Go ahead… take a bite…

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Over a year ago, a Saint John based I.T. professional voiced serious concerns about the approach taken by the New Brunswick Medical Society to establishing its provincial EMR monopoly.

In his prescient comments to CBC reporter Jacques Poitras in January, 2013, Stephen Alexander questioned the wisdom of adding an extra-layer of business management to the mix with the creation of Velante.

Time has borne out his predictions.

Doctors, for the most part, have roundly rejected the monopoly approach, and have expressed shock upon learning of the exclusionary Data Sharing Agreement, the secret document designed to cripple any potential competitors.  At last word, only 34 of the province’s 1600 doctors had started using a limited version of the software more than a year after the program was announced.

We should consider ourselves very fortunate that uptake of the Velante program has been so sparse.  If it had been adopted by all eligible New Brunswick physicians, the cost to taxpayers would have been a whopping $19,000,000 in the first year alone.

Velante Worries Run Deep

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The shape of things to come…

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The Minister of Health announced today that his department and the New Brunswick Medical Society have agreed upon a new contract for New Brunswick fee-for-service doctors.  No details are available at this time and the agreement will not be in force unless it is ratified by the affected physicians.

I have never had much luck predicting the future, but that doesn’t stop me from trying.

Here’s how I expect it will play out…  figures are approximations only.

There will be no raise in the new contract.   There will be a one time offer of $16,000 for any doctor who signs on with the Velante EMR program.   NBMS will pitch it as a clever way to extend the handout previously offered via the Canada Health Infoway.   They will claim it amounts to an effective 4% increase over each of the two years of the contract, assuming average gross billings of $200,000 ($8000/$200,000 x 100 for two years).  Those who have already qualified for Infoway funding will get nothing (but who cares, they are already caught in the web).  Those who refuse to switch EMRs will also get nothing and will be deprived of the fee increase they might otherwise have received.

From the Velante perspective this is brilliant.   It effectively extends the “pot o’ gold” for another two years and presents doctors with a choice of getting nothing, or getting a handout for buying the Velante product.  It is even possible that the government will get sucked into paying the money up front for any “enrolled” physician, where it can be invested, or used to pay the Velante staff, or incrementally doled out as the sales folk continue to badger more people into signing on.

From the DOH perspective it is also brilliant.   It gives the illusion of offering something of value to doctors.   However, the underlying DOH assumption is that doctors didn’t like Velante before, and they won’t like it now.   DOH will end up paying virtually nothing because very few fee-for-service doctors will buy into Velante, and the DOH will have neatly and effectively dodged any fee increase for doctors.

The only people who won’t like this scheme are doctors.    We have already determined that the Velante plan is doomed and physicians don’t like having it crammed down their throats.  Doctors will be left with the equally unappealing prospects of getting 0% and 0% on the contract, or reaching for the cash and buying into an EMR program we don’t like and don’t want.    If we complain we will be painted as not being team players, or moneygrubbers.

Nice.

If this, or something close to it, is the deal that is offered, doctors should vote it down and send both parties back to the drawing board.

The fee-for-service contract must not be linked to the EMR program.   They are separate issues and the provisions of the former must not be used to coerce doctors in to accepting the latter.

Aurum-taxis…

Gold

In 1990, after I’d returned to the University of New Brunswick to upgrade my postsecondary education I had a decision to make. Would I continue along the path I was on which led to postgraduate work in plant genetics?  Or would I throw in the towel, give up any hopes of earning a PhD, and apply to medical school?

I mulled it over, as I worked in a plant genetics lab for the summer, sneezing and wheezing in the stifling 40°C humidity of the acquatic plant greenhouse on the roof of Loring Bailey Hall.    I had not realized until that point how annoying environmental allergies could be.    The pollen of Zizania aquatica, A.K.A. wild rice, had me working with a respirator in no time flat, and gulping antihistamines like they were going out of style.  Maybe that is ultimately what tipped the balance in favour of the medical career.

I wrote my MCATs, applied to a few medical schools, was accepted by Dalhousie, and decided to take the plunge.   I announced it one day to the assembled crew at the Biology Department coffee room.   Congratulations all around.  I was feeling pretty pleased with myself, but also a bit guilty that I would soon part ways with the congenial group of academics and technicians that prowled the halls of the “Old Bailey.”

That’s when Dr. Bong Yoo, senior botanist – and the closest thing the UNB Biology Department had to Yoda – spoke up with his take on my decision.

