Electronic Medical Records and the Medicare Sustainable Growth Rate

[Note: This afternoon, I notified Congress we (the Administration) support a requirement that doctors adopt e-prescribing and electronic medical records in order to get the full Sustainable Growth Rate update (HHS statement). I've written more below about why I think this is important.]

When I was a boy, there was a Tennessee Ernie Ford ballad titled, “Sixteen Tons.” It told the story of a coal miner who bought all of life’s necessities from the company-owned store on credit. 

Apparently, the miner in the song spent more at the company store than he earned, but the company store just kept running his tab up higher and higher, making it more and more difficult for him to ever pay it back. It created a hopelessness reflected in the song.

The chorus of the song was:

"You load sixteen tons, and what do you get;
Another day older and deeper in debt.
Saint Peter don’t you call me cause I can’t go;
I owe my soul to the company store."

This week, the Congress will begin working on the Medicare Sustainable Growth Rate (SGR) or what people call the “doc fix.”  The doc fix is a ritual crisis brought on annually by a terrible system Congress put into place in 1997 to manage the amount Medicare pays doctors for various procedures.   

Here’s how it works: Each year, the Secretary of Health and Human Services is required by law to establish a target for the rate of overall spending on Medicare Part B. (Think of that as the total of all the miners’ wages)

If, collectively, doctors bill Medicare for more than the target, the Secretary of HHS is then required by law to make it up on future updates. (The mining company reduces the future wages to pay off past debts at the company store)

However, the doctors just keep billing more and more procedures to Medicare and spend far more than the target.

This has gone on now for more than 10 years and Medicare has now paid so much more than the target that the formula in the law dictates that doctors receive negative updates, cutting the amount they get paid for each procedure. This year, the SGR hole is so deep the law requires HHS to reduce the future rates we pay doctors by 10%.

So, each year Congress steps in and overrides the system by instructing Medicare not to cut the reimbursement rates.  Consequently, the amount that doctors get paid at least stays the same or is a little more.

Here’s an important point.  When Congress overrides the law, it doesn’t fix the system or pay off the deficit which is now so large it would require nearly $200 billion to pay off the backlog. 

This is a lousy system and it hasn’t reduced Medicare costs.  The total expenditures just keep going up.  Why? When rates per procedure don’t go up, doctors have simply done more procedures.

Moving toward a long term solution

Long term, the solution to this problem is to change the way we pay doctors.  At least some portion of their payment should be based on how successful they are in keeping people healthy, rather that just the volume of procedures they perform.  Sometimes that is called pay for performance or value-based health care. Whatever you call it, we cannot make progress unless doctors adopt a system of electronic medical records. Such a system depends on being able to gather quality data electronically.

Electronic medical records are widely accepted as providing significant long term efficiencies. The technology is maturing but doctors have not adopted them in sufficient numbers to create critical mass. 

Doctors want Congress, in the next couple of weeks, to once again override the Sustainable Growth Rate law.  It will cost taxpayers at least $4 billion. This year it’s a 10% reduction they will be overriding.  Next year it will be 15%.  We just dig a bigger and bigger hole. We need to begin the process of moving toward a longer-term solution.

It is the position of the Administration that any new bill overriding the SGR law should require physicians to implement health information technology that meets department standards for interoperability in order to be eligible for higher payments from Medicare. 

The benefits of utilizing interoperable health information technology for keeping electronic health records, prescribing drugs electronically and other purposes are clear.  This technology will produce a higher quality of care, while reducing medical costs and errors, which affected an estimated 1.5 million Americans last year through prescription drug errors. 

Such a requirement would accelerate adoption of this technology considerably, and help to drive improvements in health care quality as well as reductions in medical costs and errors.  I’m confident that many members of Congress are of a like mind on this issue and I look forward to discussing it with them in the next few days.   

Comments

VistA, VistA, VistA.

The US government/we the people already own an excellent EHR - the VA's VistA system. It is fast, simple to use, incredibly stable and a large portion of the work needed to make it viable in private practice is already done. Two organizations have taken it, "de-veteranized" it and gotten it CCHIT certified. With a small fraction of that cost, the system could be fully upgraded and modified to meet all of the needs of the commercial market-place and fully implement the quality measures and disease registries necessary to adopt pay for performance and improve the quality and lower the cost of healthcare.

