NOSH ChartingSystem

A new open source health charting system for doctors.


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Primary Care Physicians are a Dying Breed

Primary care in the United States is a paltry shadow of what it used to be and nothing like what it is in other developed countries in the world.  I can point to numerous articles that confirm this slow death since the 1990’s:

The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care

More Doctors Giving Up Private Practices

Death of the Family Practice – Doctors Struggling to Survive in Face of Mounting Obstacles

Family Physician Can’t Give Away Solo Practice

I can also point to numerous articles that validate that a vibrant and strong primary care component in a health system improves outcomes and lowers costs for a population:

Greater Reported Patient Access to Selected Primary Care Attributes was Associated with Lower Mortality.

How is a Shortage of Primary Care Physicians Affecting the Quality and Cost of Medical Care?

Primary Care Physician Workforce and Medicare Beneficiaries’ Health Outcomes

Contribution of Primary Care to Health Care Systems and Health

This slow death of primary care has many origins, starting with the disparate incomes of primary care physicians versus specialists.  It’s a negative spiral that only serves to degrade and decrease the number of new physicians into the primary care fields.  In fact, only 5% of graduating medical residents in the United States chose primary care as a profession over the past decade or so.

Income Disparities Shape Medical Student Specialty Choice

This graph tells it all (source):

Adding dirt to the wound, there is currently a ‘silent exodus’ of primary care physicians as we speak.  I know of other primary care colleagues who have packed up their outpatient practice and headed for the hills of hospitalist medicine, urgent care, or non-clinical jobs (one popular one is a company that serves hospitals to make sure that they meet compliance with Medicare readmission guidelines, it’s something that you can do from home).

If you think about it, these other avenues I mentioned are really picking up the void that is left behind when primary care had been decimated.  Economically, these avenues are much more attractive to the hapless primary care physician, and it’s doing the work that had primary care really done it’s job in prevention, we wouldn’t have to get to the point of acute, higher-cost care.  It’s another negative spiral.

This whole thing stinks of negative vortexes and the cost of health care conundrum is just a big black hole sucking up everything in its path.  It is a very sad state of affairs for primary care physicians.

I was a victim too – I closed my practice down in 2012 due to the increasing uncompensated demands by insurance and continued decline of reimbursement for my services.  My NOSH ChartingSystem worked wonders for my productivity but it didn’t matter because the greater problem was something that my EHR alone could not solve.   As I had mentioned before on my blog regarding EHR certification, certain laws have made it much, much harder for a primary care physician to survive.  Whether it was intended or not, these policy decisions have continued to push the extinction of primary care physicians like me, especially those who are trying to pave a brave, new path against the current trend of seeing more patients in less time.

Small Practice Evolution: The Medical Micropractice

So now, we’re at a crossroads.  Can primary care be reinvigorated?  Is it too late to change?

I think primary care can be reinvigorated.  In time, we as a society will look upon this time of decline as something that we should never repeat again.  I fear, though, that the kind of change and the kind of vibrancy that primary care can be will not be fully realized in my lifetime (with tears in my eyes).  But with this project, maybe I can bring about the solidarity and voice that is needed to bring primary care out of the ashes towards a better future.

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The Adverse Childhood Experiences (ACE) Study Suggests That Focus on Early Treatment and Prevention of Certain Childhood Experiences Can Impact Health Care Costs in the Future

The ACE study was a landmark study involving 17,000 participants surveyed between 1995 and 1997 enrolled at Kaiser Permanente.  The aim of the study was to assess associations between childhood maltreatment and later-life health and well being.

The results and associations are extremely revealing, but also makes incredible sense when you apply this to the idea of controlling health care costs.  For example, the total lifetime estimated financial costs associated with just one year of confirmed cases of child maltreatment (physical abuse, sexual abuse, psychological abuse and neglect) is approximately $124 billion.  The impact of child maltreatment, specifically increases the risk for these conditions (this is not the exhaustive list, here’s more): ischemic heart disease, alcohol abuse, drug abuse, obesity, headaches, smoking (and all the medical conditions associated with it like lung cancer, COPD), teen pregnancy, unintended pregnancy, mental health conditions (depression, anxiety, and much more).

So why isn’t this a major headline and why isn’t more being done to address this?

My answer is that part of this is related to the stigma of abuse in our society.  Although the recent Jerry Sandusky coverage has highlighted that abuse can happen anywhere and doesn’t just happen in lower socioeconomic groups, we as a society have mostly focused on sensationalizing the abuser and the bringing them to justice, but we don’t talk much about treating the victims.  Although there are breakthroughs in the neuropsychological fields regarding recognition and management of childhood trauma, there is much work to be done to really focus on helping the victims on the ground.

The second part of this answer is receiving mental health care also carries a social stigma as well as a significant cost barrier. Compounding the problem is that individuals who have mental health issues, in general, do not have the means to pay for health care, and thus are either uninsured or under-insured.