“Ah.” he said.   “I think Dr. Varty suffers from ‘aurum-taxis!”   Everyone got a good laugh.   We were all familiar with chemotaxis, the process by which organisms are drawn to or repelled by compounds in their vicinity.  The insinuation was that I would turn my back on basic research in order to “go for the gold.”

It wasn’t really that.   I was just tired of sneezing repeatedly into a close-fitting respirator.   You don’t really want the details, do you?

Going for the gold.   When it comes to Olympic hockey, we expect nothing less.   And when we get the gold, boy, do we feel good.

Doctors are sometimes characterized by their non-medical peers as being motivated by the promise of a fat pay check and a comfortable lifestyle.   I certainly would not complain about how I am compensated for the long days I put it tending to the medical needs of my patients.   But I think it would be unfair to suggest that we are only in it for the money.   Most doctors I know are extremely dedicated – some would say to a fault – to their profession.   Our medicare billings are offset by expenses and the effective hourly rate we receive is significantly lower than what you might expect, when all the hours of paperwork, research, and office administration are factored in.

Still, there are those that believe that aurum-taxis can be used to manipulate our behaviour.   Take Velante, for example.   There seems to be a belief that an unpopular software package can be foisted upon the medical community by simply sweetening the pot with a big cash handout.

Wait a minute, slick, it’s not that simple.   We are not that simple.

Doctors know that an EMR is a big commitment.   We talk amongst ourselves.   We hear stories about EMR successes and failures, and we trust what we hear from our colleagues.  We know that purchasing an EMR system is a serious decision, and the decision should not be rushed.

What we don’t trust is a fast-talking, high-pressure salesperson, fresh from a holiday in Cuba, smiling, and holding out a bag of lucre.

How dumb do you think we are?

Charting a course…

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The following is a commentary I wrote and which the Daily Gleaner published on March 15.  I wrote it after reading a letter to the editor  from a discouraged 71 year old woman who has not been able to find a family doctor.  This is an all-to-familiar scenario in New Brunswick, where billing numbers are tightly controlled by the same Department of Health which is simultaneously flinging the doors open to a rag-tag collection of alternative health care providers, who all seem to think they can do the work of a doctor, but without undergoing the tedious process of actually training to be one.

Meanwhile, an army of clipboard-carrying experts think they have found a solution to our health-care woes and seek to unleash it upon the public in the form of collaborative care clinics.

It’s the flavour of the month, but I’m not buying it.

Improving Health Care – One Patient at a Time 

Last week I called Mary MacLennan and told her that if she is willing to come to my office, I will be her family doctor.  

On March 6 the Gleaner published Mary’s letter describing her frustration with being unable to find a family doctor in our city.  That she finds herself, at age 71, in this predicament is a shame – an embarrassment to our province and our medical community.  No one should have to beg to get proper medical care.

I have over 3000 patients.  I’m not looking for more work.  But her letter touched a nerve.

There are thousands of people in New Brunswick who do not have a family doctor.  Without one, there is no one to quarterback the team, no one to steer the ship.

One of the reasons for the looming shortage of family doctors is the ongoing erosion of the traditional role of the family physician by the process of “primary health care reform.” 

Pharmacists wish to diagnose and treat common minor illnesses.  Nurse practitioners boast “the mind of a doctor, the heart of a nurse.”  Walk-in clinics have ballooned in recent years, treating primarily minor ailments and referring anything more serious to our already overcrowded emergency departments.  Naturopaths,  osteopaths, practitioners of “holistic medicine,” and others also want in.

While many of these practitioners have a role to play in healthcare, and may be quite good at what they do, they are nonetheless having a significant impact on the viability of traditional family practice.  Here’s why: most family physicians work on a fee-for-service basis.  We are paid a flat fee for each patient seen.  An office visit with a five-year-old with a sore throat pays the same as an 84-year-old fellow with six serious life-threatening diseases, 20 medications, who needs referrals to four different specialists, a disability parking pass, monthly bloodwork,  and whose medical file is three volumes, and 6 inches thick.

Like any small business, we have to pay our rent, heat, lights, hydro, office supplies, office insurance, salaries, benefits, parking fees, and taxes.  On top of that we also need disability insurance, malpractice insurance, professional dues, medical supplies, and have to set money aside for retirement.  

The net effect of “collaborative care,” is to skim off all the quick and easy visits which offset the lengthy and complicated encounters.  The balance has been lost.   Family practice is increasingly centred on complex, long-term care of serious illnesses.  Is it any wonder that new doctors are choosing to work in other specialties?

Collaborative care has been ballyhooed as a cure-all for healthcare in many parts of the world. I see it differently.  I see it as a pricey, second-rate alternative to traditional family practice.  We don’t need collaborative care clinics.  We need more family doctors.

