Beyond common sense…

ICD 10

One of the benefits of increased uptake of electronic medical records often cited is the ability for government to “mine” massive amounts of health care data.    By analyzing raw data about disease prevalence, testing, treatments, and resource utilization, the hope is that increased efficiencies may be found within the system, allowing us to cut costs and decrease the overall health care costs in this province.

The New Brunswick Medical Society has published a predicted savings of $6,000,000 (presumably per year) through wider adoption of EMR systems.   How and where this savings will be realized is not clear.  Assuming that the quoted figure is based on proper research and statistical analysis – and not just pulled out of a hat – it’s no wonder people are starting to take notice of EMRs.

The generally held belief is that in order for data to be “mined” effectively, clinical diagnoses need to be coded, most likely using the International Classification of Disease method.    The one in use at this time is known as ICD-9, but ICD-10 is coming, and its planned introduction in the United States is creating quite a stir.

Why?  Well, while ICD-10 coding may be a dream for the bean counters, it is being widely panned by the people of the front lines of medicine.   It includes some 68,000 individual service codes, and for each clinical encounter, physicians south of the border will be required to figure out which code applies, or they won’t get paid for the work they do.

It can go to ridiculous extremes, as you are about to see.

Take a look a the following explanation, extracted from the excellent blog KevinMD.com:

 

ICD-10 will accelerate the demise of private practice

You won’t read about the International Classification of Disease (ICD) on TMZ or hear it discussed on The View, but it has the potential to be an unpleasant October surprise in the healthcare world. It is a list of codes that physicians and hospitals use when billing insurance companies. These codes cover all manner of medical diagnoses for diseases, conditions, and injuries.The first version of ICD appeared in 1946 with periodic revisions since. Six months from now, on October 1, the latest version, ICD-10 was supposed to be implemented in the US. We are late to the party, with other countries implementing this over the past 15 years.  ICD-10 has already been delayed for a year, but the administration promises no further delays. But similar to other promises, this may be another “never mind.” Congress voted for the 17th time to delay the April 1 SGR cuts, and attached a one year delay in ICD-10 implementation to their bill.ICD-10 is not the fault of Obamacare nor is it Bush’s fault. Instead this classification even preceded Bill Clinton.  So this is not a partisan issue. Instead it is an issue of complexity, arriving in the wake of the largest healthcare overall in history with its attendant chaos and confusion. The current version, ICD-9 uses a 4 or 5 digit number to code for a particular disease, such as 540.9 for appendicitis. ICD-10 will have up to 7 alphanumeric characters to specify a condition such as S52.521A for “Torus fracture of lower end of right radius, initial encounter for closed fracture.” And there are now over five times as many codes for doctors and hospitals to choose from. But isn’t specificity better? Sure it is. Big data is the new frontier in medical research, making sense of the huge amount of generated healthcare data. But can this go to far?In an effort to push specificity to the limit, some ICD-10 codes have gotten silly. Codes exist for being hurt at the opera (Y92253), walking into a lamppost (Y92253), walking into a second lamppost (W2202XD), getting sucked into a jet engine (V97.33XD), or being burned due to water skis on fire (V91.07XD). But this is not the Achilles’ heel of ICD-10.

First, medical practices and hospitals must know and have all of these 68,000 codes readily available to add to the medical record in order to bill correctly and hope to be paid. One more distraction for physicians, aside from all of the daily distractions of electronic records. When physicians pay more attention to their computer screen or tablet than to the patient, guess who suffers? This is the reason why texting and driving is illegal.

Second, electronic medical records (EMRs) must be able to incorporate these codes into the exam or procedure report. Are all EMR vendors up to speed on these codes? Will their system upgrades work as advertised? Or will they work as well as the Healthcare.gov website? And if the codes don’t work, physicians and their practices don’t get paid. Yet landlords, employees, and utility companies still want to be paid.

Third, will the insurance companies recognize each of these new 68,000 codes, correctly match them to billed procedures, and promptly pay the providers? If I treat a patient with macular degeneration with a monthly dose of a $2000 drug, I now bill a single code, which insures I will be paid. Under ICD-10, there will be 20 codes, specifying which eye(s) and severity, which allow payment. Will every insurance company have each of these codes in their computers? Will it recognize each code? Remember that these are the same insurance companies that don’t even know who hasactually paid their insurance premiums.

