Government IT Spending: Rapidly Multiplying
On the surface, state and local-level IT healthcare spending is literally spurting ahead. It is expected to reach $6 billion by year's end and to then increase to $9 billion by the end of 2009.These anticipated increases are effectively federally- driven by demands for greater use of electronic medical records (EMR) in the processing of HHS-supported programs such as Medicaid and Medicare.
The feds are still not satisfied and are most vocal in their complaints. In an attempt to speed up the increased use of electronic medical records, HHS has initiated a ten year plan that hopefully will convince participating parties that -- quite literally -- it pays to move quickly-as-possible away from paper-based records and into digital computer-based record keeping. They estimate that the healthcare industry could save between $78 and $112 billion a year in a full switchover to EMR.
Once again, HHS has made it clear they want the healthcare industry to willingly participate in more aspects of the information technology age. Their current estimates are that just 15% of hospitals and 15-30% of doctors' offices have EMR up and running.
They are more than hinting that it is an essential element in full compliance with HIPAA regulations. And not too subtly, they are demanding that it must get done internally…or it must get outsourced. Great demands for most.
…….Many point-with-pride though to Massachusetts which is making great strides in this direction, thanks in part to a $50 million funding grant from the state's Blue Cross Blue Shield. Goal is to enable doctors to access patients' computerized medical records from any hospital or clinic within the state.
The so-called "eHealth" project will begin a pilot program in three still-unnamed communities in the near future. Plan is for the system to run statewide within five years. Governor Mitt Romney forecasts this will be the first such system in the nation that will totally switch from paper to EMR.
The project leader not-too-subtly inferred that "outside the box" thinking is what hopefully made all this get under way. He points to an Indiana test program that started and then abruptly stopped a year or so ago; reason for the apparent failure was the assumption that financially-strapped hospitals and too-busy doctors would invest valuable time and effort now in the hope of possible gain years down the road. It just would not happen!
Massachusetts took a new path and began looking for a sponsor who had both current funds to invest and an understanding of how this "seed money" could result in a savings and efficiency payback that could easily be much, much greater than their initial investment. BC/BS found the idea innovative and agreed to make the investment.
To a great degree, that is what the following article is all about.
Needed: "Outside the Box" EMR Thinking
Dr. David Brailer is a physician who has found an even more-noble cause…last spring he was appointed HHS Coordinator of Health Information Technology.
Though HHS keeps making broad-based demands and promises to rapidly move ahead into the world of EMR, many think insufficient time and effort is being spent on creating the atmosphere that will make people want to willingly move from paper to EMR. Innovative pilot projects are needed to learn how to get maximum support and usage from doctors and other healthcare workers…from the managed care companies that pay most of the bills…and especially from their patients concerned about privacy.
Congress keeps promising the money for these projects but never seems quite willing to allocate the funds to do the job. The latest turndown…a "mere" $50 million in "seed money", requested to finance a wide variety of these pilot projects, was struck down by Congress at its end-of-the-year session. So we are left with complaints, finger-pointing, lack of basic decisions and many say too-little well-thought-out interaction in an effort to meet established target dates. All this even in the face of the potentially-huge healthcare industry savings spelled out in the previous article.
Small case in point…currently there are two methods of electronic data entry in use, one a view of the future, the other still too-anchored in the past. The former is obviously "more electronic" but currently less-popular because the caregiver has to put valuable time into learning how to make the most of a new system. There should be a short cut or some tangible incentive for the individual willing to move ahead; it hasn't been invented yet. That's a challenge which needs to be met.
The electronic system is generally referred to as point and click, which enables the person making input to select from a menu of choices (effectively "customizable templates" to best-describe a patient's condition and the caregiver's treatment). Result is accurate and complete data, automatically stored for easy retrieval and follow-up. Input is immediate, while all facts are fresh. Retrieval is virtually instantly-attainable. Problem is that the doctor must devote time and effort -- the kind most simply don't have -- to a steep learning curve.
The second system is dictation (transcription), pure and simple. It is much-favored because it is convenient, "comfortable" and generally requires less time for the physician to perform. The transcription is then made part of the patient's EMR, which can easily be accomplished transcribed into preformatted templates and interfaced with the EMR system. Retrieval of this information, of course, is usually 12-24 hours away. A new approach, or at least a "middle ground", is needed.
