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THURSDAY NIGHT IS HEALTH CARE CHANGE NIGHT, a weekly Daily Kos Health Care Series. We're switching the time as of this week from 8pm EDT to 9pm EDT (6pm on the left coast!).

So, what is there in the health care system that will make you mad? Oh... lots. As you might know, I just left a 5 year career in electronic medical record implementation. That means that I had my paws on all of the data that a hospital or clinic moves around during your visit - your registration info, your appointment on the schedule, your medical info, your tests, prescriptions, results... and of course... your bill. So I know an awful lot about it. Some of it's boring and mundane - but some of it will MAKE YOU MAD.

First off, about electronic medical records - some people worry about their safety and security. I don't see this as a problem. The thing you need to ask yourself isn't "are they 100% safe?" but "are they considerably safer than paper charts?" I'd say yes. Paper charts are vulnerable to snooping just as much or more than electronic charts, and on paper you don't have an audit trail of who snooped. On the computer, you do. I've seen people fired for snooping where they shouldn't.

An electronic medical record is essentially a file of everything that used to exist on paper - your history, info about each appointment, notes about you by the doctor, test results, the meds you're on, your allergies, etc. The increase in organization of the chart and the ability of doctors to view the complete chart easily is a big bonus over a paper chart. I know one doctor who went on a vacation overseas and was able to log in and answer patient's questions while out of the country.

Some people are worried about the idea of a government-owned national patient chart. We are YEARS away from that being technically feasible so it's not something I worry about now. Right now your chart is owned privately by where you get your medical care and they (mostly) don't release it without your permission. A few exceptions exist there, like if they find evidence that a child is being abused and have to report it.

And about medical billing... how does it work? Well, there are 3 different basic systems I know about.

  1. You get a service (a doctor's visit, a test, etc), the clinic bills your insurance, they pay the claim, and most of what they don't pay falls to you (i.e. if you get a cosmetic procedure that won't be covered by your insurance).
  1. "Capitation." An insurance pays a monthly amount per patient to the health care organization no matter what services were given. This gets recalibrated occasionally based on the cost of care the patients are getting.
  1. Billing by diagnosis. I believe this is what medicare does in the hospital. Each diagnosis is worth a certain amount of money, no matter how many days the patient stayed or what services were rendered. The idea is that it should probably average out - if some pneumonia patients need more care and some need less, hopefully all of the pneumonia patients' care is paid for by the amount paid for a pneumonia diagnosis times the number of sick patients.

Now, when your clinic or hospital sends the claims over to the insurance, they use a standard set of codes to describe what was done to you and what you were sick with. The procedures are all identified by CPT codes (I remember the P for Procedure) and diagnoses are all identified by ICD-9 codes (I remember D for Diagnosis). People actually go to school to become coders - experts at knowing these codes - because for the most part, the doctors sure as fuck don't know them and don't want to either. They are doctors, not coders.

Here's the kicker: The insurance companies make all kinds of rules about these codes - what they will cover and what they won't. Let's say you were sick with something, you saw your doctor, the doctor provided the care you needed, and then accidentally sent the claim to the insurance with the wrong codes? The insurance won't pay. Even though you were REALLY sick and the doctor REALLY did a good job and deserves money.

Some codes are NEVER OK. We make those unavailable for doctors to pick. An example? 250 diabetes. Or even 250.0 diabetes. Nope, the doctor needs to pick 250.00 for diabetes. So that's the one we make available. Other times a diagnosis might be perfectly OK in general but NOT in combination with the procedure that was done.

On some level, this makes sense. If you came in with a bad cough and a fever and the doctor did a chest X-ray, that's appropriate. If you came in and your toe hurt and the doctor did a chest X-ray, well... why should the insurance company pay because your doctor can't tell the difference between your chest and your toe? But sometimes this can get tricky, where a diagnosis the doctor thinks is appropriate will not get you paid for the procedure the doctor thinks you need.

So in order to make sure the right codes get picked and the wrong ones don't, hospitals and clinics have to jump through a LOT of hoops. When we say that Medicare has less overhead costs compared to private insurance, this is where some of those savings would come in.

For a software geek like me, Medicare is easy to deal with. Why? Because it's universal. There's 1 set of diagnoses that are OK for each procedure. Pick those diagnoses and you'll get paid. Pick something else and we pop up a screen that says "Hey! This won't get you paid." Then you can either change your diagnosis if there's a correct one that WILL get you paid - or you have the patient sign a waiver saying they'll pay out of pocket.

We get the data files for that from a third party and it's pretty efficient because it's the same file of data that the entire country uses. And there are a lot of patients on Medicare. It gives you GREAT bang for your buck. But what about all of the other payors and plans out there? Is a geek going to program in EVERY single diagnosis that gets reimbursed for EVERY single procedure? And even if someone DID do that... they change! Like, MONTHLY! It's impossible.

So if you're on private insurance, your doctor is basically crossing his or her fingers and hoping that the insurance will pick up the tab based on the diagnosis and the tests ordered. And for the hospitals and clinics, well... crossing fingers isn't a good strategy because they NEED to get paid. (Typically a doctor gets a professional fee for the visit or they get paid for performing a procedure and then all of the lab tests or imaging studies ordered are billed by the hospital. Sometimes the clinic charges a "facility fee" too for your visit based on the level of care given.)

So... your doctor places orders, diagnoses you, and sends you home. What happens next? Your charges go to a billing system and step one might be that they run them through something that checks them based on rules that are programmed in. For example, if we don't have the name of the doctor who you saw, that's obviously a problem that will make the claim get denied. If there's a common mistake doctors make while ordering, they might electronically fix it. Otherwise they might send it to an error queue for a human to take a look at and fix.

Now... voila! Off the claims go to the insurance. Some get paid, some get denied, and some come back with a request for more info. So the health care organization has a team of people in the billing department - often each devoted to a particular insurance company - who goes through the denials and the more info requests. They do the research, and send it back to the insurance.

I don't have my notes with the full process that takes place (it's long and complicated and I'm leaving steps out) but the basic take away I had was that health care organizations are wasting TONS of effort and money trying to get paid. It would be far more efficient if they could just work with one payor. Why? Because we'd rely on those pop-up warnings on the computer UP FRONT to let the patient and doctor know in advance if they are going to get paid or not.

All of the extra effort it takes for hospitals and clinics to get paid trickles down to us when we pay premiums and pay the costs of our care. Obviously I'm mostly referring to outpatient care because that's what I know best but I bet it applies to the hospital too.

Now... why is medical billing so complex in the first place? Because the insurance companies don't want to pay the claims. They will do ANYTHING to avoid paying the claims. So they come up with all kinds of goofy rules. Stuff like "If you get a tetanus shot, you need a diagnosis that basically equates to 'needs a tetanus shot' or else we won't reimburse that claim." Or they say that certain diagnosis can be used but not as a primary diagnosis. Or a diagnosis can be used to describe an accident where you got whatever injury you're being seen for but only if they include details about the injury.

Usually these confusing and complex coding systems make their way to doctors as forms to fill out that present them with the information in the most straightforward way and let them know what the requirements are in order to get paid. Like "If you order this test, you need to add a modifier." But on the whole, the coding systems were not made for doctors' use - they were made for billing use - and they aren't necessarily useful or straightforward for the doctors. And as a patient, do you want to pay for your doctor's time while he or she looks up codes in a book instead of caring for you? Especially if they bill hundreds of dollars an hour!!! I don't!

The digital age gives us some tools to make medical billing more efficient and more accurate, but it also allows the insurance companies to set up more freaking rules. In my opinion, we'd save a lot of money by having medicare for all. Geeks like me don't come cheap ($1500/day... and no, I didn't see most of that money) so if you are improving your billing system by streamlining it with a great electronic medical record set-up, that means paying someone like me to program all this stuff in. So now you know - when they talk about reducing overhead costs by going single payor - just what they are talking about.

