Tuesday, February 1, 2011
Carrots and sticks
Depending on your viewpoint (and the pertinent issue), government regulation either snarls the wheels of commerce and chokes American competitiveness OR enables us to live productive, happy, equitable and safe lives. [As Oprah says, "Live your best life ..."]
Medicine is full of regulations. For the most part, this is good. Certification and licensure of doctors means that there's an explicit level of vetting and trust that a patient can bring to any encounter. Agencies like the FDA test and certify the safety of medications and devices for the public's good. Controversy abounds in its decisions, but for the most part the agency is looking out for us.
Which brings me to medical records. For hundreds of years, medical records were inscribed on paper, and locked away inside health care institutions and doctors' offices. With the advent of computers, it made sense to keep these records electronically. For one thing, this saves paper and space. And now your doctor's crappy handwriting is less of an issue--for you, the insurance company, or the pharmacist.
In theory, the computers (servers, really) housing electronic medical records could be connected for purposes of data sharing (epidemiology) and research. Moreover, if you are enabled to view your own records and lab results online, you (well, let's say the average patient) might be more inclined to take initiative with regard to your own health. Such opportunities would make the doctor-patient relationship much more of a two way street.
Whose information is it really, anyway? Does it belong to you or your doctor (or your HMO or medical home or "provider" or whatever you want to call it)?
The feds in their role as regulators-in-chief and encouragers of best practices passed something called the HITECH Act, as part of the 2009 stimulus package ("ARRA"). The idea is simple: entice medical practices into going electronic by subsidizing the cost. Practices that "meaningfully use" electronic records can get up to $44,000 in payments. Sounds like a good deal, right?
Anything is certainly better than nothing.
Here's the rub: How is meaningful use defined? The government has issued its first stage of criteria in this regard, with stages 2 and 3 expected in 2013 and 2015, respectively. The rules make some intuitive sense: What good is computerizing medical records if you can't collect and measure basic data to show that you're providing quality health care? Also, if computers simply become just large cul-de-sacs of information that don't communicate or allow data retrieval/submission, then what will implementation have really accomplished?
Okay; so far, so good.
Up until now, the vast majority of doctors have stayed on the sidelines, perhaps awaiting these incentives. Most were probably taking the "No, I insist, you go first!" approach. Why would a doctor or practice invest in the major costs of hardware, software, maintenance, and security not knowing if a product would be adaptable for future use and/or meet the government's performance criteria?
Now comes the big news: According to the most recent national data, more than half of office-based doctors have now adopted electronic medical records! The carrots (or at least the promise of future carrots) seem to be working!
And though we like to gripe about regulations, these new ones regarding electronic medical records level the playing field to a certain extent.
What's most impressed me, however, is how amidst the maelstrom of change the regulations have unleashed, new market players have sprung up to fill the void. Take as a prime example Athenahealth. (Please know that I have never used their products, have received no consideration from them, and have not spoken with anyone affiliated with the company. My comments are merely as an interested observer.) This New England-based company started by doing electronic claims (billing) for doctors' offices and groups. Anticipating the direction that health care was taking, they invested heavily in programming platforms that would appeal to doctors looking to make the jump to electronic medical records with a minimum of hassle.
At one point, they were running ads boldly guaranteeing clients that they'd qualify for "all of" the stimulus payments, though I haven't see those ads running for some time. The idea is compelling: What busy doctors' group has time to research, trial and invest in value-conscious but appropriate medical information technology? Instead, outsource it! Let it live in The Cloud! Pay a monthly subscription only (without the huge startup cost) and rely on a vendor to deliver updates, promise security, and offer compliance.
From regulation springs rules but also blossoms major new markets. Perhaps this is why America is able to keep re-inventing (and investing in) itself over and over. Maybe there is some hope our economy will soar once again.
Or I am merely drinking from the IT world's Kool-Aid? The pessimist in me can see a "tethered" future. See here. And here.
This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university's human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.
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Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
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Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
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Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
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Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
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Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
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Other blogs of note:
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.