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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 “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 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.

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.

A Process for Replacing CPT Codes

Those of you who have been kind enough to read my blog know I criticize CPT coding on a regular basis.  Finally after my last tirade, a comment from John finally said what I have been dreading to hear:  “I’d love to hear more about what you think a good replacement to the current CPT system would look like.”

That is the question, isn’t it?   I’ve been criticizing long enough.  Time to put up or shut up.  A brief Internet search does not reveal any significant activity regarding a replacement for CPT except for vague “pay for performance” concepts that would pay for results rather than the care itself.  I must confess that despite thinking about CPT replacement for the past few months I don’t have any bright ideas either.

But since I raised the question in the first place I’m willing to take a shot at it.  Ignorance has never stopped me before…

I would like to begin a 4 step brainstorming process with you:

  1. Outline the shortcomings of CPT coding
  2. Translate those shortcomings into desired characteristics for a replacement system
  3. Explore applicable technologies that allow us to leverage the use of EMR to create an IT-based payment system with the desired characteristics
  4. Formulate proposals to replace CPT

I’m going to resist the urge to write my usual 1000 word post and stop here.  Please share your thoughts regarding the wisdom of this project and whether or not these 4 steps are the best way to approach the question of a replacement for CPT.

January 27, 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.

Over-Automation of EMR Note Creation Encourages Missed Diagnosis and Incurs Medical-Legal Risk

Over the past several months I have read several online discussions and comment threads on the medical-legal issues raised by EMR, including an HIMSS brochure on the subject.  Most of these discussions miss what I consider to be most important legal weaknesses of an electronic medical record. I finally came across an online discussion that comes closer to covering what I consider to be the most important medical-legal issues.

When we were setting up our EMR about 6 years ago many of our docs came to me with the same request:  “I want to create a chart note with a single button click.”  Although that was obviously a bad idea, their desire for it was understandable, given our inexperience at that time.  Templates are widely recognized as an effective method of documenting care and complying with CPT coding requirements.

For many common diagnoses physicians have been using “mental templates” long before EMR existed.  For example, a pediatrician refers an otherwise healthy 4 year old child to an ENT doctor for recurrent middle ear infections.  Because pediatricians are capable of utilizing all conservative treatment options for middle ear infections, the pediatrician will usually not refer the child until he needs ear tubes.  This is one of our most common operations.  The ENT doctor’s mental template is thus geared towards documenting indications for ear tubes.  The template includes quality and duration of ear symptoms, number of doctor visits for ear infections, and the antibiotics that have been tried so far.  Also included would be the appearance of the eardrums and the results of testing performed in the office.

So why not create a “one button click” template?  When this child comes to your office bring up the template, fill in the blanks and you are done.  Come to think of it, let’s save some money and have a nurse, nurse practitioner or a physician assistant do the entire visit.  Sounds like an ObamaCare Dream Come True.

There’s just one small problem.  Hidden among the dozens of children with straightforward ear infections are a few kids who look like they have chronic ear infections, but actually have something else going on.  It might be something benign like allergies or enlarged tonsils and adenoids, or it might be something rare and ominous like eosinophilic granuloma or malignancy.  It is the physician’s job to recognize these patients in the crowd of children with symptoms consistent with chronic ear infections.  To find these patients the physician uses an open diagnostic thought process.  In the physician’s mind, mental templates and open diagnostic thought coexist in a non-competitive, complimentary fashion.   A good clinician automatically uses the right thought process at the right time.

The same cannot be said of EMR.  EMR templates must be carefully designed to support the open diagnostic thought process that is essential to practice medicine well. EMR templates will subtly influence the physician’s thought process as they are used over and over.  Depending on the EMR template structure that influence can be positive or negative.  Templates that over-automate the note creation process emphasize template thinking at the expense of open diagnostic thought.  This increases the risk of a missed diagnosis and incurs medical legal exposure.  Such templates augment the already unfavorable influence of CPT coding requirements, which also force clinicians to focus on documentation of care rather than the care itself.  Among the worst examples of such templates are those that prompt the user to check a bunch of boxes and then create a narrative based on the user’s menu choices.  The result is awkward text that reads nothing like prose composed by a real person.

From a legal standpoint it is easy to read through the facade of automated detail and completeness to see the clinician’s lack of true diagnostic thought.  In the event of a bad outcome the legal exposure is just as severe, perhaps worse, than a sparsely completed paper chart note.  To avoid this hazard, those who design and customize EMRs must seek an optimal level of automation – one that leverages the advantages of EMR but still supports and documents the physician’s direct participation in care.  A properly designed template requires at least one “physician narrative”.  A physician narrative is a few sentences of prose composed totally by the physician with no IT automation involved.  In legal matters this narrative my be the only clear proof that the physician actually touched the patient him/her- self and gave that patient some thought.

January 6, 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.