Like Scorpions, Closed Records Cause Paralysis

Take a step back from the challenges that surround health information technology (HIT) interoperability and you will recognize that market forces and a desperately fragmented health care system make hospitals and vendors act the way we do.

It calls to mind the fable of the scorpion and the frog, which is worth revisiting.

Wanting to cross a river, a scorpion spies a frog in the water and asks for a ride to the other side. Naturally afraid of being stung and killed, the frog hesitates, but is finally convinced by the scorpion’s argument that stinging the frog would be the end of them both in the dark flowing water. Midway across the river, the scorpion does indeed sting the frog, dooming them both. When the frog asks why as they sink beneath the surface of the water, the scorpion says, “Because I’m a scorpion.”

Compare what the fable has to say about innate characteristics with the current state of interoperability. The predominant proprietary HIT vendors know about the interoperability gap yet engage in prolonged foot-dragging on even basic data interfacing. Yes, healthcare IT is their business. No, interoperability is not in their nature.

A recent report by health research firm KLAS underscores this less-than-ideal reality: The federal government (they use our tax dollars, I must remind) has spent more than $25 billion on EHR adoption incentives and less than half of acute and ambulatory providers say their EHR is interoperable with other systems. Indeed, only 20 percent of providers are "optimistic" about vendor collaboration initiatives like the Cerner-led Commonwell Health Alliance.

The problem (apologies for beating a dead horse) is with the business model. The prevailing proprietary HIT business model is based on making the vendor the sole source of technology. Complexity of data sharing helps create a vendor lock scenario in which opening up the records is bad for business.

This situation has not gone unnoticed in Congress. As widely reported this past summer, U.S. Rep. Phil Gingrey (R-Ga.), a physician and member of the House Energy and Commerce Committee, singled out Epic for criticism, quoting a RAND report that asserts Epic provides “closed records.”

With incentives focused on driving interoperability, Gingrey asked the obvious question:

“Is the government getting its money's worth? It may be time for the committee to take a closer look at the practices of vendor companies in this space, given the possibility that fraud may be perpetrated on the American taxpayer.”

Of course Epic founder and CEO Judy Faulkner counters that her system is actually open and interoperable. In a September interview with the New York Times, Faulkner explained that Epic’s Care Everywhere solution connects hospitals nationwide. What she did not say is that the company created this bridge to compensate for the complexity of Epic implementations, which are so unique that two distinct Epic systems cannot plug and play. Uniqueness drives complexity and dependence.

Hospital-based health systems, the primary clients of proprietary vendors, are not embracing true interoperability even when it’s mandated. Once again, our fragmented health care market drives hospitals to hold onto patients and keep them in the system. Beyond the financial carrot of Meaningful Use, what is their incentive to truly interoperate on patient care and sharing patient information? The squeeze on hospitals is only increasing; the compulsion to retain patients and provide all possible services, thereby driving up revenue, persists, ACA be damned.

I experienced these forces recently while talking with a large health system that wanted to integrate more tightly with affiliated hospitals. The health system uses a proprietary EHR that the affiliate hospitals cannot afford. When lawyers for the health system became involved in the search for a “less expensive alternative” to use at the affiliate hospitals, talks abruptly ended. Restrictive contracts? Anti-disparagement clauses? The exact cause remains a mystery.

The JASON task force, an independent scientific group that advises the federal government, provided a glimmer of interoperability hope last April in a report commissioned by the Agency for Healthcare Research and Quality. The report called for HIT to open its platforms through as many application programming interfaces (APIs) as possible, enabling EHRs to truly interoperate.

JASON Co-chair Micky Tripathi, CEO of the Massachusetts eHealth Collaborative, believes government should require “public APIs” and the market will drive outcomes oriented around true interoperability. "Federal government doesn't have to be regulatory in this model," he said, explaining that Washington could simply align its own programs around an API strategy and use its massive purchasing power to move the market.

Like the frog in the fable, the US health care system, patients and taxpayers are all paralyzed, as is Congress (still and again). Like the scorpion, large health systems and proprietary HIT vendors are doing what comes naturally. Unless something dramatic happens in the way we pay for care, the paralysis in the American health care system will endure.

Edmund Billings, MD, is chief medical officer of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: billings

EHR Design and Dissatisfaction: It’s a matter of time.

As reported last year at HIMSS and by many online news and opinion sources since, physician dissatisfaction with EHRs is growing. Indeed, while this blog post doesn’t focus on the broader picture, general physician career dissatisfaction is disconcertingly high.

