Remember The EMR!

I have been railing against the roll-out of the electronic medical record (EMR) since I first started blogging when I was CEO of NorthBay Healthcare.  I have continued whining about EMRs in this space.  I have become a serial whiner.

At times I feel like I am beating a dead horse except this horse is not truly dead.  The EMR horse continues to consume oats and spew out you-know-what at the other end.  It’s a mess.

My latest bout of EMR whining is prompted by an excellent article in the April issue of that well-regarded medical journal–Fortune Magazine.  It relates the EMR follies and how good intentions were subverted by poor planning, political posturing and the law of unintended consequences.  Business as usual in D.C.  It is a must read.

Health policy makers (also know as pundits) and politicians on the hustle are a toxic mixture.  It never ceases to amaze me how ignorant these people are about the actual delivery of healthcare.  Yet it is these people we rely upon for considered reform of health care.

As the Fortune article points out, the push to have national adoption of the EMR was because it was viewed as a shovel-ready endeavor which could help with economic recovery from the recession of 2008.  However, the shovels were not ready, physicians and hospitals were not consulted and the providers of EMRs were selling a product which complicated the delivery of care and in many instances caused injuries.

The EMR vendors saw explosive growth after 2010 when healthcare providers were under the gun to adopt EMRs.  The federal government created financial incentives to adopt the EMR as well potential penalties for not doing so.  The EMR vendors as a group were not ready for prime time but they sure prospered.   Their revenue growth was impressive and matched only by their ability to not deliver on their promises.

As I have related recently, we now have scribes entering medical data so that physicians can be freed from that task and devote more time to attending to their patients.  Costs have not gone down as a result of the EMR; they have increased substanially.   And because of the poor design of the EMRs, the quality of care has often been affected.

Making the EMR work to the benefit of providers and patients is now a rescue effort that is likely to involve significantly more expense.  Even most of the early proponents of the EMR including former President Obama are expressing regret about how a good idea turned into a fiasco.

Has the lesson been learned that a good idea is not necessary amendable to uninformed political intervention?   The answer is a resounding “No!”

“Medicare For All” has again reared its head, promoted by a multi-millionaire socialist (only in America is that possible) senator with the 150 Democratic presidential candidates all supporting it.  The other party meanwhile seems to be pretending there is not a problem in terms of healthcare coverage.  Both sides give new meaning to the term “useful idiots”.  Actually, the term should be “useless idiots”.

We have a problem.  Medicare for all is not the answer.  It is an empty slogan meant to be defined in multiple ways.  There is political safety in vagueness.

Doing nothing is likewise not the answer although that seems to be the default position of the other party.

Adopting a solution for political purposes will repeat the EMR fiasco.  Wiping out the health insurance business which needs to be reformed but not eliminated will have its own unintended consequences.  Doing anything that increases demand for healthcare without providing more trained providers will simply make access even more difficult.

Solving the vexing problemn of universal coverage is going to require much more thought than blindly adopting a nonsensical slogan like “Medicare for All”.  A much better slogan would be:

“Remember the EMR”.

A poor memory will result in yet another fiasco and more importantly no improvement in coverage.

 ADDENDUM TO THE ENTRY ABOVE WHICH WAS POSTED ON APRIL 16:

The April 17 Wall Street Journal contains an excellent column written by two academics, one of whom frequently writes healthcare related articles for the Harvard Business Journal. The article critically examines “Medicare for All” and contrasts the failing Canada model with much more successful universal coverage models in Germany and Switzerland, both of which maintain a robust private healthcare sector. The last paragraph nicely summarizes the authors’ point:

 Con­sumers and the pri­vate sec­tor drive the health-care sys­tems in these coun­tries, which ac­com­plish ex­actly what Mr. Sanders and his sup­port­ers say they want—uni­ver­sal cov­er­age, con­trolled costs, high qual­ity and ready ac­cess. In con­trast, Cana­da’s ex­pe­ri­ence shows the dan­gers of the Medicare for All model.

 So once again, Remember the EMR!

