emr-ndr.net Topic.6 January 6, 2012: Do EMRs reduce medical costs?

This Part 1 of 2 posts concludes “yes”

The following are interview excerpts from F David Winter, Jr, MD, MSC, FACP

 The excerpts from the interview with DAVID WINTER, MD can be viewed on the documentary website, http://www.emr-ndr.net

IN: Some broadly publicized studies have examined the effect of EMRs on medical costs and quality of care.

F. DAVID WINTER, JR.: A Rand study indicated EMRs would reduce medical costs and improve quality of care; but a Harvard group questioned whether hard evidence existed to support Rand’s findings.

IN: Have you had changes in costs and quality of care since your EMR system was implemented?

 F. DAVID WINTER, JR.: Costs have not decreased. EMR systems are expensive to install and maintain; I do not expect ours to reduce total costs. On the other hand, we used to spend much more on transcription; we have reduced costs there and could end up breaking even.

F David Winter, Jr, MD, MSC, FACP

David Winter serves HealthTexas Provider Network, a 475+ physician organization in partnership with Baylor Health Care System, as its Chairman of the Board and Chief Clinical Officer.  He also is in the private practice of internal medicine at the Tom Landry Center on the campus of Baylor University Medical Center

END of excerpt

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The authors of a Rand paper (Hillestad, Bigelow et al. 2005) state that health information technology can decrease healthcare costs in the USA. In this paper, health information technology (HIT) which is also referred to as electronic medical record (EMR) systems include the EMR, clinical decision support (CDS), IT-enabled functions and a central data repository (CDR) for the information. EMRs contain present and past patient information. CDS presents best practice protocols for patient treatment. An example of an IT-enabled function is computerized physician order entry (CPOE). CDR is the database that contains all this information.  (Hillestad, Bigelow et al. 2005) Most medical records are in paper form. Therefore, the information on the paper cannot be easily used to coordinate patient care, measure quality or track medical errors.

The National Ambulatory Medical Care Surveys, produced by the CDC, did a national probability sample survey of nonfederal office-based physicians.” In 2005, 23.9 percent of the physicians polled had adopted an EHR. The numbers have steadily risen with a 48.3 percent adoption rate at the end of 2009.” (Hsiao, Hing et al.)

The central assumption of this Rand study that EMR systems can influence healthcare cost savings, improve healthcare outcomes and patient safety is based on the assumption that “interconnected and interoperable EMR systems are adopted widely and used effectively."

The impact  of vendor barriers to sharing information was emphasized by the Rand study’s “lower-bound estimate of HIT adoption which assumed an integrated system that had an EMR, clinical decision support, and a central data repository—from the same vendor to ensure interoperability.”

The “estimation of potential HIT efficiency savings” was based on a “literature survey” to identify “evidence of HIT effects”. Expert opinion was sought for their opinion of this evidence. The authors conceded that the “evidence is not robust enough to make strong predictions, and we describe our results only as "potential." Nonetheless, the authors believe that their estimates are most likely an underestimation of the healthcare cost savings due to a number of factors not included in their analysis. Other factors such as “as transaction savings, reductions in malpractice costs, and research and public health savings” can reduce costs as a result of using EMR systems. Interconnected EMR systems may be more effective, than current sources of medical information, in providing data that characterizes the effectives of patient treatments.  Potential changes in the cost and quality of long term care between the current systems of medical information with a fully integrated EMR system is not included in this study’s estimates.

The authors did not include evidence of a “negative or no effect of HIT” because they felt that such a result would be due to “ineffective or not-yet-effective implementation [of EMR systems].Our next blog issue will focus on analyses that do not indicate that EMR systems will result in large healthcare savings. 

The authors assumed a ten- and fifteen-year adoption periods “and excluded products that did not have most of the desirable features of an ambulatory EMR system.”

The authors estimated the “potential safety benefits” by using medication error and adverse drug event rates from the literature, as well as limited evidence of CPOE’s reduction of medication error rates”.

Interventions for disease prevention and chronic disease management were used to estimate “other potential health benefits” that would result from the use of “key features of HIT”. The authors used the “literature and clinicians’ opinions regarding the effect of the interventions” to calculate the “potential safety benefits” that would be realized by the use of EMR systems.

The authors analyzed evidence from other industries (telecommunications, securities trading, and retail and general merchandising) that adopted IT for its impact on productivity.  The impact of IT on these industries over more than years can be seen with the introduction of “bar-coded retail checkouts, automated teller machines, consumer reservation systems, and online shopping and brokerages.” Experts estimated that about 25-35% of the 6-8 percent of the annual productivity growth was related to its “IT investments”. On the other hand, the hotel industry did not experience a significant increase in productivity presumably because it “underused its IT investment”. The authors estimated productivity gains in healthcare over an 8 year period to be from 1.5% to 4% annually. This represents the productivity gains in retail/wholesale and half of that realized in telecommunications. This represents an “average annual [healthcare] spending decrease of $346 billion, and the upper end, $813 billion. “

The authors identified   6 “ingredients” that were needed to achieve a productivity growth that was realized by “the telecom and securities industries: gains of 8 percent or more per year, year after year”. The ingredients were “strong competition on quality and cost, substantial investments in EMR systems, an enhanced infrastructure that can accommodate increased future demand or reduce costs without increasing labor, a strong champion firm or institution that drives change and integrated systems”.  Most of these factors are “absent” in our healthcare industry.

The Potential Efficiency Savings from HIT were based on the assessment of decreased costs from both outpatient and inpatient activities based on “a simulation model of HIT adoption and scaling literature-based HIT effects”. The outpatient activities included transcription, chart pulls, lab tests, drug usage, and radiology. The inpatient ones were nursing time, lab tests, drug usage, length of stay and medical records. The largest sources of the estimated savings were from “reducing hospital lengths-of-stay, nurses’ administrative time, drug usage in hospitals, and drug and radiology usage in the outpatient setting.”

