AAPS News – July 2008

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Volume 64, No. 7 July 2008


The biggest barrier to acceptance of the electronic medical
or health record (EMR/EHR) is said to be physician resistance.

Cost, of course, is one enormous barrier. Proposals to
“incentivize” physicians to adopt the technology focus on the
money: grants to buy the system, technical support, and rewards
for practice changes (“quality improvements”) that require
electronic data collection.

The recent
AAPS survey
, to which some 430 physicians responded, started
with the same questions asked by EMR advocates, but also explored
other barriers, which are even more important. Of the 82% of
respondents who do not currently use an EMR except for billing,
75% cited concerns for patient privacy protection; 71%,
disruptions to practice; 75%, third-party or government
interference with clinical decision-making; 77%, a link to
centralized government medical records; and 66%, potential for
linkage between EMRs and pay for performance. About 72% “prefer
personal clinical notes.” [Survey results are posted on www.aapsonline.org].

Unregulated Medical Devices

In a May 30 presentation to the AAPS board of directors and
in comments to the FDA, Pittsburgh cardiologist Dean Kross, M.D.,
noted that the FDA adopted rules for computerized systems as
medical devices in 1989, but these have not been enforced. An FDA
proposal to reclassify medical device data systems (MDDS) devices
from class III to class I devices, which have a reduced
regulatory burden but actually to enforce the rules led
to an outpouring of comments by worried vendors. (See
www.regulations.gov; search on “2007N-0484.”)

McKesson Corp. argued for excluding clinical data repository
systems and EMRs certified by the Certification Commission for
Healthcare Information Technology (CCHIT). Kaiser Permanente
recommended that “the final rule should exclude systems and
infrastructure serving multiple uses.” It is important that the
FDA “not disrupt current efforts to implement health information
technologies in clinical settings.”

Contrary to vendors’ assertions, HIT is far different from a
typewriter or a library, which are exempt from regulation, Dr.
Kross points out. And while it is widely assumed that HIT is safe
and efficacious, this has never been proven. The limited existing
studies have shown an increase in hospital length of stay, an
increased delay of more than 90 minutes in dispensing
medications, and an increased mortality in the one outcomes study
(Pediatrics 2005;116:1506-1512). In particular,
computerized physician order entry (CPOE) is “errorigenic,” Kross
states. A widely used CPOE system facilitated 22 types of
medication errors, which occurred weekly or more often (Koppel R,
et al. JAMA 2005;293:1197-1203).

Because HIT systems are experimental, human rights are
violated when used on patients without consent, Kross states.

Disruption of Care

A photograph from Dr. Kross’s hospital shows six workers,
presumably nurses, lined up facing portable computer
stations interacting with terminals, rather than with each other
or with patients. Sometimes they are searching for “hidden data”
from different MDDS devices, he says.

Workdays are longer, or fewer patients are seen or both
during “initial” implementation, concede EMR advocates Robert H.
Miller and Ida Sim of UCSF (Health Affairs, March/April
2004). The slowdown continues for months, or even years after EMR
implementation, they note. Both physician workflow and office
workflow must be re-designed.

Neither EMR hardware nor software can be simply used “out of
the box.” Instead, “physician practices must carry out many
complex, costly, and time-consuming activities to complement’
the EMR product.”

When complications from care disruptions caused by MDDS
failure or dysfunction occur, they are generally attributed to
“human error,” Kross states. But if it exists, “error is a
consequence of interaction with IT systems rather than a
cause of adverse events,” write Christopher Nemeth and Richard
Cook, commenting on the JAMA article on CPOE-facilitated
errors. Many HIT systems are multi-million dollar failures and a
continued threat to patient safety. “They are, in a word,
experiments” (J Biomed Informatics 2005;38:262-

IT designers don’t understand the demanding technical work
that clinicians perform, explain Nemeth and Cook. “Just beneath
the apparently smooth-running operations is a complex, poorly
bounded, conflicted, highly variable, uncertain, and high-tempo
work domain” (ibid.).

