Americans invented the idea of  “McDonaldization” in which consumer services are standardized to be efficient, predictable, and controllable.  When we want something, we want it now!  We want to be able to understand it, predict it, and control it.  However, healthcare isn’t a service that’s amendable to McDonaldization.  Cooking and serving up fast food has a relative small number of variables that can easily be controlled and predicted such as the size of the hamburger patty and the heat and time required to cook it. The diagnosis and treatment of human illness has literally hundreds of millions of variables to deal with. This is why medical care is not anywhere near as “convenient” as fast food.

But the folks at X-prize want to change this.  Their solution is to open a competition for inventors to develop a Star Trek style “tricorder” to detect and diagnose disease just as the fictional medical tricorder was used in the science fiction series. What is the specific problem to their tricorder solution? According to their promotional video, consumers are faced with a paradox.  From the video;

You want to know what’s wrong. Is this normal?  Is this urgent?  Do I need to see a doctor? But, today, the only way to know if you need to see a doctor is . . . to see a doctor. And that’s not fast, not convenient, not easy. So you wait . . .

The average time to get an appointment is 21 days. The average visit to the doctor takes nearly 2 hours.  Cause you’ve got nothing better to do, right? And then you only receive the right diagnosis or treatment 55% of the time.

Correct. Medical care is nether efficient, convenient, predictable, or controllable and this drives Americans crazy. Part of the reason is the massive complexity of human disease. Part of the reason is how our health care system is organized with way too much emphasis on advanced medical care and procedures and too little emphasis on health care access, primary care, and prevention.

The X-prize foundation’s approach to this problem is to empower consumers and patients with a quick and easy home or outpatient mobile  device to provide real time data on critical health metrics such as vital signs to accurately diagnose disease.  The requirements appear to be only that the device is mobile and be able to accurately diagnose a set of 15 diseases. There is no information on what these “diseases” would be.  The device should also be able to give information to the patient as to whether everything is “OK” or not.

The push to develop a more patient friendly health monitoring device is certainly laudable.  However, it’s not likely that such a device will work in the way that they intend it to. The problem won’t necessarily be with limitations in technology. The problem will be in how we interpret and act on information. The limitations and complexities of the diagnostic and treatment process is something that doctors have to deal with every day. Doctors take a limited set of data and formulate what they believe is the best diagnostic and therapeutic course of action that is uniquely tailored to each patient and each  situation.  They take into account not only the data but their training, experiences, statistical probabilities, and “educated guessing”. This is why medicine is still an art.

And data is not the end point of the diagnostic process. Each abnormal data point could have multiple meanings depending on what you are looking for (the pre-test probability) and the statistical likelihood of disease in your particular population. For example, an elevated blood pressure could mean that you have hypertension or it could mean that you are anxious or because of medications or because of renal artery stenosis. A high heart rate could mean anxiety or a pulmonary embolism. Abnormal laboratory results have the same problem. A low sodium level could be caused by anxiety or a brain tumor. Anemia could be caused by a poor diet or colon cancer. Even imaging is tricky. A mass seen on an XRay or CAT scan could be benign or malignant. There is even the fixed and known possibility of false positives and false negatives for each test that has nothing to do with error or technical variability. Detecting abnormalities is easy. It’s the interpretation that is hard. To say with confidence that your device will be able to diagnose a specific disease with “accuracy” is dangerous thinking.

And who or what will interpret the data for the tricorder user? A computer algorithm can be used but is likely to come up with a diagnostic differential list that may not be accurate and will certainly not be exhaustive. This is because the initial evaluation of a patient is often followed up by more advanced evaluation and it is currently not possible to put every diagnostic modality (Xray, CT scan, PET scan, nuclear imaging, EKG, EEG, biopsy, stress testing, and exploratory surgery) into a mobile phone. Maybe in the far future we will develop a “universal” diagnostic device that includes everything but this is not one of the stated goals of this X-prize.