This annual ritual is accompanied by an annual denial of responsibility. A bill like that would push physicians into the willy-nilly purchase of EHRs that aren't efficient or effective yet, just to have one to satisfy the requirement. This will cause a crisis of confidence in EHRs and all things technical with physicians. It is well past time for the government to step up and provide physicians with a basic system for free. If they like it, they can upgrade to more bells, whistles and functionality. If they don't like it, HHS will at least get the data they need to make intelligent decisions for the funding of Medicare Part B.

I implore you to contact the VSA to get more and deeper information about what VistA can do.

Posted by: Chris Farley | December 03, 2007 at 07:31 PM

Sec. Leavitt's idea appears very appealing on face value. But his contention is neither proven nor disproven. After having utilized Electronic Records for more than 5 years (2 of those using CCHIT-certified EMR) and having helped thousands of patients become educated in self-management and potentially having prevented hundreds of Emergency Room visits over the past 5+ years (can be proven via surveys), our practice has yet to receive a single penny for such efforts, either from Medicare or Private payers.

It is very easy for the Sec of HHS to say that Electronic records are the answer to rising Medicare costs. It is very short-sighted to ignore the reality that the numbers of the Medicare-eligible are increasing every month. Besides, with increased litigiousness of society, has the HHS conducted an objective study of what percentage of procedures physicians carry out are just to protect themselves against frivilous law suits?

While agreeing that the current formula is an utter failure, I would like to point out that Physicians are now working at 2005 reimbursement levels (far from keeping pace with inflation). The moral of this horror story is that if professionals are paid their legitimate dues, they will not abuse the system. It is useful to remember that neither the gas nor electricity prices; employee salaries nor office rent; neither liability premiums nor cost of EMRs have stayed at 2005 levels - unlike Medicare payments under this convoluted SGR formula. I have yet to see any effort by Medicare or any other paye to actually interact with practices who have had extensive experience with EMRs to identify real world solutions to real world problems. Until that happens, it will be unreasonable for Mr. Leavitt to expect physician practices to voluntarily adopt Electronic records. So if HHS would like to push this idea, let there be a level playing field and objectivity in assessment of its impact.

Posted by: A Cavale | December 03, 2007 at 10:17 PM

For different reasons, the patients perspective, I agree that extensive electronic databases are a really, really, bad idea. As far as holding physicians accountable for the successes or failures of their patients...another bad idea. They can prescribe the right treatment but cannot enforce compliance.

There seems to be a recurring theme that technology holds all the answers to every problem in society. Technology is a tool, not a god. It would behoove us to remember that fact.

I agree with the comment above. Physicians and other health care workers are struggling enough as it is, adding yet another task takes away from hands on, heart to heart, patient care.

Posted by: standingfirm | December 04, 2007 at 01:29 PM

With all due respect, the post above ignores how the way Medicare updates the RBRVS system has distorted its reimbursement system by grossly inflating what it pays for procedures.

The RBRVS system was initially meant to be a rational, transparent way to reimburse physicians in proportion to the efforts and resources they consumed in providing particular services, and to reduce the traditional reimbursement imbalance that favored procedures over primary care and cognitive services.

However, since instituting RBRVS, Medicare apparently chooses to take all its advice about updating the system from the shadowy RBRVS Update Committee (RUC), nominally a private advocacy group run by the AMA. The RUC is dominated by procedural subspecialists, and operates so secretly that even the identity of its members is not public. Its updates have managed to worsen the reimbursement balance favoring procedures over primary care and cognitive services.