The Rule

I really did not want to be negative when I read a number of articles updating Walmart’s and other large employers’ efforts to encourage employees to use physicians consider the “best” in their area of expertise as a way to decrease the cost of health insurance. Then I remembered my rule:

When a company or the government says it is about quality and saving money, it is about saving money.

The lead sentence is a recent Wall Street Journal article inadvertently could not have been any clearer:

“Walmart and other employers want more say over which doctors care for their workers, and they are ramping up efforts to pick and choose physicians in health plans as they seek to reduce health spending.”

Pick and choose physicians? A laudable goal, I guess, but a little frightening when you think about it.  Do you really want your choice of doctors determined by someone whose bonus or stock price is tied to financial performance?

The article relates how Walmart has developed a network of physicians they have deemed the “best” and provides incentives for their workers to travel, if necessary, for consultation and treatment by those doctors. Those incentives are meant to guide the decision making by employees to the financial benefit of the employer and secondarily (maybe, possibly, hopefully) result in better quality care..

The assumption is that the care provided to those workers would be better, not to mention cheaper.  The evidence for the “better” part of that assumption is shaky.

Identifying top performing doctors is still a mix of science leavened with a healthy dose of voodoo.  Measuring physician performance is difficult.  Measuring who is a cheap physician is not.

The idea that the plan of care developed by the chosen doctors is an improvement over what a local doctor may think is equally dubious.  In fact, what Walmart is doing is further fragmenting care.  They are looking at sourcing health care the same way they do for the merchandise they sell.  But as Walmart proudly proclaims, it has saved them money.

Walmart employees who choose the travel option will save money.  They get whatever procedure the “better” doctors perform at a reduced co-pay or deductible amount.  Walmart pays the doctor at a negotiated discount rate.  Everyone is happy.

So what happens with the necessary local follow-up care where the Walmart patient lives?  It is one thing to travel hundreds of miles to have back surgery performed by the annointed surgeon but  the “lower” quality local  doctor or hospital is expected to provide that follow-up care.  Good enough to do the follow-up but not good enough to do the procedure.   What’s with that?

The evidence for the success of such programs is anecdotal.  According to the Wall Street Journal, Walmart, Lowe’s and McKesson Corp (which is a vendor of expensive goods and services to healthcare providers) “saved” $19.4 million for spine surgery provided to their employees under the programs.  Just how they “saved’ and the basis of comparison is  hazy and the total amount is not even a rounding error for these huge companies.

It seems to me that tangled in all this may be an absence of a degree of fiduciary responsibility when your employer selects a doctor and steers you to that doctor.  If you have a financial advisor who is a fiduciary you know that he or she does not financially benefit from whatever specific investment they recommend.  Their only interest is do what is best for their clients.

That is not the case with what Walmart and other large employers are doing.  Their first imperative is to save money.

An interesting question:  Suppose under this scheme,  quality improves but costs increase? Would these companies be as interested?  I think I know the answer.

While high quality is not always more expensive, there are many instances where high quality does mean higher expense.  It depends on the definition of quality being used.  As in most of life, you get what you pay for.

There is another time proven way to make sure that a medical course of action is the best–get a second opinion independent of your employer or health plan..  At NorthBay Healthcare, we became part of the Mayo Clinic Care Network and that allowed our doctors and patients to seek a second opinion from the preeminent medical group in the world.  There is no cost to the patient for these second opinions.  That is a better option, free of self-serving conflicts.

Over the years I have grown leery of grand schemes to save money developed under the guise of quality.  I know that is not politically correct.  It is absolutely backward thinking, sufficient to get me booted out of the council of wise people in healthcare. That’s fine with me since I am on the beach and now know that the wise people in healthcare are not as wise as they think they are.

Call me a cynic but I still believe in The Rule:

When a company or the government says it is about quality and saving money, it is about saving money.

Always keep The Rule in mind when organizations with built-in conflicts of interest want to make healthcare decisions for you.

 

 

 

 

 

Perspective

This week marks the second anniversary of my retirement from NorthBay Healthcare where I was CEO for over thirty-five years.  It is an important milestone for me but not for most people taking the time to read this entry.

I had  a total of forty-five years as a senior manager under my belt when you include my time at Herrick Hospital in Berkeley.  I enjoyed having the privilege of trying to make a difference in the providing of healthcare.  I worried whether I could step away from the day-to-day challenges with which I dealt.