Even worse than diagnostic uncertainty is the false sense of security that could be provided by normal data in the setting or real disease (i.e. a false negative). The FAQ page from the X-prize foundation states that the tricorder should be able to “give confirmation that everything is ok with a consumer and notify that something is not ok (a “check engine light”)“. This approach is simplistic and absurd to the extreme. Show me a person with completely normal vital signs and blood tests and I’ll show you a patient who is has undiagnosed HIV or a smoker who has a malignant growth in their lung. The danger is that whatever limited data this device does provide will, if normal, give consumers a false sense of security and lead them to cancel that trip to the doctor.

The biggest problem is that such a device is either not required for it’s intended purpose or won’t make any difference in outcomes. Will it really be able to help people make a decision on whether or not to see a doctor or go to an ER? True medical emergencies almost never present subtlety. Ironically, PAIN is one of the biggest indicators that something is seriously wrong and the measurement of pain is not something that can currently be directly done by a tricorder or any other device.  Bleeding, passing out, shortness of breath, vomiting, decreased consciousness; patients rarely have a problem knowing when something is seriously wrong because their bodies do a much better job than any tricorder could do in letting them know. And when should you go to see a doctor in an non-emergent setting? The best way is to use a simple rule of thumb. If you have to consider it then likely you should go. And as far as prevention, do we really need a device to tell us to stop smoking, loose weight, and get some exercise?

There yet may be some uses for such a device. More frequent monitoring of metrics like blood pressure and blood glucose levels in the outpatient setting may, if accurate, help doctors to better control such chronic conditions as hypertension and diabetes and better control can lead to better outcomes. Cheaper and mobile medical devices would help health care workers enormously in areas of the world that are remote and/or lack access to modern medical care.

But to develop a device with the stated goal of “empowering” consumers in their health care decisions by helping them know when they can avoid the inconvenience of having to see a doctor is amazingly shortsighted and ridiculous. And it’s potentially dangerous by giving people a false sense of security that they do not need to see a doctor.

I foresee one main outcome of the development of this tricorder. The typical civilian users of such a device are likely to be suburban, middle aged, relatively healthy and health obsessed. These are the types of patients that doctors in affluent areas dread. These patients Google the differential diagnosis for every single symptom or strange noise coming from their bodies and make frequent trips to their doctor with pages of printouts about their “condition”.  Congratulations X-prize! You’ve begun the process to develop the most important enabler for hypochondriacs that the world has ever known.

It’s stunning to think about the national debt in these terms.  What’s even more stunning is how brazenly both parties, liberals, and conservatives are willing to risk long term economic security to feed their own ideological interests.  A case in point is the NYT’s Paul Krugman who dismisses any short or long term concerns about the US debt with a fanciful wave of his a priori wand. What is Dr. Krugman’s calming tonic in the face of a 15 Trillion dollar IOU? Basically, he implies that the debt doesn’t matter as long as you can raise taxes and interest rates remain low.

Deficit-worriers portray a future in which we’re impoverished by the need to pay back money we’ve been borrowing. They see America as being like a family that took out too large a mortgage, and will have a hard time making the monthly payments . .

First, families have to pay back their debt. Governments don’t — all they need to do is ensure that debt grows more slowly than their tax base. The debt from World War II was never repaid; it just became increasingly irrelevant as the U.S. economy grew, and with it the income subject to taxation.

So as long as we have rich Americans from which the US government can feed from then we will be OK. After all, the top 5% of income earners pay 60% of the US income tax even though their income is 35% of all personal income. For liberals, as long as we can raise taxes, we can continue deficit spending ad nauseum.  For conservatives, it’s even worse. The mantra appears to be deficit spending with low taxes now (trickle down) and to hell with the future.

Of course, Krugman is correct . . . .  about the present. The enormous US debt does not pose a serious short term threat to the stability of the US economy or economic recovery.  Given the sheer size of the US economy, there is no credible risk that the US government would default on it’s debt nor is there any reason to believe that the market for US Treasury bonds would dry up or become unstable. And interest rates are at an all time low, thanks mostly to the severity of the recent recession and the efforts of the Federal Reserve to stimulate the economy through borrowing and investment.

