Certification Tax

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TaxReadyIsn’t certification nothing more than a tax on healthcare providers?  Or, has someone seen some value in being certifed other than paying money to get money?  For the large providers, the ARRA money will amount to little more than a rounding error on the total cost of their EHR.

I encourage you to look at John’s post about the cost of certifcation, http://www.emrandhipaa.com/emr-and-hipaa/2009/09/14/cost-of-new-cchit-ehr-certifications/comment-page-1/#comment-120681

It seems like a lot of money for no ROI.

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Fantasy Healthcare

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Fantasy-Football-Draft-Board-2009_2What if we create fantasy-healthcare.com?  Annual registration fees must be paid prior to the fantasy draft, and may be paid at healthcarefantasy@paypal.com. Participants will have to participate in the annual draft from the pool of available doctors and specialists, and will be limited to two specialists per person, five for a family.  The same process will apply for selecting a hospital.  If your choice is no longer available when it’s your turn to draft, you may submit another bid, or offer to trade with another member.  Each trade will cost you one thousand Healthcare Points.  Additional points may be purchased at the Public Option web site, www.we’vegotyoucovered.com .

You may purchase fantasy insurance to protect your fantasy-healthcare investment.  In the event your doctor is sued or retires, you have the right to pick one of the doctors provided they are in the same or lower price category. For those who are concerned about the possibility of disputes, we have created www.fantasyhealthcaredisputes.com.  You and your provider submit your arguments online, and the winner will be notified on-line.  Additionally, we’ve added a new feature this year to help you understand your medical costs and bills, www.fantasyhealthcaremath.com.  Join now, or take the chance that there may not be any doctors left within a three-hour drive from your house.  Good luck

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EHR: How to purchase an EHR

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shoppinggirlAre you really going to where that?  Do these pants really make my…

Did you ever have one of those non-halcyon days when you felt the need to ask someone “Did a house fall on your sister?”  Try to stay with me, it will come to you.  Enough about falling houses Toto.

I sought the counsel of a friend before heading down this path, and I’ve decided to choose the road less traveled anyway.

I may have written that I have observed differences between men and women.  You too?  Here are a few examples from my side of the gated compound.

  • We are willing to make mistakes as long as someone else is willing to learn from them
  • A good excuse is almost as good as getting it right
  • Good intuition will often make up for a lack of any facts
  • We refine our personality flaws, for without them we may not have a personality
  • Peter the Great heard the voices too

I regret that I am unable to share my list about women, for I am a coward.

While shopping the other day, I noticed that women shop for clothing differently from men.  For women, shop is a participatory verb—whatever that is—involving all twelve senses, for men it’s something we’d rather do online while watching the game.  From what I’ve observed, in fostering the she-conomy women:

  • Do their homework—what’s in, what’s not, what’s on sale
  • View shopping as a competitive sport, for some, a blood sport
  • Try on things, often more than once
  • Buy something they may need in case they someday find some other thing they may need that may go with it
  • There is no rule about having too many shoes—buy in volume
  • There is no rule about having too many black shoes

So, let’s see if we can segue beyond this jingoistic tractate on one to something more in line with the lofty subscription fee you paid for this site.

Permit me to employ two definitions which help me keep my ideas cogent.

  • IntraEHR—EHR statements that relate mostly to the healthcare provider
  • InterEHR—EHR statements that relate mostly to the movement  or transport of the EHR record from point A to point B

EHR and shopping.  Can one be at one with this duality?  How can one not be?  From having spoken with a number of healthcare providers about their IntraEHR selection, my take on a lot of the process is that more often than not there is no process.  It’s a lot like watching men shop.  It’s over and done with without much reasoned or substantiable—I was afraid I’d have to invent this word but I found it on Google—thought.  Over and done with, now back to the game.

Maybe EHR scholars will one day be able to trace speed buying of IntraEHRs back to that whole Neanderthal hunter gatherer thing in the Pleistocene epoch.  Sort of a think fast on your feet or you’ll be eaten approach to software selection—an awful metaphor, however CNN ran a feature with that title, so it has some legitimacy.  Maybe the hospital’s executive committee will be able to trace the hastily made IntraEHR purchase back to a lack of a plan, the lack of business requirements, and the lack of an adequate request for proposal RFP.  Maybe your successor will figure it out.

For those who haven’t contracted for their IntraEHR, it may be better to approach this like a woman.  To those who are women—you should know who you are—you are probably already approaching it that way.