The breakneck push for more and better EHR use as a component of regular medical care is a significant part of that malaise, but it is insufficient as an explanation. For the most part, doctors really don’t like what the health IT industry is giving them to work with. The HIMSS survey proves it, showing that around 40 percent of physicians would not recommend their EHR to a colleague.

One would expect an industry to develop better products and improve usability, acceptance and satisfaction over time. In health IT, the opposite has occurred, with most pointing fingers at Meaningful Use as the culprit for awkward workflows and Rube Goldberg solutions cobbled together so everyone can get paid in a timely manner. 

It seems EHRs are taking more time to use rather than less, which was the original goal.

According to a survey published this week in JAMA online, this is exactly the case. In an article called, “Use of Internist's Free Time by Ambulatory Care Electronic Medical Record Systems,” a team led by Clement J. McDonald, MD, looked at the amount of time EHRs carved out of what physicians consider their free time.

Here is a summary of their findings:

  • 411 physician respondents
  • 61 different EHRs used
  • 9 EHRs used by 20 or more physicians
  • 59.4 percent said they lost time after moving to an EHR from paper
  • 63.9 percent said note writing took longer with an EHR
  • 33.9 percent said it took longer to review EHR charts than paper
  • 32.2 percent were slower to read other clinicians’ notes

So, how much time did physicians lose to EHRs? 

On average, they lost 78 minutes a day or 6.5 hours per week.  If a clinic workday is 8 hours, these physicians were spending almost a full extra day each week on EHR-oriented stuff. Because responsibilities and lurking error potential are relentless, physicians operate in a state of constant urgency. (This is also a potential explanation for unreadable handwriting.)  It’s no surprise, really, that losing the better part of a day to the EHR will cause significant frustration. 

Naturally, since 78 minutes extra per day was the average, some EHRs took much longer and others took less time. The EHR that took the least amount of time was VA VistA, which averaged about 20 minutes per day and 100 minutes per week—80 percent less than the overall average of 6.5 hours. 

Think about that. How much more would your level of job dissatisfaction rise if technological change added 78 minutes to your day versus 20?  

Understanding why VistA requires so much less time means understanding the evolution of system design. VistA was created to be rapidly adoptable. All other goals were and have remained secondary.  Physicians interning at the VA rotate through frequently and cannot spend a day or more learning the health IT system. Generally, they get a two-hour orientation and the rest they learn on the job. The EHR has to be inherently straightforward to learn and use or efficiency is lost and the VA ends up like every other hospital in America. 

VistA’s core functions—orders, notes, notifications and chart review—are easy to manage and enable rapid workflow. In large measure, this is the product of a community development process as opposed to a company competing in the feature function wars that have bloated most EHRs. The effectiveness of VistA is validated by a recent Medscape EHR study in which VistA CPRS was rated number 1 overall for physician satisfaction, number 1 in data entry, and number 1 in usefulness as a clinical tool.

The key component in the effective use of EHRs is time. A well-worn axiom tells us it takes a long time to write a short note. So, perhaps it also takes a long time to design an EHR that generates short notes … that helps get work done efficiently. Ultimately, EHR’s should create time for patients, not take it away. Technology may make patients safer—an arguable point for many in medicine—but if it can’t improve efficiency, it will only contribute to what looks like the ongoing disintegration of American healthcare.

Edmund Billings, MD, is chief medical officer of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: billings

The squeeze is on for U.S. hospitals

Lots of financial scrambling, but the numbers still don’t add up

Is healthcare a business?

In the United States, the question has been asked time and again but never satisfactorily answered. By virtue of publically financed healthcare systems, the rest of the developed world has decided, to a greater or lesser extent, that medicine and healthcare are not pure businesses—that citizens have a right to care, even when they can’t pay all associated costs.

It’s starting to look like Americans won’t be able to duck the question for much longer.

In the last year, the profitability of U.S. hospitals eroded for the first time since the Great Recession, pushing some closer to and others over the solvency precipice. Revenues are down and costs are up.  And these issues appear systemic and entrenched, giving rise to a series of important and relevant questions: How can hospitals adapt?  If they do, will they still survive? And, do we as a nation think it’s important to make hospitals accessible, even if they lose money?

As recently reported in the New York Times, analysis by Moody’s Investors Service shows that this year nonprofit hospitals had their worst financial performance since the Great Recession. Among the 383 hospitals studied, revenue growth dipped from a 7 percent average to 3.9 percent on declining admissions.  For the last two years, expenses have grown faster than revenues, and fully one quarter of all hospitals are operating at a loss. 

