Certainly affordability is a major concern. However, EHRs aren’t marketed like cars or shoes, so price is rarely mentioned – unless it’s Practice Fusion which constantly boasts that it is provided free (with ads).

An interesting article in the May 7 issue the AMA News reports that charge capture ranks high on physicians’ list of EHR benefits.

With an EHR in place, charge capture improves, “which means more money.”

The article quotes an internist who said that while his exams are just as thorough as always, the EHR has helped him document their completeness.

“In the past, I would ask all the questions and only document half of them because of having to write it all out. The EHR allows me to document more thoroughly, which is good for a number of reasons.”

The medical director of a mid-size hospital noted

“I know that we were missing a boatload of charges on the nursing side on things like start and stop times for IVs, which we could never keep track of.”

All this is fine for the provider – and the patient whose quality of care is improved – but the more billed charges means higher costs for payers.  That is not going to lower medical costs in the long run and it may be one of the reasons health insurers have never been strong advocates of EHRs.

Many EHR vendors with cloud-based systems have pointed to the ability to access medical data remotely and indeed, a number of physicians cited that capability.

“Physicians say ‘I can get the data in from my home office, from my PDA, from iPhone or my iPad, and it becomes a truly networked scenario that we have not really had before in health care.’”

Finally, another EHR feature cited by physicians is the patient portal. Physicians whose systems have this capability report an increase in productivity because “the patients are now taking responsibility for doing some of the administrative work that front desk staff used to do.”

While the article didn’t specify which tasks the patients are doing, it is probably self-reporting of demographic information and later downloading of the summary-of-care.

In the healthcare industry today, many people are demanding “save me the money.”

Example #1 is Massachusetts. The Wall Street Journal reported last week that the state will soon introduce some of the strictest health-cost containment legislation in the U.S. The new bill, which has bipartisan support, will cap how much expenses can rise annually at hospitals.

The Journal reported

The rate of growth in spending on health…would be enforced by a regulatory authority. Health-care providers and health plans that the regulator found to be pushing spending above the goal would have to submit improvement plans to bring expenses down. Institutions would still be able to challenge their findings by showing extenuating circumstances…The authority, which will include government, industry and consumer representatives, would ultimately have the power to force them to renegotiate their contracts.

Will placing a lid on hospital rates work? Some experts have said this is like pushing down on one side of a balloon – the costs will simply expand in another area.

Simply looking at money (i.e. rates) may be the wrong approach, according to a commentary piece in Friday’s iHealthbeat.

The article notes that the healthcare industry (and its supporting IT systems) is now “optimized for the ‘do more, bill more’ model of reimbursement. However, that model is rapidly being replaced by a focus on value and outcomes — a 180 degree shift.”

The commentary points out

Providers who have demonstrated outstanding results with challenging patient populations recognize that there are two main care approaches. In a setting such as a hospital, many leading hospitals have successfully adopted a manufacturing-based model borrowed from Toyota. However, with chronic disease, a service-based approach is necessary to effect behavioral change.

Since 75% of health care spending is currently directed toward chronic disease, adopting a service-based approach to engage individuals is paramount. The article cites telemedicine, particularly, secure messaging, as a technology that can successfully engage patients and save money.

Whatever happened to Jerry McGuire?

The LA Times reported recently that sports agent Leigh Steinberg, who represented many of the NFL’s biggest stars and was the inspiration for the movie “Jerry Maguire,” filed for bankruptcy protection earlier this year.

Let’s hope we can avoid that path.

The American Telemedicine Assn.  (ATA) annual conference, which wrapped up today in San Jose, attracted 4,500 attendees and 220 vendors, a record crowd.

Jasper Zu Putlitz, MD, the president of Bosch Healthcare, noted in a Monday panel discussion that until recently telemedicine had been held back by the “business model problem.” In the past, it has been difficult to obtain reimbursement for telemedicine services. Health plans general did not reimburse physicians for telemedicine consultations, based on the fact it was not a “face-to-face encounter.”