See our blog posts on Health Care Renewal (http://hcrenewal.blogspot.com) on this subject, and the references below about the machinations of the RUC.

http://hcrenewal.blogspot.com/2007/11/well-deserved-rant-about-ruc.html
http://hcrenewal.blogspot.com/2007/05/more-on-disparities-between.html
http://hcrenewal.blogspot.com/2007/03/on-disparities-between-reimbursement-of.html

The relevant journal references are:
1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306.
(http://www.annals.org/cgi/content/full/146/4/301)
2. Maxwell S, Zukcerman S, Berenson RA. Use of physicians' services under Medicare's resource-based payment system. N Engl J Med 2007; 356: 1853-1861.
(http://content.nejm.org/cgi/content/full/356/18/1853)
3. Newhouse JP. Medicare spending on physicians - no easy fix in sight. N Engl J Med 2007; 356: 1883-1884.
(http://content.nejm.org/cgi/content/full/356/18/1883)
4. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310.
(http://jama.ama-assn.org/cgi/content/short/298/19/2308)

Were Medicare to have a rational, transparent method to set reimbursement that was not deliberately tilted to favor procedures, we would be well on our way to controlling costs and improving access.

Posted by: Roy M. Poses MD | December 04, 2007 at 04:41 PM

I am not sure forcing physicians to use electronic medical records and e prescribing will decrease errors and improve medical care as much as has been stated. Our practice has been using a CCHIT certified EMR for 5 years and Surescripts e prescribing for 3 years. Handwriting is no longer an issue in mistakes but mistakes can just as easily be made because of the technology. Using touch screens and scrolling create significant avenues for errors and the programs themselves have some basic flaws that need to be addressed.

I also would like to know if there is anyone in the decision making chain pushing the electronic agenda actually seeing patients full time.There are definite improvements in our practice but there are also some major drawbacks in using technology and these are ignored in public comments.

It is interesting that there is never much mentioned when discussing the cost benefit analysis regarding small practices. Typically we read about how large systems such as Henry Ford will see cost savings but that does not translate to small private groups who have spent hundreds of thousands of dollars of their own.It is very disconcerting to read headlines of a pending 10% pay cut when we have invested and are trying to do the right thing for our patients.

Finally, I find it very difficult to find an avenue to express these concerns - I have written emails to various branches of government in the past without response and it seems that the only individuals being heard are lobbyists for their own specific agenda. I would suggest that the government survey individuals and medical practices who have actually invested their own time and money in EMR's and E prescribing to help understand the pro's and con's better before mandates are passed.

Posted by: Michael A Filak MD | December 04, 2007 at 07:25 PM

Sec Leavitt,

I applaud that you recognize that the SGR is indeed a fatally flawed mechanism for determining physician compensation. However, given that you admit fully and candidly that the formula for determining the value of physician services has failed, you then propose that, in order to obtain the deserved compensation for the services rendered, physicians must jump through expensive hoops in adopting EMRs? It makes no sense, and it smells of extortion, to piggyback onerous, unproven, and unpopular new regulations onto fixing the SGR.

To deal with this crisis fairly, the two items should be de-linked. Congress screwed up with the SGR, so Congress should fix it. If, as a matter of public policy, the administration thinks that EMRs or P4P or whatever "initiative of the week" should be made law, then let's have a open and unrestricted debate on the issue on its own merits.

But don't insult us by making fair payment for our services conditioned upon physicians rolling over and accepting irrelevant restrictions and regulations. It's an abuse of power, and not the way good policy is developed.

Posted by: shadowfax | December 05, 2007 at 02:22 AM

One problem with EMRs.

Unless you make them unified and super regional (multi state) at the least, possibly even national, the only one possibly benefiting is the doc that owns that EMR.

For example. I am a hospitalist. I admit a primary care doctor's patient to our hospital. I see patients in consultation for specialists. Lets assume the primary care doctor has an EMR for their office. On it is a data base of labs, xray reports,

Now lets assume the patients cardiologist has an EMR that makes digital all the cardiac records for that docs office.

Now lets assume the same for the pulmonologist

The rheumatologist...
The endocrinologist...

Lets even assume the hospital has one.

So what. Big deal.

Having an EMR at my hospital makes it easier for me to see what studies have been performed at MY HOSPITAL.

It has no effect on my ability to see what studies/imaging/labs/procedures have been performed at

the cardiologist..
the pulmonologist..
the endocrinologist..
the rheumatologist..
the competeing hospital down the street...
the outpatient radiology center where two MRI's were done last week.

This is the reality of the situation. I am practicing it every day.

Let me tell you how things are now.

Many of my primary care doc referrals have EMR.s Many specialists have EMR's. The competeing hospitals have EMR's.

