Presbyterian Healthcare has appealed North Carolina regulators' decision to allow Carolinas Medical Center-Union to expand its emergency department in Monroe. CMC-Union is proposing a $21.5 million renovation and expansion of its ED that will include a 23,000-square-foot addition and the renovation of 8,800 square feet of existing space. The appeal will delay the project by four to six months and add to initial cost estimates, said CMC-Union representatives.
The Colorado Senate has approved a resolution which proposes to give all Colorado children access to healthcare by 2010. The resolution sets a goal of covering roughly 180,000 Colorado kids without insurance, but provides no details on how the state will achieve that goal. Some senators expressed strong concerns about making a pledge that may set unrealistic expectations.
Nearly 3,500 patients went to Heart of America Surgery Center in Kansas City, KS, last year. Heart of America is licensed in Kansas and is required to adhere to state regulations for outpatient healthcare. The center also is accredited by the Accreditation Association for Ambulatory Health Care, a nonprofit agency that helps organizations improve safety and quality in ambulatory care. For many patients and their families, being treated at accredited healthcare centers adds another layer of trust to the outpatient experience, say Heart of America's administrators.
Like the chicken-and-egg conundrum, healthcare has its own longstanding riddle: Does technology lower costs or raise them? In search of an answer, I spent an afternoon last week poring through an exhaustive report from the Congressional Budget Office.
Technological Change and the Growth of Health Care Spending suggests that technology does as much to spur costs as to contain them. Surprisingly well written for a government document, the CBO treatise lays out the case that: a) healthcare costs are rising in an unsustainable way and b) the advent of new technology is a primary culprit. "On the basis of review of the economic literature, CBO concludes that roughly half of the increase in healthcare spending during the past several decades was associated with the expanded capabilities of medicine brought about by technological advances," it says.
Despite its potential to improve care and outcomes, new technology can spur price increases in several ways, the report says. For example, the very power of diagnostic imaging results in increased deployment. A diagnostic scan may be less expensive than costly surgery. "But by their nature they invite much greater use and therefore tend to increase total spending compared with previous methods," the report says. Likewise, life-extending coronary and dialysis procedures have become commonplace. True, patients are living longer, but in the meanwhile, they are running up more bills and creating more demand.
The report, however, does not lay the rising cost of healthcare exclusively at the doorstep of older people, saying that while elderly people incur higher costs than younger ones, the overall contribution of an aging population to spending is often exaggerated. Other social factors, such as rising obesity, also are driving up costs.
Technology creates its own silent time bomb of future cost. Consider IT storage. The unit cost of disk space has dropped remarkably in the last few years. Alas, the demand for more space has gone the other way. Modern hospitals now measure their data centers in terabytes. And as more images work their way into digital archives, the budget for storage will continue to grow--even though the hardware may be shrinking in cost and physical size alike.
The report is short on specific solutions to this problem, only suggesting that Medicare should revisit its payment policies on high-tech procedures. Ironically, the presence of health insurance in the first place may drive up costs, because it insulates consumers from the real cost of medical technology. We already know that technology races far ahead of the ethical debate around its use--witness the controversy on stem cell research. Now we can add that technology also races far ahead of our understanding of the economics surrounding its use.
The vast majority of healthcare transactions still take place on paper, a system that has remained unchanged since the 1950s. The interoperability of EHRs can mean a patient's entire medical history is available--for editing, eyeballing or lawsuit-mongering-- system-wide. In a large hospital, roughly 150 people, from doctors and nurses to technicians and billing clerks, have access to at least part of a patient's records during a hospitalization.
Hospitals and health systems have an ethical, and likely soon-to-be-legal, obligation to investigate the potential breach of confidentiality. However, without interoperable EHRs, practicing physicians, pharmacies and hospitals cannot readily share patient information.
In the United States, standards for electronic health records are at the fore of the national medical agenda. But implemetation remains a legal gray area. Currently, no law obliges physicians or hospitals to inform their patients of the switch to electronic recordkeeping. That landscape may soon change.
In 2005, our private practice was issued a tax-free grants from Evanston Northwestern Healthcare to non-employee physician offices. The grants were intended to defray the cost of implementing an electronic system in our office, including hardware, software, staffing, training, and lost hours of patient care.
As a concierge practice for 30 years, we looked at EHRs as a way to stay on the cutting edge and improve service for our patients. With the help of these funds, our private practice of four full-time physicians and two nurses in Winnetka, IL made the full switch to electronic recordkeeping.
Implementation was by no means easy. My advice to those interested in establishing themselves electronically is to budget time and financial resources for over a year, as well as to inform your patients. A schedule of dry runs and staggered implementation were key for our office. First, billing was instituted through the electronic system, followed by scheduling, office visits and note-writing. We raised our rates slightly and found revenue in new places like an in-house lab.
We began informing patients with each visit that in mid-2007, we would be changing to a new electronic charting system and that there would be periods of disruption. All staff members were required to take detailed classes necessary to work the EHR system.
Implementation also meant budgeting more time to type in data. Annual visits were given a breadth of 80 minutes; general office visits were to last 20-40 minutes. We also built in time for us to type information into the new system. We were prepared financially to weather a significant decrease in revenue because we would be seeing fewer patients.