The American Medical Association announced that ICD-10 implementation will cost three times as much as originally estimated. The  “costs of raining, vendor and software upgrades, testing and payment disruption” could be  $225,000 for a small medical practice and over $8 million for a large practice. How do medical practices of marginal profitability absorb these costs? With physician reimbursement rates set to grow at only1/2 percent per year over the next five years, far below the true rate of inflation, of close to 10 percent, the financial writing is on the wall. This will accelerate the demise of private practice, already underway due to Obamacare. When ICD-10 is eventually implemented, “The doctor is in” may be a phrase of historical interest only.

Brian C. Joondeph is an ophthalmologist and can be reached on Twitter @retinaldoctor.

Presto! Change-O!

Bunny

In a nifty bit of sleight-of-hand the people responsible for the tentative fee-for-service contract being offered to New Brunswick’s doctors have pulled another somewhat bedraggled bunny from the hat in support of the provincial EMR monopoly.

Within days of the end of the juicy cash handouts to Velante clients – courtesy of the Canada Health Infoway – the proponents of the exclusive Velante/Department of Health electronic medical records scheme have come up with a clever way of offering even more taxpayer money to Velante conscripts.

Buried on Page 10 of the 21-page Tentative Fee-For-Service Contract, is the puzzling Section 26, which states the following:

Effective April 1, 2014, in an effort to support early adopters who wish to switch to the Provincial EMR (Velante) and to help off-set enrolment costs and monthly license expenses for FFS physicians, the parties have agreed to an Electronic Medical Records Protected Funding Pool of $1.5 Million (recurring) to support the Provincial EMR Program (Velante).   Any unused funds will be retained by the NBMS to support EMR adoption through the Provincial EMR program.

It’s puzzling because this clause has NO PLACE in an agreement which, by its very name, is intended to address how doctors are compensated for the work they do.    It doesn’t belong in this agreement.   It should be part of a separate deal, and should be voted upon independently by the general membership.

The fact that it is buried in the middle of a fee-for-service contract says to me that those pushing the Velante monopoly are admitting, once again, that the business plan they have devised cannot stand on its own merits, and requires an ongoing infusion of taxpayer money to preventing it from collapsing under its own weight.  Cleverly, they are going to embed this latest nugget in an agreement which will see doctors receive fee increases of 4% over two years.

The overwhelming majority of doctors don’t have EMR’s, so Section 26 matters not to them.   What most physicians will see is that, after being handed 0% and 0% over the last two years, 4% looks pretty good.   And it is.   And that’s why the agreement will be overwhelmingly ratified by the province’s doctors.

When it is, the $1.5 million dollars per year will effectively land on the lap of Velante to use “to support EMR adoption throughout the Provincial EMR program,” whatever that means.

To me, it looks very much like another needy, greedy corporation – unable to compete in a free market – coming to the government with its hand out saying “Please, may I have some more money?”

And now, Velante is going to get it… in spades.

This slippery bit of prestidigitation is annoying enough by itself, but when you consider the role of the Department of Health in forging this contract, it really becomes galling.    The logic fails me.   How can a government, on the one hand, claim to support a free-market economy – one of the hallmarks of conservative ideology – while simultaneously pumping millions of dollars in the direction of one particular EMR vendor?

Enough.   It’s a mugs game.  The cards have been stacked and the outcome has been predetermined.

New Brunswick appears to be destined to be saddled with an exclusionary, second-rate EMR monopoly, and taxpayers are going to be ridden into the ground.

And there is not a damn thing you can do about it.

A worthy cause…

Hospice

It’s time again to take a break from the ho-hum inertial world of electronic medical records to contemplate the bigger questions of life and death.  In particular… death.

Few people are comfortable talking about death.   It’s a topic which most of us would rather sweep under the rug. I see this every day in my medical practice, when I try to raise the issue of advance directives and end-of-life care.   Most people would rather just change the topic.