The authors estimated that at 90% adoption rate of EMR systems would results in average annual savings of $77 billion. This estimate is smaller than the “annual IT-enabled productivity gains just described in other industries”.  “Process changes” and “resource reduction” are needed to realize this savings rather than “radical changes in the health care delivery system”. These efficiencies and costs savings could be used to improve health care quality. Healthcare providers, according to the authors, have less incentive to purchase EMRs because there is usually a net revenue loss from this expense.

In February 2009, Congress passed a stimulus bill allocating $150-billion to healthcare. A large portion of this, thirty-six and a half billion dollars, is for health information technology. Most of these billions will be spent on electronic medical records (EMRs).

CPOE is at the heart of the potential safety benefits of EMR systems with its use of reminders, alerts and other components contained in this system. “CPOE makes information available to physicians at the time they enter an order”. This is called “decision support”. Drug-drug interactions are such an example. These systems can track each step involved in a drug order and, therefore, enable it to update the process when errors are discovered. In the in-patient setting, alone, the authors estimate a $1 billion per year savings by reducing adverse drug events. Length of hospital stay, in this estimate, is significantly impacted by decreasing adverse drug effects in those older than 65 years of age. The amount of hospital bed days caused by adverse drug effects is so large that estimated savings accrues even though this age group comprises only 13% of the population. There is less data on the frequency of adverse drug events in the out-patient setting and, hence, on the estimated savings that might accrue due to a reduction in such events. But, small practices such as the solo practioners could comprise about 37% of the potential savings in this out-patient setting. (Wang 2003)

The potential health benefits of EMR systems are based on two interventions: disease prevention measures and chronic disease management.  The following components of EMR systems will be used to realize improved safety benefits: “communication, coordination, measurement, and decision support.” These components will allow a reduction in the 50% failure rate of physicians to deliver the recommended care to their patients. The cost of caring for patients with chronic disease consumes 75% of the national health care dollars. (McGlynn, Asch et al. 2003)    Similar failure rates found in adults to delivery care were found in children. ."(Mangione-Smith, DeCristofaro et al. 2007)

Reactions to the McGlynn study have ranged from agreeing with its predictions and suggesting that future studies should look for improvement of these numbers (Steinberg 2003) to skepticism that the authors recommendations can be carried out in a significant manner because physicians workloads presently leave little room for a significant increase in hours worked that would be required to implement the changes they recommend. (Spiegel and Pechlaner 2003)

Another aspect in the ability of EMR systems to achieve health care benefits is through the use of health information exchange regional health information network (RHIN) or personal health records can facilitate the more accurate flow of patients’ medical information with multiple chronic illnesses between different physicians’ and hospitals. This issue will be discussed in a future blog.

EMR systems use “patient data (such as age, sex, and family history)” to identify patients needing “preventive services (such as screening exams)”. Reminders have been shown to increase patient compliance “with preventive care recommendations” when they are used during routine patient follow up visits. (Burack 1997 )

Although increased compliance results will increase health care use and cost “modestly.” The authors estimate that cervical cancer screening can increase life years gained as a result of this screening by 13,000 at a cost of $0.1-0.4 billion.

Using HIT for near-term chronic disease management

Over a 3 year period through 2000, 15 chronic diseases accounted for 50% of the increase in healthcare expenditures, 5 of which accounted or 31% of that increase. (Thorpe, Florence et al. 2005)

EMR systems can use predictive modeling algorithms to target high risk populations for specific types of interventions that can prolong survival, decrease complications and costly acute interventions.

The authors of the Rand study stated that using national disease registries allows for physicians to compare their performance to others. Electronic messaging can facilitate communications between patients, specialists and remote home monitoring of a patient’s data. This allows health care provides to quickly respond to a developing medical problem. Web based patient education can “increase the patient’s knowledge of a disease and compliance with protocols.”

Improved control of acute care episodes of four common chronic diseases, asthma, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes with EMR system management resulted in a decrease of admissions to hospitals decreases and increased outpatient office visits and use of prescription drugs for a net decrease in the cost of managing these diseases by as much as $10 of billions of dollars per year.

The authors identified a “key misalignment of incentives”, the savings resulted from a decrease in acute care provider income, which is an “important barrier to EMR adoption.

“Since chronic diseases are, by and large, diseases of the elderly, a large fraction of the long-term savings attributable to prevention and disease management would accrue to Medicare. Yet, to realize these benefits, people would have to begin participating in these programs as relatively young adults.”

“We estimated the potential combined savings, again assuming 100 percent participation, to be $147 billion per year.”

For these benefits to be realized a “a substantial portion of providers and consumers participate.” The authors assume that about half of the patients will be compliant with the EMR systems because that is the percentage that complies with their medical therapy. (Haynes, McDonald et al. 2002)  Only about 10% of patients comply with physicians’ lifestyle recommendation. (Roter, Hall et al. 1998) The authors assume that with “EMR-based reminders and decision support and patient-physician messaging, we could realize at least 20 percent of the long-term benefits.” This represents a net savings on the order of $540 billion per year.

The estimated of the costs of implementation of EMR systems in physician offices in the United States has been in the range of “$28 billion per year during a ten-year deployment, $16 billion per year thereafter and net savings ($21.6–$77.8 billion per year, depending on the level of standardization) of a broadly adopted, interoperable EMR system.”  For hospitals, the “cumulative cost for 90 percent of hospitals to adopt an EMR system is $98 billion if 20 percent of hospitals now have such a system.”

The net cumulative and yearly potential savings

For hospitals and physician practices, the benefits over costs from EMR systems could be nearly $371 and $142 billion over fifteen years. This benefit doubles if the “savings produced by chronic disease prevention and management were included. “

Although the authors predict that “potential savings would outweigh the costs relatively quickly during the adoption cycle” of EMR systems, there are barriers that might impede the “adoption and effective application of EMR systems”. These are the “acquisition and implementation costs, slow and uncertain financial payoffs, and disruptive effects on practices… providers must absorb the costs of EMR systems, but consumers and payers are the most likely to reap the savings and the market might fail to develop interoperability and robust information exchange networks. “ (Bates, Ebell et al. 2003; Miller and Sim 2004) Because of this the authors conclude that there is a “substantial rationale for government policy to facilitate widespread diffusion of interoperable HIT.”

