Dominoes and Data

From my last post, I spoke about the power of data…who it belongs to and the power that it wields based on who owns it.  A couple new developments in the Health IT world have got me wondering where this is all going (and unfortunately confirming some of my concerns I addressed in my last post).

1.  A “free” EHR company, Mitochon, has bit the dust.  Not only are doctors who use the service in the lurch, but they are not the only casualty.  Mitochon is one of many “smaller” vendors that have fallen like dominoes (either shut down, acquired by a larger EHR entity, or both) since Meaningful Use began.  We are now in the consolidating and monopolizing phase of this grand crony capitalism experiment.  Along with monopolization, we are now seeing data ownership (as well as profits) increasingly belong to a small elite of corporations.

2.  Along with consolidated data ownership, there are now observations in the field that data mining will go full steam ahead.  From Chandresh Shah’s blog,

To me, it is clear – there is something else cooking. That stew is ‘data mining’. For sure, I am not talking about selling patient data, but analyzing aggregate intelligence, which is in dire need by Pharma. Today I believe Practice fusion EMR company is building the mass and momentum. This is why they have billionaires like Peter Theil behind them. They need lots of cash to burn every day.

If you have concerns about patient data privacy and unmanageable health care costs, this comment should raise a few goosebumps.  The future of health IT may look enticing for those that have the “in” right now, but will be a disaster for health care providers and patients in my honest opinion.

3.  Deloitte put out an executive summary based on a survey of 610 physicians regarding health IT adoption.  One of its findings showed that more than 1/2 of the current non-adopters of EHR’s have no current plans to implement one at all.  Furthermore, it states that most physicians do not use mobile health technologies in their clinical practice, and most are slow to adopt online tools and health technologies in direct patient care.  I see this as a further proof that there is clearly a “digital divide” now and with the way Meaningful Use is heading, those physicians that are left behind will be truly left behind.  What’s going to happen after that?  After all 2015 is coming up pretty soon….

The future can be changed if we start here.

There are alternatives, with open source projects leading the way for offering realistic and reasonable models for data security/privacy, cost of implementation, and decentralization of data with my project being one of them.  My vision for real health-informed information technology is for a focus on a user-centric interface, low-cost of use and ownership, and an open standard for exchange of information, NOT monopolization of services and data aggregation to be used for marketing, which only raises health care costs for everyone with questionable improvement in health care for all.

UPDATE:

On the issues of the effects of health care costs due to the ridiculously expensive installation and ongoing maintencne of EHR’s (Epic in particular), I’m pointing at these two blog posts involving Wake Forest Baptist Hospital, and Maine Medical Center…both hospitals are now struggling financially and announcing budget cuts because they have implemented Epic, the money pit.  Imagine that this is happening to large-scale hospitals across the nation, and then imagine what this is doing to small physician-owned practices!  It’s a sad affair when health care access and quality care is being compromised by technology and greed.  What a waste.

A Critical Time to Act

In my previous post, I’ve spoken about how primary care physicians need to improve their self-esteem when it comes to demanding fair reimbursement for their services as well as being leaders in health IT and health care data for the future.  Why is the second just as important as the first?  Other than money (which is fairly obvious), owning and controlling your data is one of the keys to exerting influence and making significant and sustainable change in our currently bleak situation for primary care and private practices.  Let me explain.

Data is knowledge.  How data is collected and interpreted and then used is one of the most powerful forms of communication and human interaction.  Just look at Google.  They are the technological masters in data collection, interpretation, and innovative users of this data.  Without their obsessive data gathering tools, we wouldn’t have tools such as its search engine or Google Maps.  The integration of their data makes it the envy of all other internet-based companies.  The reason why Apple Maps was a pale comparison to Google Maps is due to this one factor alone: Apple didn’t have the infrastructure and data that Google had carefully amassed years and years ago.  Now one thing that does frighten me about Google is that all this data is held by one organization/corporation.  We trust that they don’t do anything nefarious to the data that they have and use (but on the other hand, it’s foolish to believe that this could never happen).   I’ll discuss more about this later.