We scheduled our go-live date to begin directly after our quarterly taxes and malpractice insurance were due. Four weeks prior , we mailed every patient in our system a letter explaining that their charts were being converted to EHRs and what that meant to them: potential access of personal health information to many more healthcare providers, for example. We promised better billing and scheduling in the future. As a practicing attorney with a specialty in medical ethics, this step is essential to covering your legal bases.
Prepare for a range of patient reactions. Most were pleased by the billing efficiency. Others left the practice entirely, claiming our affiliation with Evanston Northwestern Healthcare made their information vulnerable to too many parties. Staffing was also interesting. Before the implementation there were three employees out of 16 who we felt should retire or leave for reasons not involved with the EHR. As we began to plan for implementation and as all the employees began to take the detailed classes necessary to work in the EHR system, it became apparent that those same three employees were having trouble with the change. Without prompting, they all left before or very soon into the new system. The change in office culture and alteration in traditional work flow can be difficult for some employees.
On a larger scale, I was the senior resident in the Glenbrook Hospital ICU when Evanston Northwestern Healthcare went live with electronic records, a trying but successful night. ENH then continued to expand its inpatient adoption of the system to the ER and the floors. Finally, outpatient clinics of the employee-physicians went live.
ENH is one of the few hospital systems in the country to have fully implemented an electronic medical records system with computerized physician order entry capabilities across 100 percent of its operations. The improvement in billing and scheduling, the accessibility of patient medical information from all three hospitals and other doctors offices, as well as the security of getting rid of paper charts, convinced both ENH and our small private clinic that electronic records were the best option for timely, patient-centered, portable care.
But what of the legal ramifications? According to a study recently released by the eHealth Vulnerability Reporting program, EHRs can be accessed and personal information gained through "standard tools and techniques," making EHRs, well, no less vulnerable than any other traditional data system. The study also revealed that some health systems may be as ignorant of the threat to privacy as their patients because vendors were inadequately disclosing system vulnerabilities to their customers. The exploitation risk can be "dramatically reduced when vulnerabilities are known and appropriate security controls are in place," the report states.
eHealth recommended that EHR software vendors implement better testing of their systems' security and disclose to customers any vulnerabilities they find. Vendors' remediation of vulnerabilities often takes too long, the report added. One of the systems tested was the system used by HealthCare Partners Medical Group in Southern California. Physicians and hospitals should not only insist full disclosure on the part of their vendors, they may reference HL7, the organization currently setting the standard for flexible guidelines and methodologies enabling the exchange and interoperability of electronic health records.
HL7 has allowed for the interoperability between electronic Patient Administration Systems, Electronic Practice Management systems, Laboratory Information Systems, Dietary, Pharmacy and Billing systems as well as EHRs. These data standards are meant to allow healthcare organizations to easily share clinical information.
Ultimately, the implementation of EHRs will be necessary to ensure patient records geographically accessible and consistent. The successful information achieved by electronic health records keeps hospitals and health systems on the cutting edge, and will soon be the gold standard in care.
David R. Donnersberger Jr. MD, JD, FCLM is the site director for the Internal Medicine Clerkship for Northwestern University Feinberg School of Medicine/ Evanston Northwestern Healthcare in Evanston, IL. He can be reached at drdonnnersberger@yahoo.com.
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Children's Hospital and Regional Medical Center in Seattle plans to grow into a neighboring condominium complex, and the hospital has started buying condos in the 6-acre Laurelon Terrace complex. So far, the hospital has bought 21 of Laurelon's 136 units. Supporters of a proposal for the hospital to buy the entire complex all at once say it could lessen the effect of the hospital's planned expansion.
A plan to provide health insurance coverage for all Minnesotans through a government run program has been advanced by the state's DFL legislators. The Minnesota Health Plan was touted as the most effective way to transfer savings resulting from lower insurance overhead and other costs to provide coverage for an estimated 400,000 uninsured state residents. Spokespeople for Gov. Tim Pawlenty, however, said the governor is opposed to government-run healthcare and is working with a bi-partisan task force on other plans.
Blue Cross of California is sending physicians copies of health insurance applications filled out by new patients, along with a letter advising them that the company has a right to drop members who fail to disclose "material medical history." The letter is not sitting well with physicians, who say Blue Cross is asking doctors to violate the sacred trust of patients by disclosing medical information that patients would expect their doctors to handle with the utmost secrecy and confidentiality.
Georgia Gov. Sonny Perdue's proposed budget for fiscal 2009 would increase the fees that the state pays doctors for treating poor and disabled patients in the Medicaid program. Hospitals, home health agencies and nursing homes also would get a rate increase, which would extend to Peachcare, a second government program. But physicians and hospitals say it won't be nearly enough to erase their losses. Lingering pay gaps also may make it harder to find doctors who will accept new patients covered by Medicaid and PeachCare, which together cover 1.4 million Georgians.
Six Provena Health hospitals in the Chicago area have hired LifeWings Partners LLC to reduce errors by standardizing their obstetrics departments' procedures and staff communications, using practices similar to what pilots follow. Six months after Provena employed the LifeWings method, miscommunication reports are down 50 percent, said Provena service line administrator Joan Cappelletti.