Dr. Brailer wants to make HHS the clearing house for this innovative thinking. To make the point, he speaks to various professional groups often-as-possible, always sincerely requesting imaginative input that he hopes could possibly result in the full, speedy and well-thought-out implementation of some element of EMR's potential. He consistently points out that the HHS ten-year plan will only work best if we learn the right steps to take as early-on as possible. That's where trial and error pays off. Handsomely.
All the advice he has received to date is reportedly being assembled into a document which will hopefully be used to initiate "phase one" action this year; as soon as Congress allocates some extra money pilot projects. Which Brailer feels certain will happen in 2005.
Fast-Food Fight
Until recently, the huge area that makes up "the campus" of the Cleveland Clinic, one of America's most-prestigious medical centers, also included a number of fast-food stops for visitors and staff…including Pizza Hut, McDonald's, Subway, Au Bon Pain. The Pizza Hut is now closed in the face of extreme pressure from the hospital's new CEO, a highly-regarded heart surgeon. Seems this is just step one.
The Clinic says it has marked the remaining fast-food outlets for removal, simply because it can no longer be associated with the unhealthful high-fat content of most of their food. The concessionaires say they will fight back because they 1) have long-term leases and 2)serve the kind of food people want. Most also point-with-pride to the salads on their menus. The hospital administration points to the much more popular Big Macs and fries.
The medical center's senior heart surgeons are offering strong support, saying they must teach by example; therefore it is unconscionable to present all these unhealthful products to visitors and staff. The concessionaires are being strongly supported by their parent companies, led by McDonald's which has 30 outlets in hospitals across the country. Several of these are also currently under siege for similar reasons.
Stretching Services Up North
Canada's province of Ontario -- where healthcare was once praised as being both fair and available for all -- has agreed to immediately spend an additional $107 million to reduce the long waits for some of the most critically-needed medical procedures, all of which were found to be causing unacceptable levels of pain and suffering for patients. Heart procedures, cancer surgeries, knee and hip replacements and cataract surgeries will be among the prime targets.
The province's Health Ministry anticipates these funds will enable thousands of now-stalled procedures to go forward, with much more to come in the immediate future. Also planned…the purchase of badly-needed MRIs and CT scans.
This flood of new dollars is being backed by some innovative thinking, too. For example, Toronto's world-class Hospital for Sick Children is opening what is referred to as three "ER franchises" at community hospitals in the greater Toronto area…all in an attempt to reduce the overwhelming 150-200 cases that come to "Sick Kids" ER every day. Patient wait time sometimes reaches close to eight hours.
"Sick Kids" has been trying for years to shift some of this ER burden, but parents continue to feel it is still the only place to take a seriously-ill child. Now the hospital will be supplying special equipment and training nurses at local hospitals in the level-of-care-and-attention that has made "Sick Kids" such a magnet.
Eventually the hospitals will become loosely-tied affiliates and ambulances will be on-call at the community hospitals for emergency transport of patients to "Sick Kids".
Massage Therapy Gets Recognition
According to a survey conducted by the American Hospital Association, supportive massage therapy is now the most-common "nontraditional" care offered in hospitals across the country…with emphasis on patients in the most pain.
Memorial Sloan-Kettering Cancer Center has eleven massage therapists on staff. UCLA's Center for East-West Medicine has four, available to patients with severe migraines and chronic pain in various part of the body. Results of a recent study of fifty massage patients at their facility concluded that 95% referred to the therapy as a very important part of their recovery. A cardiothoracic surgeon at another renowned LA hospital -- Cedars-Sinai -- reported that "most" of his patients found massage therapy an important part of their recovery.
The American Massage Therapy Association claims that nearly 50% of America's adult population has used massage to relieve pain. The association also claims that increasing numbers of "traditional" healthcare providers are recommending massage for pain relief. And, finally, an increasing number of insurers are reported willing to pay for massage therapy under "reasonable" conditions.
Biggest continuing drawback according to the AMTA is that massage takes longer to show results than so-called traditional methods of care, so many patients simply tire of it before the results are realized. Biggest advantage…few, if any, side effects to worry about.