Now, when it comes to health care, we must ask ourselves who is driving the data gathering and how it’s being used.  Back in the “good old days”, physicians gathered the data, jotted them down on a piece of paper, organized them by patient to be used later on when a patient comes back for a re-evaluation.  The data was singular, local, and relatively secure (I call them silos).  Perhaps back in the those times, this type of data collection was sufficient because there was not as much travelling and moving for families and most patients went to their general doctor since there were not that many specialists to go around.  Fast forward to now and we see a substantial increase in subspecialist health care providers (due to our perverse payment system) and patients are seeing not just one doctor, but most likely two or more.   With data still in silos (both in paper and electronic format), we start to see the inefficiencies and consequently errors and reduplication of efforts to gather data from one provider to another.   This further fuels the increase in health care costs (duplication of tests, for example) for the patient and society.  It also decreases safety (drug-drug interactions and allergic reactions, for example) for the patient.

As technological advances accelerate in these times (like Google, smartphones, social media, cloud computing), health care can no longer ignore the impacts of electronic data.  While it used to be that physicians were in the driver’s seat regarding data formation, gathering, and use; over time, physicians have abdicated the ownership and use of electronic data to other agents that seek to impose mandates on care and how care is to be delivered, often to the detriment of the physician and patient.  These agents include insurance companies, governmental agencies that monitor reimbursements and incentives, and administrative bodies that determines productivity and pay for the physician.  As you can see, these agents control the flow of money.  Although I cannot blame these agents for what they do, and I suppose they are serving some useful purpose in the framework of “controlling” health care costs, I sense that the US health care system is now entering a situation where these agents are now defining how health care is to be delivered, to the point that if these agents wanted, they would do the work that physicians used to do, like determining the type of tests or medications to be performed on a patient, and even establish a diagnosis.   These agents are now literally making clinical decisions that directly impact patients.

If the work that physicians do is really all about rigid clinical decision algorithms and purely calculated on cost analysis, I might as well hang my stethoscope out on the porch and say goodbye.   I don’t know necessarily what has happened (possible media/TV show representation, but also the existence of  rapidly advancing biomedical technologies) , but there seems to be a mistaken notion that medicine is all about science and technology.  I would argue that medicine is still very much a 50/50 split between the “art” and the “science.”  And as we know more about the effects of trauma on the brain’s neurodevelopment and the subsequent impacts of a person’s health, I would argue that this is even more salient.  These agents are not even face-to-face with the patient, let alone talking to them.  They just calculate the diagnosis and treatment based on data that physician’s gather (accurately or otherwise) to determine our worth.  This is what all these “pre-authorizations” are all about.  From a business perspective, this may sound reasonable to manage the bottom line, but from a medical perspective, I don’t think this is humanly fair or ethical.   I feel a professional line has been crossed when the use of our data is used against us and the patients we serve. 

And the race to control and gather that electronic data has already begun.  We have large vendor EHR’s trying to monopolize their share of the marketplace, keeping their data proprietary and even take them as hostage for physicians who want to switch systems.  We have insurance companies savvy with electronic data gathering through our current billing process to effect our clinical decision-making (pre authorizations) and threaten us with auditing and at times, taking away our reimbursement right or wrong.  We have our government, also savvy with electronic data gathering, now requiring us to enter another set of data that has no impact or meaning whatsoever on our clinical care of patients, just so that we can “possibly” recoup the enormous cost of these EHR’s and if we don’t play along, we get paid less.  The more I see it, physicians in general have allowed our control of data slip away and we (physicians and patients) are now paying the enormous price because some of us decided to put our heads in the sand and pretend that we don’t need electronic data to keep our profession going in the future.   And in the end, we are not furthering our cause for keeping our patients safe and healthy because we refuse or unable to share data with other medical providers even if we have the electronic tools to gather data effectively.