Would I be bored?  As my successor recently jocularly texted me, “If you are bored and want some fun in your life, there is always budgets and managed care to entice you off the beach.”  I think he is envious.

To my surprise I am not bored.  I have traveled, spent more time with my seven grandchildren and explored personal interests for which I never had enough time to do when I was actively engaged in healthcare.  My old movie poster collection now numbers over thirteen hundred which inexplicably gives me great pleasure.

I am a retirement cliché and not bothered at all about that fact.

I do miss seeing on a regular basis the people who make NorthBay great.  Some have retired.  Some have moved on.  Sadly, some have passed away.  Still, those who remain continue to live the organization’s mission of compassionate care, advanced medicine, close to home.

I have gained, though, a perspective on healthcare which was not possible when I was in the middle of it.  I have learned not to react to every harebrained idea about healthcare which comes from a politician or second rate actor.

I have come to understand that there is much more right about our healthcare system than there is bad. The ignorant pundits need to get a life.

Most importantly, I now understand that healthcare is important but not as important as those of us immersed in it think it is.

It is part of an array of issues with which we cope.  That perspective–putting healthcare in its proper place–came to me only after I hit the beach.  Unless we fall ill or have chronic health issues, healthcare is not in the forefront of our daily activities.

With the 2020 election campaign now beginning in earnest, healthcare is once again becoming an issue for politicians of all stripes to exploit.  It has been that way since 1969 when Richard Nixon declared a healthcare crisis.  Fifty years later, we are still talking about that crisis.

“Health Affairs” in a September 18, 2018 blog article asked this  question.–how long can a crisis last? It is a great read and adds perspective.

“Health Affairs” in that article points out that most of the problems noted fifty years ago remain.   It also points out, though, that the percentage of healthcare costs covered by insurance for most people far exceeds what was the situation in the 1970s.  That is just one indication that the use of the word “crisis” is overblown. Again, it”s a matter of the proper perspective.

After two years on the beach, I do indeed see things differently.  I am not worrying about budgets or managed care.  And while things could be better in healthcare, they are not as bad as politicians and “experts” would lead you to believe.

I will be thinking about these things later this month when, for the first time since I metaphorically hit the beach, I will actually be on a beach in Maui.  I will be the guy in the Tommy Bahama T-shirt and shorts (required attire for Jimmy Buffett wannabees) reading “Modern Healthcare”  and “AARP Magazine” for pleasure. And I will maintain the proper perspective about healthcare.

 

If Tesla Ran Healthcare

Would things be different if Tesla ran healthcare?   For one thing, there would be more charges.

OK, bad joke.

Nevertheless, everyone it seems is looking for the killer (kind of a bad term) app in healthcare or the big technology disruptor as Tesla has done with automobiles.   So far, it has not been found.

Sure there are things like urgent care centers with iPads for registration and emergency services which advertise their current waiting times on freeway signs.  Not to be forgotten in this list of non-disruptors are the boo-boo clinics in drug stores.

There are the call centers maintain by health plans where you can call with your health concerns.  Their main goal seems to be to prevent you from going to where you really want to go–your doctor or local hospital emergency service.

Don’t forget the Silicon Valley heroes who are looking to cause disruption in healthcare.  Who can forget Theranos, the brainchild of a 19-year-old Stanford drop-out?  If you have forgotten that sad story of non-disruption disruption, you should watch the excellent documentary currently showing on HBO about this fraud.

Where is Bones from Star Trek with his Tri-Corder?  That handy handheld gadget could diagnosis anything!  Captain Kirk often found himself on the receiving end of the Tri-Corder.  That was real disruption.

Maybe instead of looking at disruption we should lower our sights and simply look at improving service to patients.   That’s where two recent experiences with Tesla come to mind.  Tesla is about much more that technology.

Last week I got two flat tires over the span of four days on my Tesla Model S.  That’s a problem since Teslas don’t have spare tires and towing them is tricky and requires a special technique for reasons I don’t comprehend.

