Welcome to EMR and HIPAA

Today I found a really interesting article in Utah’s local paper the Deseret Morning News. In the story, a box of medical charts was lost by UPS after being sent from a Hospital to somewhere in Las Vegas for a medicare audit. You can read the article for all the facts, but essentially the box somehow got misdirected and ended up being bought by a Utah school teacher purchasing some “scrap” paper.

I was kind of surprised by how long it took the hospital to get in touch with UPS after the box was lost. Ok, so I’m not really surprised that the hospital is not watching all of the HIPAA information they sent out to make sure that it arrives safely, but maybe it should. UPS has some pretty incredible tracking tools these days that really aren’t that hard to use.

The other interesting thing to consider is how these types of audits/information transfer happens in an electronic world. I know that we transfer eligibility lists to insurance companies using Secure FTP and that works quite well. We’ve worked with a scanning company who is scanning our old paper charts and when we need to access one of those old records, they send us an encrypted file through email. That works pretty smoothly.

Unfortunately, I think if a patient wants a record right now or if we needed to send some health information out for an audit (not sure why we would need to) then we’d have to pretty much just print out the electronic record like we do when a patient makes a . In fact, we’ve even made a request to our EMR software company to give us a one click method that will allow us to print the entire chart. It’s a pain to print out everything in the paper chart from what’s scanned in, to prescriptions, to lab results, to referrals, etc etc etc. Any EMR companies have a better way to do this?

I recently came across a healthcare IT related blog that I really enjoy called Health Train Express. They recently posted an article about the Boston Health Network requiring all their physicians to adopt EHRs by 2009 or else they’ll be removed from the network. The article then says that they “expect to lose between 15 and 20 primary care physicians this year because of the mandate, and it could lose some patients if those physicians stop referring patients to Partners hospitals.” The article goes on to say that “To retain their network status, about 5,000 physicians in the network will be required to adopt either Partners’ or GE Healthcare’s EHR or sign an agreement that they will adopt EHRs during 2008.”

A number of things I’ve read about this article have people crying for Partners Community HealthCare to start putting up money to help those 5000 physicians that will be required to adopt an EHR system. I honestly don’t understand this reasoning from a business point of view. The article said that they’ll only lose 15-20 physicians this year. That seems like a very small amount since 5000 others are going to implement a new EHR and how many others already have implemented an EHR? I don’t know all the economics of this particular situation, but on face Partners Community Healthcare is making a great decision and shouldn’t need to pony up some money to help these doctors use an EHR.

Of course, it would be a nice thing if Partners Community Healthcare helped out these doctors, but what about all those doctors who already implemented an EHR without any help? Those are the ones that Partners should be rewarding. Those doctors are the ones that have probably been saving Partners money doing things electronically.

I think there’s another important reason why I think it’s a great decision for Partners Community Healthcare to not subsidize their physicians purchase of an EHR. Looking at the percentages of failed EHR implementations, you can almost guarantee that a large number of physicians will have major problems implementing a new EHR. The physicians for these costly “failed” implementations are certainly going to incur expense over and above anything Partners would have offered as a subsidy. This increased cost to physicians will incur the same type of backlash that they are experiencing from not subsidizing at all. So, Partners would gain almost nothing from these subsidies.

Furthermore, I don’t have hard evidence to prove this fact, but I think it’s fair to assume that physicians who are paying for their own EHR will make much better decisions, be more invested in the decisions and work harder to make the EHR work for them. I believe that the amount of buy-in by physicians in the EHR implementation process is a key determining factor in a successful implementation. Making physicians pay for the EHR, increases physician buy-in.

Now I don’t think everything is rosy with what Partners Community Health is doing. I don’t quite understand all the details from the article, but it seems like physicians are pigeon holed into a specif set of EHR systems: Partners’ or GE Healthcare’s EHR. The article says the caveat of “sign an agreement that they will adopt EHRs during 2008.” Does this mean that a physician can choose their own EHR or not? I imagine that if they choose an EHR other than Partners’ or GE Healthcare EHR, then they’ll be required to create some sort of interface between their chosen EHR and Partners Community Health.

This makes it a very tough decision for a provider. While specifying a certain EHR software product can lead to reduced pricing of an EHR software product, it’s not always the case and can mean that many physicians will have to pay more for an EHR that has less features or features that don’t match their practice. I think that every EHR vendor knows that it’s hard to create an EHR that works for pediatrics, GYN, neurologists, dermatologists etc etc etc. They just have very different needs. Pediatricians want nice graphs and charts of children’s growth while dermatologists want pictures and drawings of things.

“Forcing” certain EHR software can also be a challenge on a physician’s budget if the “chosen” EHR software use the very popular model of a huge up front cost to the physician. This would be very unfortunate, because there are a ton of different EHR packages out there that have creative pricing models that better match a doctor’s cash flow. However, I expect that many physicians won’t choose a separate EHR package since they will want the software to integrate nicely with the other Physicians in the network.

My suggestion would be that Partners Community Health allow doctors to choose whichever EHR fits their practice the best. Then, Partners Community Health foots the bill to integrate that EHR with Partners’ system. It’s a win for the doctors that want a specialized and inexpensive EHR. It’s a win for Partners, because they now have an even more robust set of interfaces with a variety of vendors. Unfortunately, if they do this, then they might have to pay back GE for all the nice meals and golf games they’ve gone on.