Richard Hillestad (Richard_Hillestad@rand.org) and James Bigelow are senior management scientists at RAND in Santa Monica, California. Anthony Bower is a senior economist there; Federico Girosi is a policy researcher; and Robin Meili is a senior management systems analyst. Richard Scoville and Roger Taylor are senior consultants at RAND Health—Scoville, in Chapel Hill, North Carolina, and Taylor, in Laguna Beach, California.

This report is a product of the RAND HIT Project. It benefited from the guidance of an independent Steering Committee, chaired by David Lawrence, and was sponsored by Cerner, General Electric, Hewlett-Packard, Johnson and Johnson, and Xerox.

Updates from literature since this publication:

A review of just a few of the more recent publications that support the RAND HIT Project’s predictions are summarized.

The Health Information Technology for Economic and Clinical Health Act (Blumenthal 2009)has provided incentives for the adoption and implementation of EMR systems.

Miler describes a 10 percent increase in births that occur in hospitals with EMRs reduces neonatal mortality by 16 deaths per 100,000 live births as a result of EMR “assisted careful monitoring” .  The authors calculated “cost-effectiveness” valued at $531,000 per baby's life saved. (Miller and Tucker 2011)

The use of the EMR was associated with a significant reduction in hospital mortality in trauma patients.  (Deckelbaum, Feinstein et al. 2009)

The adoption of EMR systems allowed an increase in chart reviews which resulted in an increase in antimicrobial recommendations. This was associated with a sustained decrease in antimicrobial use and nosocomial infections with methicillin-resistant Staphylococcus aureus following implementation of the EMR. (Cook, Rizzo et al. 2011)

Summary

In summary, the authors of the Rand paper outline the basis for their projections of large cost savings with the implementation and widespread use of EMR systems in the USA. Two of the ingredients, discussed in this Rand paper, strong competition on quality and cost and integrated systems, will have a limited impact on the EMR systems’ ability to deliver such savings until the present barriers of patient privacy regulations and the proprietary nature of medical information can be adjusted to accommodate the sharing of medical information between hospitals and physicians.  (Blogs 1, 2, 3).

The assessment of the quality of patient outcomes in an more accurate manner then is done today would require that medical databases use the master patient index (MPI) that allows the tracking of individual patient treatments and outcomes as compared to the standard of “de-identified data” used in medical databases across the country except for a few states like Utah that uses the MPI. Nonetheless, that the state of Utah was able to introduce the MPI to replace the use of de-identified data in its state medical database indicates that patient privacy and proprietary medical information can co-exist with this method of tracking individual patient outcomes.

Another issue raised by this Rand paper is that Americans will have to start making value judgments about the cost of extending patients’ lives which medical innovations allow. The EMR systems will be an integral component of this process as discussed in this paper. For example, an increase in patient compliance with cervical cancer screening can increase life years gained as a result of this screening by 13,000 at a cost of $0.1-0.4 billion. This comes out to a healthcare expenditure of $7,692 to $30,769 per patient for each year of life extended for the high and low end estimated cost of the screening. 

Clearly, each country has to decide the value that the public and private healthcare sectors will pay for each year of life that is extended by such screenings. Today, such decisions are made on a case by case basis in committees that, often, are not transparent to the public, by private insurance companies and the federal government. As the economist, John McCracken, said in the documentary, “EMR and Healthcare Reform” which can be found at www.emr-ndr.net, there is no right or wrong answer to this issue. It is a matter of values.

Part 2 of this topic will be in the next blog which will present the case that the large cost of implementing EMR systems in all hospitals and physician offices in the USA, estimated by some experts to be more than $100 billion over a ten year period, will not realize the large healthcare dollar savings that experts on the Rand panel have predicted.  Some experts have said that the cost to implement the federal mandate to install EMR systems nationwide by 2014 could be one of the most expensive failed federal government initiatives because these EMR systems cannot produce the cost savings that experts have predicted relative to the cost of implementing these systems.

Bates, D. W., M. Ebell, et al. (2003). "A proposal for electronic medical records in U.S. primary care." J Am Med Inform Assoc 10(1): 1-10.

Blumenthal, D. (2009). "Stimulating the adoption of health information technology." N Engl J Med. 360(15 ): 1477-1479.

Burack, R. C. G., P.A. ( 1997 ). "Promoting Screening Mammography in Inner-City Settings: The Sustained Effectiveness of Computerized Reminders in a Randomized Controlled Trial  " Medical Care 35(9): 921–931.

Cook, P. P., S. Rizzo, et al. (2011). "Sustained reduction in antimicrobial use and decrease in methicillin-resistant Staphylococcus aureus and Clostridium difficile infections following implementation of an electronic medical record at a tertiary-care teaching hospital." Journal of Antimicrobial Chemotherapy (JAC) 66(1): 205-209.

Deckelbaum, D. L., A. J. Feinstein, et al. (2009). "Electronic medical records and mortality in trauma patients." Journal of Trauma 67(3): 634-636.

Haynes, R. B., H. P. McDonald, et al. (2002). "Helping Patients Follow Prescribed Treatment: Clinical Applications ." Journal of the American Medical Association 288    (22): 2880–2883.

Hillestad, R., J. Bigelow, et al. (2005). "Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs." Health Affairs 24(5): 1103-1117.

Hsiao, C., E. Hing, et al. "Electronic Medical Record/Electronic Health Record Systems of Office-based Physicians: United States, 2009 and Preliminary 2010 State Estimates." NCHS Health E-Stat Division of Health Care Statistics,

McGlynn, E. A., S. M. Asch, et al. (2003). "The quality of health care delivered to adults in the United States." N Engl J Med 348(26): 2635-2645.

Miller, A. R. and C. E. Tucker (2011). "Can health care information technology save babies?" J Polit Econ 119(2): 289-324.

Miller, R. and I. Sim (2004). "Physicians’ Use of Electronic Medical Records: Barriers and Solutions              " Health Affairs 23(2  ): 116–126   

Roter, D. L., J. A. Hall, et al. (1998). "Effectiveness of interventions to improve patient compliance: a meta-analysis." Med Care 36(8): 1138-1161.