My flat tires were on separate wheels and both were on busy I-80 in the Bay Area.  I called Tesla’s roadside assistance number and they quickly sent out a truck emblazoned with the Tesla logo. My flat tires became a status symbol as cars flashed by.

IMG_6CF5D22E035F-1

In the truck was a supply of new loaner tires which would be put on my car if the tire could not be repaired on the spot. The first flat tire was repaired and in 30 minutes I was on my way.  The second flat tire later in the week was removed and a loaner tire put on.  The service was superb in both instances.

That got me to thinking about healthcare and its service component.  Like Tesla, we provide a high cost product or service.  Unlike Tesla, we seem to have a difficult time meeting expectations in terms of how we provide our service.  Long waits and poor communication are more the norm in healthcare.  Why is it despite our best efforts that level of non-service continues?

As I was writing this entry, an example of non-service in healthcare came to my attention.  A friend called who was concerned about his very elderly mother.  She was not eating, getting weaker by the day and beginning to have problems with activities of daily living.  She recently had a stroke. Was she suffering a physical problem or depressed?

She was resolutely refusing to go see her doctor who practiced in a very well-known integrated healthcare system here in California.  Her son found her primary care physician uninterested in trying to arrange a home evaluation.  He tried several ways to enlist aid from the healthcare system to no avail.  It finally took an outside physician friend who wrote a  letter he could send under his signature to gain the healthcare system’s attention.  The letter contained enough trigger words so it was no longer possible for the healthcare system not to do the right thing.  A home telemedicine consultation was arranged.

I think even more highly of Tesla after my two experiences last week. Contrast Tesla’s approach with my friend’s experience with a healthcare system which never misses an opportunity to publicly pat itself on the back. If Tesla ran healthcare,  things would be done differently.

When was the last time you felt there was a true service commitment from your healthcare provider?

I find myself beginning to believe that true disruption in healthcare does not require cutting edge technology, a fancy app or even a Tri-Corder.  The way to true disruption is a lot simpler.  Take care of patients in a way that meets their needs rather than  those of the provider or health plan.  In the long run that pays off.

 

The Case For Mountain Dew

I hit the beach two years ago this month.  My involvement with healthcare has been a more distance affair as a result—-unless it involves members of my extended family.  Then I often get an earful.

Since the first of this year, a  number of family members have had encounters with healthcare including two hospitalizations.  These encounters have included care from three very large healthcare systems and two smaller systems.  I have been keeping notes of what I have seen and will share them here:

Who’s In Charge?

The healthcare provided to my family members has been satisfactory  and in some cases superb.  If you look at the process of healthcare as involving segments of care, each segment of each hospitalization my family members experienced went well.  It was at the connecting points within each hospitalization where things sometimes did not go well.

There needs to be further thinking about how to make hand-offs of care from one provider or work shift go better.  This extends as well to the segment of care which is post hospitalization. Often, patients and their family members were not adequately kept in the information loop.  Whomever figures out a way to make the patient care process consistently go more smoothly and in a coordinated way is going to get rich or at least appreciated.

Why Do We Bother With the EMR?

Electronic medical records are great!  They improve patient care.  If you are a provider, you get punish if you don’t use one. That has been the hype.

I don’t buy the EMR hype any longer although before I hit the beach I was an enthusiastic supporter of EMRs. Reality has set in.

A recent personal experience. I just had my annual physical which I have every 18-24 months, longer if I can get away with it.  I have a great primary care physician.  He asks all the right questions even if a number of them are a little embarrassing.  His scribe takes it all down.

His scribe?  Yes, there is a third-party in the exam room with me and the doc.  It’s a little get together. That’s because the EMR which was supposed to make life easier for the physician has done the opposite.  What used to involve just the doctor has required the addition of another person. Two’s company, three’s a scribe.

So now there is the distraction of the scribe tapping away my answers to personal questions.  So much for my fifteen minute appointment.

EMRs have become a burden and with the lack of interoperability between systems not very useful when the information is most needed.

What Can Be Done About Electronic Tumors?

There was a time when at work you were expected not to make personal phone calls or otherwise divert your attention from your work.  Not anymore.  Everyone has electronic tumors, usually attached to one of their hands or ears.

