Archive: 22 April 2016

Life expectancy in US hasn’t changed much. Where did all the health dollars go?

CDC has released the new US Life Expectancy data for the year 2014 this week. The overall life expectancy has not changed between 2013 and 2014 but in some demographics life expectancy at birth steadily receded to the level in 2009!

At the same time the healthcare expenditure, both at the consumer level and at the federal level, has increased quite substantially. So where did all the dollars go?

Here is my take on this – we are spending a lot more on our healthcare than what we used to, only to live up to the same age. By the way, US healthcare expenditure is the highest in the world but many Europeans live a lot longer than Americans. We are spending a lot of money only to find sooner that we are sick, but just because we know we are sick sooner, is not making us live any longer!

Here is an example, a patient in 2000 who was 65 years old is diagnosed with cancer with a life expectancy of five years from the date of diagnosis. The cost of that diagnosis was $1000. In the year 2016,  because there are more advanced diagnostic procedures available, another patient who is 64 years old is diagnosed with the same cancer and he has the life expectancy of 6 years from the date of diagnosis.  Since more expensive diagnostic procedures have been used on this patient he had to pay $10,000 for the diagnosis. But the interesting point to note here is that both patients died at the age of 70, but one spent $1000 and the other $10,000. It is saddeningly ironical.

All of us are running faster and faster on the treadmill only to stay in the same place.




Medical transcription is dead. Long live medical transcription!

Doctors are increasingly frustrated with the clinical documentation features in EMRs
Doctors are increasingly frustrated with the clinical documentation constraints placed on them by EMRs

Many in the EMR industry have long forecasted the demise of the medical transcription industry.  However medical transcription still continues to exist and this industry is starting to see an uptick in the dictation volumes in the past 18 months.  The EMR vendors have aggressively sold their software by convincing physicians that transcription was an old fashioned idea and that it only adds significant costs to their operations without giving any corresponding return. They also convinced them that EMR was the panacea that would cure all the ills of clinical document creation using traditional transcription services. Physicians reluctantly adopted this technology without fully realizing the consequences of what doing away with transcription service can do to their current work load. Once physicians started realizing the woes of generating the documentation themselves, they started to push back on this workflow process. The EMR industry came back with even more crisp PowerPoint presentations, colorful data sheets and cookie cutter templates which showed that incorporating speech recognition into the EMR workflow would make the clinical documentation task easier for the physician, and tried to convince them again that using a transcription service was a bad and an expensive idea.

Now the physician has to not only enter all the key strokes, spend hours learning how to correctly dictate, actually dictate and make sure that the dictated text is accurately recognized by the speech recognition program, deal with excessive alert fatigue from the EMR, switch between multiple screens to enter patient data, view multiple tabs within the screens, and within each screen focus on a sections and subsections to ensure that all data points are correctly captured to maintain revenue integrity and coding accuracy, make sure that all quality measures criteria are being addressed, all population health alerts are reviewed etc. And they have to do all these while the patient is sitting in front of them and when they should actually be focusing on the patient and listening to the patient’s story!

Physicians are increasingly getting frustrated with these tasks. No wonder that a recent article in The Wall Street Journal states that doctors are increasingly getting disillusioned with their profession. Too much work is being pushed on to the physicians and too much is being expected from them; and many of these additional tasks are less about patient care and more about coding, billing and compliance. Doctors are not trained to do this and the patients are suffering because of this. Under the pretext of reducing the cost of healthcare we cannot unfairly push the burden onto the physicians. A 2014 nationwide survey has actually shown the doctors who use EMRs spend more time on administrative work than those who use paper records. The authors who are lecturers at Harvard Medical School state “Although proponents of electronic medical records have long promised a reduction in doctors’ paperwork,” they write, “we found the reverse is true.”