Studies conducted by a number of organizations over the past few years concluded that massage therapy seemed to do some good on both the physical and psychological levels. Reducing chronic pain and enhancing immune function for some …diminishing anxiety and depression for others. The NIH is currently funding several studies designed to discover exactly how the therapy may help and exactly what type of patients may benefit from it.
Taking Control
Tired of Congress dithering about an independent board to review the safety of individual prescription drugs, several years ago, a handful of states decided to band together to do the job themselves. Their number has now grown to twelve and they seem to be doing an excellent job!
The states -- responsible for billions of dollars in yearly drug purchases for their current employees, retirees and Medicaid patients -- are effectively comparison shopping for the most-effective and safest-proven products in an area that now has directly-competing products in just about every category of the pharmaceutical field.
All the member states are in the midwest and west coast, with the exception of North Carolina. Two private and non-profit health groups -- from California and Canada -- are also members.
Currently member states contribute just under $100,000 each year to receive dozens of reports.
Two of the original founders of the group -- Oregon and Washington -- point-with-pride to their reaction to early warnings about the safety of Vioxx, which was received over two years ago. Each investigated, then quickly removed the product from the list of acceptable drugs that may be pre-subscribed for their Medicaid patients.
So far fifteen classes of pharmaceuticals have been reviewed under this project. They include anti-cholesterol statins like Crestor and cox-2 inhibitors such as Bextra…both of which are currently under high-profile reevaluation by the FDA.
Unhappy Patients
According to a recent study by the Harvard School of Public Health, 55% of Americans said they were dissatisfied with their quality of healthcare. That is against 44% who felt the same way just four years ago.
Even more-troubling is that 40% of current respondents say their quality of health care is deteriorating…with over 30% of respondents saying a family member has been harmed by some form of medical error.
A small 17% of respondents said they believed America's level of healthcare was improving.
The survey questioned 2,000 adults and did not release their geographic breakdown. The survey was funded by the US Agency for Healthcare Research and the Kaiser Family Foundation.
General feeling of all sponsoring parties was that this apparent perception was weighted by "high profile" reported problems and not in line with actual quality of care Americans generally receive. Dr. David Brailer of HSS (see cover story) said that technology for hospitals and healthcare systems has both become affordable and can make the difference in quality of care. He said that well over $100 million has been distributed by HHS to support existing systems.
However, the study's lead professor said there was much room to improve and that $200 billion will be needed to computerize America's medical records system, which would eliminate a good percentage of the errors that people see and hear about.
Coding Tips
Insertion of a Pleural Catheter
Code 32019 was added to CPT for 2005 to report the insertion of an indwelling tunneled pleural catheter with cuff.
A pleural catheter can be placed in the pleural space to treat chronic or recurrent pleural effusions.
A tunneling device is used to tunnel a catheter through the subcutaneous tissue to an exit site to which a suction device is attached to the external catheter to drain the effusion.
Do not confuse code 32019 to code 32020, tube thoracostomy with or without water seal, which is a temporary procedure performed by puncturing the chest wall followed by the insertion of a chest tube.
The catheter insertion procedure described in code 32019 may remain indefinitely.
Transcription Tips
Language to Avoid: Dictators frequently use awkward language or use neologisms (newly formed words) when dictating.
Watch your Spell-Checker and avoid using 'created' verbs, back formations or new words formed by altering an existing word, coined terms or phrases, non-official, non-standard terms, jargon and slang.
If you are not sure what is meant, leave a blank space or type as dictated.
Example:
D: Stool for guaic'd. T: Stool guaiac test was done.
D: For wound not to dehisce, extra tape was placed. T: Extra tape was placed to prevent wound dehiscence.
D: We lased the lesion for complete removal. T: The lesion was completely removed with the laser.
D: Urines were taken. T: Urine samples were taken.
D: An emergency appy was performed. T: An emergency appendectomy was performed.
Point of Information
Father of today's artificial hip was a British orthopedic surgeon, Sir John Charnley, who saw the damage -- and patched it as best could be done -- in World War II. Any replacement surgery performed post-war used an uncomfortable and noisy device built around stainless steel rods and screws.