Now, where did I leave my black pumps?  And no, I am not going to finish my thought about the pants.

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How large is the reform effort?

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dr_evil_one_million_dollarsA trillion dollars.

What does a trillion look like?  A dollar bill is about six inches long.  Stacked end to end, a trillion dollars would go from the earth to the sun, and back, twice.

Healthcare is one fifth of our economy.

One fifth of our GDP is larger than the GDP of five of the G8 countries, including France and the UK.  Would we try to reform the entire economy of the UK?  Would we succeed?

We have about six million miles of paved roads in the US.  How long do you think it would take the government to repave twenty percent of them, 1.2 million miles?  Could they do it?

Maybe we really should have a plan before we write a check.

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Public option dead? Let’s lead with a solution

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Who Will Lead

Who Will Lead

Dirk Stanley posted this link from the NY Times about the death of the public option.

 

http://www.nytimes.com/2009/09/13/health/policy/13plan.html?_r=1

Now, we can either bemoan this or we can try to lead.  Here’s my take on how to strat the discussion.

To insure the uninsured we don’t need a public option.  When poor people were denied access to banking and credit, the government did not create a public bank.  It regulated the banking organizations and made it illegal for them to redline the poor.

Can we not regulate the payors in the same fashion, requiring them to insure the uninsured?  Were not Medicaid and Medicare created in part because payors relined the elderly?

The government requires everyone to have automobile insurance, placing the onus on the individual.  Why not flip it?  If the goal of reform is to get people access to healthcare, which under the existing business model implies insurance, require the payors to provide it.  The government can subsidize the payors, or pay it in full, and it can do so without adding to the bureaucracy of further entitlements via a public option.

To me, two other ideas make much more sense, one of which I’ve previously offered.  Large groups of people are without insurance or are under insured.  The government wants them to have access to medical care.  As stated above, the government already created two agencies to address this problem, Medicaid and Medicare.  Why create a third?  Can’t those people be added to the two existing agencies?

The other idea may be the same, but if implemented differently, could streamline the processes and the cost.  Make the cost of the coverage to those groups an offset against whatever tax they would owe.  If it costs ten thousand dollar to insure a family of five, offset it against their income tax obligation.  Net net its’ the same cost whether you collect it and refund it or simply don’t collect it.  Give these families so sort of smart healthcare debit card, the government owns the account, and all healthcare providers can accept it for payment.

Sure, there is unlimited fraud potential, just like there is under any other option.

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EHR: Impact on DR Patient Relationship

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feastI’m a fan of foreign films, but since I don’t speak the language for me to really enjoy the movie, the visual story must be really compelling.  I also love to cook, not from recipes, but creatively, making it up as I go along.  Fortunately for purposes of this blog, there is a film which does both—Babette’s Feast.

The Danish film is set in France in the early eighteen hundreds.  The story centers around a group of pious sisters who receive a visitor who offers to spend her lottery winnings by preparing a feast for them.  The visitor, Babette, happens to be a very skilled chef.  There are those who may think the movie’s plot has more to do with the interplay among the participants.  However, as I am not a professional movie critic, we can skip the interplay and fast forward to the parts I find most relevant, the feast.

(This paragraph comes from Wikipedia.)  The sisters agree to accept Babette’s meal, and her offer to pay for the creation of a “real French dinner”. She leaves the island for a few days in order to return to Paris, as she must personally arrange for supplies to be sent to Jutland. The ingredients are plentiful, sumptuous and exotic, and their arrival causes much discussion amongst the clan. As the various never-before-seen ingredients arrive, and preparations commence, the sisters begin to worry that the meal will be, at best, a great sin of sensual luxury, and at worst some form of devilry or witchcraft. In a hasty conference, the sisters and the congregation agree to eat the meal, but to forego any pleasure in it, and to make no mention of the food during the entire dinner.  The last and most relevant part of the film is the preparation and the serving of an extraordinary banquet of royal dimensions, lavishly deployed in the unpainted austerity of the sisters’ rustic home.

The denouement—I thought it appropriate to use a French word—is whether or not the piety of the guests will prevent them from participating in the feast. It wouldn’t have made for much of a movie if the guests never came and the food sat there getting cold, but what if?  What if there was all of this preparation and no guests?  What if she prepared the feast, and in her haste forgot all about the guests?  Indeed.