Steinberg, E. P. (2003). "Improving the quality of care--can we practice what we preach?" N Engl J Med 348(26): 2681-2683.

Thorpe, K. E., C. S. Florence, et al. (2005). " Which Medical Conditions Account for the Rise in Health Care Spending? ." Health Affairs, 25 August 2004,

Wang, S. J. (2003 ). "A Cost-Benefit Analysis of Electronic Medical Records in Primary Care." American Journal of Medicine 114(5 ): 397–403.

 Words 3135, 3523 with references, 3688 with references and footnotes

Metamorphoses Healthcare is a non-profit organization that advocates for the establishment of a national disease registry as an adjunct to the federally mandated purchase and installations of EMRs in all hospitals and physician practices by 2014.

The views presented in this organization’s documentary, “Electronic Medical Records and Health Reform”, focus on physicians' opinions about these issues. These physicians represent a diverse group. They are from a different background in regards to race, ethnic ancestry, religion, regions of the country, medical specialties, and political views (from conservative to liberal viewpoints).

The goal of this organization is to identify reforms that benefit the quality of patient care outcomes. We do not advocate a particular political point of view. That is we are a non-partisan organization.

A transcript of the full interview will be sent with the purchase of DVD of the documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM. http://www.emr-ndr.net/index.html

Links to Facebook, twitter and our blog can be found on the website.

EMR.NDR.Health Reform. Topic.5. Continuing series: Is healthcare an individual right or responsibility? Medicare cuts and a National Health Insurance Program

Posted by Metamorphoses Healthcare 12/23/11

“The Senate…met… to give its unanimous thumbs up to both the Medicare "doc fix" and other deal provisions… "With this brief reprieve from the massive 27 percent cut to Medicare payments, Congress now has to enact a real and fiscally responsible solution to this sorry cycle of scheduled cuts and short-term patches that compromises access to care for patients and drives up costs for tax payers," said the American Medical Association in a statement after last evening's eleventh-hour deal, worked out among House Republicans. The association continued: "Members of Congress need to use this time to work out in a bipartisan manner to provide stability for seniors, military families, and the physicians who care for them." Whether such "a real and fiscally sound solution" can be worked out by Congress …remains doubtful…revamping the much-reviled sustainable growth rate formula, which is the basis for the draconian Medicare pay cuts, remains among the thorniest. (Guglielmo 2011)

The following are interview excerpts from DAVID WINTER, PROFESSOR UNIVERSITY OF TEXAS at DALLAS (UTD). The excerpts from the interview with DAVID WINTER, MD can be viewed on the documentary website, http://www.emrdocumentary.net/transcripts.htm

IN: A medical economist we interviewed about health reform believes we can’t move forward effectively until we decide whether healthcare is an individual right or responsibility. Given the strengths and weaknesses of private insurance as well as federal insurance programs such as Medicare and Medicaid, what are your recommendations to policymakers about best ways to manage runaway healthcare costs?

DW: Universal healthcare would solve a lot of problems. Doctors struggle with Medicare and Medicaid criteria (reduced reimbursements, restricted use of treatments and tests, etc.). Overall, Medicare has been great for Americans. It’s brought healthcare to many who otherwise would have none. Nonetheless, physicians find it easier to work with commercial payers than with the government, which lacks flexibility and makes changes slowly. Some have proposed merging private and federal coverage, but all the proposed solutions have problems.

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The case for private medicine in USA: healthcare as a personal responsibility

  A private physician’s view of Medicare and Medicaid

The state of Kansas and 34 other states are submitting amendments to their states’ constitution, often called “the Healthcare Freedom Amendment”. The proponents of these amendments believe that “Medicaid [is] for the truly desperate situations” and “that private contracting was the way to bring down medical costs.” They also believe that “rationing, like charity, is best decided at the local level.”

This private medical model proposes the following tenets.

Patients should own their own health insurance not their employers. This is the economic model used for auto and life insurance. Patients, therefore, would not lose their insurance if they lost their job. Health insurance premiums should be tax deductible for both individuals and employers. Physicians who render charity care should be allowed tax deductions for the cost of that care. The author states that his groups “mission clinic” has done very well with this economic model. If the physicians contracts directly with each patient, tort reform is a less pressing issue.

The author gives an example of how he negotiated a refund of part of an unsatisfied patient’s bill. The author goes on to say that physicians can move to independence by opting out of Medicare and Medicaid contracts.

This doctor’s patient said: "Medicare only paid the doctor 17 percent of his bill. How long will he be able to stay in business?" The physician went on to say that even if the percentage of your practice of Medicare (or BCBS) is 50% of his patients and you cancel your contract and lose 50 percent of those patients… If you are getting 17 percent of what you bill (as in the Medicare example above), you could set your new cash fees at 25 to 50 percent of your previous fees and be much better off. Years ago, 10 percent of my monthly revenue came from Medicaid. When I cancelled my contract with Medicaid, the very next month, I received twice as much revenue in the time slots that Medicaid had previously taken…What will another 21 percent cut in Medicare payments do to your bottom line? Or, How much will you get paid when the global payment goes to the hospital to be divided among the 'providers'?" (Watson 2010)

George R. Watson, D.O., practices family medicine in Park City, KS. Contact: drgeorge@watsonmedicalgroup.com. He serves as president of AAPS.



The case for government funded medicine in USA: healthcare as an individual right


  In a 2002 survey of physicians, 49% supported government legislation to establish national health insurance (Ackermann and Carroll 2003). In a six year follow up survey, the same authors randomly sampled 5000 physicians from the American Medical Association Masterfile. They asked the physicians if they supported government legislation to establish national health insurance and if they supported introducing universal coverage through an incremental reform.

The response rate was 51%. The majority of physicians who responded to the survey (59%) supported legislation to establish national health insurance, 9% were neutral on the topic, and 32% opposed it.

Similarly, the majority of physicians (55%) supported incremental reform in order to achieve universal coverage, 21% were neutral on the topic, and 25% opposed it.