Originally posted to OrangeClouds115 on Thu Mar 12, 2009 at 06:00 PM PDT.

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Comment Preferences

  •  Tips (68+ / 0-)

    The Thursday Night Weekly Health Care Series is published every Thursday. It is meant to provide a forum and encouragement for people organizing for positive health care change.

    The following upcoming diaries are (tentatively) scheduled:

    March 12: Orangeclouds115- Medical Records Reporting
    March 19: TheFatLadySings- How Obama Should Measure Health Care Success
    March 26: efgmso-topic TBA
    April 2: DrSteveB-Topic TBA
    April 9: ramara-A Passover Healthcare D'Var Torah
    April 16: dadanation-An Easter Health Care Homily
    April 23: losanjalis- topic TBA
    April 30: boatsie, Topic TBA
    May 7: nyceve, Topic TBA

    •  Is single payer the only answer? (6+ / 0-)

      Or are their other options that will effectively address our system's shortcomings?

      •  I think single payor is the best (25+ / 0-)

        for a number of reasons besides the ones here but I could live with a system where we set up Medicare for anyone who wants to buy in and then force the private companies to compete.

        •  There would have to be a very strong... (10+ / 0-)

          ...patients' bill of rights as well. Here's a shot at what such a bill of rights might look like...

          1.) Insurance companies would no longer be able to turn someone down for pre-existing conditions, or refuse to treat pre-existing conditions.

          2.) Premiums would not constitute more than 5% of a given family's net income, or 10% of after-tax receipts of a family business if self-employed. If this cannot be made to work by private or not-for-profit insurers, the family will be allowed to buy into Medicaid at the same maximum rate.

          3.) An exhaustive, evidence-based analysis of the data regarding efficacy and cost-effectiveness of treatments and medications will be done, and a list of "must-cover" treatments and medications will be made. This list will enumerate treatments and medications which cannot be vetoed by insurance company analysts. If a doctor prescribes a course of treatment, medications, or both that are on this list, he or she cannot be second-guessed. This analysis will be done by a consortium of representatives of top medical schools, and will not be allowed to be influenced by the health insurance, hospital, pharmaceutical and medical device industries.

          4.) A medical consumer will have an inalienable right to adequate pain management, particularly at end-of-life.

          5.) No treatment or medication on the "must-cover" list can be used to calculate lifetime limits on health care reimbursal.

          6.) There will be an office of the Health Care Ombudsperson created, to provide a truly neutral means to mediate any and all disputes between medical consumers and their insurers. If an adequate settlement cannot be mediated, the medical consumer will then be free to sue for relief in the court system. No private system of mediation, conciliation or arbitration will be allowed to be mandated as a condition of insurance.

          7.) Pharmaceutical and Medical Equipment manufacturers will no longer be able to market directly to patients or to doctors using promotions, commercials, advertisements or event sponsorships. A code of ethics will be drawn up for health insurance promotions, commercials, advertisements and event sponsorships, including compulsory disclosures of rates, policy limitations and other information.

          8.) A public insurance option, which will allow healthy individuals to buy in to FEHP, Veteran's Administration Tricare, Medicare and/or Medicaid, must be allowed to compete with private health insurers. Private health insurers will not be allowed to disparage, defame or degrade public options. They will have to compete on their merits and on price.

          9.) Nothing in this Bill is to be construed to prevent State governments from applying unique and novel solutions to the health care problem. States will be allowed to petition for leeway to institute pilot projects, which will be evaluated for efficacy and efficiency by the Department of Health and Human Services.

          You shall not crucify humankind upon a cross of blue. (Apologies to Bryan.)
          Dump Harry Reid. Now.

          by Pris from LA on Thu Mar 12, 2009 at 07:05:24 PM PDT

          [ Parent ]

      •  At this point, there are huge gaps and failures (16+ / 0-)

        in they safety net, at least in my state. The inconsistent medical records and IT systems OC discusses are a serious threat to the success of single payer. In my opinion, we need to address some of the IT, payment and gaps in services issues before introducing single payer, because otherwise, opponents will blame flaws that existed before its introduction on single payer.

        A big issue to address at the moment is to make sure the public option remains on the table. If it is an option, we can all choose it. In the meantime, we can begin to systematically adopt the Medicare ICD 9 Codes as OC suggests. This will get us there.

        Baucus et al are working hard to eliminate the public option. We need to be united on this one and push it through.

        "Big boss ain't so big, just tall, that's all."

        by TheFatLadySings on Thu Mar 12, 2009 at 06:18:54 PM PDT

        [ Parent ]

      •  Single payer will address ONLY coverage (6+ / 0-)

        it will not address the other serious, serious problems we have in the healthcare system that significantly increase costs.

        The whole system needs to be revamped, but it's unclear if we have the stomach for that.

        Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - WSCoffin

        by stitchmd on Thu Mar 12, 2009 at 06:29:27 PM PDT

        [ Parent ]

        •  what are those problems? nt (2+ / 0-)
          Recommended by:
          TheFatLadySings, Pris from LA
          •  myriad (13+ / 0-)

            I'll just hit one, and it's really coming home for me because I am an employed doc, looking for a new position as an employed doc, so I will owe my living to some form of healthcare system.

            The reason these systems want to employ primary care docs is not because primary care itself makes money, but because primary care generates fees and services down line. So the hospital/healthcare system that employs me is happier if I order more tests, more services, more consults, than if I actually, well, think and not order more tests. Do you see where I'm coming from?

            The vast majority of the healthcare dollar goes to hospitals and related entities, which make more money off of sick people than they do if people stay healthy. Healthy people may be better for society, but not for the "health"care system.

            When you have piecemeal, pay for the service provided healthcare, you're going to have this problem, it's a perversity of the system.

            It's only one, though.

            Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - WSCoffin

            by stitchmd on Thu Mar 12, 2009 at 06:39:44 PM PDT

            [ Parent ]

            •  So... (0+ / 0-)

              If you see a patient and he's overweight, and you do a quick A1c test on him and find a diabetic or prediabetic result, and you talk with him, find out his needs, likes, dislikes, etc., and provide nutrition and exercise counseling as the initial phase of treatment, the hospital will disapprove despite this being the preferred first line of treatment?

              Mmmmhmmm. No wonder the PTB kept hassling Dr. I. until he jumped ship right into a new practice. He provided our primary and diabetes care, and he didn't order a boatload of tests except when necessary (such as after he found my kidney disease), and sent me off on a consult to the university at my request rather than to a specialist affiliated with his hospital. It's going to take two docs to replace him, one primary care and one endo, and neither one of them is affiliated with the aforementioned hospital. Funny, that. We asked him to refer us to the best docs in the county who took our insurance, since his new practice doesn't, and are following his recommendation.

              So how would you go about fixing this? Inquiring future primary care providers want to know...

              Want to be a living kidney donor? I need one from someone with a bloodtype of B or O. Drop a note at

              by Kitsap River on Thu Mar 12, 2009 at 09:55:56 PM PDT

              [ Parent ]

          •  OMG where to start. (11+ / 0-)

            It is nearly impossible to keep medical professionals in rural low income communities, in part because of lack of a payment source, in part because they cannot support facilities.

            Behavioral health is simply not covered. It is treated as a criminal issue, with mandatory minimums for non-violent substance abuse related offenses. Increasingly mental illness is being addressed throught the penal system as well. As a result, our jail is filled with mentally ill people who have nowhere to go. They are locked in tiny cells without windows 23/7 for two or three years without appropriate treatment. We have returned to 19th century asylums.

            This forces local governments to spend heavily on enforcement while shortchanging education, community services and economic development. The result is an increase in behavioral health issues and in health issues due to improper sanitation.

