Wednesday, October 9, 2013

The Perfect Storm


I have used this metaphor, the perfect storm, several times during the past ten years to sum up the simultaneous multiple counter-intuitive shifts in medicine .

Another perfect storm has developed with the confluence of health information exchanges, health IT, the affordable care act, and the debt crisis as well as congressional gridlock.

Storm # 1 (to be named)

Health Benefit Exchanges:  The initial rollout has been sporadic with variability in reliability and accessibility. Initial success is much greater in the state sponsored and operated online health benefit exchange portals.  The federal HBE at has  receive a failing grade from consumers attempting to sign up for the individual mandated coverage.  Most reach the page shown on the portal.

Why are the state sponsored sites working well and the federal site poorly? What exactly is plaguing the federal insurance marketplace website,, even as most state exchanges are functioning well, remains unknown. But Web developers and software engineers across the country have a few ideas. In the best tradition of the Internet, they've been crowdsourcing their various diagnoses on Reddit, the popular social media site.

The difficulties appear to be more technical than political. The sheer scale of a national network are much greater than individual state networks. The individual state networks stand alone and depending on which state the national HBE link will take you to the state HBX.  However if the state HBX is run by the FEDS it is a different story.  The Reddit site goes into much detail by ‘nerds and geeks’.

Those who are familiar with the DOD EMR and the VAEMR know how many years and iterations have occurred with those systems.

Second guessing is always easier to do than getting it right the first time. Heavy initial demand may be part of the problem as everyone tried to sign on at once.

HHS, CMS and federal contractors, meanwhile, are trying to address problems they find through testing and that are reported from users, all while asking for patience from would-be shoppers and encouraging them to visit assistance centers or to call and speak with navigators.

However despite the IT nature of the challenge it makes a bad political statement for the Affordable Care Act along with other postponements such as the employer mandates and many other waivers.

While the HBXs undergo a shakeout and even if they are running smoothly, that is only the high tech side of it. The real ‘back end’ is how consumers and insurers will face off after the application process.  What health systems (insurers, hospitals, and providers) will be ready and operating correctly.

We should not forget what this is all about….patients.   We always need to remember this is about patient and patient care….high tech serves them and it should never be the master//

Doctors are cautious about HIX, says MGMA, and many 
say they're still weighing their options

Storm #2

Docs 'stressed and unhappy' about EHRs. No less important and on the other side of the equation is the effect EMRs have had on efficiency and quality of care.  Regardless of what data analytics, statisticians, and bean counters claim EMR is affecting quality of care at the bedside, and in the clinic. Patients, despite their wanting their MD to use EMRs find that the next clinic encounter their ‘beloved’ doctor is paying more attention to his tablet, or laptop.

While physicians recognize the benefits of electronic health records, they also complain that many systems deployed nowadays are cumbersome to use and often act as obstacles to quality care, according to a new report from RAND Corporation.

The most poignant results from physician surveys: (Rand)

While physicians recognize the benefits of electronic health records, they also complain that many systems deployed nowadays are cumbersome to use and often act as obstacles to quality care, according to a new report from RAND Corporation.

The findings are from a project, sponsored by the American Medical Association, designed to identify influences on doctors' professional satisfaction – a snapshot of physician sentiment as the U.S. healthcare system moves toward new delivery and payment models.

Docs who were surveyed expressed concern that current EHR technology interferes with face-to-face discussions with patients, requires physicians to spend too much time performing clerical work and degrades the accuracy of medical records by encouraging template-generated notes, according to the RAND report.

In addition, they worry that the technology has been more costly than expected, and cited frustrations about poor EHRinteroperability, which prevents the transmission of patient data when and where it's needed.

"Physicians believe in the benefits of electronic health records, and most do not want to go back to paper charts," said Friedberg in a press statement. "But at the same time, they report that electronic systems are deeply problematic in several ways. Physicians are frustrated by systems that force them to do clerical work or distract them from paying close attention to their patients."

Other items that have created physician frustration are given in the article (page 1)

Administrators of all sizes, and shapes love this stuff…numbers,graphs and seemingly measurable data objectified. It’s a digital world. However patients and medical care are analog. It may be excellent for imaging and lab reports.


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