A minority of physicians (14%) opposed national health insurance but supported more incremental reforms.

Most (>50%) medical specialties supported national health insurance legislation. A minority of respondents opposed to this were from the procedural specialties: the surgical subspecialties, anesthesiologists, and radiologists.

There was a 10% increase in support for a national health insurance from 2002 to 2008 (49% to 59%) amongst physician respondents. Pediatric subspecialists were highly supported of such a program in both surveys. Support increased in every subspecialty between the two surveys time periods. (Carroll and Ackerman 2008)

In summary, we present two different models of healthcare from physicians’ viewpoints: The first model is based on the value that healthcare is an individual responsibility. Patients own their own health insurance policies, not employers, which would make job loss less onerous in regards to its impact on a patient’s access to continued healthcare. The premiums would be tax deductible. This model contains a pathway for those patients that do not have health insurance with tax deductible "charity" clinics. The second model is based on the value that healthcare is an individual right. This model reflects the opinions of physicians who participated in a survey. This model contains a national health insurance plan.


Ackermann, R. T. and A. E. Carroll (2003). "Support for national health insurance among U.S. physicians: a national survey." Ann Intern Med 139(10): 795-801.

Carroll, A. E. and R. T. Ackerman (2008). Support for National Health Insurance among U.S. Physicians: 5 Years Later, American College of Physicians. 148: 566-567.

Guglielmo, W. J. (2011) "House and Senate Give Nod to Medicare Pay Cut Postponement." Medscape Medical News 12/23/2011

Watson, G. R. (2010). "We can win the battle to maintain the practice of private medicine. Journal of American Physicians and Surgeons 15(1): 4.

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************************************************************************************* Metamorphoses Healthcare is a non-profit organization that advocates for the establishment of a national disease registry as an adjunct to the federally mandated purchase and installations of EMRs in all hospitals and physician practices by 2014.

  The views presented in this organization’s documentary, “Electronic Medical Records and Health Reform”, focus on physicians' opinions about these issues. These physicians represent a diverse group. They are from a different background in regards to race, ethnic ancestry, religion, regions of the country, medical specialties, and political views (from conservative to liberal viewpoints).

The goal of this organization is to identify reforms that benefit the quality of patient care outcomes. We do not advocate a particular political point of view. That is we are a non-partisan organization. A transcript of the full interview will be sent with the purchase of DVD of the documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM. http://www.emr-ndr.net/index.html

Links to Facebook, twitter and our blog can be found on the website. .

EMR-NDR-Health Reform. Topic.4. Can small physician practices afford to purchase and install EMRs by 2014? Why is there a shortage of general practioners? What can be done about it?

Posted by Metamorphoses Healthcare 12/05/11

The federal mandate to purchase and install EMRs by 2014 has many small physician practices concerned about their ability to afford such systems. Why is this? In the USA, small physician practices are decreasing in number partly due to the increasing difficulty in maintaining a profit due to decreasing reimbursement from insurance companies and increasing overhead costs.

In the documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM, Dr. James Frame explains why it will be difficult for small physician practices to install EMRs by 2014 and why there is an ever increasing shortage of general practioners (GPs). IN: Can small physician practices absorb the relatively high costs of implementing EMRs?

JF: Most small practices cannot. The ever increasing financial drain caused by malpractice insurance, regulatory requirements, restricted Medicare reimbursements, etc., already has resulted in reduced numbers of general practitioners and internists, while hospital-based practices are increasing.

Many private physicians can’t afford to care for UN- and under insured patients. Like hospitals, they’re fortunate to have financial margins (net income /operation costs & expenses) at 2, 3 or 5 percent. (ERs have absorbed the costs of caring for the un- and under-insured, partly because small practices can’t afford this.)

End of documentary excerpt

This overall shortage of GPs in the USA will aggravate the long standing shortage of GPs in traditionally medically under-served areas; this is a problem in countries throughout the world.

The shortage of GPs is not related to whether a countries medical care economic model is public or private.

Barnighausen et. al., state that many countries are faced with shortages of general practioners, especially in underserved areas. A review of studies that assessed the efficacy of financial incentive programs to increase the supply of GPs was done. Studies between 1930 and 1998 were reviewed. The authors investigated financial-incentive programs in the US, Japan, Canada, New Zealand and South Africa. Five different types of programs (service-requiring scholarships, educational loans with service requirements, service-option educational loans, loan repayment programs, and direct financial incentives) were identified. Financial incentives to serve for one year in an underserved area ranged from year-2000 United States dollars 1,358 to 28,470.

Financial-incentive programs for physicians to serve in areas that are medically underserved have been studied mainly in the USA. This limits generalizability of these studies. “Program participants are more likely than non-participants to work in underserved areas in the long run”. But, this difference may possibly be due to “selection effects”. Therefore, it is unclear whether these programs have “caused increases in the supply of health workers to underserved areas”.(Barnighausen and Bloom 2009)

In the United Kingdom, a country with a public healthcare system called the National Health Service (NHS), Ding et. al., state that the NHS national policy changes has recently offered “salaried employment, which offers reduced hours and freedom from out-of-hours and administrative responsibilities, aimed at improving recruitment and retention in a labour market facing regional shortages.” Ding assessed the “salaried GPs and their mobility within the labour market” by profiling all GPs in England in late 1990s through 2005.

Salaried GPs tended to be either younger (35 years) or older (65 years), female, or overseas-qualified; they favoured part-time working and personal medical services contracts. They were more mobile than GP principals, scored more Quality and Outcomes Framework points and were located in slightly more affluent areas.

Salaried status appears to have reduced limitations in the labour market, leading to better workforce deployment from a GP's perspective. However, there is no evidence to suggest it has relieved inequalities in GP distribution.(Ding, Hann et al. 2008)

In the Republic of Ireland (ROI) and Northern Ireland (NI), Galway et. al., evaluated the access to GP services in both countries. Both populations are very homogeneous with similar levels of health and number of patients per GP. But the healthcare systems are very different with free universal access for all citizens to healthcare in NI and a mixed private/public systems ROI.