Has anyone felt that something is missing in the discussion on EHR?  There’s plenty of talk of Washington and payors.  ARRA and money.  Stimulus and penalties.  Where are the guests?  Are we all responsible for not inviting the EHR dialog to include the patients?  I know it’s there, tucked away somewhere.

We’ve discussed on several occasions the notion that EHR should not be about the EHR.  It should be about the users and the patients.  Nevertheless, how is it being viewed by those groups?  Is it seen as a success?

Let’s make it a little more personal—my recent trip to my cardiologist at a superb teaching hospital in Philadelphia, Pennsylvania.  I usually get about an hour with the doctor—face time—clinical, examination.  Important time to a heart patient, eye contact that communicates you are doing all the right things, your test scores are all off the charts in the right direction, and you are healthier today than most people twenty years younger than you who haven’t had a heart attack.

That’s the real reason I go for the annual checkup, not to find out what I should be doing—I know I’m doing those things, not to find out if I am sick because I know I’m not.  I am there to reap the comfort that comes from having this specific person tell me things that help me believe that if I continue to play an active part in my recovery I will be there to raise my children.

During my last visit, we had about ten to fifteen minutes of eye contact, and the rest of the hour was spent with me watching him enter data into the EHR system.  It wouldn’t have been his choice, and it wasn’t mine.  Other than the first ten minutes, my entire checkup could have been done on WebEx.

I wonder if they offer an EHR?

 Paul Roemer Business Card

Inside & Outside

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When speaking about EHR system there are huge differences from an implementation and usage standpoint depending on if one is discussing record inside the healthcare provider or the movement or transport of the information from point A to point B.

Since most EHR statements have to do with one or the other, not both, for purposes of clarity, is there merit to labeling statements about EHR that mostly relate to the healthcare provider as IntraEHR, and those dealing the the transport of the record as InterEHR?

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Certification & Meaningulful Use

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Doctor cartoon bad funny silly goodHere’s a comment I made to John’s Blog, http://www.emrandhipaa.com/emr-and-hipaa/2009/09/12/preliminary-arra-certified-and-cchit-certified/.  Any time I need details,this blog is my first stop.

My 2 takeaways are the phrase to “justify meaningful use”, and the question about whether anyone should worry about any of this. Meaning no slight to those working on this, I think that with each new bit of information on Cert & Meaningful Use, the less likely it is that either will be relevant.

A word to healthcare providers who are implementing EHR. Do not use these benchmarks as your guidelines. Do not use ARRA as a business reason to implement an EHR. If you make an EHR decision as though Washington played no role in the decision, and make your selection of an EHR based on your actual business requirements, Certification and Meaningful Use will not matter. I believe we will learn that the only test that will matter is interoperability. The sooner we learn that under the present framework interoperability can’t happen, the sooner we will get to a solution that will work.

Here’s my take away.  Meaningful Use has no meaningful use.

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Your EHR –Do you neeed to change the threat level?

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escapekeyboard“Step away from the wall,” Veronica yelled through her ear microphone, loud enough so everyone could hear her.

I knew if I released my grip, the chances of me remaining upright weren’t very good.  Permit me to roll back the clock thirty minutes.  Friday morning in Philadelphia.  It’s raining.  In Texas they call this much rain a frog-floater.  Two and a half hour delays at the airport.  A cold biting rain, the kind that sees you in Gortex and simply laughs at you for being too silly to be indoors.

I cancelled my run and decided to sit in on one of the classes at the gym, take a break, rest up for a long run tomorrow.  The only class scheduled was kickboxing, and it’s being led by the mother of my seven year-olds best friend—not exactly my biggest physical threat. She wore her hair like Veronica in the Archie comic books, and because I couldn’t remember her real name, for purposes of this narration, that’s how we will address her.  I don’t even know what kickboxing is, but I know it doesn’t get any easier than that.  I’d finished my lifting, finally got to thirty pull-ups today—yes, in a row, and I was pumped.

I walked into the mirrored room.  The floors were recently shellacked—I love the smell of shellac in the morning.  Spandex clad women decked out in puce—isn’t that a great word—purple, lime green, and hot pink were everywhere.  The music—some sort of electronic something or other—started to blare and bodies started to move.  Knowing that I wouldn’t be sucking wind, I thought about asking Veronica to put on some music with words so we could sing along.  She gave me one of those looks that said, “In five minutes you will be so mine.”

