Gyroscopic Investing

Despite all the government funding, EMRs haven’t lived up to the promise of lower cost and increased efficiency—something we predicted back in 2009. On the contrary, the new approach seems to be increasing costs through overbilling. Electronic recordkeeping makes it easier to overbill for services. For example, the percentage of the highest-paying claims at Baptist Hospital in Nashville climbed 82 percent in 2010—one year after it began using a software system for its emergency room records. In general, hospitals that received government incentives to adopt EMR showed a 47% rise in Medicare payments from 2006 to 2010, compared with a 32% rise at hospitals that did not receive any government incentives.

Fraud is a huge problem with EMR. Some EMR programs can automatically generate detailed (but fake) patient histories, or allow doctors to cut and paste the same examination findings for multiple patients (a procedure called “cloning”?) so it looks like they conducted far more examinations than they actually did. Doctors can also click a box indicating that a thorough review of patients’ symptoms had taken place, even though the exams Medicare is paying for were rarely performed.

Dr. Donald W. Simborg, who was the chairman of federal panels examining the potential for fraud with electronic systems, said, “It’s like doping and bicycling. Everybody knows it’s going on.”? The Office of the Inspector General is studying the link between electronic records and billing.

https://www.nytimes.com/2012/09/22/busi ... cords.html

It isn't necessarily overbilling - most of the increase is probably legitimate.  Hospital & practice administrators love EHRs because they increase billing capture.  Before EHRs, billing was done by having MDs fill out extra billing sheets or cards and hand carry them to the office of the severely underpaid person whose job it was to review the bills for accuracy, then package & send them to the outsourced billing agency in India.  If bills somehow managed to find their way to said underpaid person's desk, they stood a good chance of being thrown out because of illegible signatures, faint carbon copies, fits of pique, etc.  I designed electronic inpatient progress notes for our group after I figured out that around 30-50% of inpatient visit notes weren't being billed.  In the never-ending game of let's-reduce-reimbursements, one of the best weapons on the practice side is increasing billing capture and coding the maximum level for the services you provide.

It's kind of laughable, what Medicare thought would be the result of EHRs.  Everyone on this side knew exactly what would happen.  Another great example:  "better communication"??  Please.  EHR systems are blocked from direct cross-communication by HIPAA (passed by the same government that somehow thought that EHR's would automatically interconnect), and because different companies don't particularly want to make their systems compatible with their competitors'.

EMRs improve care.  As a doctor being able to go to one place with a computer interface where you can find any info on a given patient vs not being able to find the info at all (or having to wade through reams of paper notes with illegible writing) is a big deal.

Benko wrote: EMRs improve care.  As a doctor being able to go to one place with a computer interface where you can find any info on a given patient vs not being able to find the info at all (or having to wade through reams of paper notes with illegible writing) is a big deal.

Maybe one day it will be like that, but this doesn't even come close to painting an accurate picture of the current state of EMR's.  I guess you have to start somewhere, but for now, the EMR thing has just resulted in tens of thousands of $$$ for each doctor spent on software over the last decade, with little upside benefit, IMO.

clacy wrote:

Benko wrote: EMRs improve care.  As a doctor being able to go to one place with a computer interface where you can find any info on a given patient vs not being able to find the info at all (or having to wade through reams of paper notes with illegible writing) is a big deal.

Maybe one day it will be like that, but this doesn't even come close to painting an accurate picture of the current state of EMR's.  I guess you have to start somewhere, but for now, the EMR thing has just resulted in tens of thousands of $$$ for each doctor spent on software over the last decade, with little upside benefit, IMO.

I agree. 

They are more time consuming for the physician (much more so in some cases), and the privacy laws make the information less portable than one might think.

clacy wrote:
Maybe one day it will be like that,

I am a doctor and this is my day to day experience now.

Benko wrote:

clacy wrote:
Maybe one day it will be like that,

I am a doctor and this is my day to day experience now.

Yeah...it's probably speciality/institution dependent.  Most of the ED EMR's that I've used aren't that good.  They slow me down, and don't produce a much better chart.  A lot of times they're worse, bc they auto populate certain things inaccurately, and I have to spend a lot of time editing the chart.

Benko wrote:

clacy wrote:
Maybe one day it will be like that,

I am a doctor and this is my day to day experience now.

That is good to know.  I spent over a decade consulting and working with hundreds of surgeons and physicians (as well as support staff) and that was not the prevailing attitude, nor did my observations see that in practice.  Maybe things have changed as I made a career change over 3 years ago.  Anecdotally, I observed a very large time commitment to satisfy recordings although much of that is probably forced upon the profession by litigation avoidance.

I can certainly see the big picture benefits as records become more integrated within the larger health care system.

Benko, as an end user, what you think of it is really what matters.  And your report of experiences is a lot more credible than EMR software sale person's 

AdamA wrote: Yeah...it's probably speciality/institution dependent.  Most of the ED EMR's that I've used aren't that good.  They slow me down, and don't produce a much better chart.  A lot of times their worse, bc they auto populate certain things inaccurately, and I have to spend a lot of time editing the chart.