Technophobia does not explain physician resistance. “I have
been programming computers for more than 30 years, am very
comfortable with them, use them all the time,” writes one AAPS
survey respondent. “My opposition is…that EMR is really bad for
health care and will decrease the quality of care for patients.
How [can] I listen to a patient while I’m typing?”

The EMR does not permit anatomic sketches; using calipers on
the EKG tracing; viewing several EKGs or images at once; filing
children’s drawings; or easily expanding the note to include the
“oh, by the way, docs.”

“Our EMR is down sometimes; when it is, I’m the only one in
my practice who can function well. Because I’m the only one with
a paper chart!” writes one physician.

While some respondents do like their EMR systems, many write
that they will quit if forced to use one: “I would rather
retire…than put my patients’ medical records in a digital
format that could be hacked into by criminals, foreign hackers,
or government officials…” Loss of physicians or profound
changes in the thought processes of those who remain is one of
the uncounted costs of imposing the EMR experiment.

Data Insecurity

Theft. Computer files on more than 2.1 million
patients, including financial information and Social Security
numbers, were stolen from a storage company contracted by the
University of Miami Health Systems.

Leakage. UCSF Medical Center in San Francisco
acknowledged that information on 6,000 patients was available
online for 3 months. The leak occurred when information was
shared with Target America, which mines databases for information
on potential or existing donors (AM News 5/19/08).

Official Use. The FDA and unspecified “academic
researchers” will be given access to Medicare databases to
monitor prescriptions as well as laboratory tests and
hospitalizations (Buffalo News 5/23/08). “All of this
research will be performed on Medicare beneficiaries’ without
their express consent,” writes Dr. Lawrence Huntoon. “Apparently,
our government is following the recommendations of the Institute
of Medicine with respect to this surveillance system.'”

Online Records. Google Health service promises to give
users a free central storehouse for their medical records. In
addition to doctors and insurance companies, Google Health openly
says it may share a user’s information with subsidiaries or other
“trusted” companies who process personal information for Google,
the U.S. government, and merger or acquisitions partners (Mike
Adams, NaturalNews.com 5/20/08).

One reason many are moving to cloud computing for data
storage is that enterprise data security is like “a big gate with
no fence.” The biggest threat is not in the corporate warehouse
itself but in the endpoints of the network on the laptops, hard
drives, and flash drives of end users. More than 2 million
laptops are stolen in the U.S. every year, and 68% of thumb drive
owners have lost a device at some time. But can Google, or the
Internet in general, be trusted?

“To me it seems like an awful lot of trouble and at least a
little bit of risk for a modicum of convenience. Will having
these records on line really make me any healthier?… Will my
doctors make better treatment decisions for me?” (John Pallatto,
Ziff David Enterprise, First Read 5/21/08).

EHR Incentive Program Announced

CMS plans to spend up to $150 million over 5 years on a
project that would provide a bonus to 100 physicians in each of
12 selected communities (up to around $25,000 each/yr) if they
meet or exceed HIT benchmarks. The first year, they would be
evaluated on how effectively they use their EHRs [not on how well
the EHRs work]. The second year, they will be required to report
on a set of national quality measures. In years three through
five, they’ll be graded on whether they used EHRs to improve care
(HITS 6/11/08).

Independent, Informative EMR Websites

Dr. Kross recommends: Wachter’s World (www.the-hospitalist.org/blogs/), www.SEEDIE.org, www.extormity.com, Health Care Renewal, and www.e-healthinsider.com.

“The Devil…the proud spirit…cannot endure to be

St. Thomas More

Nominating Committee Report

The Nominating Committee presents the following slate:

President-elect: Hilton Terrell, M.D., Florence, SC

Secretary: Charles McDowell, Jr., M.D., Johns Creek, GA

Treasurer: R. Lowell Campbell, M.D., Corsicana, TX

Directors: Curtis Caine, M.D., Brandon, MS; Kenneth Christman,
M.D., Dayton, OH; James Coy, M.D., Punta Gorda, FL; Lee Hieb,
M.D., Yuma, AZ.