In virtually every clinical setting I saw staff during the time they were supposed to attend to the business at hand,  accessing personal cell phones.  I saw it in doctor offices, nursing stations, in hallways and in other outpatient areas. It’s not a good look and to outsiders conveys a lack of interest in patients.

Interestingly, I seldom saw physicians with the cell phone affliction.  They seemed much more focused on their patients and their needs.  Perhaps a new surgical procedure can be developed for cell phone amputation. It will be painful.

Why Could I Not Get A Mountain Dew?

I have spent hours recently in four different hospitals worrying about a family member. It can be very stressful when a family member is sick enough to be in the hospital. You need to be emotionally comfortable in such situations.

My favorite hospital was NorthBay Medical Center but not for the reason you may think. The reason is that at NorthBay you can get a Mountain Dew with SUGAR! Liquid comfort— and caffeine—was readily available.

The other hospitals have decided to become food nannies and do not sell  sugared soft drinks.  I have been to their cafeterias and vending machines and all you can get is high price water and soft drinks artificially sweetened (if that is the word) with complex chemical compounds.  Research is inconclusive as to whether these chemicals are good for you or will cause your nose to fall off.

I also observed Starbucks refugees in these food nanny cafeterias loading their cups of coffee with sugar. Some sugar is better than other sugar?

What I found even more galling at the other hospitals is that they blithely sell donuts, pastries and ice cream which are full of sugar.  The food nannies are not consistent.  Or maybe they just like donuts. I had two one morning just to spite the food nannies.

Visiting and worrying about a loved one is stressful enough.  Having access denied to soft drinks with SUGAR is an insult and a micro aggression.  I am an adult fully capable of making my own decisions.

I think I am going to sue.  I need my Mountain Dew.

Hopefully the next few months on the beach will not be so stressful. I will always have a six pack of Mountain Dew—with SUGAR— close by for comfort.

 

 

Hubris

There is a place for story telling in organizations.  At NorthBay Healthcare we used stories to reinforce our culture.  Stories work best if there is substance to back them up.  Otherwise, the recipients of stories can get cynical.

I thought about stories the past week when “Haven” was grandly announced.  This is the improbable name of the nonprofit organization formed by the CEOs of Amazon, J.P. Morgan and Berkshire Hathaway. What was Haven’s name supposed to convey?

“Haven” to me sounds more like a name better suited for a church or homeless shelter but I am sure the branding experts at these three companies spent hours and many dollars to come up with it.  I could have done it for free for them.

More to the point, was this another ego stroking effort by three prominent CEOs? Was that the story?

The mission of Haven per their website is as follows:

“Our mission is to transform health care to create better outcomes and overall experience, as well as lower costs for you and your family.”

That’s their public story and they are sticking to it.  Notice as usual, the initial emphasis in the mission statement is on quality.  It is only in the last clause they stick in “lower costs” as also part of their mission.

Haven’s CEO, Dr. Atul Gawande, made it clear that the cost of health care was a driving force in creating Haven.  In a memo he said the following:

“Haven was formed by the leaders of Amazon, Berkshire Hathaway, and J.P. Morgan because they have been frustrated by the quality, service and high costs that their employees and families have experienced in the U.S. health system.”

I feel the same way about the cost of my Amazon Prime membership which keeps going up.  And don’t get me started about J. P. Morgan which holds my home mortgage. I hope every month they will lower my interest rate but alas I hope in vain.

I think I will start an organization to address this issue of the costs of super large corporations. I’ll call it “Craven”. No one will mistake that for a church.

More seriously, one can be encouraged by the fact that Dr. Gawande is involved in this latest venture by do-gooding, profit maximizing, publicity seeking CEOs. He has written several compelling books about health care quality.  He also is a very good speaker on this subject.  Whether his leadership will be sufficient to make a difference remains to be seen.

There have been no shortage of other organizations with a similar focus formed by business organizations.  Usually, after a year or two, they wither away as the sponsoring organizations lose interest or focus or change CEOs.

Management guru Peter Drucker once said hospitals were  “the most complex human organization ever devised”.