Very true.  It also depends on how accurate and efficient the office is running on paper. From what I have seen (in a very efficiently run practice), there would/will be a large decrease in productivity unless each MD has 2 scribes in the background doing the chart preparation and entry (one on current patient, and one completing the last one).

One other factor that no one is mentioning is the utility of the product produced and sent to other offices. I have yet to see a good, legible letter from an office that is EMR based. For the most part, I don't read EMR "communications" any more, and this translates into poorer care for all. It is all about compliance with "meaningful use" now with not enough attention to good, individualized patient care.

I am a radiologist and since other doctors often order tests and give us little information, either as to what they are looking for, or background on the patient, the information that I can find out, both as to what the ordering doctors are looking for, what problems the patient is having and to background labs, surgeries, etc. is invaluable and can make huge differences in our ability to provide the best interpretation of the tests.  I would say that radiologists where I work consult the electronic medical record many times each day and it is very helpful.

The electronic medical record where I work is probably better than many.  Then again I used to moonlight at a major academic hospital nearby about 10 years ago, and one of their computer systems used a circa 1970s text editer i.e. when typing and you came to the end of a line, it would not automatically go to the next line, you had to manually hit return, otherwise the letters would type over one another.

The Veterans Administration is almost all online now.It seems to be a good system for information but
they spend a great deal of time just putting the data in.

The VA is blessed with a wonderful system (CPRS).  It was designed with medical care in mind - not "meaningful use" coding, billing, or administration.  It also links across VA hospitals & clinics, and is Linux based so it's inexpensive to install & maintain.  In my view, the Obama administration missed a golden opportunity by not mandating CPRS as the universal electronic health record.

Benko, as a radiologist you just get to READ the electronic record, you don't have to USE the thing.  That's a huge difference.  Also your particular hospital may have a home-grown system that was designed to be usable - unlike most "approved" EHRs.  Our medical center has a beautiful home-grown system.  Then the hospital bought an "approved" EHR system.  Then the university (separate faculty practice) bought an ENTIRELY SEPARATE system that had no relation whatsoever to the hospital's.  Both of these newer EHR systems are so painful that no one actually tries to use them to review charts.  I tried to use one of them for a time, until I discovered that it randomly drops lab results so I couldn't rely on it.

The cost of these new EHR systems is ridiculous.  I know the university paid $40M for their system, and I can only assume that the hospital paid a similar amount for theirs.  You want to know what's happening to medical costs?  Look no further!

If you ask an administrator whether these new EHRs are worthwhile, the response is "they're a bargain at twice the price."  That's because of the increased billing capture (described above) and the meaningful-use incentive payments.  Other than that, they're an enormous time drain for physicians and residents.  Of course, extra physician/resident time is "free" so no one cares. The "cloning" that the article MG cited complains about happens because people are desperate to find shortcuts to try to claim back some of their wasted time.

WiseOne wrote: Benko, as a radiologist you just get to READ the electronic record, you don't have to USE the thing.

True 99% of the time.

I certainly did not mean to imply a consumer reports type rating of cmr's.  I only know them from my point of view.  But I gather from the grapevine that other radiologists at other institutions also make use of CMRs.  Which means that today they are helping patient care in a not insignificant way.  Which is important.  So the benefits are not just for billing.

Ordering radiology studies (for referring docs) in our system is horribly confusing, but that has to do with the person who set it up.  And if it is a terrible pain on your end, that is unfortunate and I hope the bugs can be smoothed out.

WiseOne wrote: The cost of these new EHR systems is ridiculous.  I know the university paid $40M for their system, and I can only assume that the hospital paid a similar amount for theirs.  You want to know what's happening to medical costs?  Look no further!

This sounds like a great VP opportunity if the companies that put out this trash are publicly-owned. Are hospitals buying these crappy systems because they're mandated by some law, or are the decision-makers at these facilities simply bamboozled by the promise of fancy tech?

Pointedstick wrote: This sounds like a great VP opportunity if the companies that put out this trash are publicly-owned. Are hospitals buying these crappy systems because they're mandated by some law, or are the decision-makers at these facilities simply bamboozled by the promise of fancy tech?

They're buying because of the mandate.  Systems have to be certified for meaningful use, and there are only a few of them so monopoly pricing is definitely happening.  And two of the major ones (Eclipsys and Allscripts) just merged.

Benko wrote: But I gather from the grapevine that other radiologists at other institutions also make use of CMRs.  Which means that today they are helping patient care in a not insignificant way.  Which is important.  So the benefits are not just for billing.

Ordering radiology studies (for referring docs) in our system is horribly confusing, but that has to do with the person who set it up.  And if it is a terrible pain on your end, that is unfortunate and I hope the bugs can be smoothed out.

