverage poorly written and randomly enforced government regulations to make lots of noise in an attempt to scare physicians.  At the other end of the forest lurks Secure Texting Snake Oil – products that only pretend to rescue doctors from prosecution and patients from identity theft.  Their only true effect is to raise health care costs without any improvement in quality of care or data security.

September 6, 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.

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.

The Future of Meaningful Use

I had the pleasure of attending two meetings last week related to health care IT.

The first meeting was a 5-hour event sponsored by the Physicians’ Institute for Excellence in Medicine, a subsidiary of the Medical Association of Georgia.  The meeting was dedicated to helping medical practices achieve compliance with Meaningful Use (MU) guidelines.  A $4000 incentive was offered to cover expenses related to MU compliance.

The first speaker was the Chief Medical Officer of the Atlanta Regional Office of CMS.  He gave a nice talk that covered both the minutia of MU and the broader scope.  The talk was well received by the group of about 50 participants.  When his talk was finished he left the meeting.

With The Government no longer present, the mood slowly changed over the remaining hours.  This occurred as the following issues were reviewed:

-       Over 18,000 Georgia physicians were invited to the meeting.  Despite the financial incentive only 50 (including administrators) attended.

-       The sum of the number of installed users claimed by each of the top EMR vendors exceeds the number of practicing physicians in the U.S.

-       Only 4% of practices have a truly functional EMR.

-       As we go from MU phase 1 to phases 2 and 3, the requirements go up but the financial incentive goes down.

 

When the meeting began I assumed I was the only MU “doubter” in the room.   But as the meeting continued the level of trust within the group increased, and the comments became more candid.  Each of us gradually realized that everyone in the room felt the same way – we were all doubters. This is a remarkable process occurring within a group of docs and administrators that is presumably at the top of the bell curve on MU interest!  The meeting ran out of gas and most of the participants dispersed about 30 minutes before the meeting was scheduled to finish.

The second meeting, completely unrelated to the first, took place over lunch the following day.  I invited the CEO of a local health care IT company to meet some programmers that I know.  This company sells a very nice tablet device / service for automated paperless patient check-in.  The purpose was to build an interface for this product to work with our EMR.

After the introductions the conversation took off immediately and continued without interruption for nearly 2 hours.  The longer we talked the faster the creative energy flowed.  Finally we had to force ourselves to stop because everyone had other commitments.  The only mention of MU came when I raised a question.  The CEO made it clear he had no interest in MU and that his product was designed to avoid dealing with MU.

The contrast between these two meetings was striking.  Similar individuals – those who are motivated to become thought leaders in HIT and are willing to donate uncompensated time – attended both meetings.  In the MU meeting the conversation was limited to a single closed-end question:  How do we jump through government hoops to get the money?  The true benefits of EMR were never discussed.  Quality of care and practice efficiency were rarely if ever mentioned.  Individual motivation and creativity were stifled and replaced with frustration and, I think, a bit of anger.

The lunch meeting the day after had a completely different feel.  As creative minds gathered around the lunch table the brainstorming began immediately.  New ideas came fast and furious, and each was measured appropriately – by how it would improve practice efficiency and quality of care. Despite the inexperience and clumsiness of the facilitator (me), the meeting was a success.

My experience with these 2 meetings makes me wonder if the future of Meaningful Use is already in doubt.  The Medical Association of Georgia offers a free MU seminar with expense reimbursement, and 50 physicians out of 18,000 invitees attend.  And even these select few highly motivated MU candidates are already frustrated.  During the meeting we saw numeric evidence that some statistics that describe EMR use are grossly overinflated.

Our (soon to step down) government HIT leader Dr. Blumenthal has claimed “The Age of Meaningful Use” has begun, citing survey statistics that 41% of office based physicians plan to achieve MU.  It is hard to reconcile that number with statistics from the MU meeting showing only 4% of practices have a fully functional EMR.  The difference can probably be found in how the survey questions were worded in each case.  Assuming that achieving MU requires a fully functional EMR, how are we going to get from 4% (or let’s say less than 10%) to 41% by the end of 2012?  I don’t see that happening.   And even those practices that achieve MU stage 1 and get their (Medicare) $18,000 may walk away from the MU stage 2/3 requirements that will be tougher and offer less incentive.