Physician appointments are generally slotted every 15 minutes and this includes the time a physician has to spend outside the exam room. A 2014 article from Kaiser News says the physicians are being asked to see a patient every 11 minutes! Physicians are under constant pressure to churn patients through the system. Research has shown that patients are allowed to speak for 12 seconds before they are interrupted and more than a quarter percent of the time physicians did not allow the patient to complete a sentence. The same research also points out that computer work interrupts the physician and patient interaction much more than all other interruptions like a knock on the door, etc.

Clinical documentation plays a very critical role in any patient’s care and the objective of creating a clinical document is for the physician to capture the patient’s story and then document each patient’s care episode in detail so that the same physician can go back and refer to the notes when the patient is back in his office again, or when the care is being shared by multiple physicians. These days providing high quality care to a patient is often complex and each episode of care involves multiple doctors across multiple care settings.  This type of involvement by multiple providers is becoming more and more important with the advent of bundled payments and value based payments. Therefore, it is going to become even more imperative that the clinical documentation be of high quality and that the document accurately captures the entire patient’s story. This cannot be achieved with point and click data capture alone. It requires physician’s narrative and documenting his or her critical insights and thinking.

Over the last few years, the role of clinical documentation has been reduced to a point where it mainly serves the purpose of capturing the required clinical terms that are needed for performing accurate coding and billing.  With this new emphasis on collecting and documenting structured data for coding and billing, the role of the narrative is highly diminished. When doctors are asked to work with such an incomplete picture of the patient story, quality of care is bound to suffer. The longitudinal care document is critical in improving the doctor – patient communication and trust.

Research has also shown that EMRs encourage defensive documentation by physicians. Defensive documentation is defined as ‘note bloat’ which means superfluous documentation that unnecessarily highlights negative findings and obscures positive results.  It also means that there are excessive brought forwards and use of copy and paste function from previous notes that oftentimes do not add any significant to value to the current document.

The pendulum has swung too far to one side in the last few years and now there is an urgent need to find an equilibrium. An equilibrium where the EMR and transcription can each play a complementary role so that the requisite information is available in a form and manner that enables the physician to improve patient care.

Hospitals are not ready for bundled payments

Effective April 1 many hospitals will be paid a bundled fee for Knee and Hip replacement surgeries. This is a part of the overall strategy by CMS to move providers away from Fee for Service to Value Based Payment model. CMS’ goal is to make such payments reach 30% of all reimbursements for this year. It is a lofty goal but we all know that is the direction all providers have to transition to.

Bundled payments create a host of challenges for hospitals. CMS still pays everyone involved in the care process on the fee for service model but at the end of episode of care (90 days) CMS either pays the hospital for efficiency or penalizes them by asking hospitals to pay back the excess money that CMS paid over and above the hospital’s standard rate. There is no doubt that to make healthcare providers more responsible for outcomes rather than just for providing services, value based payments is a great idea. But many hospitals in the country are nowhere near ready for such a payment model.

At the current time hospitals do not have technologies in place that they can use to monitor and measure a patient’s care across hospitals and providers. An acute care facility and a post-acute care facility may or may not talk to each other. The doctors in one acute care hospital do not communicate with the doctors in another post-acute care hospital. The post-acute care hospital may or may not have an EHR system. Even if they have one, the two EHRs may not be talking to each other. Same is the case with primary care physician offices, surgeons offices, outside rehab facilities. So how can a hospital keep track of the care being provided to a patient for 90 days after the surgery? Most of the hospitals today do not have an idea of how each of their own service costs them in their hospital. How are they supposed keep track of costs across the care settings?

Hospitals now not only need to communicate closely with each other but also get involved in each other’s operations. All discharges and discharge medications have to be reviewed by the doctors from the acute care facility with the doctors from the post-acute care facility. Not only that, they have to continuously monitor the care and progress of the patient outside of their facility. They need to start implementing systems that will enable 360 degree communication and interface with all the providers involved in each episode of care. They need to start doing this now because it is hard to stop a train.