The health care landscape from a primary care perspective may look bleak, but I believe there is still hope.  The hope comes from these same primary care and private practice providers that remain steadfast in their belief to provide direct, meaningful care with their patients.   The hope comes from those that have exited the field out of frustration and burnout or have been incorporated by a larger organization but are keeping one eye out to see if a better future remains for our health care system.  Along with hope, we also need the right tools and organization to get us out of this bleak landscape.  It is indeed a critical time to act.

This is where an open source electronic health record system coupled with a patient portal system is the gateway towards true interoperability.  I emphasize that this is only a gateway and not a panacea to all that ails our health care system.   An open source community allows doctors to have a say in what would make their system usable and customizable to work the way that clinicians work, not based on the needs of administrators, insurance, or a government mandate.   It is chance for doctors to feel engaged in the process rather than feel left out.  We can make our voices heard when we have the numbers and our public support behind us.  It is the opposite of the  top-down approach to change governed by who has the most money.  Instead, this approach is a thriving, grassroots effort, united with our patients, that is governed by who has the means to gather, integrate, and use electronic data to improve the health of our society.  It is really the only way when primary care and private practice physicians do not have the money and means to organize. 

On data ownership,  one of the reasons I chose to create NOSH ChartingSystem as a web-server based model and that it can be easily downloaded and installed on any desktop computer or installed on a virtual machine or in a cloud is that the data ultimately belongs to the physician or group of physicians use it.  Several individuals who had interest in NOSH ChartingSystem stated that it would be great if I could provide a hosted program on the cloud (similar to Practice Fusion or other web-based EMR’s), but I’ve decided against it.  I have no interest in storing centralized patient data from thousands of providers nor does it benefit the provider when it comes to security and safety for the patient.  What would happen if the owner of this centralized patient data goes away?  Outside of the health care sphere, there is increasing appeal for a de-centralized form of social media and data storage rather than leaving the data to only one organization for exactly these same concerns.  Health care ought to be the first to venture in this new type of data framework and focus on interoperability of data technologies rather than centralizing data to only a few.

I propose that this is where the discussion can start, whether it be what you’d like to see in a physician usable EHR, or what it means to have true interoperability.  If we can demonstrate that this cooperative model works for health IT, we could be the model of a future in healthcare, where patients and physicians are partners again and no longer divided.

Know Your Own Worth – A Primary Care Manifesto

Several months ago, as I was in the last few months of my private practice (which was coming to an end), I watched the Joy Luck Club with my wife.  I had seen the movie many times before, but somehow at that moment in time, when I was grieving for my practice and my profession, I began to have some startling clarity.

Specifically, I was particularly struck by this dialogue in the Joy Luck Club:

I tell you the story because I was raised the Chinese way. I was taught to desire nothing, to swallow other people’s misery, and to eat my own bitterness. And even though I taught my daughter the opposite, still she came out the same way. Maybe it is because she was born to me and she was born a girl, and I was born to my mother and I was born a girl, all of us like stairs, one step after another, going up, going down, but always going the same way. No, this cannot be, this not knowing what you’re worth, this not begin with you. My mother not know her worth until too late – too late for her, but not for me. Now we will see if not too late for you, hmm?

Knowing your own worth is all about self-esteem and how much one values themselves in the context of a larger community and society.  Being a doctor that worked with child victims of sexual, physical, emotional abuse, and neglect at a child abuse assessment center, I have witnessed and understood the insidious nature and the destructive effects of abuse on a person’s self-esteem.  But little did I realize that I, too, was also a victim from a professional standpoint.  To take it a step further, primary care as a whole is also a victim in its own right.  Along the way, somehow, we (which I’ll refer to as primary care from now on) stopped knowing what we’re worth.  So let me explain, through my own experience.