Given Drucker’s opinion, it is obvious that an internet peddler of goods, a bank which caters to the wealthy and a company which collects other companies are perfectly suitable to revolutionize healthcare including hospitals. You just have to develop an app.

Peter Drucker in his writings recognize that a service industry like healthcare is inherently more complicated than other endeavors like selling and loaning. That does not mean healthcare should be exempt from examination of its practices. That’s happening everyday in healthcare.

I don’t believe the issues of cost and quality are really amendable to a top down approach as seems to be the way organizations like Haven view things.  Even with a star as its leader, Haven seems a reach. Perhaps a better name for Haven would be “Hubris”. That may be the real story here.

 

 

 

 

 

Executed

Last week I contended that the increasing utilization of hospital emergency services is a good thing.   Before anyone else could do it, I then excommunicated myself from the punditry religion which as a matter of dogma feels otherwise.

This week I will expose myself to possible capital punishment by committing a felonious act against the common view held by a motley crew of policy makers, “leaders” of large healthcare delivery organizations and consultants always on the lookout for a new opportunity to offer their services. Where is Joan of Arc when you need her?

So what heinous act am I committing?  It has to do with the Affordable Care Act (aka “ACA” or “Obamacare”). The ACA was not just a vehicle for mandating insurance coverage.  There were other goodies in its 2000 plus pages including the hospital “Value Based Purchasing Program” or VBP which would be applied to the Medicare program.

VBP also sometimes goes by the more accurate name of “Pay For Performance”.  You don’t see that term used as often as it seems crass to policymakers and politicians, neither of whom wants the public to know what they really are up to.

Under VBP, the Medicare people issued an ever-changing set of goals which if hospitals met them, they would receive a bonus in Medicare reimbursement.  Not meeting the goals would result in a decrease in reimbursement.  The goals would change from process oriented (i.e., did you do the right thing for the patient) to outcome oriented (i.e., how did the patient do) and back again.  With the constant changes in goals and the bureaucracy necessary to oversee VBP, things got complicated.

The VBP was embraced by leaders of large healthcare delivery organizations who always are seeking virtue and a possible cover story about their virtuous selves in “Modern Healthcare” magazine. Here is a way to improve quality, they croaked

Insurance companies also eyed pay for performance as perhaps being adaptable for their  contracts with hospitals.  The insurance companies were not interested in virtue or quality; they were interested in a better bottom line.  VBP gave them good cover.

Your eyes will quickly get crossed if I go into too much more detail.  We are now eight years into VBP and the results are at best mixed.  Studies disagree as to whether VBP has resulted in an improvement in patient care however it is defined.  VBP or pay for performance so far is a disappointment to policymakers but a continued boon to Medicare bureaucrats.

It also is a bit of paradox.  VBP awards more money to hospitals for doing what they are supposed to do, at least according to the goals issued by Medicare.  You get less money if you don’t meet the mark.

Why should you get more money than standard Medicare reimbursement for simply meeting, not exceeding, a standard of care?

There can be very good reasons, particularly for outcome related goals, that a hospital misses a goal.  It may not have enough patients in a given year subject to the goal to adequately measure performance.  It may serve a demographic segment which is less compliant.  A strong case can be made that these hospitals should receive MORE not less reimbursement in light of their circumstances.

At its core,  VBP or pay for performance is not about quality.  It is yet another cost control mechanism.  That is a hard truth that the virtue seekers heading large healthcare systems refuse to acknowledge.

Modern Healthcare recently had this quote in an article about alternatives to VBP that might be more effective:

“We pay more for our healthcare in the U.S. because we pay our providers more,” said Christopher Koller, president of the Milbank Memorial Fund and a former Rhode Island health insurance commissioner. “We have to put the whole system on a diet and let them figure out how to live with it.”

Aside from being Captain Obvious, this guy deserves credit for being honest about the actual intent of the VBP. He has no future in politics.

There you have it.  It’s about money and the solution is to reduce reimbursement. Medicare already pays what it wants for care.  Just ratchet it down further.  End the pretense about it being about quality.  Watch more hospitals, particularly in rural areas, go out of business.

I cannot wait to see how this works under M4A (Medicare For All).

Excuse me as I have a date with the firing squad.