Thursday, April 30, 2009

Medicare Reform Will Raise Physician Howls!

I am flattered that influential U.S. senators must be reading MDWhistleblower for important policy advice. Senator Max Baucus, Democrat of Montana, and Charles Grassley, Republican of Iowa issued proposals that aim to change the Medicare payment system to doctors and hospitals. Payment would be directly linked to quality, rather than to volume of services. Under the present system, if a surgeon operates on a patient 3 times to correct his own complications, he is paid more than a colleague who got it right the first time. However, as discussed in many prior postings on this blog, medical quality is very difficult to measure.

One of the senators’ specific proposals receives a 5 Star Whistleblower Award for medical quality. The government will aim to reduce the excessive use of CAT scans, MRIs and other advanced medical imaging techniques that cost a fortune and create unnecessary medical cascades that chase after trivial lesions that will never cause illness. (Click here for a related rant. ) While I am reluctant for the government to be the one establishing the national radiography standards, as the senators propose, I endorse the concept enthusiastically. If physicians were smarter, we would be devising quality standards ourselves before the government and insurance companies do so in the near future.

One of the failings of the medical profession is that whenever there was a need for reform, we remained passive. Then, after the ‘reformers’ and bureaucrats stormed in and attacked the problem we ignored, we physicians howled in protest. This time, a medical reform tsunami is approaching and most doctors will drown in denial. Do you have a good pair of earplugs? You will need them because there will soon be ear piercing howling from hamlets, towns and cities across America.

Monday, April 27, 2009

Electronic Medical Records: The Fear Factor

A paperless society is approaching for all of us, which sadly will include the demise of my beloved New York Times, which I cherish each day. Our medical practice will have electronic medical records (EMR) in the foreseeable future, if we can mollify the objections of one of our technophobic physicians. There are several reasons why most physicians haven’t made the move to EMR yet.

First, it is not easy to learn. This is not like getting a new e-mail address. It is a complex software system that is like a giant onion with endless layers of functions that will perform office tasks that have been successfully done manually for decades. It introduces an entirely new computerized culture into the office. This adjustment is particularly difficult for doctors who were not trained in the I-pod era. However, even for the cybersavvy, learning these complicated systems takes months. During this training period, patients, doctors and staffs become frustrated when it takes 10 minutes or longer to perform a task using EMR that could be done in 5 seconds the old fashioned way. During this transition period, patient volume and practice revenue will decline creating financial pressure for the practice. Patients will wait longer in waiting rooms. When they do reach the exam rooms, they will enjoy the entertainment of watching their doctors fumbling with electronic equipment. At least, patients won’t complain about rushed office visits, since their doctors will now be spending plenty of time slipping and sliding on the electronic learning curve.

An EMR computer glitch can shut down a medical office STAT. After a couple of these unfortunate episodes, the frustrated doctor and the frazzled office staff will need to be treated for anxiety and high blood pressure. If the vendor does not provide the urgent tech support that was promised before the sale, then the office chatter will include words and phrases not suitable for a family blog.

These systems are expensive. While a hospital or large institution that is spending someone else’s money can afford it, costs for smaller practices can be prohibitive. Profit margins for many medical practices today are extremely narrow as a consequence of declining reimbursements and rising overhead costs. These practices will confront an enormous financial challenge once EMR is required, unless the cost is substantially reduced or subsided. The Obama administration is prepared to devote large sums of money to incentivize physicans to adopt EMR, but many experts maintain that physician costs would still be prohibitive for many small practices.

EMR systems must be compatible with other software. Would our office, for example, want to invest the money and time in a system that didn’t cleanly interface with all of the different hospitals we work at?

Finally, there are confidentiality issues to be addressed. Despite encryption and other techniques, would patients’ privacy be protected? Your medical record would not in a chart in a filing cabinet, but would be floating in cyberspace. Could security be guaranteed?

EMR is coming and it can’t be stopped. Despite what the salesmen promise, it will cost more than they say, it will be harder to learn than they promise and it will crash more often than they predict. Our office expects to plunge into EMR this year. I expect that it will be as pleasant and comfortable as a 6 month root canal procedure.

These are some technical concerns of going paperless. EMR also is a direct threat to the doctor-patient relationship. This deserves its own posting. Click here to link.

Monday, April 20, 2009

Electronic Medical Records: Promises Made

The Obama administration will be devoting billions of dollars to promote electronic medical records (EMR) for doctors. Today, EMR vendors run in and out of doctors’ offices trying to hawk their software. Each one claims to be the holy grail of electronic records. I admit that the concept seems intoxicating.