Bylaws Amendment

By petition of ten members, the following bylaws amendment
will be presented for assembly approval:

“Any board member may be removed from the board by a two-
thirds majority of the remaining board members.”

Is EBM Scientific?

In a May point/counterpoint, Martin J. Tobin, M.D., argues
that “evidence-based medicine” lacks a scientific foundation. He
notes that EBM grading is detached from scientific theory and
that EBM “confuses statistics for science.” Harm results from EBM
because “clinical medicine requires thoughtful reflection about
each individual patient, whereas graded guidelines encourage
reflexive action.” He writes:

At a metaphysical level, the EBM dream is
reminiscent of Marx’s well-intentioned hypothesis:
regulation of society based on scientism will guarantee
human happiness. The EBM version: clinical practice
based on grading of clinical research studies will
result in wiser decisions. Utopian projects aimed at
eradicating uncertainty and introducing universal good
have produced more misery than good fortune
(Chest 2008;133:1067-1077).

Medicine Is Not the Same as Counting

Would-be reformers assume that best practices can be
discovered through data mining, and that physicians can be
induced to implement these practices widely, writes Richard
Warner, M.D., Past President, Kansas Medical Society. Computers
seem to offer limitless possibilities. For 200 years “social
scientists have aspired to the precision and predictability of
the natural sciences. Interoperable medical record systems now
seem to offer virtual laboratory conditions through which the
health of populations can be improved.”

Pay-for-performance plans totally distort care. The criteria
for rewarding physicians are all countable events; they measure a
small fraction of what physicians do, and presume the correct
diagnosis has been made. “The participation of organized medicine
is being used as a cover to provide credibility and quell debate.
Physicians and their organizations should stop participating in
the development of [P4P] programs,” Dr. Warner writes (Kansas
, June 2007).

Data Mining for Fun and Profit

CMS and state Medicaid offices are turning to advanced
mathematical modeling and supercomputers to ferret out fraud and
mistakes. The huge data warehouse that New York State purchased
from Hummingbird, a Canada-based software vendor, has 5 years of
Medicaid data.

“It’s really fun to use,” said Medicaid management
specialist Catherine McCulskey. “We’ll never run out of areas to
look at…. There are so many services.”

She can put a million claims into a “cube” and instantly
drill down to the individual provider, finding obsolete procedure
codes, changed billing patterns, upcoding, unbundling, transposed
numbers, and more. Every morning she sits down at her desk and
starts clicking. “No mistake is too small to pursue.” And
every provider files false claims.”

Sometimes, McCulskey says, staff will call a provider and
point out a problem. “We don’t always go automatically with a
hammer to beat them.” Mistakes may not be prosecuted as fraud,
but providers must pay back any erroneous payments, say if they
missed a new guideline.

Data mining is expected to net tens of millions of dollars
in fraud and errors (Medicare Compliance Alert 6/2/08).

MCA tips: Be sure to time and authenticate every
entry in a patient’s record. Do not forget to document the site
of service. Watch out for patient whistleblowers; take every
claims question very seriously. Don’t count on the “claims
scrubbers” in your EMR to protect you; they are frequently wrong
or overzealous in recommending certain codes such as the 25
modifier. “You can’t put the machine in jail,” states attorney
Peter Keohane. “So who goes to jail?” (ibid.)

Keep a Muzzle in the Waiting Room

A proposed new rule prohibits marketing Medicare Part D and
Medicare Advantage plans in “public” locations in medical
facilities. Unless you have rules limiting vendors’ interactions
with your patients, and materials left in your waiting room, you
could be held responsible if prohibited solicitations occur on
your premises (MCA 5/19/08).

