The flaws with eCWs system aside, the larger problem with EHRs, and the fact that to date they have not improved outcomes in any significant way, lies with the fact that they are primarily designed to “optimize” revenue cycle management. Everything has to be documented correctly - or else it can’t be billed for or may get rejected on audit.
Hospital staff, including physicians, are responsible for the accuracy of this documentation, but that’s a big responsibility to bear.
The only way this may change is if we change how we pay for our care. This is not on the horizon at this time. Even the value based programs that CMS has implemented are really fee for service with a look back and adjustments to payments made based on savings that were encountered.
"Everything has to be documented correctly - or else it can’t be billed for or may get rejected on audit."
The clue is right here. This is how complexity in the private health insurance market drives costs and inefficient outcomes into every other aspect of our health care. A thousand different plans each with different billing standards and the software reflects the need to focus on making sure you can meet all the billing standards.
You think a government payment system is going to be less complex? Won't demand correct documentation? Have you ever dealt with a government records system?
Evidence from around the world is that government plans are likely to be cheaper and more effective. Are US private plans standardized regarding what will be covered, as well as the justification of a given procedure or drug? As far as I've had direct experience every plan is different, and even within the same plan there have been inconsistent approvals, doctors have to often get re-involved to add more or different justifications for procedures that are denied then covered. It's all unnecessary added overhead as exemplified by the relative costs of more than 2x other nations with government unified healthcare.
I'd much rather be paying for the time of my doctor to treat me instead of fighting my insurance company armed with a similarly high-overhead software package.
Uh medicare is more efficient than private insurance, despite having it's hands tied by current legislation keeping it from negotiating drug prices. Medicare also takes on the oldest in the population demographic, needing the most and highest cost care that the private insurance companies are then relieved from managing.
You’re completely right and wrong at the same time.
Since Medicare reimbursements are so much lower than private insurance - the consequence of moving to all Medicare would have immense consequences, and the dollars removed would Largely need to be replaced, or quality and access to care would be dramatically impacted
These rhetorical questions are disingenuous given that many examples of working government healthcare already exist. You’re asking if a problem that has been solved multiple times is solvable. The answer is yes.
That hasn’t been my experience with Medicare or Medicaid and I haven’t ever spoken with a healthcare provider that agrees with that statement. I also have family that has used Medicaid and the health care is abysmal.
The Administrator of the US Centers for Medicare and Medicaid Services has a salary of $165,000.
I don’t envy the person making that kind of money, but given that the government can do a similar task cheaper, I question the legitimacy of the boards decision to pay an excessive amount, which impacts the profitability of the firm.
> The only way this may change is if we change how we pay for our care.
Agree 100% on this. The incentives in a fee-for-service world are just so badly misaligned with the goals of functional healthcare system.
> Even the value based programs that CMS has implemented are really fee for service with a look back and adjustments to payments made based on savings that were encountered.
So CMS is acutely aware that merit-based adjustments on top of a fee-for-service model is an incremental improvement (and a very modest increment at that). So within the Medicare's Quality Payments Program, there is MIPS (Merit-based Incentive Payment System) which is exactly what you describe and where most providers default to right now. But there are also several APMs (Alternative Payment Models) that providers can elect to participate in, some of which have full or partially-capitated payment mechanisms where there is a fixed fee per beneficiary, rather than the fee-for-service model. Everything I've heard from CMS suggests that APMs are the future and fee-for-service needs to go away. That's not going to happen over night but MIPS is the narrow end of the wedge to get us there.
Are you familiar with the free market medical movement? It's definitely not a fix for the entire US healthcare system, but I think it has the potential to create some major positive improvement in outpatient care for people who don't live hours away from the nearest cashpay specialist and can afford to pay for small things out of pocket.
I work in inpatient now, but I previously worked for a radiology group that was cashpay focused. The total cost for a brain MRI at most locations was over 10x less than the technical component alone for the hospital I'm currently working for.
A related aspect is liability. Since EHRs are going to be looked at in any postmortem for a health intervention gone wrong (where lawsuits happen), providers have an incentive to not write anything that implies uncertainty. "I didn't see anything" is a hard position to get in trouble with - "I thought it might have been pneumonia but didn't do anything" can bite you.
The funny thing is, the early stimulus has lead to so much investment in US EHRs that they’re quite competitive internationally and being installed in other public-payer health systems.
What I would like to see is a comparison of truly foreign EHRs.
FTFA, non-US clinicians write up much shorter notes in the same EHR. So there’s something about the pressures on the US user that don’t exist elsewhere.
Private insurers are already moving toward value based care where providers bear some of the risk. For example it's common to have bundled payments for certain things like joint replacements covering the procedure itself and all necessary follow-up care. But the fee-for-service model will still be used on some claims for many years to come.
>Even the value based programs that CMS has implemented are really fee for service with a look back and adjustments to payments made based on savings that were encountered.
And let’s not forget one of the more troubling aspects of EHRs and Medicare patients is that physicians are now required to turn over all patient EHR data to the government (CMS) every year for a reimbursement bonus and failure to turn over patient records results in a penalty.
Government collecting patient digital health records...what could possibly go wrong?
The parent comment gets this a little wrong, but there is truth to the data collection aspect.
An increasing number of physicians have to be part of an integrated health network in order to get competitive reimbursement rates. Those networks upload individual patient data to state exchanges which in turn have started to upload to nationwide databases.
The rollout of this is staggered and uneven, as of a couple years ago when I stopped working at a company with its own electronic health record product.
As a sibling comments correctly notes, the CMS bonus (or absence of penalty) does not depend on direct uploading. It does, however, depend on using a system which has the capability of doing that uploading ('sharing').
Finally, I saw over the past 10 years a giant increase in the number of records audited by health insurers. Those audits involve giving the entire patient file to the insurer.
I'm waiting for the day one of these large databases gets compromised and everyone acts shocked that the data was being collected.
Physicians are in no way required to turn over all patient EHR data. CMS collects quality measures in the aggregate, numerators and denominators. There may be vendors in the middle who are collecting the data to calculate the measures, but the patient-level data does not go to CMS. (Obviously, their claims do, they're a payor.)
The only way this may change is if we change how we pay for our care. This is not on the horizon at this time. Even the value based programs that CMS has implemented are really fee for service with a look back and adjustments to payments made based on savings that were encountered.