            Same thing is happening in primary care. We must see people in the ER. However, because we threaten Mexican Nationals with deportation, and addicted individuals with jail, they don't seek preventive care. By the time they hit the ER they are delivering a high risk baby or have a lifethreatening and expensive to treat condition. The county must spend a great deal of money to support the ER while shortchanging primary care.

            "Big boss ain't so big, just tall, that's all."

            by TheFatLadySings on Thu Mar 12, 2009 at 06:52:09 PM PDT

            [ Parent ]

        •  But it will address two specific cost issues (12+ / 0-)

          One is overhead, both at the delivery site and in claims processing -- the former because there will be fewer different systems to navigate, as OC detailed, and the latter because there's no profit motive and no marketing costs.

          The other is risk. If you want to lower the cost of insurance, you increase the size of the risk pool, thus making all your costs more predictable. A universal, nationalized single-payer health insurance system gives you -- literally -- the largest risk pool possible.

          "The great lie of democracy, its essential paradox, is that democracy is first to be sacrificed when its security is at risk." --Ian McDonald

          by Geenius at Wrok on Thu Mar 12, 2009 at 06:37:06 PM PDT

          [ Parent ]

          •  agreed, on both points (5+ / 0-)

            for that part of it.

            Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - WSCoffin

            by stitchmd on Thu Mar 12, 2009 at 06:40:22 PM PDT

            [ Parent ]

            •  Thanks (7+ / 0-)

              I'm really surprised more people haven't picked up on the risk pool argument. I've been making it for 16 years.

              "The great lie of democracy, its essential paradox, is that democracy is first to be sacrificed when its security is at risk." --Ian McDonald

              by Geenius at Wrok on Thu Mar 12, 2009 at 06:41:16 PM PDT

              [ Parent ]

              •  cause it's erroneous. Single payer - biggest pool (3+ / 0-)

                does not by itself reduce cost (aside from eliminating the multiplicity of forms and rules).

                Big pool spreads risk but does not change it. It reduces costs for some but raises it for others.

                Unless you change what is occurring within the pool you won't change costs of giving care.

                The ones who think they will pay more are fighting. Or rather those who are self righteous pigs who love "your on your own."

                May people are will to pay some more IF it is well spent to protect all.

                Any universal care system of financing if coupled with a better primary care system will reduce costs. Single payer is probably the best one for many reasons.

                We are in a time where it is risky NOT to change. Barack Obama 7-30-08

                by samddobermann on Thu Mar 12, 2009 at 07:50:21 PM PDT

                [ Parent ]

                •  I'm not saying it reduces costs for individuals (1+ / 0-)
                  Recommended by:
                  Hens Teeth

                  Rather, it reduces the overall cost. It's cheaper to insure 300 million people in one great big pool than in a bunch of smaller pools.

                  "The great lie of democracy, its essential paradox, is that democracy is first to be sacrificed when its security is at risk." --Ian McDonald

                  by Geenius at Wrok on Thu Mar 12, 2009 at 08:25:17 PM PDT

                  [ Parent ]

                  •  It might mean that insurers would charge less - (0+ / 0-)

                    or more.

                    We, all of us in the USA including all government funds, pay about $7,000 per head per year. Pooling it doesn't make the total more or less.

                    Unless we change what the health care system was doing costs won't change. The insurance companies would be still taking a cut. Without more primary care docs and more local clinics costs won't come down. Without chaning the hospitals systems of treatments errors will still cost about 100,000 lives per year from medical errors in hospitals alone with the attendant costs of trying to fix the damage caused by the errors.

                    Without a more complete system of getting people vaccinated the costs of preventable diseases won't decrease. Without good nutrition programs costs with malnourished children won't decrease....

                    Sorry, didn't mean to go on like that.

                    Risk spread only reduces the costs from those who were covering it to those who weren't paying in.

                    It is fairer to spread the risk.

                    Look, if an insurance company sees the cost of insuring me as $10 and it (or another co) sees the cost of covering you at $50, then pooling the 2 of us means we each pay $30. Now if I can teach you to drive better (or whatever) and your individual risk goes down to $30 then, as a pool of 2 we can each pay $40.

                    Scale that up to 300 million and it will still hold.

                    The low risk individual will pay more than if he were in a small low risk pool and the high risk person would still pay less.

                    The overall cost will be less but that is because I taught you to drive better, or eat better or get a shot, or ...

                    In other words there has to be input into the system to reduce the cost, not just pooling. Input can be negative like removing a factor that adds expense.

                    If by pooling you mean "eliminate the Ins. corps" then cost goes down because of the input of eliminating the ~30% they eat.

                    We are in a time where it is risky NOT to change. Barack Obama 7-30-08

                    by samddobermann on Fri Mar 13, 2009 at 01:43:09 AM PDT

                    [ Parent ]

        •  single-payer addresses only financing (0+ / 0-)

          of healthcare, that is, how do we pay for whatever we get.  But single-payer enables all the myriad improvements to delivery that are also being discussed, and in some ways enhances the ability to implement these improvements effectively.  What really needs to happen is to split the conversatin of healthcare reform into two topics (and legislation): financing and delivery.  Single-payer will then quickly defuse any ideas about other ways of financing healthcare, especially heading down the path we appear to be going now.

    •  As someone (1+ / 0-)
      Recommended by:

      with both a legal and an IT background, I really need to be convinced about electronic records.

      It is true paper records can be stolen, but the notion that databases can be made "secure" is to some extent IT industry sales talk.

      There is always an Admin, and that admin has immense power if all the medical records are connected.  

      I don't mean to be contrary here, but I have pretty significant privacy concerns about the IT spend being proposed.

      The bitter truth of deep inequality has been disguised by an era of cheap imported goods and the anyone-can-make-it celebrity myth - Polly Toynbee

      by fladem on Fri Mar 13, 2009 at 07:13:17 AM PDT

      [ Parent ]

    •  I'd like to see a diary on HIT! (1+ / 0-)
      Recommended by:

      We've seen a lot of scare tactics by the right-wing conservatives on how this will allow the government to deny health care to uninsured Americans.  I personally think that improvement of our electronic records, and enhanced health information technology, will make diagnosis a lot easier, and perhaps raise the bar for treatment of diseases.

      "I believe in compulsory cannibalism. If people were forced to eat what they kill, there would be no more wars." - Abbie Hoffman

      by Jensequitur on Fri Mar 13, 2009 at 01:35:25 PM PDT

      [ Parent ]

  •  There is a problem with (6+ / 0-)

    electronic medical records and privacy:

    We get the data files for that from a third party

    These third parties, as it were, are not covered by HIPPA, the Health Insurance Privacy and Portability Act. Medical records can be sold for marketing and other purposes.

    NH Passed a law against data mining, which is a whole industry. Data mining companies buy information from these "third parties"  and sell it to drug companies so they can market directly to patients.

    There are loopholes in HIPPA, and they need to be fixed. Electronic medical records are the wave of the future, but policy needs to be set around them to protect people's privacy. In NH, patients technically own their medical information, but it is still not always easy to access or control.

    Does a woman's podiatrist need to know she was raped? Or was treated for chlamydia?

    •  The IT systems I am working on trying to have (8+ / 0-)

      developed for my county have firewalls built in so that different providers can only access specific information. The podiatrist would not be able to access the full record.

      The system I am most interested in allows case managers to query regarding a patient's eligibility for multiple programs such as Medicaid, Medicare, County Indigent Funds, Food Stamps, Disability, etc. The case manager can only access specific information from the record, but is also able to remotely enroll the patient's family in multiple records without forcing them to repeatedly return with all kinds of paperwork and documents.

      Meanwhile,t he doctors and nurses have access to other information.

      "Big boss ain't so big, just tall, that's all."

      by TheFatLadySings on Thu Mar 12, 2009 at 06:23:53 PM PDT

      [ Parent ]

    •  And just because you 'own' your information (10+ / 0-)

      doesn't mean you can GET it from the care givers who ducumented it.  What you don't know is there is hard to demand - especially if the provider has made a mistake.