Primary care physicians, in general, have been constantly reliving trauma after trauma for many years that appears to be beyond our control.  To me, examples of this type of trauma come in the form of  persistently low and declining reimbursement combined with increasing uncompensated work.  I directly experience this type of trauma every day for nearly 10 years, because I have been on the front lines as a micropractice doctor.  I saw the immediate, direct effects of my practice whenever there were changes in payment structure, changes in my patient’s ability to pay for medical care, and any legislation or technology that changes in my workflow.  As a micropractice, you had to be quickly adaptable to these changes…otherwise you’d be swept into the tide.  I saw and understood the consequences of public health policies, especially those that appear to be with developed with good intentions, but seriously misguided, and how it affects my work and the health of my patients.  Perhaps, that is why I have so much say about primary care and health care technology.

For some trauma victims (especially those in an abusive relationship or in situations where the victim is being groomed for ongoing victimization), they don’t realize, recognize, or accept that they are a victim.  The victim is looking for acceptance by anyone, even from their own abuser.  The victim begins to lose their self-worth, self-esteem, and their own dignity in the search for this acceptance.  In many ways, primary care has become that victim in its search for acceptance in our health care system.   For me, I lost sight of my own self worth in the hustle and bustle of seeing complicated patients and getting reimbursed for little and struggling to make ends meet, ultimately failing to see the forest for the trees.

Besides losing self-esteem, a negative self-fulfilling cycle begins to happen to the victim.  For primary care, we’re witnessing a steadily eroding work force and persistently poor desire by medical students to go into primary care.   We have data and articles that continue to highlight these plights and yet somehow, our trajectory continues to be the same.  Furthermore, primary care has been defined by others about what we do (being called a “gatekeeper” and being called “worthless” by some of our patients).  In short, primary care physicians have been and still are victims in this hostile health care system that does not value what we do.

And sometimes, I wonder, if we as a group actually value ourselves by how we conduct ourselves with our patients (even though we take great efforts to provided good care for our patients) and with other organizations or entities within the health care system.   Although it should be acknowledged that money, prestige, and influence are big factors in maintaining a position of power in the current health care system (the hospital, insurance, pharmaceutical, and the large EHR industries are a clear example of this), I see disturbing trends in how the leaders of primary care organizations these past few years reflect the lack of self-esteem that appears to define primary care.

For example, back in 2011, the American Academy of Family Physicians implicitly threatened to leave the RUC (AMA’s Relative Value Scale Update Committee), a committee whose lack of transparency in deciding what health services get paid to physicians (which is discussed here), if it’s demands were not met.  Well, the end result was that the AAFP backed down on its threat and the RUC still has the full clout that allows them to set recommendations for these reimbursements rates for Medicare (and other health insurance companies too).  The response by the AAFP sounded like a reasonable justification for its decision.

Furthermore, as a justification for progress, we hear seemingly positive news that there are some efforts to may increase reimbursement of primary care in the near future.

With these seemingly reasonable justifications though, I thought about how easily domestic violence victims justify their own decision to stay in an abusive relationship.  Regarding reimbursement rates, we are truly fooling ourselves to think that this is a sign of a major turnaround when one looks back at how much reimbursement inequality has been going on for decades.  I don’t get a sense that medical students will instantly flock to primary care based on this development alone.  Likewise, we allow ourselves to be victimized time and again because we worry that if we decided to take value in ourselves, we could potentially hurt those that we care for.

The reality is that if we don’t take value in ourselves, the health care system will implode, and many more people will have lack of access to care.  It’s not a matter of “if”, it’s a matter of “when”.  Already, many people are uninsured or under-insured, don’t have adequate access to health care and primary care, and the costs (both financial and the emotional costs to each person and to society) keep rising.  That would be a colossal tragedy, all because we didn’t value ourselves on behalf of our patients.

I believe it is past time that we hope and wait for lobbying and legislation to save ourselves.  Approaching and proving to other academic experts about the benefits of primary care in our ailing health care system ad nauseam will not change our situation.  It is apparently not profitable to be a primary care physician or an advocate because they have already determined our “worth”, which was rated as “worthless”.  Take a look at how our Meaningful Use initiatives have gone for most primary care physicians, especially those in the trenches and in independent practices.