Dr. Charnely invented today's low friction total hip replacement after more than twenty years of experimentation; the device was built with sculptured polyethylene parts and simple dental cement. The first such device was implanted in 1972.
Within four years more than 9,000 arthritic people were walking normally. The development of knee and shoulder replacement surgery is directly credited to his initial work.
A charitable organization was created shortly after his death in 1982; its purpose to advance imaginative research in the field of orthopedics.
Auditing the News
An article in the Journal of Neurotrauma reports that Perdue researchers have enabled several dogs paralyzed in their hind legs to walk again, some quite well, after getting an injection of a chemical "cousin" of antifreeze…which apparently worked to repair damaged nerve cells in their spinal cords. The treatment was only effective if given within three days of an accident. The researchers stress there is a gigantic difference between the spinal cords of humans and canines. But a corporate sponsor will appar- ently soon be producing a variant of the chemical combination in anticipation of an application for first-stage human trials.
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Along the same amazing lines...another team of scientists implanted an oscillating field stimulator in dogs with a spinal cord injury in an effort to restore some degree of function. The experiment showed enough promise to be moved on to ten human patients without actual severed nerves. Marginal results were seen; enough to convince the FDA to approve further research. The complete report appeared in the Journal of Neurosurgery-Spine.
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A heart transplant offers much hope for a new lease on life, but results are still counted in relatively short-term (five year) increments. However, things seem to be improving; currently there are eleven patients who have been living relatively stable and comfortable lives with transplanted hearts for twenty years or more! Latest member is a 55-year old woman whose procedure at the Texas Heart Institute dates back to October, 1984. The chief of the hospital's heart transplant program recently gave her a full checkup and reported she was doing extraordinarily well. The patient, Doris Skinner, is a chemist and an accountant; she works full time, and is active in local organ donation programs.
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The National Children's Study is recruiting 100,000 infants potentially at risk for a huge, long-term monitoring that will follow these kids for 21 years; it will be administered and monitored by HHS and the Environmental Protection Agency. Children in 96 locations around the country will take part in this huge program that hopefully will impact on health and safety guidelines, prevention strategies and possible special treatments that will add to their general well-being.
Seventy-five of these locations will be in densely-populated communities, the balance will be in rural areas.
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Proof is here that the proverb of "An apple a day keeps the doctor away" has quite a bit of validity according to a recent study. The Cornell professor who led the study reports that fresh apples have some of the highest levels of antioxidants to other fruit and vegetables. Medicinally, best part of the fruit is in the skins.
Red apples reportedly are better for you than green or yellow ones. And if you can't reach for an apple, blueberries, cranberries and even onions are good substitutes.
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A recently-launched web site, "Consumer Report Best Buy Drugs", has become an extension of the Consumer Reports franchise. It is a free service designed to compare drug safety, value and effectiveness; it is based on analyses for twelve states by the Center for Evidence Based Policy (which, in turn, is a division of the Oregon Health and Science University).
The new site has singled out a number of highly-promoted prescription drugs which they found little or no better than OTC products that can be bought at a fraction of their cost. Consumer Reports included the caveat that their reports are "not meant to substitute for a doctor's judgment".
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EMR apparently brings better hospital care, this according to the results of a study recently published in the Annals of Internal Medicine. Warning, though… the overall results will surprise you. The study covered 1,588 men with a total of 26 medical conditions. The VA system, which now provides each of its doctors nationwide with electronic access to virtually every aspect of their own patients' files, scored these patients as receiving 67% of recommended care for their conditions. Other facilities -- with less-sophisticated EMR -- received just over 50%.
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Philips portable defibrillators hit the TV screens early last fall when the FDA gave the product first approval for over-the-counter sales to their new line. Since then there has been an obvious promotional cutback , apparently due to possible major problems with other defibrillator lines. No question that such units can save lives…if they work properly. But in an area where perfection is essential, their overall record has been spotty at best. Now one of the first into the field, Access Cardiosystems, is apparently out of business, awash in litigation, including an investors' suit against its former CEO. Access is accused of using questionable second-line parts to make the product financially attractive to buyers.
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