      To move forward, we must look at the past so the same characters don't pop up again. Impeach BushCo.

      by MsGrin on Thu Mar 12, 2009 at 06:24:59 PM PDT

      [ Parent ]

    •  no, no, no (5+ / 0-)

      the data files we get from third parties are NOT patient data. That'd be a HIPAA violation as you say. I'm saying we'll get a file that says "Here are the medication formularies for all of the insurance companies" or "Here are the diagnoses for which Medicare will reimburse you for this each procedure" or "Here is every single medication available for sale in the United States."

      •  Maybe in the case you mentioned, this (3+ / 0-)

        is so. But many health care providers contract out to software companies, and those companies are not under HIPPA, so their use of information would not be a violation.

        Data mining does happen, That is how a drug company finds out Mrs. Murphy has condition y, and they directly market drug x to her for that condition.

        •  software companies ARE under HIPAA (7+ / 0-)

          anyone who comes into contact with patient data is under HIPAA. As a software geek, I've attended far too many HIPAA classes and signed too many confidentiality statements for my liking.

          •  I don't think that's the case. (1+ / 0-)
            Recommended by:
            Pris from LA

            Otherwise there would be no data mining industry, and there is.

            •  there's reporting (3+ / 0-)

              first of all, there are research studies that are done with the patient's consent. And then there's just plain old reporting, like "Find the top 10 diagnoses each doctor gives" or "Find the top 100 meds prescribed by our organization." But I don't see that used in a way to violate patient's rights really. It's typically done to improve care or for a study of some sort (again - that's usually w/ patient's consent and full participation)

              •  Well there was (4+ / 0-)

                a program studying incidences of birth defects, aka birth conditions in my state where data was collected without the knowledge or consent of the affected families. We put a stop to that, but it was going on for five years before we even found out about it.

                •  That uses records from your state bureau of (3+ / 0-)
                  Recommended by:
                  oldjohnbrown, fayea, Pris from LA

                  live statistics.

                  And it's a damned shame they stopped the study as it could have given lots of useful info such as is there an area of the state with a huge number (relatively) of cases of something which could be checked and maybe fixed? Or schools be more prepared to deal with what group of problems a few years hence. What services are needed and where?

                  By studying the incidence and clusters of spina bifida they got a good indication of what might be causing it. That narrowed the field for research and then they found it was folic acid deficiency which is now PREVENTED.

                  So, great, you worship your vaunted privacy and your big success in defending it and I'll rejoice that as least some kids are saved from lifetime crippling.

                  We are in a time where it is risky NOT to change. Barack Obama 7-30-08

                  by samddobermann on Thu Mar 12, 2009 at 08:16:20 PM PDT

                  [ Parent ]

                  •  We didn't put a stop to the study, (0+ / 0-)

                    we required that the families be notified their data would be collected unless they opted out.

                    You certainly don't know your history. Eugenics was a big thing in this country last century, and with IVF and other things, it will come up again. It is not pretty. Even our lauded IQ tests were originally developed to take "idiots" out of the general population and institutionalize them so they couldn't "breed."

                    Nobody's personal data should be collected without his/her knowledge or permission.

                    •  Hi (1+ / 0-)
                      Recommended by:

                      I work for a cancer registry. There's also a birth defects registry on campus and an agricultural health study.

                      I can't speak for the other two studies, but there has always been an exception carved into the law that allows us to collect cancer data for research without patient consent for the last 35 years. It's also in HIPAA. The logic is that cancer is a big enough problem that the need for the best possible disease surveillance justifies a pinpoint exception to the privacy laws.

                      We did send letters to patients for years, but the seven pages of legalese that HIPAA requires is so ponderous and opaque (7 pages of legalese!) that our response rate plunged to a level that made it useless.

                      I'd implore you to think before trying to shut us down (which is what would actually happen--the effort could not justify the cost relative to the plunge in data and data quality, and as it is the 2005 Congress slashed our budget 30%). There do need to be a couple of very small, very limited exceptions.

                      [F]or too many, the cruelty of our system is part of its appeal. - eightlivesleft

                      by oldjohnbrown on Fri Mar 13, 2009 at 08:30:57 AM PDT

                      [ Parent ]

                    •  Also (0+ / 0-)

                      Yes there's a bad history of eugenics. That's not what the birth defects registry have any interest in. There are what anyone would concede are painful and lethal birth defects, and it is the narrow task of the birth defects registries to survey the problem and assist in research in prevention and cures.

                      Or are you anti-abortion because some of the pioneers in providing abortion services were also caught up in the period enthusiasm for eugenics?

                      BTW, you make it sound like this was going on in secret ("before we even found out about it"). All registries receive public funding, are listed in the phone book, are known to every media outlet (they call us for statistics), and can be "discovered" simply by contacting any state's department of health.

                      Additionally, my registry responds to all civilian and media requests for surveys and statistical data free of charge.

                      [F]or too many, the cruelty of our system is part of its appeal. - eightlivesleft

                      by oldjohnbrown on Fri Mar 13, 2009 at 08:40:16 AM PDT

                      [ Parent ]

                      •  D-uh on me. (0+ / 0-)

                        I forgot to mention the main point.

                        The data they were collecting was IDENTIFIABLE data.

                        We had no objection to using de-identified data at all, even without permission.

                        That was the difference.

                        I can't believe I left that main point out.

            •  There are many ways to mine data. (0+ / 0-)

              For example, I notice that whenever I am on the web or sending emails, ads pop up with the name of my town or on the topic about which I'm writing. I have not had drugs marketed specifically to me, nor has my husband. But my doctor's office is one big billboard. Every pen, poster and notepad has a drug logo on it!

              "Big boss ain't so big, just tall, that's all."

              by TheFatLadySings on Thu Mar 12, 2009 at 07:34:03 PM PDT

              [ Parent ]

            •  They get info from credit card records and (0+ / 0-)

              look for anything pertaining to medications you are taking. Especially over the counter remedies. If you charge your copay you give them that info just as for anything you charge.

              We are in a time where it is risky NOT to change. Barack Obama 7-30-08

              by samddobermann on Thu Mar 12, 2009 at 07:58:19 PM PDT

              [ Parent ]

    •  What I am afraid about with electronic security (1+ / 0-)
      Recommended by:
      Pris from LA

      is that something will end up in my record that insurance companies can use against me.

      If we have universal care, that's not a problem. But we don't at this time so it is a big problem to me.

      Only power used to empower is everlasting. Prof. Scott Bartchy

      by ludlow on Thu Mar 12, 2009 at 08:04:32 PM PDT

      [ Parent ]

  •  Wow! Very Educational Diary. I loved it. (6+ / 0-)

    In fact, I kept thinking throughout that there's lots of money to be made here for someone expert in the ins and outs - and kept wondering how I could capitalize on it, lol!

    Anyway, great diary, it's how I always sort of imagined, but this gives it so much more context.

    The crooks are leaving have left office, unprosecuted and scot-free.

    by BentLiberal on Thu Mar 12, 2009 at 06:19:25 PM PDT

  •  Good summary of complex info (21+ / 0-)

    and that's part of the issue with these background on healthcare diaries: it's not at all simple.

    As for codes, they were established by the AMA and by Medicare for simplicity purposes.

    The third billing you talk about above, for hospital billing purposes, is a system called DRGs - for diagnostic related groups. These were established under the Reagan administration for Medicare, and that's what established ICD-9 codes, the codes for diagnoses. For example, COPD is 496. Your point about diabetes is a good one: the extent of the numbers (beyond the decimal point) has to do with specifics of the diagnosis. I don't have it off the top of my head, but there's type I (insulin dependent) and type II (non-insulin dependent) and also whether it's controlled or not. However, the endocrinologists/diabetologists use even more specific codes: diabetes I or II with renal complications, with neurologic complications, etc. etc. Higher degrees of specificity frequently lead to higher reimbursement. You get paid more, for example, for a hospitalized patient with uncontrolled diabetes than for controlled.