Do you see the same pattern in the previous post?  Cost is the largest barrier here, yet again.

The lack of prioritization on prevention and early treatment as demonstrated by the inequality of reimbursement rates produces outcomes that are woefully inadequate.  It’s further reflected by our prioritization (or the lack thereof) of mental health interventions compared to other interventions, such as drug intervention.  Not too long ago, the standard belief was that mental health was separate from physical health and their treatments were paid differently (less, of course).  In fact, remnants of this belief still exist, especially for treatment, even though the Mental Health Parity Act in 2008 was an attempt to improve this disparity.

Although mental health providers are bearing the brunt of this unfair system, primary care providers also experience a significant share of the burden.  In my own practice, 60% of my time was spent managing mental health issues, including depression, anxiety, bipolar disorder, chronic pain, addiction, and a large majority of that was related to a past history of childhood maltreatment.  I can also attest that managing adults is much more challenging than children because positive change happens much more slowly.  The neurological plasticity of children is the main reason why early intervention is so crucial and so cost efficient in the future if we actually paid attention (more time for providers to interface with the family and patient), and we directed health care costs towards early intervention that has been shown to work.

If money is indeed the measure of worth to society, society is saying right now that mental health treatment is not valuable to society.  Is that really what we believe?


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Many Individuals Remain Uninsured or Have Limited Access to Health Care

Right now in the United States, there are at least 47 million uninsured individuals with no way to pay for their health care. 47 million men, women, and children live day to day without knowing how to pay their doctor or hospital should they get hurt accidentally or caught a life-threatening infection, or found a suspicious mole on their skin. I’m sure you can develop a very long list of other scenarios where an individual, by no fault of their own, will need medical care at some time in their life. Some will do whatever it takes to avoid getting medical care; others will have no choice because their medical condition has become so bad or life threatening that they have to be treated. Most times, these individuals in the latter will seek care, but it would be too late to change the outcome. Millions have died, at times unnecessarily, because their access to health care has been compromised. Right now, in the United States, access to care is directly tied to their ability to pay.

And the cost of health care in the United States has been and continues to skyrocket out of control in the past 3 decades.

And the reasons why this continues are best described here (source):

With the downturn in the economy since 2008, the top 3 reasons (cost, lost job, changed employment, employer did not offer insurance) became even more substantial.

So if cost is a major factor in the number of uninsured patients, and costs continue to skyrocket…what is causing the cost of healthcare to rise?

The answer is elusive and depending on who you ask, you’ll probably get a different answer. And this graph only give a partial idea of the driving costs of healthcare (source):

Here is my answer:

In the United States, we as a society have prioritized procedures, drugs, and futile, heroic treatments rather than focusing on prevention and early intervention.  Even if we as a society “know” that prevention and early intervention are better approaches, “doing” the action and encouraging the “doing” is not happening.

We, as a society, have not realized or understood the impact of untreated mental health conditions on the cost of society as a whole. We have not realized that there are proven interventions available to improve outcomes to reduce that cost on society and we have not focused or efforts to support these programs and interventions, especially for children.

We, as a society, believe that health care is a commodity and not a right for everyone.

We, as a society, believe that there is an infinite pool of money to fund technologies and treatments that may or may not improve health outcomes and that the free market is the final answer to all of the problems health-care related.

I argue that these beliefs are what is ultimately driving the costs of healthcare out of control.

I argue that these beliefs can be changed. I know that I might be crazy, but I don’t think I’m alone.

With this backdrop of information, I’ll talk about the next headline…


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Personal Thoughts About NOSH ChartingSystem and the Five Headlines

“It takes a really brave doctor to develop their own EHR.”

“Is this doctor crazy?”

These are some comments that I received over the past few weeks since I released my project.  I’d like to use this blog post to talk about how I got to this place and where I hope to head in the future.  I’m going to bring to the forefront my “Five Headlines” and how it has directed my work.

These headlines reflect the fundamental issues that I feel are paramount regarding the current state of healthcare systems (at least in the United States, but certainly applicable around the world).  These headlines impacted me as a practicing physician.   In detail with as many charts and graphs as possible, I’m going to discuss these headlines starting with what is flawed or wrong with the current system and then how it pertains to my development of the NOSH ChartingSystem.

Many Individuals Remain Uninsured or Have Limited Access to Health Care

The Adverse Childhood Experiences Study Suggests That Focus on Early Treatment and Prevention of Certain Childhood Experiences Can Impact Health Care Costs in the Future

Primary Care Physicians are a Dying Breed

Primary Care Physicians Lag in EHR Incentive Payments

Independent Practices are Being Left Behind in Health Information Technology

Although these headlines seem to be distinct issues unrelated to each other, I will show you how they are all interwoven and interconnected with Primary Care being the hub of the problem in the next few posts.  I will then show you how this open source project could be a common focus point to bring about or advocate for changes in our health care system with primary care and independent practices in the front seat.