That is changing, however, due to new emphasis by Medicare and private payers on preventing hospital readmissions and adoption of ACO payment models. Now a number of organizations including insurers, hospitals, retail pharmacists and self-insured employers are willing to pay for telemedicine services.

Telemedicine has been proven effective in several areas. One of the most cost-effective cases can be made for placement of in-home monitoring devices for patients with chronic heart disease. Daily monitoring of blood pressure and weight can trigger a nurse call and prevent an ER visit.

The Bosch CEO noted that in the future, 20-40% of all medical consultations could be conducted via telemedicine.

At another panel discussion, Frost & Sullivan analyst Zach Bujnoch outlined the four primary telemedicine markets that currently exist.

1. Remote monitoring market

Submarkets include home and disease management monitoring, diabetes management, activity monitoring and wellness programs.

2. mHealth

Submarkets include professional/clinical apps, wellness apps, fitness apps and texting informational services.

3. Video telemedicine

Submarkets include video diagnostic consultation, remote doctor/specialist services and distance learning/simulation.

4. Healthcare information management systems

Submarkets include EHRs, health information exchange, tele-imaging, patient portals and hosted cloud infrastructure.

Several speakers noted the lack of standards for communication and data storage, what one called “the air traffic control problem.” One speaker said the industry is “in danger” of becoming like the EHR industry, where different vendors cannot exchange information with each other.

California passed a bill requiring hospitals to publish their average charges for the most common procedures on a state website.

The LA Times reported this week that “relatively few (hospitals) take the extra step of listing prices on their own websites, where people are more likely to be looking for pricing information..”

The hospital site, run by OSHPOD, a state health planning agency, allows you to search for hospitals by zip code, then check costs of specific surgical procedures. It does not include the fees charged by surgeons and other physicians.

According to Times story

David Dranitzke, 40, of San Francisco, recalled his frustration when he tried to get prices on a battery of blood tests for his 15-month-old daughter from three different hospitals and lab companies.

He gave up after spending more than 10 hours calling, waiting on hold and faxing information, all the while having to decipher arcane medical terminology and billing codes.

“It’s more difficult to get a price on blood work than remodeling your kitchen,” said Dranitzke, a visual-effects producer. “At some point you just throw in the towel.”

The Times contacted the California Hospital Assn. and they responded  ”An auto shop can give an estimate for a brake job, but people are not cars. It’s very difficult to get a random call from someone saying, ‘I need gallbladder surgery, so tell me what it costs.’ ”

The article found that some hospitals do provide helpful information.

On its website, Huntington Memorial Hospital in Pasadena allows people to select several common procedures and get an instant price quote, including an estimate of the patient’s share after plugging in their deductible and coinsurance. But even those numbers exclude the thousands of dollars that physicians, anesthesiologists and other specialists would tack on for most surgeries.

As healthcare IT professionals know, most hospitals have advanced software that is regularly analyzing their patient flow and determinging the revenue generated by procedure and by department. Cardiac surgery, for example, is a usually a big moneymaker, while most pediatric units lose money (many kids aren’t insured). So it shouldn’t be too hard to make cost estimates for prospective patients.

This issue is going to grow in importance as more and more people opt for high-deductibe health insurance. We are going to see more middle class professionals, like the man cited in the LA Times story, who actually do try to shop for medical procedures.

Compare hospital pricing with fess charged for dental work, plastic surgery and laser eye surgery. These procedures are commonly paid for in cash. Dentists, ophthalmic surgeons and plastic surgeons frequently advertise their prices in newspapers and other forms of marketing. The result is significant competition which tends to keep prices much lower.

Could our nation achieve similar free-market competition in gall bladder surgery?

While the policy committee work group found most of the MU2 rules appropriate, it questioned two proposed requirements as being “too ambitious.” The committee said the requirements for the electronic submission of data to public health agencies are beyond current capabilities of those federal agencies. In addition, the group recommended removing a cross-vendor requirement that 10 percent of electronic exchange of transition care summaries be transmitted to organizations that they are not affiliated with and that are on a different vendor platform.