    You have to be able to support these diagnoses, however. For example, 401.9 is essential hypertension unspecified; 401.1 is benign hypertension. You get paid more (even in outpatient practice) for 401.1 than for 401.9; but you have to support the coding by specifically stating that the hypertension is benign.

    As for the difference between Medicare and commercial insurance, I understand your frustration as a medical IT person. As a doc, however, I have to say that Medicare is far, far more rigid about what is covered under which diagnoses than many private insurers. The need for having people to argue for tests undoubtedly adds to costs, but as a provider I've found that I can usually argue well for a test that I think is necessary with private insurers. However, arguing with Medicare is usually an exercise in frustration.

    Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - WSCoffin

    by stitchmd on Thu Mar 12, 2009 at 06:21:02 PM PDT

    •  Our state has a "public-private" partnership in (8+ / 0-)

      which private for-profit insurers manage public funds. This hasn't worked out too well especially vis-a-vis behavioral health. They have placed impossible limits on services that render them ineffective. For example, case managers cannot bill for time spent on the phone or time spent transporting terribly disabled clients to services (we don't have public transportation in our rural area). Clients are only authorized for 14 days at a time for inpatient substance abuse treatment. And claims are repeatedly rejected because of difficulties enrolling clients into the billing system. Quite a few non-profits have gone under.

      The result is that our jail is now the behavioral health treatment provider for the county.

      "Big boss ain't so big, just tall, that's all."

      by TheFatLadySings on Thu Mar 12, 2009 at 06:29:43 PM PDT

      [ Parent ]

    •  That's all very true (7+ / 0-)

      and what makes it difficult for hospitals and clinics I've worked with is when doctors don't know the codes and use a less complex diagnosis for a patient who has a more complex problem. The doctors are often told that the billing is all about the note. So they write beautiful, complex notes, but then pick a simpler code because it's easy. And I can't say I blame them. They are doctors - not coders!!! But I also know that it's not every doctor who does this. Some are very savvy with the codes and with billing. But you don't go to medical school to learn to be a biller!

  •  This is fascinating! (6+ / 0-)

    Thanks for the explanations.  I knew the general story but not any of the details.

  •  Can you tell me... (8+ / 0-)

    based on your experience, what happens when a doc orders a test for something that turns out NOT to be a problem? For instance, elevated blood glucose leads to a battery of tests for diabetes that finally ends with perfectly normal blood glucose and no explanation for the original elevated glucose. What's on the permanent record?

  •  So, you totally dismiss fraud? (1+ / 0-)
    Recommended by:
    Pris from LA

    So in order to make sure the right codes get picked and the wrong ones don't, hospitals and clinics have to jump through a LOT of hoops. When we say that Medicare has less overhead costs compared to private insurance, this is where some of those savings would come in.

    Please don't talk about "savings" if you cannot justify the inevitable fraud that goes with doing away with "hoops".

    Medicare is plagued with up to $60 Billion per year in fraud.  Less overhead..less consistency checking = more fraud.  So where's the savings if you are wasting billions in fraud because you have no checks and balances?

    So, let's expand this model that is ripe for fraud to a universal healthcare system at least ten times the size of Medicare.. yeah.. makes sense to me!

    "Those are my principles, and if you don't like them... well, I have others." - G. Marx

    by Skeptical Bastard on Thu Mar 12, 2009 at 06:34:31 PM PDT

    •  I'm not talking about fraud (5+ / 0-)

      if someone commits fraud, they should get in trouble for it. No question.

      •  But you are promoting a system that is ripe (0+ / 0-)

        for fraud.

        I'm a programmer.. a database programmer.. so I know about the types of checks and balances, and especially about the validations, that must be addressed in complex systems.

        You are proposing those validations (or hoops as you call them) be thrown away for expediency?  Clearly you have no idea what you are talking about.

        "Those are my principles, and if you don't like them... well, I have others." - G. Marx

        by Skeptical Bastard on Thu Mar 12, 2009 at 06:44:46 PM PDT

        [ Parent ]

        •  no i'm not you skeptical bastard (8+ / 0-)

          seriously you picked your name well.

          I'm saying the system of checks would be simpler if we were checking on a single payor with ONE system, vs. having to check on every single payor and plan out there.

          •  Your point is absolutely correct. (5+ / 0-)

            Every insurance company and every state agency has its own system for reimbursement. As a result, providers have to invest heavily in their billing departments while shortchanging patient care.

            Insurance is a form of administration. But it breeds another layer of administration at the provider level.

            Frankly, it would be cheaper and more effective to allow for a certain percentage of fraud. (Although in my opinion, for-profit care denial is an especially pernicious form of fraud.) Shopkeepers expect to lose a certain amount of money to shoplifting. Can you imagine if, to prevent it, they arrested half the customers at the door!

            "Big boss ain't so big, just tall, that's all."

            by TheFatLadySings on Thu Mar 12, 2009 at 07:15:03 PM PDT

            [ Parent ]

        •  I am a database programmer (1+ / 0-)
          Recommended by:

          in fact, I own a database programming company.

          Streamlining validations does not equal throwing away validations.

          Simpler programs are less prone to error, as you should know.

          •  The success of a national healthcare system (0+ / 0-)

            is directly related to the ability of the system to detect fraudulent claims.

            Yes, of course having a single system will streamline validations and the entire billing cycle.  I just want to make sure that for the sake of streamlining we don't throw away the "hoops" built in to the system to detect fraud and over ordering of procedures to sweeten a doctor's bottom line.

            "Those are my principles, and if you don't like them... well, I have others." - G. Marx

            by Skeptical Bastard on Fri Mar 13, 2009 at 04:59:02 AM PDT

            [ Parent ]

            •  That goes both ways (0+ / 0-)

              I would be interested in a system that detects attempts to fraudulently pad a company's bottom line by declining valid procedures as "over ordering."

              There will always be people trying to game any system, but I suspect the more doctors feel screwed by the insurance system the more tempted they will be to screw back. And vice versa.

              [F]or too many, the cruelty of our system is part of its appeal. - eightlivesleft

              by oldjohnbrown on Fri Mar 13, 2009 at 08:44:02 AM PDT

              [ Parent ]

  •  I only thought of electronic medical records as (11+ / 0-)

    an advantage.

    Obviously cost savings but also the hassle of getting records from one doctor to another. I don't know if it is just New York or national but privacy laws mean that I have to fill something out from one Doctor to another so my new doc can see the old doc's records. Then instead of being handed the records, they have to be mailed.

    Now it has happened to me more that once that I arrived at a new doctor's office and my records haven't. I call the old doc from the new doc's office and old doc's assistant swears it was sent but it's not there.

    Old answer was make a new appointment. Under a new system wouldn't I be able to say "Well it's not here and the doctor is waiting. Please email it now?"  

    And not just me. wouldn't every body be able to get the records during the appointment with the doctor instead of wasting a day and making another appointment?

    "There is something infinitely healing in the repeated refrains of nature, the assurance that dawn comes after night and spring after winter." --Rachel Carson

    by Eddie C on Thu Mar 12, 2009 at 06:34:37 PM PDT

    •  unfortunately, you can't email medical records (5+ / 0-)

      you can fax. But email isn't secure.

      If you go from one doctor to another who is on the same software system, your records would already be there. But if you go from one health care organization to another totally separate one, you'd still need to do the release of information thing and get your records faxed or mailed.

      There is a potential in the future where perhaps they can be sent in some electronic format that's secure but it's not really a reality now.

    •  Hate to say this in a programmers diary (13+ / 0-)

      but I'm going to:

      electronic medical records suck.