So what else is left to do?  It starts with us…each and every one of us that still hopes and believes in a vibrant, primary care-prioritized health care system.

First, we must affirm our worth and it must reflect everything that we do, with our patients and with anyone else that has a stake in the health care system.

Second, we must engage in constant, public education of our work and what we do.  We must take advantage of social networking to spread the word and educating our youth about healthy living and how not supporting or ignoring primary care will eventually hurt them and their communities.  For example #FMRevolution is a great way to spread the word through Twitter.  It doesn’t take a astrophysics major to understand how valuable primary care can be for society.  Most of the public seem to have taken for granted that there are plenty primary care physicians around despite the reality.  (For me, most of my patients didn’t realize how problematic it was until I let them know about it when I closed my practice…talk about being too late!)  The good news is that we still have many patients on our side (whether they realize it or not).  Through grassroots engagement and public support, we can eventually change the perception of our work and our worth by others.  Let us focus our efforts with the public rather than work within the system for which we have no standing or perceived worth.  Legislation would then just be icing on the cake, once the cake is baked.

So on this National Doctor’s Day, know your worth as a primary care physician.  And spread the word.

Big Vendor EHRs and Meaningful Use – A Love Story

So word has gotten out that there was indeed significant lobbying efforts by the big vendor EHRs (Epic, Cerner, GE, Allscripts) to secure viability for years to come with the healthcare legislation in 2009 (also known by physicians as Meaningful Use Incentives).  In this blog, I’ve discussed this before, both in the context of Meaningful Use and in the context of certification for Meaningful Use.  This excerpt from the article says it all…

None of that would have happened without the health records legislation that was included in the 2009 economic stimulus bill — and the lobbying that helped produce it. Along the way, the records industry made hundreds of thousands of dollars of political contributions to both Democrats and Republicans. In some cases, the ties went deeper. Glen E. Tullman, until recently the chief executive of Allscripts, was health technology adviser to the 2008 Obama campaign. As C.E.O. of Allscripts, he visited the White House no fewer than seven times after President Obama took office in 2009, according to White House records.

I had already suspected this when I pored through the details of the legislation and how it would have affected me, a family physician who was already using an EHR and doing everything that could possibly meet Meaningful Use but would not gain any benefits from the incentives all because I was an EHR that wasn’t certified.  And to get a certified EHR meant losing an arm or a leg or a downgrade on my current capabilities…none of which made any sense to me for a physician.  Until now.  In the end, it certainly was not a benefit to me as a physician or my patients.

I thought it was appropriate to call it a love story, for surely these two entities were certainly in bed together (EHR vendors and MU legislation).  And after the bed sheets have been lifted, it is oh so clear what shenanigans were going on.  By the way, there is a more apt word for it…it’s called crony capitalism.

I’m more determined now to shut these vendors down.  Or at the very least, set all of them on a true level playing field and see what happens.  But it won’t be easy and the rules are certainly rigged against the independent physician/open-source software movement.

Many Thanks on this First Day of Spring

The blooming cherry trees along the Willamette River in Portland, Oregon’s (my hometown) Tom McCall Waterfront Park announce the arrival of spring.
source: iStockphoto

Today, on the day of the Spring Equinox, I am reminded of the support that I have (large and small) regarding the NOSH ChartingSystem project.  As with all projects, especially open-source, it is always a challenge to overcome the inherent pressures of maintaining the status quo.  Certainly, this project is anything but the status quo and I intend to soldier on in the mission.

First thing, I am so happy to announce the availability of version 1.6.4.  Since my last posting (regarding Avocado), several important developments have been incorporated.  Electronic prescribing is in its final testing phase  and will coincide with my long-awaited Kickstarter campaign.  Unfortunately, due to my other profession as being a family physician, I have to postpone the campaign due to me taking my board exams in April to remain board-certified in my specialty.  Gotta study these next few weeks and learn how to take standardized tests again!