OK to Charge Uninsured More

An Illinois court ruled that a hospital can charge uninsured
patients more than third-party payers, without violating consumer
fraud law (Galvan v. Northwestern Memorial Hospital,
Ill. App. Ct., No. 1-05-3620, 4/14/08). The court held:

That an uninsured patient is charged a higher rate
for medical services is the flip side of the revenue-
stream coin. Those that have incurred the expense of
medical insurance guaranteeing payment to a medical
services provider receive reduced billing rates; those
that have incurred no expense to guarantee
payment…must bear the full cost for those

While Northwestern may have concealed information about its
rates and billing practices, the patient failed to allege that he
suffered any damages from the alleged concealment (BNA’s
Health Care Fraud Report 5/7/08).

AAPS Calendar

Sep 9-13, 2008. 65th annual meeting, Phoenix, AZ.

Sep 30-Oct 3, 2009. 66th annual meeting, Nashville, TN.

NPI Update

SSNs. The Social Security number is an optional field
on the application, and a physician need not provide it to the
National Provider Identifier System. The Medicare carrier,
however, cannot match the NPI to the CMS claims system without
the SSN. A physician who withheld her SSN from the NPI System out
of concerns about identity theft was sent a CMS form 855I to fill
out which requires an SSN. Interestingly, the carrier was able to
locate the physician in order to demand a refund on services
provided 3 years earlier.

Secondary Enforcers. Members are receiving letters, as
from hospitals, stating that none of their patients will be
accepted for admission or testing until the ordering physician
provides an NPI. Baptist Memorial Hospital of Memphis, TN, cites
the CMS website: “Many health plans, including Medicare, will
require NPIs to be used to identify some or all [rendering,
ordering, referring, prescribing, attending, supervising, or
other types of providers].” One physician found that he had been
assigned an NPI at the request of some other entity, which
presumably needed it to collect a payment. Simply having an
NPI or an SSN does not mean that you are required to provide it
in all circumstances.

The Real Y2K? At the time of the May 23, 2008, extended
deadline for NPI compliance, providers were still unprepared. A
review of a sample of 10 million claims over the week of Apr 28
by Emdeon Business Services found that 7% would be rejected for
lack of an NPI. When identifiers were required for secondary
providers, about 30% could not meet it, translating into $1.1
billion in lost reimbursements. When other claim and service
level providers were included, the noncompliance rate rose to 69%
and lost payments to $2.5 billion. This could lead to a
“significant cash flow issue for providers” (iHealthBeat
5/15/08). In the worse-case scenario, physicians might refuse to
care for certain patients until payment is received. Full NPI
implementation “might be the real Y2K” or “nothing might happen,”
said Walter Suarez (iHealthBeat 5/22/08). On May 23, 24%
of Medicare claims were rejected, compared to the usual 6%, most
commonly because old numbers were used to identify secondary
providers (McKnight’s LTC News 6/5/08).

Physicians Protest Recertification

Elizabeth Lowenthal, D.O., and Susan Ferguson, M.D., of
Alabaster, AL, are circulating a petition to the American Board
of Internal Medicine, stating that time-limited certificates and
recertification “create a separate but unequal status among
equally qualified physicians.”

“There is no useful purpose…for the enforcement of these
policies which constitute a waste of time and money for all
physicians certified after the arbitrary time-line of 1990. In
today’s hostile credentialing and medicolegal environment, we, as
a profession, can no longer tolerate the implication of
inferiority to those who grandfathered in.’ From henceforth we
request that all time limitations on the certificates of duly
qualified physicians be removed.”

Texas plastic surgeon Terry Tubb, M.D., notes that academic
physicians and specialty boards desire income and control over
private practitioners, through recertification. He suggests
bylaws changes that prevent specialty societies from claiming as
“official” any positions not approved by members.


The White Coat Makes the Doctor. Pennsylvania thinks
all of these cost-containment schemes such as pay for performance
are just way too complicated. So, it has decided to get at the
heart of the problem. If cost containment is the goal, who needs
doctors? Gov. Ed Rendell promised to “revamp health
care…starting with a change in regulations that restrict care
by nurse practitioners.” Stating that “we need to look down the
barrel of special interests,” he proposed to “mete out pain to
everybody in the health-care delivery system everybody.”