Current interest in MU is driven by 3 forces:  1.  Government incentive programs generate interest simply because they exist; 2.  The monetary value of the incentives, and; 3.  The support of EMR vendors.  Those of us who have chosen to pursue MU despite our misgivings are doing so more out of a sense of duty and a desire for credibility than out of any true enthusiasm for MU.  But it won’t last forever.

 

 

 

March 29, 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.

Our Disaster Recovery “Fire Drill”

Last Friday our practice had an opportunity to practice our disaster recovery protocol.  This was actually good news; we are replacing our 6 year old servers with virtual servers and a storage area network (SAN).  The implementation plan required more down time than a weekend would provide so we added a Friday to it.

Unlike a real disaster we had the opportunity to prepare immediately before, knowing exactly when the system was going down.  We printed our clinic schedules and printed the clinic note from the last visit for patients who had appointments.  We did not cancel appointments or reduce the number of patients seen.  For appointments requiring other documentation (i.e., pathology reports for post-surgery visits) we printed those.  We also printed a generous number of our most common handouts and got our paper prescription pads ready.

The day was free of major problems and the staff performed very well.  The experience was very interesting:

  1. My description above is a little too rosy.  We ended up searching for some documents at the last minute.  We ran behind schedule and there was a mild degree of disorganization throughout the day.
  2. Patients were very understanding about the delay and about our EMR being down.  Everyone understands that computers go down and I was thankful to see that our patients remembered that.  In some cases I had to ask patients to refresh my memory regarding prior visits since I didn’t have the entire chart available.  No one seemed to mind.
  3. I was still able to use my PC and Dragon Speech. Dragon runs locally on my desktop.  I dictated notes in Notepad and saved a separate note for each patient.  On Monday, my assistant will create Friday’s chart notes in the EMR, enter their data (vital signs etc.) and route the notes to my desktop.  Then I will copy / paste my notes into the EMR chart.
  4. Dictating unstructured chart notes into my PC was refreshing.  It was also an impressive reminder of how much garbage CPT forces us to add to our notes.  Even for complicated, new patients I was able to record everything relevant in less than two-thirds of a page.  Adding the CPT-required material almost doubles the size of the note without adding any relevant, useful data.
  5. With the system down the front office could focus on patient service without having to obsess over data entry.
  6. With all the extra paper floating around the back office was a mess.  I can’t imagine going back to paper charts.
  7. We were still compromised operationally when we had a patient who needed to schedule surgery.  Without the EMR workflow engine we could not print customized surgical packets.  Handwriting surgical consents is not acceptable.  We will have to catch up on this workflow next week.

Take home lessons:

We need to improve our disaster readiness, but at the moment our readiness is not too bad.  Our new SAN is configured to perform incremental backups every night and full backups every weekend.  The virtual servers and SAN will allow us to redirect workload in the event of a server or hard drive failure.  For a network failure we can follow the protocol we just rehearsed, but we should take the time to update our hard copies of handouts and surgical consents.  This is interesting because on more than one occasion we have had IT vendors try to push their way in to our practice using our presumed lack of disaster readiness as their excuse.

Once our new servers and SAN are settled in I may look into an automated method of copying appointment schedules and recent chart notes for patients with appointments to a local PC in each office rather than wasting all that time and paper every day.

I understand that all that front office data entry is a necessary evil.  But I never realized how much it distracts the front office from tending to patients.  I am going to double my efforts to make it attractive for patients to enter their own data online in advance of the visit – or at least have them use the patient portal to enter their own data in the waiting room.  As much as we have tried so far, our patient portal still has not caught on with our patients in the waiting room, and there has been only moderate use from home.  I don’t think our web portal is good enough yet.