Yet death is something we will all face.   We need to talk about it and think about it while we are able, and have the  opportunity to do so.  There are a few people who have thought about this in great detail, and have formulated a plan for their own end-of-life care.   Some have been denied that option, with death coming suddenly and unexpectedly, by accident, catastrophic disease, or violence.    Others have been robbed of the chance to choose how they will be cared for as they are dying by insidious diseases like any of the many forms of dementia.

Fortunately, in many communities there are people willing to meet death head on.   In Fredericton, we have Hospice Fredericton, and our (relatively) new palliative care medical specialist Dr. Debra Gowan.   Together, they are putting end-of-life discussions, planning, and infrastructure development on the front burner, and we need to thank them for it.

If you have not heard about Hospice Fredericton, take a listen to this:

Hospice Fredericton on CBC

Hospice Fredericton needs your help.  I have donated to this very worthy group in the past, and intend to do so  again.   And I have a plan which, if it can be actualized, will provide a much needed infusion of cash to help with the purchase and refurbishment of Rosary Hall, making it the 10-bed focal point of the program.

So, you may be thinking, are you not going to say anything about EMR’s this time?

In fact I am.

In the new fee-for-service contract developed by the New Brunswick Medical Society, there is a promise of $1,500,000 per year to support the provincial EMR program.    This will be coming from the budget of the Department of Health.   There are many doctors who are already using EMRs, and have not required any government handouts to make it work.    There are many others who don’t have any interest in using an EMR.

I propose that any physician who does not need or intend to ask for EMR money from the government write to the NBMS and ask that their share of the money be redirected to Hospice Fredericton.    I have already done so.   Here’s how I put it to the CEO of the NBMS:

Dear Mr. Knight,

I see in the new FFS contract there is a provision for $1,500,000 to encourage the adoption of EMR technology.   With 950 doctors eligible for the provincial program, that would make my share approximately $1578 per year.

Since I am already using an EMR and am happy to continue to pay for it on my own indefinitely, I would like to have my share of the available funding donated to the Hospice Fredericton program, to support end of life care in my home region.

Once the contract is ratified, please have the cheque mailed to:

Hospice Fredericton
P.O. Box 802
Fredericton, NB
E3B 5B4

Thank you for your assistance in supporting this very worthy cause.                                                                                                                         

Now, I expect the nay-sayers will come up with some sort of procedural excuse for why we can’t do this.

But wouldn’t it be great if we could!

An oldie, but goodie…

Image

Velante:  “Hey doc!   How would you like to use our EMR software?   We REALLY want to establish our monopoly.   We’ve got $1,500,000 to give to you and your buddies every year just for signing up!

Physician:  “Sure!   That sounds great!”

Velante:  “How about if we forego the handout of taxpayer money, and you just pay for the system out of your gross revenue from Medicare billings?”

Physician:  “What!   Do you think I’m an idiot?”

Velante:  “We’ve already established what you are.  Now we’re just haggling over the price.”

Setting the record straight…

Bad!

I received yet another public scolding from the leadership of the New Brunswick Medical Society recently.  It really is getting a bit tiresome.   “Sit down and shut up” might have worked well for badly-behaved elementary student in the 1960’s, but this is 2014, I am 56, and it’s not working at all for me.

Here’s what Dr. Hansen had to say on March 18:

Provincial EMR program in the news

I was pleased to take questions from the media about our EMR program. With over 250 physicians already enrolled for the program, I believe it is quite likely that we will hit the Department of Health’s estimate of 300 physicians in our first year of operation, which is quite an achievement. The Minister of Health has recently stated that he is open to renegotiating several elements of the Program, which is good news. We look forward to addressing some challenges with the Program with the Department of Health while we move forward with dozens of implementations over the next months. Velante is already the largest EMR provider in the province. Members are reminded that there are only two weeks left to enrol!

I must say that I am personally disappointed at some of the criticisms of the program and more directly, public attacks against the leadership of the NBMS. Some have gone to the media without voicing their concerns to us first; others have made claims that are inaccurate in public fora. There are legitimate concerns about this new and fast-paced program, and some have been raised in proper forums for informed discussion and debate. Some members will not choose to adopt the Velante program, and that is an understandable decision. But to be clear, the EMR program is similar to those in other provinces; costs taxpayers a fraction of some estimates made by members in the media; and no patient’s health information is being kept from any health provider. We look forward to discussions with the Department of Health to improve the program and will endeavour to better explain the Program’s details to members.