The promise of a paperless office is certainly seductive. The notion of physicians and patients having access to their medical records from any computer would improve medical quality and efficiency. Every doctor knows how frustrating it is to see a patient in the emergency room when the relevant medical records are sitting in the primary doctor’s office or in a hospital across town. Conversely, EMR permits the primary physician, who may not have been the hospital treating physician, to be easily updated after hospital discharge when the patient returns to his office. Many patients I see today in my office don’t know their medications and can’t recall prior illnesses or even operations. EMR solves this issue.

EMR also permits easy analysis of patient data to track important medical benchmarks including colon cancer screening, Pap smears, immunizations, mammograms and other preventative tests. Doctors like me who still use paper, rely on old fashioned methods to track who is due for a screening colonoscopy. EMR technology could permit our office to contact all patients who reach the milestone age of 50 alerting them that their colon cancer screening experience is beckoning. This would be superior to our current manual mail & call technique. EMR also eliminates the frustration of a missing medical chart. Electronic files are also more current, since data is entered much faster than paper reports. Sending medical records to other physicians’ offices could be accomplished with a keystroke, which traditionally can take weeks. EMR also eliminates the inscrutable penmanship of physicians, which at times needs CIA code breakers to decipher.

With EMR, patients could have their complete medical data, including EKGs and actual x-ray images on a personal flash key. With this technology, a doctor on a cruise ship could see your chest x-ray from 2 weeks ago.

Over time, EMR saves money by improving office efficiency, reducing repeating medical tests and reducing postage expenses.

If this system promises physicians a medical utopia, then why doesn’t every doctor sign up? The New England Journal of Medicine reported in their April 16, 2009 issue that only 17% of physicians is using some degree of EMR in their offices. Hospitals are much further behind in acquiring these systems. See the next posting to learn why most physicians haven’t pulled the EMR trigger yet.

Monday, April 13, 2009

Understanding the CAT Scan Cascade

If we are ever to prevail against the CAT scan cascade, we must understand why these tests are ordered. Here are 7 explanations of why doctors scan their patients. Talk to your own doctor and see if I’ve missed a few. While some physicians have financial conflicts of interest, most order scans for other reasons. This is not a ‘choose the best answer’ multiple choice test. Physicians often have more than one reason to scan you.

The physician orders a scan to follow trivial lesions identified by accident on prior scans.

A patient or the family want a medical test believing that a diagnosis has been missed.

The physician orders a CAT scan hastily, without sufficient thought if it makes medical sense.

The physician has a financial interest in ordering CAT scans.

The physician correctly believes that the scan is medically necessary.

The physician orders a CAT scan defensively for his own legal protection.

The physician orders a scan to bypass a difficult discussion of a patient’s chronic complaints.

I don’t pretend to be a medical saint. I have certainly ordered CAT scans for many of the wrong reasons listed above. Clearly, there should be only 1 reason that a doctor orders a CAT scan on a patient. It’s right there on the list. Can you spot it?

Monday, April 6, 2009

Beware the Radiologic 'Incidentaloma'!

The last few postings in the Radiology Quality category have detailed the risks of pursing trivial CAT scan abnormalities. Physicians created the term incidentalomas to describe these lesions that were discovered incidentally, or by accident. There is an epidemic of these lesions today as the volume of CAT scanning increases each year. When a scan uncovers an abnormality, the healthy patient is dragged into the medical arena. This unlucky patient may not be healthy for long. These scans are a potent accelerant that fuels the vicious cycle of unnecessary and excessive medical care.

Medicare expenditure for radiologic imaging tests, including CAT scans, is exploding. John Iglehart analyzed this trend in the March 5, 2009 issue of The New England Journal of Medicine.

Medicare Expenditures for Imaging Studies

Year 2000 Annual Expenses: $3.6 billion
Year 2006 Annual Expenses: $7.6 billion

The government capped fees paid for imaging studies performed in out-patient facilities and doctors’ offices in an effort to rein in spiraling costs. This did not work. When reimbursement for these services was frozen, the volume of these imaging studies increased resulting in additional costs to the federal government. Plan B anyone?

Why do individual doctors order so many scans? Most of them have no financial incentive to do so, yet they are quick to pull the CAT scan trigger. On the next posting, I’ll offer some explanations.