I have also added a new extension, based on the Medicare Medication Therapy Management program.  With this, NOSH ChartingSystem can be used as a collaboration tool between physicians and pharmacists to assist in improving medication compliance and health education for patients.

Also in this release, preparation for the awesome template engine is now fully incorporated in all the old code.  Soon, practitioners and users of the system can create their own templates in an intuitive manner using a Template Builder (similar to they way WordPress builds its forms for their blog pages).  This cannot be achieved without using json and incorporating the jQuery plugin, dForm, which I own a debt of gratitude in making NOSH even better.

Speaking of gratitude, and back to the topic of this blog, I first like to give thanks to viewers of this blog and those that have looked at my project.  Although I don’t have hard numbers in regards to new viewers and those that are truly using NOSH ChartingSystem in their own practices, this is just a snapshot of my current stats:

Since the start of this project (approximately 1 year ago today), I’ve had 2059 visitors, 868 individuals have checked out my full-featured demo, and 405 individuals have downloaded my project!!

Thank you to all for making NOSH Charting System a world-wide project!  I’ve had interested coming not just from the United States and Canada, but England, Germany, Austria, Spain, Portugal, France, Italy, Netherlands, Norway, Denmark, Greece, Croatia, Poland, Russia, Pakistan, India, Nepal, Bangladesh, Taiwan, Japan, Mexico, Ecuador  Venezuela, El Salvador, Costa Rica, Jamaica, Morocco, Saudi Arabia, Israel, Ethiopia, South Africa, Australia, New Zealand, and many more!!  I’ve had some who wanted to translate this project to other countries as well.

Thank you to medfloss.org for posting my updates!  NOSH ChartingSystem is the 4th top viewed project (with up to 30,671 views!) on medfloss.org alone.  All I can say, is “WOW!”

Thank you to EMR and HIPAA for interviewing me about my project, its origins and its aspirations.

Thanks to KevinMD for posting my essay regarding my work as a family physician in the United States and the struggles we face (and the dark days, are unfortunately not over).

Based on my unexpected positive reception of my project, I believe I have struck a chord with health providers, health information technology followers, and even patients and patient advocates about the need for something different to change the landscape of our health delivery system, not just in the United States, but worldwide.  NOSH ChartingSystem is a tool meant to reach the masses, irregardless of a health provider’s ability to afford an electronic health record system.  And they all deserve to have a system that is easy to use and understand, irregardless of their ability to use a computer.  And through this tool to build an interconnected community of users, we can unite to make change to ensure healthcare for all and to support those in primary care who need all the help they can get while they advocate for their patients.  And even if you can’t use NOSH ChartingSystem directly, you can help be a part of this community and to ensure its future by simple words of thanks or donating to the project.

May the rest of the year bring good tidings to all and enjoy NOSHing!

NOSH 1.5 Avocado released

NOSH ChartingSystem version 1.5 has been released and is ready for download through the Launchpad PPA.  This is a major milestone release with a multitude of features and updates from 1.4.

Some highlights include the ability to make full featured addendum to signed encounters with the ability to view previous versions, increased Mirth integration, new Updox integration scripts, and a cleaned up interface thanks to the updated jQuery and jQuery UI libraries.  Of course there are the usual small bug fixes and code optimizations.

One exciting byproduct of this recent milestone development is that NOSH is easily used on a tablet thanks to its 980 minimum width pixel programming so nothing gets lost when using a tablet-sized screen and resolution.  In fact, try using the demo with your Android tablet or IPad and see for yourself.  By the way, NOSH looks gorgeous with the Google Nexus 10, which was my tablet test bed for development.

After this release, I’ll be dedicating more of my time with my Kickstarter campaign, which I’ll discuss more in future posts.

In case you’re wondering why this version is called an avocado, I’ve decided that all milestone releases (which are multiples of 0.5) will be named alphabetically after a healthy snack (as opposed to some unhealthy varieties, ahem, from a specific smartphone OS ), specifically fruit.  Enjoy noshing!

I’ve been published at KevinMD.com!

See this link here.