Lets just set the record straight on a few issues which seem to be a bit off the mark in the latest President’s Letter from the NBMS and in the imbedded links in the original document:

1)  Velante is NOT a physician-run company.   It has a seven member board of directors.   Two of the directors are doctors.   Three are Accreon executives, one is the CEO of the NBMS (who is NOT a doctor), and one is a UNB business professor.  That’s the way it was in October.   Correct me if I am wrong.

2) I did not go “to the media.”  They came to me.   I turned down invitations for interviews twice before Minister Flemming came out with the news that Velante was failing to meet conscription goals.

3)  I DID go to the NBMS multiple times with concerns about the EMR program.   I got the distinct impression that nobody was listening.  One letter I sent to the President went unanswered for two months.  I finally got a reply when the media started to question the viability of the Velante plan.   The reply I got was more of a reprimand than an answer to my legitimate questions.

4)  At last fall’s NBMS Annual General Meeting, the membership approved a resolution which directed the NBMS to not interfere with doctors using other EMR products interconnecting with Department of Health computers.  The leadership did not follow the direction of the membership and continued to obstruct early adopter of EMR technology.

5)  At the AGM, the CEO of the NBMS denied the existence of the secret Data Sharing Agreement, despite the fact that he had signed the document three months earlier.   We only found out about it after another doctor used right-to-information legislation to get a copy of it.  The CEO has never explained how he was able to sign this agreement and then seem to be unaware of its existence.

6)  Velante is not the the largest EMR vendor in the province.   At last report there were 34 people using a limited version of the advertised product.   Practice Solutions has 60 or more satisfied customers who received no handouts and were happy to pay the going rate for a top-quality, fully-functional EMR.

7)  The Minister of Health did say he was willing to renegotiate the secret Data Sharing Agreement.  What Dr. Hansen fails to mention is that the leadership of the NBMS refuses to even discuss permitting more than one approved software vendor, in defiance of the wishes of the membership.

The bottom line:

Increase in fee-for-service payments to doctors over 4 years (if the contract is ratified):  4%

Increase in NBMS membership dues over the last four years: 39%

Number of taxpayer dollars being offered per year  to convince doctors to jump aboard the S.S. Velante:  $1,500,000

Number of doctors in New Brunswick:   1600

Number of doctors who signed a form indicating they are interested in EMRs:   350

Number of doctors said to be using a limited version of the Velante product:  34

Number of doctors using the Velante product who will tell you that they are satisfied with the Velante product, and that it has lived up to the claims of marketers:   ???

The leadership of the NBMS is pulling out all the stops in its effort to bail out Velante.   The latest move uses taxpayer money – redirected from a general fee increase – to try to convinced the many satisfied Telus Health and Oscar users to jump ship.   Problem is, we don’t want the money.   We like our EMRs, and we can’t be bought.

Make no mistake about it, medicine in New Brunswick is under an all out attack by those who wish to shape healthcare in their own image.   The NBMS, like Nero, fiddles while Rome burns, and Accreon is calling the tune.

By what authority has the leadership of the NBMS transformed our Society from its traditional role as protector of patients and doctors to a public relations company for a failing information technology project?

Remember, not a single New Brunswick doctor was using Intrahealth software prior to the Velante scheme.   The only reason anyone uses it now is because salaried doctors were given the system for free, and a handful of fee-for-service doctors were given thousands  of taxpayer dollars as an incentive to adopt the system.  At least one Saint John family doctor has been offered the Velante system for free, because he trains a lot of residents, and Velante clearly subscribes to the “get ’em young and bend them to your will” philosophy.

Any reasonable person would conclude that a product that cannot sell itself on its merits and survive without government subsidy is not much of a product.   Yet this is exactly the sort of product that the NBMS has chosen to offer us as the ONLY authorized software package in the provincial EMR system.

There are better systems available, but our Medical Society doesn’t want us to use them, and is willing to throw money at the problem until doctors either knuckle under to their will, or the Society is bankrupt.

Stop the merry-go-round, I want to get off.

No comment…

Math

“Velante, our company that’s managed by physicians, for physicians.”