In the study, 22,796 patients were surveyed. The response rate was 52% (n=11,870). The outcome measures were overall satisfaction and the access to GP services. Overall satisfaction with GP practices was high in both countries but slightly higher in ROI than in NI (84.2% and 80.9% respectively). Access scores were higher in ROI than NI (69.2% and 57.0% respectively. Only 8% of patients waited more than 2 days for an appointment in ROI compared to 45% in NI.

In both systems satisfaction decreased as size of practice increased. ROI imposes a consultation charge for faster access to GPs. This is believed to have a deterrent effect and may explain the difference in waiting time for appointments between the two countries. This improved accessibility in ROI may be realized at the cost in equity, i.e., since the poorest and sickest are deterred more by this charge. Policy makers value the provision of equitable services, so this inequity raises a concern for them. Access is reduced in both systems in large practices as compared to smaller ones
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Medical care economic models in ROI and NI

As in all the UK, NI’s health services are free at the point of delivery. The majority of a physician’s income in the UK is based on a “capitation” fee. That is, they are reimbursed a negotiated fee from the government based on the number of patients that they provide medical care. The new GP contract has introduced economic incentives to physicians by increasing the portion of their income that is based on physicians meeting “quality/process targets”.

Like the USA, ROI has a mixed medical economic model: part public and part private medical care. The majority of patients are private patients (70%) and they pay a consultation charge when they visit the GP (40-50 Euros at the time of publication of the paper). Means testing and age (greater than 70 years) determine those patients (called GMS patients) that are given care in the public medical model (30%).[In the USA, public/private distribution is 48% and 52%]. They receive free care at the point of delivery.

So the income of physicians in ROI is based on capitation for GMS patients and fee-for-service for private patients. The cultural and historical homogeneity of this population suggest the overall high satisfaction with both economic medical models is not based on bias. The authors concluded that despite the inequities of the public/private medical model in ROI,” enhanced accessibility [to GPs] may occur where supply and demand financial incentives are present."

But, the price that is paid for this increased accessibility is that 1 in 4 patients who had a medical problem in ROI in the previous year did not seek medical care due to financial concerns in ROI. Since low income and elderly receive free care, the deterrent effect is felt largely in the middle income group of patients. They are four times as likely to be deterred from seeking medical care as are the affluent. The poorest and most medically sick of the private patients are most affected by this “charging structure”.

The authors conclude that more comparative studies like this one need to be done in other countries in order to identify “the best balance between enhanced accessibility and optimal equity.” (Galway, Murphy et al. 2007)

This is a complex problem to study. Within both public and private medical models throughout the world, the source and magnitude of physician income and the amount of out of pocket expenses incurred by patients is highly variable. Therefore the actual impact those public and private medical models have on physicians’income and patients' out of pocket expenses are also quite variable. Comparative studies will have to take these factors into account.

So, in summary, the downward spiral of patient care reimbursement from both public and private insurance companies and increasing costs to run a medical practice in the USA will result in an increasing shortage of GPs in the USA.

There is a shortage of GPs throughout the world in both public and private medical care systems. What appears to be clear from the data summarized in the papers reviewed in this article is that a salaried physician model without economic incentives does not appear to attract the number of GPs needed by society with the proper distribution, especially in underserved areas, nor achieve the best quality medical outcomes. More studies are needed to identify the ideal economic medical model to solve this worldwide problem.

Barnighausen, T. and D. E. Bloom (2009). "Financial incentives for return of service in underserved areas: a systematic review." BMC Health Serv Res 9: 86.

Ding, A., M. Hann, et al. (2008). "Profile of English salaried GPs: labour mobility and practice performance." British Journal of General Practice 58(546): 20-25.

Galway, K. J., A. W. Murphy, et al. (2007). "Perceived and reported access to the general practitioner: an international comparison of universal access and mixed private/public systems." Ir Med J 100(6): 494-497.

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Metamorphoses Healthcare is a non-profit organization that advocates for the establishment of a national disease registry as an adjunct to the federally mandated purchase and installations of EMRs in all hospitals and physician practices by 2014.

The views presented in this organization’s documentary, “Electronic Medical Records and Health Reform”, focus on physicians' opinions about these issues. These physicians represent a diverse group. They are from different background in regards to race, ethnic ancestry, religion, regions of the country, medical specialties, and political views (from conservative to liberal viewpoints).

The goal of this organization is to identify reforms that benefit the quality of patient care outcomes. We do not advocate a particular political point of view.

The excerpts from the interview with JAMES FRAME, MD can be viewed on the documentary website, http://www.emr-ndr.net/index.html

A transcript of the full interview will be sent with the purchase of DVD of the documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM.

Links to Facebook, twitter and our blog can be found on the website.

Words: actual article 1679; total words that include article, references and notes about organization: 1589

EMR.NDR.Health Reform. Topic.3. Proprietary medical information: how does it impact the sharing of medical information?

Posted by Metamorphoses Healthcare 11/27/11

Summary of previous blogs

In blog # 1 entitled, “Electronic Medical Record, National Disease Registry & Master Patient Index”, on Friday, October 28, 2011, we discussed a central design feature of a national disease registry, the master patient index. In blog #2 entitled, “Is Healthcare a Right or an Individual Responsibility?” on Wednesday, November 16, 2011, we discussed the two healthcare models that presently define the American healthcare delivery system: healthcare as a right under Medicare and Medicaid (~48% of all insured) compared to healthcare as an individual responsibility under private insurance company plans (~52% of all insured).

In this article (blog # 3), we will discuss how the proprietary nature of medical information impacts the ability for hospitals and physician offices to share medical information.

In Canada, the private sector of medicine has worked out arrangements to share medical information. In India and Korea, similar legislation was proposed but was resisted by various groups. We will present interview excerpts from our documentary, “EMR and Healthcare Reform”, with Dr. James Frame, MD, JD, who discusses the implications that the proprietary nature of medical information has on the sharing of medical information in the USA.

In the USA, that issue is not actively being assessed by the various political and medical groups that would normally create such a plan. During the Clinton administration, in the early 1990s, Hilary Clinton tried to pass healthcare legislation that would have assigned unique medical numbers to all patients, the equivalent of the master patient index discussed in blog #1. Privacy and proprietary medical information interest groups successfully opposed this proposal.