Unless the patient tells me, unless I remember to ask, there is no way for me to know who has done what and when it was done, inspite of everyone having an EMR.

The systems do not talk to each other.

So I have to remember to ask for records to be faxed, the ER doc has to remember to ask for records to be faxed, the cardiologist has to remember to get records faxed. The pulmonologist has to remember...and on and on. The patient has to remember and understand what I'm asking for (which is often times not the case).

Some hospitals take hours and hours to fax records. Some never make it. Some hospitals (rural) do not have anyone that can access records for hours, sometimes days (weekends). Primary care docs offices are not open on weekends. I can't get records from a PCP, inspite of them having an EMR.

If you have ever followed a doctor around for an entire week (I suspect you haven't) you will understand why doctors do not have time to wait for anything. There are days where 12 hours are spent without a break. No food. Too busy. I don't have time to stop and wait for records to get here. If the information is not immediately available during the assessment, it will get repeated.

The hurried nature of physicians every where is courtesy of the RVU/SGR fiasco. The system that encourages volume and penalizes primary care by underfunding their services in comparison to specialty reimbursement and makes a job in primary care about as appealing as being a soldier in Iraq.

Chest xrays, sometimes performed on the same day. Repeat labs, Repeat MRI's Repeat heart caths.

But it won't get better by having every single physician pony up for their own EMR, as you propose. In my community, that is the current system.

Only when all physicians have access to all patient information, courtesy of a much needed super speed medical internet, only then will electronic medical records sway the tide of unnecessary testing.

And that is only part of the story.

You have to fund primary care. Make that a priority. With less than 15% of medical students choosing primary care now, you have a system full of specialists, who love to do procedures, because that's what pays well in the current system.

The viscious cycle of fragmented care will only get worse and the small portion of waste related to repeat testing will like like a mole hill within a mountain range of expanding costs.

A well organized paper chart is as effective as an EMR, for a single site office. A site specific visit. But medical care is highly fragmented and

Unfortunately in the disconjugated system and reimbursment model, every office owns their own records, no offices talk to each other and communicating with each other costs them money.

When I talk to primary care docs offices, often times I feel like I am interrupting their busy office (which I am), which your policies have created.

When you underfund a clinic visit, the value of that visit becomes a detriment to care. "How do I get this patient out as quick as possible to get the next one in". Waiting rooms 5,6,7 people backed up.

Not "What can I do to make the patient better and save money at the same time". When you devalue time of a primary care doc, you get what you pay for. More referrals to specialists who by nature order more testing/images/procedures. Why? Because specialists make money on procedures. They do not make money on cogitating and thats a product of the system RVU/SGR.

If you want to save the system money, you must bring value back to primary care and fund it appropriately, whether within the confines of the Medicare system, or separately through a funded Primary Care Initiative.

Posted by: The Happy Hospitalist | December 05, 2007 at 11:42 AM

The tie in of IT to a fee schedule fix is admirable, but too late for this year. A 10.1% fee reduction, higher for some,even primary care specialties, is a major problem, when your practice is 25% Medicare. Please remember many PPO's and HMO's peg their reimbursement to Medicare RBRVS.
A temporary fix, again,is called for now, with serious dialogue for this year focused on a permanent fee schedule fix and a tie in of not only IT, but also, PQRI.

Posted by: avram kaplan | December 05, 2007 at 01:11 PM

Many patients (especially elderly i.e. medicare) still get their primary care from a small private office.

I don't see how you can think forcing such practices to make a $50,000+ zero-return investment (while at the same time reducing reimbursement rates) will not drive small practices out of business altogether.

Posted by: happyman | December 05, 2007 at 08:54 PM

I am disturbed by Sec. Leavitt's comments that seem out of touch with the reality that practicing primary care physicians face. Mandating an EMR at the same time that physicians are experiencing decreasing reimbursements from private payers and Medicare is not the solution. Inferring that physicians perform more procedures to make up for lost income is also not helpful. The reality is that primary care physicians are working longer and harder than ever, making less money and struggling everyday to keep their door open. In the meantime, more and more folks are added to Medicare each day. In the short term, you must not allow the 10% cut to go through. Forward looking solutions are required, not last minute mandating of EMRs.