The class is scheduled to last sixty minutes.  We began by jumping rope and I almost broke both of my legs—I am the poster boy for the theory that white men can’t jump.  I grabbed a pair of dumbbells to do with the exercises, just to make sure I got a bit of a workout.  Twelve minute into the class and I looked like the rain had followed me inside.  At minute thirteen, I dropped the dumbbells.  By minute sixteen, I no longer had any feeling in my shoulders.  I thought I saw a few of the participants checking me out, one advantage of being the only Y chromosome in the class—the one closest to me came over to ask if I was okay.

A twenty-second break for a sip of water—I had already downed my liter.  The colors of the spandex outfits had started to blur into what looked like a Peter Max painting that had been left out during a downpour.  Minute twenty-two, thighs are burning.  Twenty-four, I am found clinging to the wall.  I would not have made the twenty-fifth minute.  I reached for my cell phone and pretended that I had a voice message.  Two minutes later, I crawled out of the room.

I had under estimated the threat level, under planned, and under delivered, surpassing even my own inadequacies.

My fall from grace was short lived.  A fall from grace once you get beyond seven figures of cost implementing your EHR won’t be so short lived.  Those names will echo down the commercially carpeted hallways for a long time.

What’s being under planned?  The plan for one thing.  Once you’re into eight figures, I hope you have a written and signed-off plan.  That sign-off may be your life jacket, unless they decide to parole only those above you.  Once you get into even the potential of a nine-figure spend, I’d plan on a planning process of three to six months.

Anything less may find you clinging to a wall.

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A solution to the problem of EHR standards

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I borrowed the following paragraph from the August 31 post of the Healthcare Blog.

August 20th, HHS Secretary Kathleen Sebelius and ONC head David Blumenthal announced $598 million in grants to set up about 70 “regional extension centers” (RECs) that will help physicians select and implement EHR technologies. Another $564 million will be dedicated to developing a nationwide system of health information networks.

It goes on to state that the RECs are based on the federal agricultural extension offices of the early 1900’s.

Do you ever get the sense that some days the topics just walk up and slap you in the face?  I may have deciphered the difference between the federal sector and the private sector—for those of you who were thinking I was going to write competency, it crossed my mind, just couldn’t decide to which group.  I think it’s speed and planning.  The private sector travels at the speed of the Dow and plans at speeds approaching the half-life of a fruit fly.  The federal sector travels at the speed of a ten-year-old eating broccoli and plan around the life span of a black hole.

They plan, and then plan and then write the backup plan, and then back that up.  It’s like the healthcare version of the movie Fail Safe.  Only this time it’s not done ‘in case’ the plan fails, it’s done for ‘when’ the plan fails.  Here’s my take on all of this as relates to EHR.

  • Certification—a backup in case EHR doesn’t looks like it will work
  • Meaningful Use—backup in case certification looks like it won’t work
  • Speaking in parentheses—as I’m wont to do—at this point, neither matter, because under the current schema, interoperability won’t work.
  • Did I mention we still don’t have a set of standards?
  • Next comes RECs
  • And, another half billion for nationwide system of health information networks—HIEs?
  • Does the last point mean we are done with the notion of RHIOs and HIEs, or are HINs their backups?

What to do?  Set up another backup plan—REC centers.  The first time I read about this I thought REC centers were something like the Police Athletic League—if EHR failed, let’s play basketball.

Since you asked, here’s what I think we should do with this billion.  Give it to the EHR vendors—I can’t even believe I wrote that.  This is the same group of businesses who haven’t learned how to share their toys and play nicely in the sand box.  Ready?

  1. Some small number of EHR vendors (let’s label them Group A) does account or will account for a percentage of the installed base in the upper nineties.  The also-rans are Group B.
  2. It can be argued that not having a single set of standards is the reason we must have all of the intermediary non value-add strictures which make interoperability insurmountable.
  3. It can further be argued that not having a single set of standards causes the need for certification and Meaningful Use which would otherwise have no meaningful use.
  4. Give Group A the following mandate:
    1. Agree upon a set of standards to which you will modify your systems
    2. Modify your systems to those standards
    3. Provide that version to your installed base
    4. Agree that all future install will be of the standards-meeting application
  5. Group B may continue to market provided they meet the standards.

This could work.  It would fix a lot of the current problems and make a lot of the upstream ones disappear.  What do you think?

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