      As a provider, I've been using them for more than a year, and I still haven't been able to get back to my prior level of productivity/efficiency; I'm still focused more on "how" I'm doing it than "what" I'm doing. The practice I interviewed at tonight has used the same system for more than 2 years, and the people I've talked to feel the same way.

      In Tuesdays Health Care open thread, DemfromCt linked to a study from the Rand corporation that basically validated what I, and many of my colleagues, have felt: that it hasn't improved outcomes, and that it has interfered with the doctor-patient relationship.

      I swear, it's a good thing I went to a girl's school where we had to learn touch typing, because I would otherwise be unlikely to make eye contact with the patients as I'm taking their history.

      I have yet to find any significant advantages. Yes, I can give written drug lists, and some instructions easily, but that doesn't outweigh the other major issues I've had with this system.

      And that doesn't even begin to address problems when the system crashes or the server slows down.

      I could go on, and on, and on.

      Can I have my fountain pen back? Please?

      Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - WSCoffin

      by stitchmd on Thu Mar 12, 2009 at 06:52:12 PM PDT

      [ Parent ]

      •  it's very possible that your EMR sucks (4+ / 0-)

        or it might even be decent but set up in a way that sucks. It happens A LOT. And I totally believe you. I've seen people do very stupid things with EMRs.

      •  Could this be because (6+ / 0-)

        some people in the States are designing things from the ground up?

        Systems have been in use overseas for many years without these kind of issues.

        And in my personal experience, they definitely improve patient care.

        •  Yes. I don't know about other states in the US (6+ / 0-)

          but in my state, each insurance company has its own system, and so does each state agency.

          Here's an example. I am trying to find a way to assess DWI offenders for co-ocurring mental illnesses in order to get the mentally ill out of the jail system and into the appropriate treatment. But I am required by the state to use a bio-psycho-social assessment called the ASI. The courts are administered by a different state agency, so judges are required to use an assessment tool called the ADE. If we come in to the court and supplement with the ASI free of charge, which is more comprehensive, the judges and DWI programs could be penalized. As a result, I can't get the judges to help set up a jail diversion program.

          Our jails continue to be used as warehouses for people with mental illness, and they continue to self medicate with drugs and alcohol.

          Or something like that.

          "Big boss ain't so big, just tall, that's all."

          by TheFatLadySings on Thu Mar 12, 2009 at 07:44:10 PM PDT

          [ Parent ]

          •  WTF? I know Richardson contracted out the (0+ / 0-)

            computer systems for the state which fouled up many divisions and really screwed up the whole payroll system.

            I wonder if they set up which form each separate department uses and ut this in effect.

            Yes there were campaign contributions for that contract AND Bill Bill was warned that that corp had screwed up other states

            The guy that ran against Bernie was a typical Repub tool and a dumb one at that. I don't know if Bernie's campaign is still up but it sets out the guy's machinations.

            We are in a time where it is risky NOT to change. Barack Obama 7-30-08

            by samddobermann on Thu Mar 12, 2009 at 09:42:50 PM PDT

            [ Parent ]

            •  The move to privatize health care was supposed to (0+ / 0-)

              fix the problem of multiple IT systems for health care providers, and, to a large degree, it did. However, there are still agencies operating with their own IT systems, tools, records, and privatization has resulted in incentives to withhold payments to providers. I wouldn't want to lump those agencies into the privatized pool for that reason.

              And, as OC commented above, some problems were the result of improperly designed IT systems rather than intent to manipulate money.

              It's very difficult for providers to continue their work. I'm glad Obama is addressing IT issues.

              There are a lot of well-meaning people trying to improve our state's health care safety net! I really hope that at some point in the future, the state reorganizes itself, and builds its capacity to publicly administer funding for health care services.

              "Big boss ain't so big, just tall, that's all."

              by TheFatLadySings on Fri Mar 13, 2009 at 06:28:01 AM PDT

              [ Parent ]

      •  The only value of an EMR (1+ / 0-)
        Recommended by:

        besides the billing points raised in the diary is the archive of labs and studies and the presence of a prescription record, assuming that one is working with a fully integrated EMR system, eg. Kaiser, VAMC, etc.  
        As a private provider, I find the notes I receive from docs who use an EMR to be highly suspect.  The ease of checking off a box coupled with the difficulty of inputting detailed personal data makes the narrative content of the record nearly useless.

        Dr. Aaron Roland is a family physician in Burlingame, CA.

        by doctoraaron on Sat Mar 14, 2009 at 05:32:39 AM PDT

        [ Parent ]

        •  my colleague and I were saying to each other (0+ / 0-)

          just the other day how useless the notes we generate on this current system are, even to ourselves. There's way too high a signal-to-noise ratio.

          We had an electronic prescription system prior to the implementation of EMR that was wonderful, web based, easy to access from everywhere, gave appropriate dosages, formulary data, etc. etc. The one that's part of the EMR is far inferior. And as for study results, having them in "one place" is helpful, but for the majority of them, unless you import the data yourself, they don't wind up in flowsheets, they just sit as scanned documents. Meanwhile, in the paper charts, we had flowsheets, such as flowsheets for diabetics, flowsheets for screening protocols, etc. So actually the system we have now is inferior to paper.

          Please, can I have my fountain pen back? It thinks like I do.

          Diversity may be the hardest thing for a society to live with, and perhaps the most dangerous thing for a society to be without - WSCoffin

          by stitchmd on Sat Mar 14, 2009 at 11:42:25 AM PDT

          [ Parent ]

  •  One more question for an insider. (7+ / 0-)

    If we are going over to electronic medical records in the beginning it will be very costly and someone will be making a great deal of money.

    OrangeClouds115, do you have ant stock tips for me?

    "There is something infinitely healing in the repeated refrains of nature, the assurance that dawn comes after night and spring after winter." --Rachel Carson

    by Eddie C on Thu Mar 12, 2009 at 06:38:39 PM PDT

  •  I'm big supporter of EHRs... but (8+ / 0-)

    I am big supporter of EHRs and their potential benefits for the U.S. people and health care system in many ways. But some scepticism is good too (starting with the single payer point, of course, that they do NOT save money in the short run or even medium run).

    But more here on informed sceptic:

    Amid all the excitement over health IT’s place in the Obama Administration stimulus package, Scot Silverstein (right) is the skunk at the picnic, the quiet voice in the corner saying "it’ll never work."
    Dr. Silverstein is no crank, nor Luddite, nor troll. He is in fact a specialist in medical informatics, on the faculty at Drexel University in Philadelphia (go Dragons), and a regular contributor to the Health Care Renewal blog. (See our blogroll.)
    His problem, described in this ongoing summary of his work, is that health IT is being driven by vendors, not doctors, that standards are not yet in place, and thus that systems can’t scale to the level the Obama Administration wants.
    Writing under the nom de blog MedInformaticsMD, he writes extensively about systems that fail, saying the horror stories prove the industry is conning the government.
    While some conservatives have been using his skepticism for their own purposes, his real argument is that medical informatics needs to be directed by physicians, not just sold by vendors.
    In particular Silverstein has been a big critic of HIMSS and CCHIT, which he considers joined at the hip, and calls present vendor offerings experimental technology.
    In a December "open letter" to the new Administration, Silverstein argues that the field is divided between people who know what they are doing and are left out of decisions, and those he calls Health IT (HIT) Industrialists.
    He concludes:
    Push as strongly for HIT reform as for healthcare reform itself, lest our HIT initiatives suffer the same delays – and the same costly failures – as the UK’s national electronic medical records program.
    There is irony here, of which he seems well aware. The nation’s political divide may be between ideologues and technocrats, yet it’s possible that in health IT we’ve just put $20 billion into an industry’s ideology.
    If Silverstein is right health IT may be Obama’s Iraq War. If he is wrong industry needs to prove him wrong, and not just try to discredit him.
    A lot will be riding on whoever the Administration picks to be its "health IT czar." Will it come from the industry, from the medical-industrial complex, or will it be someone who knows what they are doing?

    see at:

    •  I'd believe that (9+ / 0-)

      esp the part about being driven by vendors not doctors and not being scalable to what the Obama admin wants. There are a few problems I see:

      First, setting up any kind of national patient record is not currently possible, particularly not if we were using discrete data elements instead of just merging it all together as a text blob (i.e. would you have a field for "blood pressure" that records the pt's blood pressure every time it's taken so it could be graphed, or are you just sending in the BP as plain text so that it can't be distinguished from other text like the note or other vitals).