Posted by: Jenny | December 05, 2007 at 09:47 PM

You talk about finding long-term solutions to reduce Medicare expenses, but my experience is that CMS is not interested in improving the system, or is incapable of seeing an improvement opportunity, even when it comes up and bites them on the butt. I have given up after talking to a long chain of CMS personnel about a simple system that could save Medicare up to $355 BILLION over the next 20 years. This could fund all 2008 Medicare beneficiaries for 9 months. I even offered to pay for a CMS demonstration project to prove the concept, but was never taken up on the offer. See http://haleygroup.com/

If you are looking for additional ways to save money, a simple way is to pay healthcare providers in a standard 30 day payment cycle, instead of the present 14 day cycle, and invest the payment funds in interest bearing accounts for the remaining 16 days.

What is so holy about the healthcare special interest group that you pay them in 14 days? The government does not pay all their other bills in 14 days! You are going broke, but you pay your healthcare claims quicker than I pay my water bill. If a 14 day payment cycle is so great, let's extend it to our seniors on social security, rather than make them wait 30 days to get their checks.

If I sound angry, it is because I am tired of the incompetency of our government. My mother only had an eighth grade education, but she told me to pay my bills near when they are due. Why can't you do the same? What did your mother teach you about paying bills? On April 23, 2007 the Boards of Trustees (of which you are one) for Medicare reported to Congress that the Hospital Insurance (HI) trust fund is expected to be exhausted by 2019 (in 12 years). Those turning 50 now will be 62 when the money runs out for everyone. The HI trust fund provides the greatest source of funding to hospitals, nursing homes, home health agencies, and hospices. When are you going to wake up and manage Medicare for the good of the taxpayer, instead of special interest groups?

Posted by: David A. Haley | December 06, 2007 at 04:34 PM

Your comments make it clear that you are clueless about the behaviors and incentives of physicians. Instead of listening to policy wonks and research groups, spend one day in a primary care doctors office and listen to him for an hour after the office closes. Just pick a random doctor, you'll be surprised at what he/she tells you.

Posted by: none | December 06, 2007 at 10:21 PM

HHS and the U.S. Congress should be embarrassed and ashamed to Not cover American Citizens for Medically Necessary Oral and Dental Health Care!! Especially Congress,- they should cover most Dental for Citizens living in Poverty, the Disabled, and Elderly. The last 3 Surgeon Generals agreed that this area is Very Important for over-all health, and the most ignored! This can be a matter of life, death, dignity, and Disease Prevention for many! How sad we waste so many $Billions and ignore the immense suffering, Pain, and inability to chew, eat, talk, swallow, digest, assimilate,- even laugh! Yet, we are forced to endure the Pain and Humiliation! Congress and America should be Greatly Ashamed for this unbelievable torture and mistreatment of the poor Citizens.

Posted by: Joe Ward | December 07, 2007 at 11:53 AM

ShadowFax - I really like your post. Here Phil Fasano CIO of Kaiser Permanente out lines making health records accessible online to its 9 millions members, 17,000 physicians using 6,500 IT workers and 170,000 employees.

Interview published Dec 4th, 2007
Kobie :: Kaiser Permanente opens up healthcare via the web
In a CIO Vision Series interview, Phil Fasano CIO of Kaiser Permanente talks to ZDNet's editor-in-chief Dan Farber about transforming the United States' ailing health care system by making information more accessible online to its 9 millions members

They spend 3 billion on IT and "make" 37 billion as a non profit.

Lab results, information and messages for physicians are all handled via the web.

As avram kaplan pointed out "many patients still use small practice" I prefer a small practice. Your post is spot on!

Web Site for 12 min video:
http://video.zdnet.com/CIOSess...
CIO means Chief Information Officer who sits with CFO, CEO and COO just under the corporate president.

NOTE: not all people have high speed internet or computers at home or work.

During a pandemic or disaster the hospital may keep their system running that does not mean the local ISP will.

Food & facts for thought.

Kobie
"its never to late to start doing the right thing"

Posted by: Kobie | December 09, 2007 at 02:54 PM

Sec. Leavitt, The systems in place are NOT interoperable. We have invested $100,000 for our group to put a system in place. You are being unfair to doctors to write this requirement into a fix. This administration is sticking by its friends in insurance to the detriment of the elderly, doctors, and the survival of Medicare. It is going to cost the party dearly down ticket. Bruce Malone M.D.