     Dr. Lynn Hansen, April 2, 2014

 

Composition of Velante Board of Directors

QuestionAnthony Knight , President,  NOT A PHYSICIAN.  Anthony Knight is the President of Velante, Inc. and the Chief Executive Officer of the New Brunswick Medical Society.
Question  Daniel Coleman, PhD, Chair of the Velante Board,  NOT A PHYSICIAN.  Daniel Coleman, PhD, is the Chair of the Velante Board of Directors.  Dr. Coleman is a professor of business administration and is currently the Assistant Vice President Fredericton (Academic) at the University of New Brunswick.
Money bag  Martin Ferguson, Velante Board Member,  NOT A PHYSICIAN.  Martin Ferguson, Velante Board Member, is the CEO of Accreon Corporate Shared Services.
Money bag  Michael Lavigne, Velante Board Member,  NOT A PHYSICIAN.  Michael Lavigne, Velante Board Member, is Vice President, Business Development with Accreon, Inc.
Money bag  Neil Russon, Velante Board Member,  NOT A PHYSICIAN.   Neil Russon, CHE, is Secretary of the Velante Board. Mr. Russon is CEO of Global Services and Solutions at Accreon, Inc.
CadeuceusDavid Flower, MD, Velante Board Member.  Dr. Flower is a family doctor in Fredericton.  He is the Chair of the NBMS Board and sits on its Executive Committee.
CadeuceusJohn Whelan, MD FRCP, Velante Board Member.  Dr. Whelan is a radiologist in Saint John.  He is the Treasurer of the NBMS Board and sits on its Executive Committee.

End of an error…

Dinos

Physicians thinking about using electronic medical record software in New Brunswick woke up April 1st to a new and better world.

Gone is the golden glow of cash handouts, offered through a federal subsidy program called Canada Health Infoway. In its place, a new, more level playing field for EMR vendors in this province.

Up until now, the process of choosing and implementing an EMR was subject not only to one-sided marketing efforts by our own professional society, but also heavily influenced by the offer of taxpayers’ money to offset initial setup costs.    In effect, every taxpayer in the country – every store clerk, cab driver, teacher, firefighter, farmer, and soldier – was helping New Brunswick doctors to pay for their fancy new Velante electronic record system.

Is that fair or appropriate?

Not at all.

Doctors are well paid for the admittedly difficult work we do.   The process of migrating to electronic medical records should not require tapping into funds which might be better used elsewhere.   If the federal government wants to give handouts to doctors in New Brunswick, why not offer incentives to new physicians to move here and help care for the tens of thousands of citizens who do not have a family doctor?  There are dozens of ways our tax dollars could be better spent.

Instead, doctors who have been earning good living in NB were offered a gift of taxpayer money to buy a specific EMR product… and that is just wrong.

True EMR believers – and there are many of us – are more than able to shell out the required money to start using electronic medical records.    About 100 of us have done just that.  Although our patients and the public recognize the investment made by early adopters of EMR technology, not so our own New Brunswick Medical Society.   Instead, when we ask to be treated fairly and equally, we are criticized for having the audacity to question the wisdom of the Velante monopoly and the secret, exclusionary Data Sharing Agreement.

Essentially, people like me are being told by the President of the the NBMS to sit down and shut up.

The problem with the subsidy program was that it was being used to lure physicians who might not be entirely sold on the concept of a provincially-sanctioned EMR monopoly, to buy into it in nonetheless, in order to take advantage of the limited time offer of “money for nothing.”   As a result, doctors were being rushed into making hasty decisions, and encouraged to “enrol” with Velante without thinking through the consequences of their actions.

Above all, New Brunswickers must avoid the establishment of an exclusive, single-vendor EMR monopoly.

Monopolies are bad for business.  Bad for doctors.   Bad for patients.

I cannot think of a single business monopoly which has been good for customers, and it baffles me to think that there are people who continue to push for such a disastrous concept.

Choosing the best EMR product for a medical practice is no easy task.  There is no “one size fits all product.”  It’s best to look at a few different options, talk to people you know who are already using EMR software, and then think about why you want an EMR in the first place.   If after careful deliberation, you decide to go ahead with implementation, there are many different options.

Taking the time to do your research will avoid untold grief further down the road.