Many of us have wanted to ask, “Whose idea was this, anyway?” There are, of course, very sound reasons to digitize medical records, and I’m sure that many patients have experienced benefits from a new doctor being able to quickly download elements of their histories. I’ve already seen savings for my own patients’ insurers from being able to scan most of their imaging history in one place, when the patients don’t recall what studies they’ve recently undergone. At our office, we have indeed been able to lay off one and a half transcriptionists, though it doesn’t feel like a benefit when these are employees who had been with us for years. On the other hand, our net payroll costs have increased substantially because of the overtime for our other employees, the contract employees we’ve had to hire to abstract and convert the paper charts, and the IT personnel costs.

Having been a school board chairman in the heyday of “technology” adoption in schools, it is clear to me that the greatest benefit is to the computer and software vendors. Once an institution becomes accustomed to using electric gadgets, there is no turning back, no matter that the advertised gains don’t materialize. Soon, the equipment and programs that were the answer to our prayers a year ago are no longer viable, and we can’t live without the next generation. It strikes me that in education and medicine both, the use of planned obsolescence has reached a zenith in “technology” (as if a pen or typewriter weren’t technical also). In addition, after working with a number of medical programs it is clear to me that the vendors’ goal hasn’t been to market the best product possible, but just to sell the system that will do the minimum job to get the contract now.

The other big winners are the payers, if only because it’s easier to use their own computers to review our care. The half empty glass view sees that as a way to deny and delay payments, and that’s true, but the positive side is a chance to be guided by them and by ourselves to a more effective and efficient style of patient care. Still, the financial benefit accrues so clearly to the insurers that it seems to me that they should be the ones paying for this wrenching transformation in our system, rather than the providers, especially independent small practices like mine. I was heartened to see that this concept was recognized in the Affordable Health Care Act and this was one of the reasons our group decided that we could borrow money now to implement an EMR, but if the Supreme Court or Congress undoes the bill, we’re stuck with all the costs.

The quality of the record in an EMR is undeniably different, whether you think it’s better or worse. I recently heard of a case involving three different physicians, one of whom had a paper check-off list with a written narrative comment, one who dictated a narrative record, and one who had a typical office EMR. The first two delivered good care and could prove it, but the third had, in spite of many pages of data including the whole family history and PMH for each encounter and sheets of picklist notations, nothing that demonstrated that she had recognized the central problem or used a rational process of decision making. The plaintiff’s attorney tossed her stack of printouts on the table with disdain and then stated with obvious glee, “Who knows what this pile of stuff says? It looks like it was written by a computer.” Unfortunately, he was right on both counts. I suspect that that doctor’s care was just as good, but she could never prove that on the basis of the boilerplate that became the record of those visits.

This gets to the notion of how the computer changes our styles of practice. As I’ve adapted to using it, I’ve learned to sharply separate my patient care from my record keeping. Some of my personal problem is being too old to easily change my approach to patients and to conceptualizing their problems. The EMR was supposed to increase my income by capturing my work and documenting all I do. However, as I tried to use the checkboxes, I found that I was losing the forest for the trees in trying to maximize the points of history and exam rather than attending to just the important questions and maintaining an open mind toward the whole differential diagnosis. This is not to mention keeping eye contact with my patient and responding to facial expression, body language, etc. I find that to continue to use the knowledge and experience of my decades in medicine, I need to approach the patient in the exam room as I always have, then use the EMR separately as the undeniably superior billing tool that it is. I know that younger doctors have used computers from the start of their training and I hope that they can integrate complex and expansive thinking with record keeping better than we old fossils do.

As for the touted advantage of saving physician time, I find that this hasn’t materialized either. In our old system, we could quickly dictate a record that said just what we wanted, then a small army of transcriptionists and medical record technicians put a lot of arguably wasted time into storing it and the other clinical reports, like lab and imaging, which we could dispatch by a simple check mark or cursive comment. Now, it is physically easier to find in the data base, but all of the keyboard work and data handling is done by the doctors ourselves, and we have traded the cost of hours of low paid clerical work for hours of our own unpaid time. If I could get back all the time I’ve wasted in increments of several seconds waiting for the next page or template in a record, or that I’ve spent doing record keeping that my employees used to do, I would be much better off financially and I would have been able to do more patient care.

All in all, I am enjoying the challenge and the advantages of the EMR, but I don’t enjoy the enormous financial costs or the expenditure of extra time. I know that a lot of physicians are very enthusiastic about their IT, and I want to learn from them how to take best advantage of my own. I do suspect, though, that most of those docs who have a positive take on their EMR’s are either younger so that they don’t fully know the alternative, or employed so that they aren’t shouldering the costs themselves, or both. These have been a few personal comments on a subject that could be and has been expanded into volumes, and I’ve probably irritated some readers and exposed my own ignorance and poor learning capacity. I do hope this generates some dialogue so that I and others who are struggling a bit with the computerization of medicine can learn how to participate more effectively.