Posted by: Bruce Malone, MD | December 10, 2007 at 09:11 AM

Sec. Leavitt:

Another December, another phony crisis. Frankly, Medicare should pay what it deems fit for medical services and allow us to balance bill for what we deem fit. The marketplace will sort this out very nicely.

Posted by: Harry Neuwirth, MD | December 11, 2007 at 12:48 PM

It is wrong to tie the physician pay fix to having an EHR. You don't understand how angry physicians are with this manipulation of our payments. If that goes through, I'm opting out of Medicare altogether once and for all. You should rethink your advocacy and begin to ignore the HIMSS lobbyists in Washington, DC.

Posted by: Alberto Borges, MD | December 12, 2007 at 07:07 AM

With all due respect Mr. secretary one only has to look as far as the annual reports of the major insurance companies participating in the Medicare Advantage program to find the money to correct the deficit. Let us consider legislating them to provide services to all Medicare recipients below their costs. Or perhaps reduce their payments by 10% a year until the system becomes cash positive, or both. I refer you to a recent AMA News to see that the Medicare business is nearly three times a profitable as their private commercial accounts.

Posted by: Samuel A.Harmon, M.D.,FACS | December 12, 2007 at 09:54 PM

I am a FP physician in Idaho.

The commenters here have surprisingly more insight into this issue than Secretary Leavitt does. I hope he reads the comments on his own blogs.

Our practice, consisting of five providers, is the largest primary care practice in Southeast Idaho. We have always had a policy of unlimited Medicare/Medicaid enrollment, but that is all about to change.

The last straw will be this year's payment "fix," I'm afraid.

Interestingly, our academy (the AAFP) is now all but openly advocating us all to abandon Medicare altogether, or opt out, or "temporarily" stop seeing our Medicare patients.

When all the PCPs across the nation unite and refuse to accept Medicare, I feel sorry for the nation's seniors. For the first time, I can realistically see that happening some time in the near future.

I agree that free market forces are the only way to control spiraling costs. Mostly, we need true, free market competition in the "procedures and tests" markets, and in pharmaceuticals. Allow capitalism to work like it is supposed to, and healthcare costs would reduce by 50% practically overnight. This could be done by making a "third-party payer" illegal. Simple as that. I bill a patient for services provided, and the patient is responsible. Patients, in turn, deal with their own insurances. Such an approach would direct accountability in the proper directions, and expose those of us providing healthcare to free market forces.

If we're going to continue to call healthcare in America an "industry," let's allow that industry to work like American industry is supposed to work, with capitalism itself controlling costs AND quality.

If we're not going to treat it as an industry, let's stop calling it that, and get the move to Hillarycare overwith already.

In which case I will be looking for a job in another sector. Anyone out there interested in hiring an otherwise competent, well-educated, experienced, compassionate physician who no longer has the stomach for the system?

Posted by: Clay | December 20, 2007 at 11:42 PM

On the subject of e-prescribing:

I would suggest that Senator Kerry, Secretary Leavitt and others so concerned that physicians adopt e-prescribing before they can expect to be paid get off their backsides and pass more modern e-prescribing legislation first.

Like, for example, fix the archaic laws that make it illegal to electronically prescribe any controlled substance, period.

Set the example, gentlemen. Provide the infrastructure instead of criticizing us for "dragging our feet."

If e-prescribing and EHRs were the panacaea our government are making them out to be, they would both have been universally adopted by now. Physicians, contrary to popular belief these days, are not stupid people.

Politicians aren't, either. They know a good smokescreen when they see one.

Posted by: Clay | December 20, 2007 at 11:48 PM

Just a couple of comments. As President Reagan used to note, Government is not the solution; Government is the problem. And this is doubly true in US medicine. As Nobel prize-winning economist Milton Friedman noted, "We have a socialist-communist system of distributing medical care. Instead of letting people hire their own physicians and pay them, no one pays his or her own medical bills. Instead there's a 3rd party system. It is a communist system and it has a communist result.... We've seen costs skyrocket. Nobody is happy."