      Second, YES, it often IS too dictated by vendors. When I work I try to really listen to the doctors and basically let them take the lead. I'll step in when I think they are asking for something that's not possible or perhaps could be so complex and expensive that it wouldn't benefit them in the long run because it would result in giving up something else that's necessary but on the whole - doctor's input is CRUCIAL to any successful EMR and often the IT geeks (or administrators, or compliance people) just don't get that.

  •  Wifey got denied coverage for a proscribed drug (7+ / 0-)

    because the drug was over $1,000 -- and the generic was nearly $800.

    We're treating the issue at home with homeopathic topical remedies.  They take longer and aren't as effective as taking the drug, but it's all we've got.

    A corrupted government. Patriots branded as renegades. This is how we roll.

    by GreyHawk on Thu Mar 12, 2009 at 07:10:27 PM PDT

    •  Hey, I am denied coverage for a $35 drug (8+ / 0-)

      I need to stay alive.  They want me to take the generic.  Which every single physician, and a trial I attempted, says is not nearly good enough.

      This is for a 46-year-old with no other medical conditions who has been with the company for over 20 years.  And I pay $1700 a month for that.

      I can't imagine what people like yourself that need really expensive drugs go through.  I can pay the $35.

      •  Wifey's on another one -- a bit more serious -- (1+ / 0-)
        Recommended by:
        Pris from LA

        that they won't pay for the non-synthetic version of; like yourself, it's a situation where the drug is crucial and that the synthetic isn't believed to be as effective.

        So, yeah -- I know where you're coming from...the $700 drug I first mentioned isn't for a life-threatening thing, but the other drug (don't recall the cost, but I believe it's less) is affordable as a generic synthetic, but the non-synthetic is just our of our reach.

        All in all -- we're making it through, and healthcare in this nation sucks for those who don't have a lot of $$ to spend.

        Not exactly what I'd expect from a nation founded on principles of "life, liberty and the pursuit of happiness" and ensconced with such ideals so as to "form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity."

        A corrupted government. Patriots branded as renegades. This is how we roll.

        by GreyHawk on Thu Mar 12, 2009 at 08:08:42 PM PDT

        [ Parent ]

  •  I loved my medical care in Australia (7+ / 0-)

    even though as a non-citizen I didn't qualify for their govt program.  You go to a place like Medibank Private on the web, or at one of their storefronts, give your age, where you live and pick one of a handful of plans.  Go try it, and see how unbelievably cheap it is.

    My visit to a doctor only cost $25 - without insurance - and with insurance, all you have to do is swipe your card and all your info is transferred.  No filling out pages of endless forms.

    Now, for that price, the doctor sits and actually talks to you.  He had one examination room, which was also his office.  With the usual examination bed and utensils, but also a desk and a computer.  Because he had the time to talk, I asked him about his computer, and he said he loved it.

    It crossed checked all the prescriptions he wrote against any other presecriptions, as well as giving warnings about side-effects etc.  He entered all the patient data directly into the system and it made it easy to find anything.

    Compare this with two incidents I had in the States.  

    I went to an ENT specialist on something minor, and he looked at me and said right away I had a thyroid problem and needed to see my GP right away.  Now I had just started a new GP about 6 months earlier, and he had ordered a whole set of blood work, and I had been back to see him twice since then and they said everything was OK.

    But I called the office and told them what I had been told, then the doctor called me back with his LAWYER on the phone with him, claiming he has left a message on my voicemail which I didn't have.  He knew he had no argument for why he didn't mention anything the two times I had been in to see him since.  

    I could have sued, but I didn't - because when records aren't computerized, stuff can fall through the cracks quite easily.  I have done it myself.  And ultimately no harm done, although he did tell me I was in immediate risk of heart failure.  NOW you tell me!  If I had had a heart attack, that would have been another story.

    The second incident happened at a doctor in Arizona.  Because I have to take thyroid medication every day, and I have a memory like a sieve, I always take my physical prescription bottle in with me to the doctor.  This doctor noted the prescription and said he wanted new bloodwork (which they always do).  After that was done, he said he wanted to elevate my level slightly.  So I didn't think anything of getting pills in a new color - and having poor eyesight as well as being forgetful, did not read what the prescription said.

    Well, 3 months on this new prescription, I go get a retest, and th doctor freaks out because I am so low.  Turns out he misread my prescription by one decimal place, and just added a fraction on.  So I was getting enough medication for a mouse.

    Again, if records, and more importantly, prescriptions, were computerized, something like this would have been flagged.

    And this is the quality I get with my high-end, $1700/month health care payment.

    For those of you out there worried about computerized medical records - look at countries that are computerized and see if they are having a problem with privacy.

    They are not.

  •  experience with my own EHR (4+ / 0-)

    The clinic I go to started electronic record keeping about two years ago. As far as my personal records go, I'm pretty happy with it. I can access my chart online and look at my complete history (only as far back since they started the electronic record).

    The results of every test they've done is in there: blood pressure, blood chemistry, glucose, my weight, etc. It even provides an easy way of comparing results over time. The other thing I like about it is I can verify what's there. If something is wrong or missing I can call someone, point it out, and have them fix it.

    As for billing though, that's still a black hole. I had a test done recently and both the EOB and the bill basically just said: Pay X Dollars. Nothing was itemized. There was the top line, minus the insurance "discount", then the bottom line I owed. No explanation.

    The one rather disturbing fact I was able to glean from the bill? As an insured person I was charged 50% of the "retail" rate. What I paid $875 for, some uninsured person is being billed $1750.

    Outside of a dog, a book is man's best friend. Inside of a dog, it's too dark to read. - Groucho Marx

    by Joe Bob on Thu Mar 12, 2009 at 07:19:28 PM PDT

  •  I could have used elec. records when my HMO BK'd. (5+ / 0-)

     In the late 1990s the HMO I was with suddenly filed for bankruptcy and shut it's doors with no warning to patients.  Fortunately I was not in the middle of some major treatment, as some other patients were, but I had been treated for melanoma about 6-9 months earlier.  
     It took them almost a year to send my print medical file to me.  In the meantime, I had to go by memory and whatever miscellaneous documents I maintained.
     Would electronic records be easily accessible should something like that happen to a medical provider?

    My Karma just ran over your Dogma

    by FoundingFatherDAR on Thu Mar 12, 2009 at 07:46:30 PM PDT

  •  Google wants your medical data (2+ / 0-)
    Recommended by:
    ladybug53, Pris from LA

    The privacy objection to electronic medical records raised for the past few years in the news and on the intertubes is not so much government as private companies owning our medical data.  Namely, Google, a company that makes its money in advertising.  

    So what's the problem with that?  Well, Google launched their medical records application last year, along with a creepy privacy notification.  Here's Google's privacy policy in re. HIPAA, back when they launched a year ago:

    If you create, transmit, or display health or other information while using Google Health, you may provide only information that you own or have the right to use. When you provide your information through Google Health, you give Google a license to use and distribute it in connection with Google Health and other Google services. However, Google may only use health information you provide as permitted by the Google Health Privacy Policy, your Sharing Authorization, and applicable law.  

    Google is not a "covered entity" under the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder ("HIPAA"). As a result, HIPAA does not apply to the transmission of health information by Google to any third party.

    Well, that didn't go over so well, so they reworded it!