In a word, Moody’s describes the situation as “unsustainable” because it is the product of what look like enduring realities:

  1. Private insurers did not increase payments to hospitals.
  2. Medicare reduced payments due to federal budget cuts.
  3. Demand for inpatient services declined as outpatient care options rose.
  4. Retail outpatient options now compete with hospital clinics.
  5. Patients with higher copays and deductibles chose not to seek care.
  6. Hospitals are buying up physician practices.
  7. The costs of electronic medical record systems are impacting the bottom line.


Will all these influencers remain constant? No. But they don’t have to. A handful should be enough to push some hospitals into the next life.

The Moody’s analysis is simply evidence of continuing weakness in the healthcare marketplace. Earlier this year Standard & Poor's evaluated 138 healthcare systems and found an operating margin of 2.2 percent for 2013, down from 2.9 percent in both 2012 and 2011. Standalone hospitals were squeezed slightly more than hospital systems because they have a narrower range of operations and services from which to profit.

While the decrease might be the point, can we pause for a moment to recognize the paltry 2.9 percent margin? Just a tremor in the operating budget of any hospital with that small a margin will probably send it over the financial cliff.

In Sebastopol, California, north of San Francisco, 37-bed Palm Drive Hospital is shutting its doors. Despite clear demand for both inpatient and outpatient care, Palm Drive has labored for years to make up for reductions in Medicare reimbursement rates with more inpatient services. Over the next ten years across California, hospitals will see a reduction of more than $23 billion in payments, including $17 billion related to prevention and readmission penalties instituted by the Affordable Care Act.

“Unfortunately, Palm Drive is not an isolated case,” said Jan Emerson-Shea, a spokesperson for the California Hospital Association. “There are hospitals across the state that are really struggling to remain open and operating.” 

Indeed, nationwide the outlook for smaller, rural and standalone hospitals is gloomy.  Moody’s sees more earth-shaking change coming when insurers move to pay for quality and not services—from a system that thrives on illness to one that rewards health and wellness. The transition is happening now, and the pace will only increase.

The knee-jerk reaction to this situation for any organization with a budget is to lower costs. For hospitals, that means reducing staff and further burdening existing employees. This may be an effective strategy in accounting or restaurants, but the result in won’t be late nights poring over spreadsheets or cold entrees.  Labor reductions in healthcare can only decrease quality and increase costs in the long run.  More errors lead to less reimbursement, and the squeeze continues until the hospital gives up the ghost.

There is a way out of the squeeze, however, available to those that can adapt by lowering costs and increasing quality. Hokey as it may sound, it is possible to redefine hospitals for a future based on best practices. 

Where does this supposedly mythical future exist even now?

How about in Wisconsin? Members of the Wisconsin Hospital Association have used quality improvement programs to decrease readmissions, lower infection rates and curtail adverse drug events, resulting in statewide savings greater than $45 million over several years.  As President Steve Brenton wrote in WHA’s 2013 Quality Report:

Health care value can be improved by either raising quality while controlling costs, or by decreasing cost while maintaining quality.  If value improves, patients, payers, providers and suppliers can all benefit while the economic sustainability of the health care system increases. When improvement work reduces hospital-associated infections and readmissions, the improvements in quality translate to cost savings, and that is a value to local employers, insurers and patients.

The WHA Partners for Patients program targets best practices and outcomes based on Institute for Health Care Improvement programs. Organized efforts across member hospitals have achieved these remarkable outcomes and savings.

Of course, these results require health IT and electronic health records for programs that create outcomes stakeholders value and will pay for. Hospitals must promote their quality metrics and negotiate rates with these stakeholders.

But, while the numbers from Wisconsin and other regions are encouraging, this is not simply a situation of making the numbers work. The savings realized when hospitals focus on quality are in the tens of millions; the reductions in payments expected to continue are in the billions. There is a yawning chasm between the two.

Currently, payers are moving to a 5/1 ratio. A survey released last month by Blue Cross/Blue Shield estimated that for every $5 in reimbursements, only $1 was a reward for improving care and lowering costs. As these and similar arrangements are negotiated, you can be certain that the smaller non-profit hospitals are last in line.

The mandate for quality care and cost savings is clear, but the numbers still don’t add up.  Can non-profit hospitals change fast enough? Until they do, or if they can’t, are we as a society willing to support them because we think the care should be available?

Edmund Billings, MD, is chief medical officer of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: billings
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