There is a lot more along the same line, but you get the picture.

If we want to control costs, then stop giving free care. There would be long lines at McDonalds if the hamburgers were free and we see the same thing in medicine.

Interestingly, the medicare age group is the demographic group with the most disposable income - that is they are the richest. They should be paying their own way. Instead, we tax 20 year old families to pay for unnecessary MRI's for multi-millionaires. I can't imagine a worse system.

We have long been socialized. The government sets the rates via Medicare. According to the racketeering law passed to punish the mafia, interpreted by corrupt judges, and enforced selectively on physicians who, by law, cannot assemble and organize even though such activity is "guaranteed" by the 1st amendment of the US Constitution, if I charge a patient or insurance a different amount than the government tells me to charge them, I am guilty of racketeering and get jail time or a fine or both. And Secretary Leavitt expects a government that came up with this scheme to add a few more requirements like computerized records and it will all get better? Please, don't insult our intelligence.

If the government wants to fix the medicare payment problem, it needs to simply allow balance billing. Instant fix. The doctor's can make up for losses caused by inflation and government-imposed regulations (many billions of dollars). The patient, who remember are the richest segment of society, will now be responsible for some of their bill. They will this not demand as many visits with specialists, MRI's and various other expensive testing since they will have to foot part of the bill. Utilization will go down, payment will go up and the medicine will be better off.

And lastly, regarding computers, there is very little evidence that computers help. They cost a lot. 25% of the groups that have used them have either turned them off or gone back to paper charts. The government system that is promoted by some on this blog led to a 25% drop in seeing patients. In other words, doctors who could see 4 patients and hour could only see 3 patients. And you think this is helpful or will save money? Again, please don't insult our intelligence.

Computerized ordering and e-prescribing actually increased the error rate in the majority of studies.

Anyway, I fear your mind is made up. So I'll include a few references for proof. I personally intend to see less Medicare patients, fire some of the ones I have, send more to the ER where they can really run up a bill, and plan on retiring early. And if any of you don't like it, look in the mirror because you elected the idiots that did it and surrendered you medical care to the government.

"EMR's don't guarantee quality care" American Medical News August 13,2007

"Pay-for-Performance pays off for Medicare, but not for doctors involved" American Medical News, August 6, 2007 (now we see the real reason for these proposals - screw the doctors and pay them less)

"EMR's DON'T guarantee quality" Annals of Family medicine May/June 2007

"Pay for performance, Quality of Care etc." JAMA 297:2373 "pay-for-performance was NOT associated with a significant incremental improvement in quality or outcomes"

"Doctors see fewer patient, longer days" Ogden Standard Examiner, Tom Phillpott (Article on the Defense Departments computerized records - they stink."

"Expected and Unanticipated Consequences of the Quality and Infromation Technology Revolutions" JAMA 295:2781
"A recent study reported a 3-fold increase in mortality among critically ill children after the installation of a popular commercial computer system" That is, computerized medical sytems killed 3 times more children than non-computerized systems. If there is a God, you will spend a lot of time burning in hell for what you are trying to do. This article has 29 more references in it. Read them. I have. Computerized medical records are dangerous, expensive and useless except for big government and big business getting a better handle on how to cheat doctors more easily.

"Role of computerized physician order entry systems in facilitating medication errors" In other words, computers caused many more errors than they helped. Read this article if you read nothing else: It has 60 references, both pro and con including the ridiculously false Institute of Medicine report on medical errors that started much of the push for this.

Sincerely, MEB

Posted by: Mark E. Baxter, M.D. | December 21, 2007 at 10:56 AM

The purpose of HIPAA was to improve the efficiency and effectiveness of the healthcare system through the development of established health data standards and requirements for the transmission and storage of electronic health information. Currently, however, most EMR and medical transcription companies dont comply with these standards. We need to create a licencing mechanism to ensure that companies are indeed HIPAA compliant, similar to how manufacturers get ISO-9001 certified. Otherwise, the act just turns into a marketing tag line for companies.

Posted by: Neurology Guy | December 28, 2007 at 06:12 PM

I think the only way to go is a national database, with webmethods tie in's so that private Application development can use the data. One Database but several different apps. Not sure that a Network of Networks will work in bringing together of data for your purposes.