In Canada, although there is a private and public sector of medicine, they are planning to launch an IT platform “to link private labs with the public system, and to connect patient records in private doctor's offices with hospitals. Plans are also afoot to link prescription information between private pharmacies and hospitals”. Healthcare officials related to the project expect that this database will “dramatically reduce the number of medication errors”. (Derfel 2011)

The Korean government attempted to standardize terminology across all patient hospital records which had been different between hospitals. In addition, the government enacted a law protecting a patient’s medical information while allowing patients to request their medical records, in a streamlined process, from a previous hospital to facilitate their treatment at another hospital. But medical organizations and civic groups complained that this process would increase the risk of a patient’s medical information also being viewed by unintended parties. Various medical groups accused the government of using the law as a cover for the purpose of legalizing and commercializing the leakage of a patient’s medical information. The government denied this charge and maintains that it has set up ways to block the leak of medical information to unintended parties. (Chung 2006)

India recently passed a law that has wide ranging influence on all data related to business including medical information. Business leaders in India and the USA both fear that this law will add layers of cumbersome disclosures “such as obtaining written consent from each customer before collecting and using personal data. “ Google has protested the part of the law that makes internet intermediaries responsible for the transmission of any “any objectionable content, which is defined as "harassing," "grossly harmful" or "ethnically objectionable." All other countries that have data privacy laws have “exempted the service provider or vendors from these obligations." “These restrictions on the use of data have been described as “far more restrictive than American and European data privacy laws”. Experts state that this law will “radically alter India's outsourcing business” and that companies will “take their business elsewhere, to China or Philippines”. India’s outsourcing business is valued at $41 billion and these companies share the concerns of clients and experts. India's deputy minister for information technology Sachin Pilot said that the law was created to respond to the IT industry’s desire to have a legal framework for data protection. In a recent survey 60% of banking customers “said that information security is a significant concern”. Russell Smith of SDD Global Solutions, a New York law firm that runs a legal-process-outsourcing business in India said that "The law will end the last remaining arguments people have against outsourcing to India”.(Lakshmi 2011)

In the following excerpts from an interview with James Frame, MD, JD, Emergency Medicine, from the documentary, “Electronic Medical Records and Health Reform”, Dr. Frame discusses how the proprietary nature of medical information impacts the sharing of medical information between hospitals.

Interviewer: Why don’t hospitals share data with hospitals outside their systems?

James Frame: An often cited example compares hospitals with other businesses such as Home Depot (HD). HD has a customer base, i.e., regular customers with credit cards. Does anyone expect HD to share its customer list with its competitor, Lowes? Similarly, investment managers do not share their list of investors with competitors.

Hospitals, too, have a need to protect and maintain their patient or customer base in order to survive financially. As I have said, the hospital industry is over-regulated in some areas and under regulated in others. Information sharing is one area where improved regulation is needed. Right now, we have no financial incentives (actually we have many disincentives) to share patient (customer) lists with competitor hospitals.
In the healthcare industry, information sharing could result in patient stealing. Although it is considered inappropriate to refer to patients as customers in our industry because people’s lives are at stake, objectively, that is what we are talking about.

To encourage medical practitioners to share data, some type of financial incentives is needed, perhaps, on a limited basis.

My sixth Corpus Christi hospital system has a completely integrated EMR system. If patients enter the CHRISTUS hospital and stay within the CHRISTUS system, all their medical history and visits for the past 20 years are in the system. We can access every patient’s progression of disease and treatment. Unfortunately, when systems do not talk to other systems across local communities, regions and states, medical practitioners cannot effectively integrate patient care. (End of excerpt)

The business world and hospitals are still struggling with balancing privacy and proprietary medical information concerns with the desire to share medical information to benefit the quality of patient care, improve patient outcomes and, thereby, decrease the costs of healthcare.

In future articles, we will discuss what the differences are between the private and public medical sectors in Canada, India, Korea and the USA to better understand the specific factors in each country’s economy that allows or prevents the sharing of medical information.

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Metamorphoses Healthcare is a non-profit organization that advocates for the establishment of a national disease registry and healthcare reform that focuses on how to optimize the quality of patient care in the most cost effective way. The views presented in this organization’s documentary, “Electronic Medical Records and Health Reform”, focus on physicians' opinions about these issues. These physicians represent a diverse group. They are from different backgrounds in regards to race, ethnic ancestry,religion, regions of the country, medical specialities, and political views (from conservative to liberal viewpoints).

The goal of this organization is to identify reforms that benefit patients taking into account the political realities that exist in the USA without advocating a particular political point of view.

The excerpts from the interview with JAMES FRAME, MD can be viewed on the documentary website, http://www.emr-ndr.net/index.html

A transcript of the full interview will be sent with the purchase of DVD of the documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM.

Links to Facebook, twitter and our blog can be found on the website.

Words: actual article 997; total words that include summary, article, references and notes about organization: 1312

Chung, P. (2006). Medical Information Law Faces Backlash. The Korea Times.

Derfel, A. (2011). Digitization of medical records proceeding one step at a time; Full computerization five years away, but some institutions already paperless. The Gazette Montreal, Canada, CanWest Media Works Publication Inc.

Lakshmi, R. (2011). The long reach of India data privacy. The Washington Post: G04.

Is Healthcare a Right or an Individual Responsibility?

One of the more important advantages of investing in electronic medical records is the ability to share medical information.

Americans, for many years, have been overwhelmingly against the development of medical databases like a national disease registry. They want the privacy of their medical records protected and not released to anyone without their permission(Fodor 2000) Patients’ medical records are proprietary information. That is, they are owned by the hospitals and physician practices.

These are two major obstacles to the sharing of medical information between hospitals and physicians’ offices as well as the development of a national disease registry.

The first step to resolving these two obstacles is for Americans to decide if healthcare is a right or an individual responsibility.