Those steering the ship need to take action to avoid a looming disaster in primary care. Remove the restrictions on billing numbers.  Stop the ongoing erosion of family practice.  Pharmacists should be pharmacists.  Nurses should be nurses.  Family doctors should be family doctors. Period. Eliminate the barriers to new physicians who want to move here. Invite them to visit and see what New Brunswick has to offer.  Bring back the incentives for those wishing to set up a new practice.  If we want to fill the existing vacancies, we need to compete with other jurisdictions for the ever-shrinking numbers of new family doctors.

Everyone loves to go on and on about “patient centred care.” The plan to reform primary care is not patient centred.  It is centred on cost reduction.  Sadly, it is a flawed model which has failed elsewhere and is likely to fail here as well.  It won’t improve health care outcomes, and it will cost a pile of money before anyone realizes what we have gotten ourselves into.

The problems of healthcare in this province run deep and are intimately intertwined with New Brunswick’s financial difficulties.  Our population is growing older and more unhealthy with each passing year.

I am willing to help in my small way by offering to add Mary to my patient roster.   

The best value for your money in healthcare in this province is the care provided by family physicians using the traditional fee-for-service model.  It needs to be strengthened and improved, not relegated to the dustbin.

Not ready for primetime….

Bank

Judging from the following article, republished from Medical Economics, the American experience with EMRs has been less than thrilling.    The sobering statistics from south of the border are more evidence that physicians should not rush into making the switch to digital records, but should instead carefully research the cost and functionality of each of the many products on the market.

While it may seem to be attractive to go with the system being promoted by the New Brunswick Medical Society, it may not be the best fit for your practice, and the long-term expense of the system may overshadow the benefits of any start-up handouts being offered.

Prudence, caution, and careful forethought should be the watchwords of the day.

Physician outcry on EHR functionality, cost will shake the health information technology sector
Publish date: FEB 10, 2014

Despite the government’s bribe of nearly $27 billion to digitize patient records, nearly 70% of physicians say electronic health record (EHR) systems have not been worth it. It’s a sobering statistic backed by newly released data from marketing and research firm MPI Group and Medical Economics that suggest nearly two-thirds of doctors would not purchase their current EHR system again because of poor functionality and high costs.

Click here to view a slideshow of the charts and data tables from Medical Economics’ exclusive EHR survey

In a surprise finding, nearly 45% of physicians from the national survey report spending more than $100,000 on an EHR. About 77% of the largest practices spent nearly $200,000 on their systems.

While physicians can receive $44,000 through the Medicare EHR Meaningful Use (MU) incentive program, and $63,750 through Medicaid’s MU program, some physicians say it’s not nearly enough to cover the increasing costs of implementation, training, annual licensing fees, hardware and associated services. But the most dramatic unanticipated costs were associated with the need to increase staff, coupled with a loss in physician productivity.

“We used to see 32 patients a day with one tech, and now we struggle to see 24 patients a day with four techs. And we provide worse care,” said one survey respondent.

While some physicians cited benefits of accessing patient data, availability of practice metrics, and e-prescibing conveniences for patients, most physicians do not believe these systems come close to creating new efficiencies or sharing data with multiple providers or improving patient care.

In fact, when doctors were asked if their EHR investment was worth the effort, resources and cost, “no” was the reply given by nearly 79% of respondents in practices with more than 10 physicians.

Medical Economics’ survey results, based on responses from nearly 1,000 physicians, were corroborated by the findings of a January 2013 RAND Corp. study, detailed in Health Affairs, The New York TimesUSA Today, and other national media organizations, criticizing the usability and interconnectedness of current EHR systems.

“The failure of health information technology to quickly deliver on its promise is not caused by its lack of potential, but rather because of the shortcomings in the design of the IT systems that are currently in place,” says  Art Kellermann, MD, MPH, the study’s senior author and the Paul O’Neill Alcoa Chair in Policy Analysis at RAND.

Another 2013 RAND report, titled “Physician Professional Satisfaction and their Implications for Patient Care,” concludes that frustrations related to EHRs are negatively influencing physician attitudes about their careers.

Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction,” the report says.