Posted by: Alan | January 02, 2008 at 10:51 AM

The future of medical records is electronic, there is no point in stalling it to accommodate the usual and expected resistance to change. In fact since we do realize that we cannot escape that change, it behooves us to work hard now to ensure the reliability, ease and security of such system.

Posted by: | January 04, 2008 at 04:18 PM

I humbly offer a free solution.

Let our nation's healthcare providers, across all sectors, walk before they run.

EMRs are handy, but no better than a paper system if we are still printing and faxing them to all the various providers who need to cross communicate these to. Healthcare must share information across all the spectrums. We must apply lean thinking to the communication process to give America healthcare a better return.

The universal communicator in healthcare is the fax machine. It is costing us a fortune in paper, time and labor.

Wenohealthcare.com has free & HIPAA secure portal to replace the fax and allow every healthcare provider in America a free Weno Mail acct., to cross communicate on, and a free Weno Site to advertise online with. Further, providers without EMRS can send basic E signed physician orders on it. Providers with EMRs can use the systems to download and attach records in Weno Mail instead of the printing and faxing, basically wasting this wonderful technology.

If the government supported this free service; then imagine the savings to the healthcare industry.

A single hospital can be responsble for 80,000 outgoing faxes per month. That's also 80,00 incoming faxes to all they are faxing too. This is one hospital.

Our healthcare crisis is communications. Free and secure and EASY is accomplished on Wenohealthcare.com.

EMR vendors can compete fairly because we have taken the diversification factor away; and leveled the playing field. Let the providers decide which ones they want. THE COMMUNICATION IS THE PRIMARY PURPOSE OF THESE SYSTEMS. We forget....all these systems are so sophisticated, but until Weno's free healthcare communication portal, there was not a way to securely mail all other providers. Just a bunch of segregated portals for large corporations.

All providers get a Weno membership free; and other valuable benefits, so there adds no controversial costs to participate.

The government gets to usher in EMRs slowly but surely....addressing communication and not bells and whistles.

I would like to speak with the Secretary about this solution that is already available. Please let me know how to go about this.

www.wenohealthcare.com

Posted by: Tina Johnson, CEO Weno Healthcare Inc. | January 11, 2008 at 06:51 PM

I have read many of the above comments but, coming from the point of view of a patient, my great concern is privacy. Secretary Leavitt wants patients' medical records and health histories online. From what I have seen in the news regarding lost discs and stolen computer records, I am not at all comfortable with this plan. Proper security for patients' privacy is not in place. I can envision employers, the press, and other unauthorized
persons finding ways to access this private information.
In Des Moines IA at the end of January, Secretary Leavitt said that consumers need to have access to their record. I agree. However, this information should not be online and, potentially, available to everyone.

Posted by: Robert | February 11, 2008 at 12:55 PM

The amount of expenditure increases because of an increase in the number of medicare recipients and their demands. Physicians are not assembly lines and cannot just "increase procedures" to compensate for a lack of reimbursiement to match the marked increase in overhead. Quality cannot be mandated without adequate reimbursement. Morale among physicians IS AT AN ALL TIME LOW. Unfortunately, I fear that Medicare patients will have difficulty being seen in the near future. We cannot increase productivity and offer quality. We cannot pay for EMR, etc for the benefit of the government and insurance companies. Reimbursement for medicare is at a breaking point and our deserving patients may be left with prolonged wait times and difficulty accessing care. Medicare needs to determine other means of containing costs rather than focusing on physician reimbursement. I am sure that we are the last group which should be targeted. We need to finally be treated fairly and with respect. Physicians are constantly being beaten down from every direction including the government and Medicare; no different than insurance companies or lawyors. We are the ones providing care in the middle of the night, weekends, and holidays. We are rarely appreciated; only by the sick. The tone is such that Medicare is mandating and threatening rather than respectfully negotiating.

Posted by: Mark Scheidler, MD | February 27, 2008 at 11:31 PM

Hello nice blog about the Electronic medical records and the Medicare sustainable growth rate. Electronic medical records are so important to a healthcare provider when responding to a patients needs, more accurate and accessible information is a must.

Posted by: electronic medical records | July 07, 2008 at 02:55 AM