February 20, 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.

How to Overcome the Cultural Barriers to EMR Adoption

My latest writing went to a publication for my specialty, ENT Today. I can’t reproduce it here but please follow the link to read it: ENT Today article.

February 17, 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 Frightening Political Side of EMR

What truly frightens me about HITECH is that it demonstrates the government’s enthusiasm for juxtaposing itself into the EMR movement.  I am frightened, but obviously not surprised.  Like any powerful technology, EMR can be used for benefit or harm.  Used properly EMR can fulfill the promise of lower costs, improved efficiency and higher quality of care.  But if controlled by sinister forces, EMR will become a vehicle to undermine the doctor-patient relationship by limiting treatment choices and covertly monitoring /controlling doctor-patient behavior.  Make no mistake: there are elements within our government that have recognized the potential of EMR as an instrument to bring health care under their control.  If you think that notion is a bit paranoid, consider the words of the new director of CMS, Dr. Donald Berwick:  “It’s not a question of whether we will ration (health) care, it is whether we will ration with our eyes open.”  Regarding Britain’s National Health Service (NHS), which rations care to British citizens, Dr. Berwick says, “I am romantic about the National Health Service. I love it.”  The NHS limits spending on life-saving care to $44,000 per year.

It is not difficult to understand how a government EMR system could be used to control and ration care.  Remember the FDA’s recent withdrawal of its approval of the drug Avastin for breast cancer?  Although doctors are powerless to reverse this unfortunate decision, at least it was formally announced and subjected to public scrutiny and debate.  And Avastin is still available to use “off-label.”  If EMRs were government controlled, no announcements would be necessary.  The “Avastin button” would simply be removed from the physician’s treatment option screen.  And it would be easy to program a government-controlled EMR to enforce an NHS-type spending limit to extend life.  When a patient’s spending limit is reached, the system locks out that patient’s chart and no more care can be given.

Ridiculous, perhaps?  The HITECH program, through EMR certification, already has established a mechanism to force EMR vendors to make their products comply with government requirements.  It would be a simple regulatory step to “upgrade” those requirements to include a method of government “back door access” to any EMR. Such access would allow the government to establish and codify within EMRs methods of limiting and rationing care.  It would also allow the government to monitor physician-patient behavior and deliver sanctions if it so desired.

I am not suggesting we storm Dr. Berwick’s office with torches and pitchforks.  But I would like to offer some thoughts to serve as a “moral compass” as we continue our work on the EMR movement:

  1. EMR should only be used in a manner that supports the doctor-patient relationship.  EMR should be used to reduce costs, improve efficiency, improve quality of care, enhance doctor-patient communication and protect the physician’s ability to properly practice medicine.  EMR and related technologies, such as health information exchanges, should be used to efficiently move data among providers and to automate those parts of health care workflow that are appropriate for automation.
  2. It is inappropriate to use EMR as a vehicle for the government or any third party payer to force itself into the practice of medicine and into the doctor-patient relationship. EMR must not be used to enforce any restriction of treatment choices.  It is improper to use EMR as a tool for the government or any third party payer to covertly monitor physician / patient behavior.
  3. The HITECH incentives are a mixed blessing. While the incentives certainly encourage EMR adoption they may also deprive the medical culture of the necessary time to make a stable, controlled cultural change to an information technology environment.  This increases the risk of failure and may paradoxically increase the time and resources that are ultimately required to complete the cultural transition.   It will take extra time and money for some medical practices to recover from poor decisions made in haste.
  4. The HITECH incentives are also harmful because they create a paradigm in which government sets the goals and the medical and IT cultures follow.  The result could be a health care IT system that serves the whims of politicians, not the needs of patients.  This is unacceptable.
  5. Let’s start thinking about a better physician payment system than CPT. The CPT coding system was created by the American Medical Association (AMA) over 40 years ago and has become an antiquated, overly burdensome set of documentation requirements.  The coding compliance industry must siphon billions of health care dollars away from patient care to help physicians comply with these incredibly complex guidelines.  The AMA profits approximately 50 million dollars a year selling CPT and ICD-9 materials to physicians.  Their support of CPT is not objective and cannot be trusted.  The CPT coding system assumes paper-based documentation.  Through EMR we have learned that a fully CPT-compliant chart note is almost useless to the clinician.  The relevant data are buried in a sea of white noise: patient demographics, irrelevant historical data, normal physical findings, and diagnosis / billing codes.  The result is lengthy documentation that is dedicated to CPT compliance rather than to communicating useful health care information. EMR gives us the opportunity to replace CPT with a new physician payment system based on information technology instead of paper charts.  Such a system will allow us to re-direct limited health resources from regulatory compliance back into patient care.
  6. Technology always brings unintended consequences.  Health information technology will certainly bring unintended consequences, including unintended and undesirable de facto changes to the standard of care.  We must watch carefully for these changes and protect physicians from these unplanned changes in the standard of care until they are examined, modified if necessary and formally recognized.