An EHR system can certainly serve that purpose, if they're designed correctly.  The meaningful-use approved systems, though, are not.  The patient histories you read have to be entered by someone.  When our hospital went to the new EMR, chart notes became so much less informative that if you really want to know what's going on with a patient, you have to page someone and ask.  Other trends (medicolegal, increased billing requirements) feed into that as well.

Also, understand that there is no incentive for bugs to be fixed in these systems.  Once a hospital or practice has paid $40M for a system, spent countless hours training employees, setting up the IT infrastructure etc, they're never going to change to another system.  There's also a law protecting EHR companies from any legal liability for medical errors caused by their systems.  I've tried to report bugs several times, and the company has simply denied that they exist.  The only bug that got attention was one that directly harmed at least two patients that I knew of, and that was only after I fired off an email to a lot of high level people and mentioned that one of the patients and her lawyer friend knew exactly what happened and why.

WiseOne wrote: They're buying because of the mandate.

[...]

There's also a law protecting EHR companies from any legal liability for medical errors caused by their systems.

Crony capitalism at its worst. Mandate the purchase of their product, then immunize them from liability. And of course, now that they're on the books, there's no chance of getting these terrible laws repealed. That would be too radical.

Forgetting radiologists there are other areas which make this a big deal for patient care:

1.  Allergies e.g. drugs, food, IV contrast.
Patients don't always remember all their allergies, and they can arrive at the hosptial unconscious.  Having ready access to their allergies can be lifesaving.

2. Meds: patients are not infrequently prescribed meds by more than one doctor.  Having all the meds in one place can make the doctors job easier if he has to presecribe another med(s) to select ones which don't interact badly with ones the patient is already taking (patients don't always bring all their meds to every visit).

X-ray images are now mostly interpreted on computer screens and manipulated by computer software.  When this viewing software was first around, and for many years, it was not much fun to use, but most of the bugs have been worked out and working with images on a computer screen is much easier and better for the patient vs looking at the images on x-ray film.  Similarly the software you are talking about will improve (though much more slowly tis true if the gov't does its usual thing).

Surely I am not the only one who has withheld (and routinely does withhold) material information from doctors due to privacy concerns directly tied to the use of EHRs. I'm quite sure this has impacted the quality of care I receive, and it may end up causing me harm at some point, but the bottom line is that if you'd sell me out for the prospect of more favorable reimbursement rates, I can't trust you worth squat.

Maddy, for once I don't quite understand your post, or why you were motivated to resurrect an old thread. Did something EHR-related happen??

Withholding info from physicians because of privacy concerns is a time-honored tradition that predates EHRs. For example, I know of quite a few epilepsy patients from New Jersey and Pennsylvania who go to doctors in New York in order to circumvent mandatory reporting laws in their home states. And I wouldn't be surprised if it weren't a big motivation for people to order medications from pharmacies in India.

If it makes you feel any better, actual medical information used to be much easier to glean from paper records than electronic. The EHRs are so packed with useless administrative crap that physician notes are nearly completely unreadable. The "real" medical information is passed around verbally or via signouts, which are either emailed or stored on EHRs as non-chart notes.

This is really weird, because this thread appeared at the top of my "Other Discussions" screen this morning, and I didn't notice that it was an old one. Did somebody post just ahead of me and then remove it? Darned if I can figure out how this happened.

Anyway, no--nothing's happened. Just the usual aches and pains. But hey, I'm old.

WiseOne, I'm glad you responded anyway, because I've always been curious about the extent to which EHRs actually get circulated around. I had a neighbor who was a surgical resident, and one day over margaritas she was talking about how the whole surgical team went into hysterics over some anesthetized guy's "butt hair." Freaked me out. I don't seriously think comments like that get into medical records, but it's the potential for
widespread dissemination of anything that I expect to remain confidential that I find upsetting.

P.S. I like your new avatar. Kind of Dr. Quinn-ish.

There was a post on this thread from earlier today, probably from a spammer. It was a really good spammer (that is, non-obvious), though. I decided I was unsure enough to leave it, especially since Maddy had replied. I'm guessing one of the other mods zapped it.

Thank goodness. I'm not going crazy after all.

it was Spam and i cleaned it up...

If you mods wanted to gaslight somebody, that would be the perfect way.

Thanks to the mods for staying on top of the spammer - modding is unpaid labor and we all appreciate your diligence.

Removing is perfectly legit, but maybe alternatively you could delete the message, replacing with a [message deleted - this is spam] insert, and then ban the account. Especially if there's been another post.

To respond to Maddy: your concerns are understandable, even though most of us would consider that conversation to be in very poor taste, and I can virtually guarantee that stuff won't find its way into the EHR. There's no getting around the fact that medical staff (not just doctors) are people, with the same personality issues as everyone else. I wonder how many people are really deterred from seeking medical care because of the fear of being made fun of, although the people who probably trigger the most such unwanted attention are the ones who, let us say, are inclined to over-use medical services.