Disclaimer: I only know what I read in the linked article about Partners Community Health. In this post I make a lot of assumptions about this specific case to illustrate principles of EHR adoption. I’d love for someone from Partners Community Health to correct any of my assumptions, give us more details on the mandate and provide commentary on why my assumptions might be flawed.

After my previous post on Michael Moore’s movie Sicko, I was glad to find someone else who shared my own thoughts on the subject. Bob Vineyard does a much better job than I did at explaining my feelings on the subject. Here’s the part that I think is the most important part:

You would think after watching Sicko that everyone, everywhere has better health care than we do and there is no downside to health care in Canada, Great Britain, France or even Cuba.

If so, then why do Canadians cross the border into the U.S. to receive treatment? Why do Brit’s have to get in the queue and have treatment for certain conditions denied? Why is it Cubans can apparently get the best in health care yet 75% of them are illiterate, almost no one owns land and unemployment is rampant. Cubans may have excellent health care, yet many die each year from curable diseases for lack of medicine.

Wonder how Sicko missed this fact?

I don’t really follow Michael Moore that much, but I do know he just came out with a movie called Sicko that basically nails the US Healthcare system. I’m sure that many of the stories he shows are dead on. However, the guy being interviewed on Charlie Rose was a complete idiot that didn’t show an understanding of the healthcare system. He mentioned other countries with government healthcare coverage as a model that we should follow. While I think there is a lot that can be learned from other countries healthcare systems, Michael Moore was going about it the wrong way. I think maybe Michael Moore should go to some of these other countries and do a video called Sicko2 which shows that even socialized medicine has its problems.

I also thought it was interesting that someone on Google came out against the movie Sicko. Here’s what a Lauren Turner of Google Health Advertising team said in regards to Sicko:

“While legislators, litigators, and patient groups are growing excited, others among us are growing anxious. And why wouldn’t they? Moore attacks health insurers, health providers, and pharmaceutical companies by connecting them to isolated and emotional stories of the system at its worst. Moore’s film portrays the industry as money and marketing driven, and fails to show healthcare’s interest in patient well-being and care.”

“We can place text ads, video ads, and rich media ads in paid search results or in relevant websites within our ever-expanding content network. Whatever the problem, Google can act as a platform for educating the public and promoting your message.”

Not a wise choice considering later Google said that didn’t represent Google’s opinions, but was Lauren’s alone. While I think that means that Google left Lauren out to dry, I am glad that blogging is available to allow people to express their true feelings on a subject.

Now where’s Google Health and Google PHR?

The IRS has come out with questions and answers to supplement the IRS guidance on EHR Hospitals’ Health IT Subsidy Arrangements with Medical Staff Physicians (as described in May 11, 2007 Field Memorandum on the IRS website):

Q1 — What if a hospital’s Health IT Subsidy Arrangements with its medical staff physicians
aren’t entirely consistent with the conditions in the Memorandum? Would those arrangements result in impermissible private benefit or inurement?
A1 — Such arrangements will not be covered by the “safe harbor” described in the
Memorandum. However, they will not necessarily generate impermissible private benefit or
inurement, because the Memorandum is not meant to set forth the only permissible Health IT
Subsidy Arrangement between hospitals and physicians. Rather, the facts and circumstances
of any arrangement that does not meet the conditions described in the Memorandum will need
to be reviewed to determine if it results in any impermissible private benefit or inurement.

Q2 — What is meant in the Memorandum by “financial assistance” and “subsidies” to medical
staff physicians to acquire and implement electronic health records (“EHR”)-related software
and services that would enable the physicians to connect to the hospitals’ EHR systems?
A2 – Consistent with the HHS regulations referenced in the Memorandum, “financial assistance”
and “subsidy” do not include cash payments from the Hospital to the physicians. Rather, they
refer to arrangements in which the hospital provides the physician with EHR-related software or
information technology and training services, and the physician contributes a portion of the
cost.

Q3 – What if the hospital provides a Health IT Subsidy to a “disqualified person” as defined in
section 4958?
A3 – Assuming that the hospital meets all the conditions described in the Memorandum, the
agent will not treat such Health IT Subsidy Arrangement as an excess benefit transaction.

Q4 — What if the agent finds inurement to a medical staff physician outside the context of the
Health IT Subsidy Arrangement?
A4 — If the agent finds that the hospital’s net earnings have inured to the benefit of one or
more medical staff physicians outside the context of such arrangement, then the hospital would
not be covered by the safe harbor set forth in the memorandum. Although the safe harbor
would not apply in this situation, a determination of whether the Health IT Subsidy Arrangement
results in impermissible private benefit or inurement will depend on all the facts and
circumstances.

Q5 — What type of restrictions, if any, may a medical staff physician impose on the hospital’s
access to electronic medical records created by the physician using the Health IT Items and
Services subsidized by the hospital?
A5 – A physician may deny a hospital access to such records if that access would violate
federal and state privacy laws or the physician’s contractual obligations to patients. Also, the
hospital and physician may agree on reasonable conditions to the hospital’s access. For
example, their agreement could allow the hospital to access a patient’s medical records only
when that patient becomes a patient of the hospital, and could deny the hospital access to nonmedical
information such as billing, insurance eligibility, and referral information.

Q6 — Does the hospital have to ensure that the Health IT Items and Services are available to all
of its medical staff physicians at the same time?
A6 –The hospital may provide access to various groups of physicians at different times
according to criteria related to meeting the health care needs of the community. The hospital
should establish a plan for providing such access.subsidies.

Elizabeth