Saturday, September 22, 2012

Revenge of EHR Nerds
Being a nerd really pays off sometimes.
Ken Jennings (born 1974), computer scientist and holder of longest consecutive wins on  Jeopardy show
September 22, 2012 – It wasn’t supposed to be this way.  Electronic health records (EHRs) were supposed to lower costs by helping document what hospitals and doctors do.   But, alas, according to today’s New York Times,  EHRs do the opposite (Reed Abelson, et al, “Medical Bills Rise as Hospitals Turn Electronic," September 22, 2012). Says the Times, “The move to electronic health records may be adding billions of dollars by enabling hospitals and physicians to bill more by providing the same services.”
How could this be?   How could hospitals be paid to install EHRs be showing a 47% rise in Medicare charges from 2006 to 2010?  How could 1700 doctors with EHRs cost Medicare $100 million more, especially when those practitioners  are family doctors,  general internists, and emergency room physicians?  These doctors, after all, are generally on the lower end of the payment scale for physicians.
Let me tell you how.   Medicare payment codes  are generally lowest for evaluation in office visits.   For years, Medicare has ratcheted down office visit codes,  so much so that the doctor is forced to see a patient every 7 to 10 minutes to make ends meet.  Doctors are paid more if they do a complete evaluation by documenting symptoms,  family history, allergies, and a detailed personal history.  But how is a doctor to do this in such a short period of time? How can he or she do a detailed evaluation and charge for the same in ten minutes or less?
One way is to let the patient do their own histories online from home or from the reception room.
A piece of software, developed by Allen Wenner, MD, a family physician nerd in  South Carolina, is something called “The Instant Medical History.”  This history is a “yes” or “no” clinical algorithm based on the patient’s symptoms,  age, gender, and chief complaint.   On their own time, the patient enters the demographic and clinical data.  Once the patient has entered the data,  the medical history software generates a narrative history,  It is sent to the doctor in the examining room.  

The key word here is “instant” medical history.  Once the doctor has the narrative history in hand,   in an “instant” the doctor can get to the root of the problem, ask relevant questions,  do an exam,  record findings, click a button, and generate a detailed history which commands the optimal code for an office visit.   In the process, the physician can save 6- 8 minutes a patient,  allowing the physician to see 5 or 6 more patients each day.
There are variations off this theme.   Many specialists are hiring medical assistants  or aspiring medical students to  record symptoms, drug histories, allergies, and family histories before seeing the doctor, or by following the doctor around to record findings.  Other doctors are cutting and pasting common symptoms for common diseases seen by specialists – saving time and embroidering the history.  
There is nothing wrong with these nerdy approaches.  One can argue they produce a more  documented history that has  the appearance of a more thorough history and examination.  They also offer medical legal protection and a more accurate diagnosis.  EHR histories are faster and easier and more complete than medical records of the past. But they do not save money. Many EHR companies have incorporated the Instant Medical History in their systems.  According to a survey of 630,000 physicians,  70% of physicians are now using EHRs. EHRs with  embedded patient-generated  histories  may represent  the revenge of the doctor and software nerds.
Tweet:   Electronic records were supposed to save money by completely documenting office visits.  But the more EHRs are used, the more costs rise.

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