As reported in Healthcare IT News

“Farzad Mostashari, the national health IT coordinator, said that the rationale for the cross-vendor requirement was to avoid a ‘walled garden’ scenario where providers could meet the exchange requirement within their own vendor’s context yet never share data outside of it.

“’From a policy view, is there comfort that without the cross-vendor requirement we won’t end up in a situation where there is a significant number of providers not exchanging information outside of their vendor boundaries?’ Mostashari asked.”

In response, committee member Mickey Tripathi, president and CEO of the Massachusetts eHealth Collaborative, noted that providers “are going to exchange with whom they need to exchange from a patient care and business perspective independent of what platform they are on. So you should create and enforce the standards for the platforms that they are on regardless of whom they are exchanging with in terms of vendors.”

Another committee member pointed out that in some areas, certain large EHR vendors have a very high penetration rate, so that a provider in a particular medical group would have to go out of his way to find another physican with a different model EHR to exchange data with.

On the requirement to collect and exchange data with public health agencies, several committee members expressed doubt that the agencies, often underfunded, can comply on their end. One member said the data collected would not be used by the federal government for several years, if ever.

In the movie Casablanca, Claude Rains said to Humphrey “I’m shocked to learn that gambling is going on in Casablanca.”

I think we are all shocked to learn the federal government will be requiring providers to collect and submit data that it cannot use.

According to Janet Marchibroda, chair of the  Bipartisan Policy Center Health IT Initiative, health IT funding will not be reduced if the individual mandate is thrown out. If the Court rules the entire law unconstitutional, some HIT funds would be lost, but not the meaningful use incentives.

Marchibroda was formerly CEO of the eHealth Initiative and prior to that COO of the NCQA. She has been at the Bipartisan Policy Center since April 2011.

Speaking to the HIMSS Southern California Chapter on April 4, Marchibroda noted that it is impossible to predict exactly what the Court will do. However, many analysts believe the individual mandate will be ruled ineligible.

That would have little, if any, effect upon healthcare IT. The meaningful use incentive funds are part of the $36 billion HITECH Act, passed in 2009. If the Court tosses out the entire PPACA, some $10 billion in funding for pilot programs (e.g. pay for quality) to be allocated by CMS would be eliminated.

Marchibroda said that currently spending for healthcare IT enjoys bipartisan support, as most legislators continue to believe it will lead to lower costs and better quality.

She expressed concern about interoperability and said that healthcare vendors need to do a better job in that area. She warned that “Congress did not allocate $36 million to invest in building more silo” and predicted the issue would come up later this year if more oversight hearings are held.

Obamacare vs. Romneycare

An article published yesterday on the Associated Press noted that aside from constitutional issues, a major threat to Obamacare is funding.

“If the Obama plan hits all of its spending targets and realizes all of its projected revenues and savings, it would have minimal impact on the federal budget deficit through 2018. But in following years, the plan would begin running a deficit that would grow to nearly $50 billion annually, according to CBO projections revised last month. In addition, there are good reasons to believe that the Obama plan will run much larger deficits starting well before 2018.”

“The health-care plan Mitt Romney signed into law in Massachusetts is the closest parallel to the Obama plan. Since 2006, costs in Massachusetts have outpaced the original projections by more than 8%. If the Obama plan experiences similar overruns, the shortfall would be greater than $110 billion a year. Add in the deficit projected after 2018, and the Obama plan could eventually increase the annual budget deficit by as much as $150 billion in today’s dollars. Just as a benchmark, that’s about twice the amount that would be raised by ending the Bush tax cuts for people earning over $250,000 a year.”

Whatever the Court’s decision, health reform will be a major issue in the Presidential race. Each side will claim the other’s plan will be too expensive and will lead to poor quality care. We are bound to see all sorts of cost projections. One good thing about our current healthcare system: it is a major engine of job growth.