Robert McFarland, MD, IMA President-Elect

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How much will it cost to develop our own medical school in Idaho? One available alternative is to increase the first year WWAMI class by 20 more students, to a total of 40, which would take $1.1 million in one-time expansion costs. To put this in perspective, this is about one fourth of the price of building a single small grade school. It would then cost about $45,000 a year per student to support his or her ongoing education. This is about five times the yearly amount for a K to 12 student, depending on how you calculate the total expenditures. It seems to me that these figures compare very favorably, particularly when one considers the substantial economic return to the state from each practicing physician. We would recover these funds easily just by taxes on the recaptured work that leaves the state now for want of adequate numbers of doctors. Just in terms of societal benefit, the cost vs. yield on a yearly basis for four years of medical education is arguably less than the price of basic education over 13 years.

The University of Washington is extending its program in Spokane to a second year of medical school, and this has been estimated to cost $2.5 million. If this were done in Idaho, for the price of less than half of a grade school we would essentially have a four-year medical education program. The third and fourth clinical years are already being taught here, and could be expanded at minimal expense.

The legislature is understandably very reluctant to add these costs in a year in which the budget is very strained. I am sure that some of our sister states have considered defunding medical schools along with their other educational facilities,due to their own financial problems. However, none have done that. They recognize the value of training new doctors, as a matter of public health and economic activity.

Even if we did not need more physicians in Idaho (which we most certainly do) and even without looking at the augmentation of the economy, if the state has long been committed to support both a basic education and college level studies for its citizens, isn’t it reasonable to help complete the job and assist with providing for medical professional education? To do so is a tremendous benefit for those Idahoans who choose a medical career and for the many whom they employ, and as outlined above is a pretty fair bargain in terms of public good per dollar.

If the state does not consider this a public obligation, how should it be paid for? Aspiring physicians already pay for a major portion of their own education costs. Should all medical schools, or at least the medical school in Idaho, be private enterprises with no state government support? There are federal subsidies through a number of channels. Should these be increased, decreased? Don’t forget that our medical students are already heavily supported by the taxpayers of Washington and Utah. Should we simply import most of our doctors from foreign medical schools? Let nurse practitioners fill the gap? These are questions which we should debate among ourselves and with our legislators. It seems to me that when medical education is looked at as just one part of overall public education, there is little reason not to proceed immediately to train more of our own right here in Idaho.

Robert McFarland, MD, IMA President-Elect

Steve Coker, IMA President

One of these issues is the ever-expanding cut to physician Medicare reimbursement caused by the SGR. A 27.4% cut is scheduled for January 1, 2012. So begins the much despised annual ritual that grows more politically problematic each year. Congress has stepped in 12 times in eight years to temporarily prevent large Medicare physician payment cuts mandated by the broken SGR formula created in 1997.

We all know that it needs to stop. Assuming that Congress passes another temporary measure to stop the cut and the cost to permanently fix the SGR continues to grow, where do we go from here? How can physicians continue to see Medicare patients and keep their practices viable? How should Congress fix the broken payment system?

We were successful at the American Medical Association Interim meeting achieving passage of our two IMA resolutions that came from our House of Delegates meeting in July. The first resolution, Resolution 206, was about CMS audits of electronic health records. This resolution generated a lot of discussion, all of it positive. There were actually amendments suggested and passed which we felt helped strengthen our resolution. We should be proud that we brought an issue from Idaho to the national level and the result should be helpful to all physicians. It will be interesting to track the results of the AMA’s efforts on this issue and hopefully, the ensuing education to physicians as a result. (View Resolution 206 as adopted here.)
 
The second resolution, Resolution 925, was regarding physicians that are in good standing in their recovery program being able to take their board exams. This was also positively received and although the AMA already had policy supporting the same position, the result of our resolution that passed with minor amendments is that the AMA will be communicating with specialty boards to request that they adhere to that policy and include physicians in good standing in state physician health programs. (View Resolution 925 as adopted here.)
 
We have very good support from our caucus, the Western Mountain States Caucus, at the AMA and it was a pleasure for Vicki Wooll, MD, and I to represent you. I encourage you to read about these and other issues that were passed at the meeting on the AMA website or in AMNews and, as always, I encourage you to be a member of the AMA so our physician voice can be as strong as possible.

This effort was started by the Board of Trustees in an attempt to keep the conversations, ideas, and fixes discussed at our summer meeting continuing throughout the remainder of the year. Our board meets immediately following our annual meeting to review the resolutions passed, and to provide a priority for staff and others to complete the work that you direct through our resolutions. Over several years board members at this meeting have been remarking on the great ideas that come from the legislative process each year, and we wish to keep the good ideas flowing until the next summer meeting. This is one of our purposes for this blog. We would also like to keep more members aware of the ongoing work of our association, and we hope to improve our communication and our response to our members. We will be posting several weeks in advance of our quarterly meeting the subjects in front of the Board. We would greatly appreciate your input for the work ahead of us. We are hoping this is a way for some of our members who may not run into their trustee in the doctors’ lounge to have a way to communicate their concerns from their office to our board members who are enthusiastic about this blog and will be reading your postings.

I am also hopeful that this blog will bring to light other remedies to problems we all face in the practice of medicine, and even to identify problems on the horizon we need to be aware of on the Board. I will be posting to the blog along with IMA CEO Susie Pouliot and other IMA staff and Board members. So, please help us get the conversation started by letting us know what’s on your mind.

Steve Coker, IMA President