Reality check…

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Physician time means nothing to programmers and policy makers

 | PHYSICIAN | MARCH 12, 2014

I have been a way from blogging for a a bit and tried to clear my head a bit with a vacation skiing.  I left the computer at home, disconnected (as best I could), and had the luxury of feeling the knees working less fluidly than they had before, but still had some fun for a brief 3 day stint.  It was nice to notice that there’s a whole world out there — beautiful mountains, fresh air, nice friends.  All things considered, I am pretty lucky to have a stable job, appreciative patients, and a fulfilling career.But it didn’t take long after my return to work for me to feel flooded again.  Two days after returning to work, it was like I never left.  Perhaps it’s like that for most busy folks, but somehow the world of health care delivery feels more frenetic than ever.  The inbox messages,  the mountains of results, the rescheduled patients on top of those already scheduled, the seemingly endless phone and e-mail messages, the late-night consults after a full day of procedures — all demanding time — it’s bordering on crazy.  I have several nurse practitioners who assist, but the volume of electronic patient care that’s happening now is overwhelming to even the most computer-savvy of us doctors.And all of this communication is not compensated.  There are no billing code for answering an e-mail.  There are no billing codes for speaking on the phone.  There are no billing codes for typing.  No billing codes for data entry and clicking a mouse.  Physician time means nothing to programmers and policy makers.

It’s a larger symptom, I think, of the new efficiencies built into the electronic medical record (EMR) that has become ubiquitous with the world of medicine today.  Information flies so fast and there’s so much of it that it’s getting almost impossible for doctors to keep up with the screen responsibilities, not to mention their care responsibilities.  The EMR is no longer just an EMR.

The EMR has morphed into  a scheduling agent, pharmacy, reminder pad, calculator, care pathway generator, instant messaging service, a procedure orderer-by-proxy (and guideline) and a patient messaging portal that, aside from a 400 character limit, provides unprecedented  access to physician in-boxes and schedules. There are so many buttons that they no longer fit on a single screen and the allergy field no longer can be displayed as it’s pushed out of the way by the name of the patient’s insurer.

Add to this the constant and growing influx of patients (thanks to marketing pushes and programs to spur referrals), voluminous administrative meetings, and growing CME requirements, it’s no wonder many of us feel flooded.  I work later than ever now thanks to these electronic efficiencies, then find myself waking in the middle of the night wondering: Did I call Ms. Smith? Did I miss something? Did I put that order in? When am I going to do those result notes?

I think I’m suffering from post-traumatic electronic overload disorder (PTEOD).

Oh sure, we could hire another guy or gal to offload some of the work — maybe even hire a wasteful manpower-intensive scribe like those that work in some ERs that click for cash – but that really won’t help stem the ongoing barrage of information that is now pummeling physicians and their care teams at an unprecedented rate.

Sadly, I don’t see this trend changing anytime soon — the business case for the EMR is just too attractive for hospitals and payers.  Still, with the prospect of ICD-10 and it’s 71,924 procedure codes and 69,823 diagnosis codes (that must be paired correctly lest doctors not be paid) just around the corner, I fear that physician stress, burnout and PTEOD will only increase as we are force-fed this diet of electronic overload without any reflection of what its doing to those who provide the care.

I need another vacation.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

The bottom line…

Bull

Representatives of the New Brunswick Medical Society have recently expressed profound satisfaction at the “enrollment” rates for the provincially sanctioned monopoly EMR program.

Taxpayers may not be quite so pleased.  Here’s why:

The Department of Health tells us 950 doctors are eligible to sign up for the program.    Using NBMS statistics, we know that approximately 25% of these are salaried doctors, the rest are paid by fee-for-service.

Eligible salaried doctors will pay nothing up front for their Velante EMR, and will pay no monthly fees, and they won’t have to buy paper, print cartridges, internet access fees, phone charges for fax lines, and so on.   The entire $24,000 to set them up will be paid by taxpayers.   Monthly taxpayer costs, including $395 paid directly to Velante, could easily total over $600 per doctor, maybe more.

Fee for service doctors will kick in $8000 each to get set up, and government will cover the other $16,000.

Take a look at what that will cost taxpayers for the first year, if Velante is successful in it’s plan to monopolize the market.

Salaried doctors:  237 doctors x ($24,000 startup + ($600 x 12 months)) = $7,394,400

Fee-for-service doctors: 713 doctors x $16,000 = $11,408,000

Total cost of the first year of the Velante monopoly to the taxpayer:  $18,802,400

Close to $19 million dollars.  In one year.  Paid for by your tax dollars.

Compare that with what my EMR has cost the taxpayers.  Zero.  Not a penny.

Not bad, eh?  Province-wide there are about 100 doctors who have done the same thing.  We’ve been doing it for years.   Our EMR’s reduce wasteful repetitive lab tests, ensure timely and effective follow-up of chronic illness, reduce medication errors, and improve the health of our patients.

All at no charge to to you.

So… explain to me again… how is the Velante system a good deal for New Brunswickers?