Recent political events clearly demonstrate a significant change in the relationship between America’s government and her citizens.  Those who work in health care information technology must be aware that EMR technology could be utilized as a government instrument to covertly take control of our health care system in the name of “social justice” and cost containment.

January 17, 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.

What if the Home Mortgage Interest Deduction Looked like Meaningful Use?


Recently I was preparing a lecture to our state specialty society on Meaningful Use / HITECH incentives.  During my research I was again disgusted by typical government intervention at work.  The Feds took a simple and worthy idea – encouraging physicians to adopt EMR – and made it as complicated and burdensome as possible.

They should have modeled EMR incentives after effective, relatively simple government incentives that already exist, such as the home mortgage interest deduction.  Ironically, this deduction is now under fire from the Deficit Commission.  If you pay mortgage interest on a home you live in, you can deduct the interest from your taxable income.  I know it’s more complicated but that is pretty much the idea.

What if home mortgage interest deduction rules looked like HITECH rules?

  1. The incentive would be fixed payments, not a variable payment based on expenses.
  2. The people living in your home would have to be “Eligible Occupants.”
  3. Your home would have to be a “Certified Dwelling.”  There would be hundreds of pages of specifications for Certified Dwellings.  An entire industry would spring up dedicated to getting your home certified.  After spending the money to get your house up to specifications, a federal certification agent would visit your home (after a several month wait) and hopefully provide certification if your house meets the requirements.  Because many of the rules would be ambiguous and unclear, certification would depend quite a bit on the agent’s judgment.  No potential for corruption there…
  4. Next you would have to demonstrate “meaningful occupancy.”  There would be a required minimum number of occupants.  Each occupant would have to sleep in the house a minimum number of nights per year.  Doesn’t take much imagination to make the list of requirements go on forever.  And not only would you have to follow all these rules, you would have to document it somehow.
  5. Finally you would have to report on Quality Measures for your home such as electricity and water use.  You would also have to report on Quality Measures that do not apply to your home, i.e., homes with electric heat would still have to document natural gas use.  This would require running a gas line and gas meter to your house even if you don’t use gas.
  6. You would have to do all of the above every year in order to get the incentive.  Failure to meet any of the above requirements would mean no incentive payment.
  7. All the above specifications would get more stringent every year.  But the incentive payment would go down and be phased out completely after 5 years – even though mortgages go on for 30 years in most cases.

New homes would be designed not for comfortable living but to satisfy Certified Dwelling and Meaningful Occupancy requirements for as little money as possible.

At some point the incentive becomes more trouble than it is worth.  Maybe it would be smarter to go the other way and make Meaningful Use rules look like the mortgage interest deduction:  Tax credits up to $20k per provider, enhanced tax deductions for expenses beyond that.  But that would be too easy.

November 11, 2010 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.