ECONOMIC MODELS: INDIVIDUAL VS. COLLECTIVE RESPONSIBILITY

Interviewer: The United States underscores individual responsibility; other countries emphasize collective responsibility. Where are we headed with this? Are there acceptable options for balancing individual and collective responsibility relative to medical care?

JOHN F. McCRACKEN, PH.D.: Our nation focuses on individual rights and responsibility--individuality—more than others. Industrialized European countries, for example, emphasize collective responsibility—the collective good. That’s why they treat healthcare as a social good.

Social goods serve collective needs. There’s a sense of collective responsibility in making such goods available to all citizens. Availability depends on need and government is perceived to be more efficient at allocating these goods.
In the U.S., healthcare is viewed more as a market good. Market goods serve individual needs. There’s a sense of individual responsibility and a personal obligation to earn these goods. Availability is based on individual ability to pay. Markets are believed to be more efficient at allocating these goods.

One of our problems, unlike the rest of the world, is:
The United States has never decided whether healthcare is a social or a market good.


These are excerpts of interview with John McCracken PhD. A transcript of the full interview will be sent with the purchase of DVD of the documentary, ELECTRONIC MEDICAL RECORDS AND HEALTH REFORM. Part of transcript of his interview can be viewed on the documentary website, http://www.emr-ndr.net/index.html
Links to Facebook, twitter and our blog can be found on the website.

Fodor, K. (2000) "Americans Opposed to National Medical Records Database." http://www.mult-sclerosis.org/news/Sep2000/NationalMedicalRecordsDatabase.html.

Electronic Medical Record, National Disease Registry & Master Patient Index

In February 2009, Congress passed the Stimulus Bill, which included nearly $150 billion for healthcare. Of this, $36.5 billion were allocated to health information technology, and most of that was targeted to electronic health records (EHRs), a.k.a., electronic medical records (EMRs). EHRs are computerized records of patient medical histories that track information about physicals, office visits, medical diagnoses and treatments.

In the not-so-distant future, electronic health records will be widespread and will establish the foundation for developing a national disease registry (NDR). NDRs are centralized, disease-specific databases used to study medical treatments and the quality of their outcomes. Carefully developed NDRs offer reliable, unbiased data for analyzing and determining “Best Medical Practices.”

National disease registries create opportunities for improving health care quality and reducing medical costs. For example, small medical groups--traditionally without access to large medical record databases--could use NDRs to examine nationwide medical data and identify the most effective treatments. In turn, patients could receive faster, more effective care, while eliminating the cost and pain associated with slower, less effective measures.

Breast cancer research is another example. This research originates in urban academic centers where demographics are drawn predominantly from urban residents. Many suburban hospitals do not participate in the research, so it is nearly impossible to examine a broader sweep (e.g., a population group that includes suburban residents). Broader study groups will expand our body of medical knowledge. (Britt Berrett, Ph.D interview excerpt from EMR documentary)

Comparative Effectiveness Research

The Stimulus Bill also allocated $1.1 billion to “Comparative Effectiveness Research” (CER). With CER, medical researches compare treatments and determine which work best for individual patients who have specific medical problems.

Although the medical community has engaged in such research for years, our current databases do not represent nationwide demographics. Instead they reflect the experience of subgroups. The data is biased because it includes some population groups while excluding others. Experts agree it’s dangerous to assume that information extrapolated from subgroups necessarily applies to all groups.

The major databases and research presently available have taken years to develop. Additionally, use of the data is restricted to a few centers. Further, they do not provide large enough samples to indicate best treatments for all patients. A database that incorporates a nationwide population of data would facilitate previously inconceivable medical analyses. By grouping patients according to treatments, and a variety of their individual attributes (age, gender, birthdates, etc.), we could better compare treatment outcomes and decide which are the most effective for different populations.

NDRs also could help identify rare diseases, recognize early stages of infectious epidemics, and better assess new treatment effectiveness.

The Tradeoff--Medical Effectiveness vs. Individual Privacy

It’s time Americans understand we are trading off improved medical care and higher medical costs for “privacy.” How many would be willing to trade some personal privacy for a better, less costly medical system? The Congressional Budget Office has estimated that $700 billion could be saved annually by identifying best treatments, but U.S. privacy laws inhibit healthcare facilities from sharing patient information with each other. (The Clinton administration proposed using a national patient identifier, but it was not accepted due to privacy concerns and loss of control of proprietary medical information.)

“De-identified Data” is the present standard applied to data used by medical researchers. This means that all information which could identify an individual is removed before it is sent to a centralized disease registry. De-identifying data complicates the evaluation of treatment effectiveness, resulting in less reliable assessments. In turn, the U.S. government’s and its citizens’ healthcare dollars are not spent effectively and we are not getting the best care possible. Considering our ever-increasing healthcare costs and ongoing concerns about quality medical care, many believe this is not acceptable. We simply cannot establish best practices without sufficient data.

To engage in more sophisticated analyses of clinical decision-making, a structured terminology is needed, e.g., a master person patient index (MPI), which is much harder to develop after data is de-identified. (Duwayne Willett, MD interview excerpt from EMR documentary)

From http://healthinformatics.wikispaces.com/Master+Patient+Index, the “Master Patient Index (MPI) is a database that maintains a unique index (or identifier) for every patient registered at a health care organization. The MPI is used by each registration application (or process) within the HCO to ensure a patient is logically represented only once and with the same set of registration demographic / registration data in all systems and at an organizational level. It can be used as enterprise tool to assure that vital clinical and demographic information can be cross-referenced between different facilities in a health care system. A MPI correlates and cross-references patient identifiers and performs a matching function with high accuracy in an unattended mode. A MPI is considered an important resource in a healthcare facility because it is the link tracking patient, person, or member activity within an organization (or enterprise) and across patient care settings.”

As we move to nationwide, electronic records and debate solutions for lowering health care costs and providing better care, Americans must consider the value of a national registry.

This article is drawn from material in the EMR documentary produced by Metamorphoses Productions. The documentary is available for $19.95 at http://www.emrd-ndr.net/.

Additional information about Metamorphoses Healthcare, a non-profit organization, is available on Facebook and Twitter:

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