“I want to free nurse practitioners to do anything they are
capable of doing,” he said. “Studies show that [they] can handle
70 percent of what doctors do” (Phil Inquirer 12/12/06).

Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY

Medical Boards. I am following the news on the AAPS
lawsuit against the Texas Medical Board (TMB); the Louisiana
State Board of Medical Examiners (LSBME) has exactly the same
modus operandi. Physicians should understand that current medical
boards are very different from the old ones. The boards are no
longer in the business of medical quality assurance. They have
become virtual factories manufacturing disciplinary actions. Like
any plant in a mass-production market, they have minimal
production quotas. The percentage of bad physicians among
licensed ones really doesn’t matter. The TMB has to punish an
arbitrarily selected percentage [see AAPS News, January
2008]. If there are not enough bad doctors, the Board will simply
discipline some good ones. Why then even bother with
investigations? Let’s organize a state lottery and randomly
assign disciplinary actions.

Walter P. Borg, M.D., Lafayette, LA

The Trouble with “the” EMR. What is so tiresome about
the politics of the electronic health records (EMR) discussion is
that they are always all or none. In some cases, web-based
records are terrific: a woman I know cares for her adult severely
disabled child who requires help for everything. If she travels,
or Medicaid makes errors, or there’s a new clinic physician or
new home attendant, she can have all parties access her child’s
web-based record. She pays a company to maintain it. An emergency
physician tells me the biggest problem for him is finding out
what drugs an elderly patient is on: a limited on-line
prescription record and limited permission would serve. But most
people probably don’t need records available except at home under
the bed.

But instead of limited, problem-focused goals, we have to
have one gigantic electronic system for everything, even though
there is No Such Thing as a secure online record, and nobody has
a clue about the cost/benefit ratio. And even though almost no
working system anybody can think of was designed top down most
evolve from early adopters to wide use, exactly the opposite of
what devotees of EMRs propose.

Linda Gorman, Ph.D., Independence Institute, Golden,

Barriers to EMRs. I don’t accept the self-fulfilling
prophecy that the “train has left the station,” so we’d better be
on board. If EMRs really served patients well, they’d already be
here. But they are chiefly being used to feed data to third
parties so central planners can decide who deserves payment and
care. They are not like the commonly cited market examples, such
as credit cards and ATMs, which benefit the customer directly.
They “will” happen as proposed by third parties (for
their benefit) not because of consumer demand but only
if mandated by government [see AAPS News, April 2008, for
Obama plan].

Besides the costs, there is the obvious problem with
confidentiality. As reported in the St. Petersburg
, a WellCare worker removed security protections,
making data on 71,000 Georgia Medicaid recipients accessible on
line at the click of a mouse.

David McKalip, M.D., St. Petersburg, FL

“Extormity Knows Best.” When you hear any deep-thinking
politicos talking about the EMR as though it is some sort of
panacea for American medicine, think about this website, www.extormity.com. It is
unfortunately all too true. You don’t know whether to laugh or
cry. It explains why we are seeing such low adoption rates for
EMRs. [The name, “created for several hundred thousand dollars by
a West Coast brand identity firm,” combines the roots
conformare and extorquere.]
Russell W. Faria, D.O., Newport, OR

Public v. Private. One proponent of government-funded
medical care stated that “governments do not go out of business
leaving taxpayers holding the bag.” Exactly. Government agencies
never go out of business, no matter how corrupt,
inefficient, or harmful their activities are. The agencies
usually blame their problem on not having enough money, so
taxpayers aren’t “holding” the bag, but constantly shoveling more
money into it.

Greg Scandlen, Consumers for Health Care Choices

Unbelievable. What physicians put up with is so
unbelievable that lay people do not accept how it could be
possible. When I first tried to explain to Texas legislators (who
were businessmen) that Texas Medicaid was paying physicians less
than half of what it cost to provide care, they laughed in my
face and claimed that I was lying, because they did not believe
that any physicians would ever take Medicaid if they did so at a
Donna Kinney, CPA, Texas Medical Association

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