This term has been used for so long in the health care debate that I didn’t think twice about it. Now Dr. Jerome Groopman and Pamela Hartzband have questioned the whole concept in a very interesting commentary in the March 30 issue of the  Wall Street Journal.

The authors note that both Democrats and Republicans are trying to convince the public that they have experts to answer questions about improving care and reducing costs.

“President Barack Obama and the Democrats propose panels of government experts to evaluate treatments and, in the president’s words, ‘Figure out what works and what doesn’t.’ Republicans claim that the free market (that is, insurance companies with their own experts) will pay for value and empower consumers. Both sides insist that no one will come between us and our doctors.”

According to the authors, both Democrats and Republicans share a fundamental misconception about medical care. Both parties are assuming there is a single right answer for every health problem.

“These ‘best practices,’ they believe, can be found by gathering large amounts of data for experts to analyze. The experts will then identify remedies based strictly on science—impartial and objective.”

“Yet in medicine, there are many contrary opinions about ‘best practices.’ You cannot pick up a newspaper, turn on the TV or surf the Internet without encountering conflicting reports about various tests and treatments. Medical experts disagree about many issues, often dramatically.”

Groopman and Hartzband point to the current controversy surrounding screening for breast cancer. They note that the U.S. Preventive Services Task Force issued new recommendations in 2009 stating that women under 50 should no longer undergo routine mammograms. This was due to the consideration that the potential benefit (e.g. lives saved) was “not sufficient to balance the pain and suffering related to false positive diagnoses, unnecessary biopsies, the unknown risks of exposure to radiation and toxic treatment of cancers that might ultimately prove indolent.”

This is not a “consensus position,” according to the authors.

“The American Cancer Society’s own experts took a very different view of the trade-offs between risks and benefits. They still recommend mammograms for women under 50.”

They conclude by stating

“Policy makers need to abandon the idea that experts know what is best. In medical care, the ‘right’ clinical decisions turn out to be those that are based on a patient’s goals and values.”

That is a laudable concept but hardly cost-effective. If you present a patient with a choice of two cancer drugs, one that costs $80,000 and another one that is “almost as effective” and costs only $8,000, he is going to choose the high-cost one every time. After all, in most cases, the patient is not bearing the cost, it is the taxpayers or (in a commercial HMO) his fellow employees.

A recent survey from the Deloitte Center for Health Solutions found that patients are still twice as likely to use the Internet for online banking than for health tasks, even simple ones such as researching treatment options.  In addition, the research found that patient engagement through personal health record services remains difficult with only one patient in nine is interested in using PHR services, let alone actually doing it.

Physicians are scoring a somewhat higher but still have a ways to go. The Deloitte survey found 46% of physicians do not use Internet tools to enhance patient care, and only one in five provide patients with the ability to view lab results or schedule appointments online.

While this lack of online patient access to medical information is hardly news, the problem has become a much more significant barrier to cross in the wake of the recent Meaningful Use Stage 2 rules.

A recent story in SearchHealtIT (http://searchhealthit.techtarget.com/news) notes that the new MU2 rules require that more than half of an eligible provider’s (EP) patients receive online access to their medical records within four days of the records becoming available to the physician.

“The kicker, though, is 10% of patients must view, download or transmit their health information. This objective moves from its current place in the stage 1 menu set to a core requirement in stage 2.”

“This requirement also presents a quandary for meaningful use compliance. Essentially, caregivers would have no control over whether patients will view, download or transmit their medical information. If compliance hinges completely on actions outside the caregiver’s hands, there could be backlash among providers who see the core requirement as unfair.”

“Additionally, how will hospitals and physicians be able to prove that 10% of patients were active with their medical information?”

This proposed requirement (the new rules aren’t final yet) is bound to draw a lot of negative comments from physicians who see it as a “bridge too far.”  I predict that it will be eased considerably when the final rules are issued later this summer.