    Some of these third-party websites will be covered by federal and state health privacy laws (such as the Health Insurance Portability and Accountability Act, or "HIPAA"), and those laws will govern how they may use and share your information. As a result, you must authorize these providers to send information to your Google Health account. With that authorization, you also give them permission to send certain types of health information (such as mental health records) that are protected by federal and state laws and require special authorization. When you ask Google to send your health information to others, you will also be giving Google permission to send those certain types of health information.

    Whew!  Don't you feel better now?

  •  "First we kill all the insurance companies". (4+ / 0-)

    With apologies to William Shakespeare and lawyers.

    Health insurance companies provide no health care services.

    Health insurance companies increase the costs for actual health care providers.

    Health insurance companies cost US economy $600B per year.

  •  We have to reframe the question from whether IT (0+ / 0-)

    but how and who designs the IT - at least the interfaces.

    It must be easy for providers especially Doctors and Nurses. It can not be left to corporations or we will run into a disaster like the IRS automation fiasco.

    Why are we not getting the nitty gritty in this area from all the countries that have functioning systems of universal care.

    I am more impressed with Japan's system than those of Shanghai or Taiwan.

    We should not get discouraged by Britain's problems because they have true socialized medicine and ownership of facilities as well as all providers are employees.

    Medicare has gotten mingy and really rude and miserable to work with but they are stressed by the damned Repubs and others demanding them to rein in "bloated" care.

    Incidentally, virtually all the fraud in Medicare is by providers. There are a few bad docs who have devised giant rip offs and quite a few that chisel which adds up. (I believe that most doctors are fantastic and as honorable as they can be and am not inditing the profession.) That can be solved by extensive in house (like an IG for the agency with adequate staff) oversight and well publicized trials and big fines. That will prevent a lot of bad behavior.

    The major fraud comes from equipment suppliers like Oxygen or motorized scooters, etc.

    One of the things a good HIT system will do is show when 2 different companies are billing for oxygen; the earlier corp "forgets" that they were canceled.

    We really have to guard against a Halliburton or KBR of the HIT flavor getting any contracts.

    We are in a time where it is risky NOT to change. Barack Obama 7-30-08

    by samddobermann on Thu Mar 12, 2009 at 11:11:24 PM PDT

  •  In the country where I live (0+ / 0-)

    everything on our medical records can and will be used to discriminate against us.

  •  Who I fear seeing my records most (0+ / 0-)

    is the health unsurance industry.

    They have the "MIB" (Medical Information Bureau) run by and for the health unsurance industry at our expense.  If your name is on their MIB list then you are actuarial and therefore human toast.

  •  This is a really good diary. (1+ / 0-)
    Recommended by:

    A good electronic record system really helps clinicians.

    As a nurse, I can tell you that a lot of mistakes are made because physician handwriting is illegible and every time the same info is transcribed in a different place introduces opportunities for error.

    Documents, like reports from specialists and lab results, get lost, misfiled, etc.

    Republicans are liars, by deed or proxy. There is no such thing as an honest Republican. Just those who do the dirty work and those who don't.

    by chicago jeff on Fri Mar 13, 2009 at 06:22:42 AM PDT

  •  Great diary OC (1+ / 0-)
    Recommended by:

    One thing I would like to see is a requirement that insurance companies post online their code list and what is and isn't covered. Going for a visit is like roulette--depending on what code is marked you may or may not be covered so it turns out to be very important why you say you are visiting the doctor and what you say when you talk to the doctor. The code system has no transparency and getting the insurer to tell you what is covered ahead of time results in very vague and sometimes wrong info from representatives who really have no idea either.

    Yes we did, yes we will. President Obama

    by marketgeek on Fri Mar 13, 2009 at 09:12:17 AM PDT

  •  Thanks for the great analysis (1+ / 0-)
    Recommended by:

    of Medical IT.  I am a doctor in a small town that has developed a modification of GE's Centricity EMR system whereby all the doctors who subscribe (most of us now) have access to a given patient's chart and can see the lab, imaging, office visits etc that the other doctors have done for the patient. We all have separate noncommunicating practice management modules so the other docs don't know what I bill. The ER also has read-only access to the EMR so if, for example, I start an antibiotic for a urinary tract infection one day and the patient gets sicker and goes to the ER the next day, they can see what has been started that isn't working, (No, patients do not always know what they are taking) plus they can see what lab I already ordered.  The urine test I ordered the day before will be available to them.  This aspect really does reduce costs not only by eliminating duplicate testing, but by speeding up the assessment of the patient by the doctor.

    As far as the security problems that many fear, it has not been a problem for us so far with nearly 3 years experience.  We audit vigorously.  The number of transgressions is very low.  The only transgressions have been scenarios like someone's exboyfriend's girlfriend's chart was looked at.  This caused immediate termination of the employee.  Since that occurrence and the buzz around the medical community, no one has dared to do this sort of thing again.  We have mandated vigorous HIPAA training that is repeated for everyone annually.  The time/date/employee sign on stamp for every chart opened is a big deterrent.  I agree that paper charts were never very secure.  How do you know the night office cleaners are not making extra bucks by "mining" information from charts for nosy exboy/girlfriends?

    I can stay in contact with my practice while I'm on vacation much better.  While recently in Domincan Republic I logged in for a few minutes every day.  I could see what patients had called in and send notes to the nurses about what to tell the patient, what to prescribe, etc.   It was no trouble at all.  I can only log in on my laptop which has some sort of special software and then I have to put in my password with an additional 6 digit number that I get off a little key fob size device that has a new 6 digit number every 60 seconds (RSA SecurID).  

    Other ways the system has saved health care costs:

    1.  patient referred for abnormal Pap smear - in the paper world, it was common that the copy of the Pap smear was not sent to my office by the time of the appt, so we would spend time making calls that day to try to get it, and then give up and just talk to the patient, maybe repeat the Pap, and reschedule another visit.
    1.  patient complains of fatigue, feels cold and has heavy menses for which I would like to check thyroid level (as hypothyroidism can cause all these symptoms).  With the EMR, I can see that she may have already had the test done by another doctor, so I don't waste my time (and hers) going down that path with further questioning about thyroid symptoms or waste $ getting another test.
    1.  patient with chronically recurrent urinary tract infection symptoms who has been treated with antibiotics many times but keeps getting symptoms.  I can see all the urine cultures over time and I might just find out that all the cultures were negative, so she doesn't really have a UTI, but maybe has interstitial cystitis.  Now I can expedite checking into that and not waste her pain by going down the wrong track with thinking it's another UTI.
    1.  patient had abdominal surgery a week before.  She went to ER with pain.  ER doc ordered CT which is read as "hernia".  ER doc sends her home.  I see CT report and, more importantly, the images on my desktop in am.  I go, "Egads, the wound has dehisced!" (deep layers torn open - except the skin is still weakly held together).  I call the patient to rush back to the hospital for emergency surgery before the wound further opens, thus saving her life from that very dangerous possibility.

    I am totally in love with my communal EMR system.  It has made my job more satisfying as my efforts are expended in helping the patient more efficiently and not wasting all our time and money on wild goose chases.  I love the access I have at home and abroad.  Lab and Imaging reports come to me much faster.  Also I get to see the US and Xray images, not just the report.

    The benefits of EMR really do outweigh the risks.  Most of the fears of security breach are due to a less than full understanding of how these systems work.  HIPAA will be obeyed fully.  Also, I have confidence that brilliant IT people will be able to plug up any holes that our future experience unveils.  
    Remember when cell phones first came out?  People were telling stories of criminals shooting rays at passing cars and listening in to their conversations.  We don't hear that type of story anymore.  Perhaps the criminals found that most of the conversations were really boring.  So are medical records.  

    I was wise enough to never grow up while fooling most people into believing I had. - Margaret Mead

    by fayea on Fri Mar 13, 2009 at 02:01:36 PM PDT

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