The first survey by KLAS, the Orem, Utah-based healthcare technology research organization, was reported last week in Health Imaging.  KLAS surveyed 104 providers about their attestation experience. The publication reported that

“Some large vendors-like Allscripts, McKesson and Siemens-had successful attesters, but it was a small number compared to the size of their client base. KLAS reported that Meditech is both a success and a struggle for providers. While they have the highest number of successful attesters at 203, the bulk of their attesters came from one large integrated delivery network (IDN).”

While this hardly a secret, it is a fact played down by the big companies and often ignored by the press, which tends to look at simple, gross numbers rather than percentages. The fact is there are a number of smaller EHR vendors with a smaller client base that can boast of having a very significant percentage of their customers achieve attestation.

According to Health Imaging, the survey found the top three investments needed to meet meaningful use Stage 1 attestation were hardware, interfaces and EMR upgrades.

In addition, most providers surveyed reported problems with adopting CPOE and problems lists, reporting quality measures and interfacing.

KLAS, which makes money selling customer survey information, issued another report last week, this one about EHRs serving surgical specialists. As reported in Information Week, the survey found that specialists are less satisfied with their EHRs than primary care doctors.

The survey assessed physician satisfaction with the ambulatory-care products of 18 vendors.  Information Week reports that

“Mark Anderson, a health IT consultant in Montgomery, Tex.,  (said)  that specialists like their EHRs less than primary care doctors do because most systems were developed for primary care and lack many of the features and templates that the specialists’ work requires.”

“’Ophthalmologists, for instance, have to take pictures of the eye and do all these eye tests, so they need totally different things in an EHR,’ he said. ‘Oncology is really hard because of the way oncologists do their chemotherapy and the supplies that they have to track.’ As for surgical specialists, he noted that few EHRs have templates designed to document procedures in the ways that surgeons require.”

In fact, several smaller EHR vendors do a very good business selling to specialists who are affiliated with hospitals using Epic, Cerner and GE. Their products are designed for particular specialists, such as orthopedists or oncologists, who find them much easier to use.

One interesting analysis comes from Andrew R. Watson, MD, Medical Director, Center for Connected Medicine, Pittsburgh, writing in the mHIMSS newsletter.

Dr. Watson notes

“As I reviewed the schedule of educational sessions and toured the exhibit hall, however, two concerns arose.

“The first was how rarely the word ‘patient’ appeared in prominent signage on the booths. I took notes during one of my tours on the floor and was disappointed to see that ‘patient’ and ‘outcomes’ were not among the primary messages vendors were projecting. Concepts that held marquee status, on the other hand, included data, scalability, cost, HIE and meaningful use.”

I agree with Dr. Watson on this point, the concept of “benefits to patients” in terms of better health, lower costs and convenience was notably lacking.

There are two reasons for that.

1. The patient rarely pays for the full cost of his health care. If you went to a car show, all of the displays would be centered on car buyers. No so at HIMSS. Patients are not the direct buyers of the technology on display. They will, however, bear the costs indirectly. Which brings me to the next point.

2. Relatively few of the technologies on display at HIMSS will lead to decreased costs for the consumer in the short-term. Most of them are sold as “improvements to workflow” or “enhancing productivity.” This basically means the physician will see more patients each day. This will lead to busier physicians, but will it reduce the number of unnecessary tests, or decrease length-of-stay? The jury is still out.

What is Dr. Watson’s second concern?

“The second consideration I found myself wondering about revolves around how all of these remarkable companies, drawn together through HIMSS and its annual event, could work together.”

I do not share this concern. For the few who went downstairs to the “basement,” the HealthStory booth in the Interoperability Showcase displayed some excellent examples of collaboration by vendors.

Fortunately, Dr. Farzad Mostashari went down and was pleased with what he saw. His challenge to send a new clinical document electronically across the country in less than an hour was quickly met by two different teams of vendors.