But, like the sky diver falling without a parachute, the danger for the US economy lies not in the present while tumbling through space but at some point in the future when the ground makes its presence known. It’s inevitable that the economy will pick up steam and with growth will come a rise in interest rates. Even small increases in rates can have a profound impact on the interest we pay on the debt.  Right now the interest payment on the national debt is about $242 billion a year.  Interest rate increases over the next decade have the capability of causing the interest on the national debt to exceed $1 TRILLION a year! Chew on this number for a while. This amount represents mandatory spending that does not go towards any social program, military asset, or regulatory agency. These billions pay investors in the US debt of which almost 50% are now foreigners (mostly the central banks of China, Japan, the United Kingdom and Brazil).

There is a very real possibility of a spiraling and out of control situation to develop as the interest on the national debt becomes bigger. Growing entitlement programs (Social Security, Medicare, Medicaid) combined with the increased interest payments could cause mandatory spending to exceed total government revenue. At this point the government’s ability to manage the debt would become even more difficult from a budgetary and political standpoint. The remaining choices, massive cuts in discretionary spending (including defense), massive cuts in entitlement benefits, and/or massive tax increases would become ever more drastic and unpopular.  Just like today there would be government gridlock, indecision, and political pettiness all resulting in  action that will be too little, too late. Meanwhile, the spiral continues, with increased budget deficits creating an ever larger national debt with increased interest payments

What happens then? The problem is that nobody really knows, not even Dr. Krugman. There is a great amount of debate among economists about how big the national debt burden could become and when the economy would become negatively affected. There is evidence that among industrialized countries, those with national debt below 60% of GDP had better annual economic growth (3-4%) than those with debts of 90% or more of GDP (1.6%). Though it’s unclear whether the larger debts were due to a slower economy and a decrease in tax revenues, the possibility remains for a negative impact on economic growth. Krugman further tries to differentiate debt held by households from the national debt.

This is the point almost nobody seems to get — an over-borrowed family owes money to someone else; U.S. debt is, to a large extent, money we owe to ourselves.

No it’s not.  As mentioned, almost 50% of our debt is held by foreign banks. And we can’t just stop paying interest on the debt because it’s “money that we owe ourselves.”  A US default on its debt or even a perceived inability of the US government to pay interest on the debt would result in volatility in the bond market causing falling bond prices and increased interest rates which would worsen the budget crunch as previously stated.  The US government is very much like a household that is very overextended on its credit. It’s like a family taking advantage of a credit card with no limit and ridiculously low interest rates.  A default would wreck the world wide economy and impair the government’s ability to borrow more money at low interest rates.

But lets assume that Krugman is correct and we can go on borrowing forever because it’s money that we owe ourselves that we don’t have to pay back. The problem with this “all is well” approach is it does not take into account the possibility of a “perfect storm” of different economic factors combining with our debt burden to result in economic catastrophe. Greece is a good example. They were forced by the Economic Union to adopt the Euro at inflated exchange rates for the old drachma that severely impaired their ability to borrow and service their national debt.  Though the US does not face the same type of monetary problems, the recent collapse of the sub-prime lending market is a good example of an entirely new economic variable that was unforeseen by almost every economist.  Hence, like earthquakes, economic disasters are very hard to predict but inevitable. The US national debt is like the proverbial sword of Damocles hanging over our heads. It has the potential to dramatically worsen and complicate what would normally be a survivable economic crisis.

Above all, however, Krugman and everybody else want job growth combined with economic growth. The problem is that the current massive amount of government spending is poorly designed to deliver this.   John Maynard Keynes famously called for the government to “prime the pump” with government spending for goods and services to stimulate the economy but the 2011 Federal budget included over $2 Trillion in mandatory spending and most of it was spent -quite literally – on people who are NOT WORKING. Social security for retirees and people with disabilities. Medicare for people older than the traditional retirement age of 65. Medicaid much of which is for children and those on disability. Unemployment benefits for . . . . people who are unemployed! And the recent bank bailouts designed to keep bank employees who already have jobs from becoming unemployed.  Even recent massive spending on two wars was primarily spent overseas during the occupations to employ Iraqis, Afghanis, and other foreigners. In theory and except for Federal employees, US government spending does not result in the creation of a single new American job.  It helps to maintain the status quo. No wonder the recovery has been jobless and sluggish.

During World War II the US government spent several hundred billion dollars to directly employ Americans to provide goods and services for the war effort. The economy responded with the biggest peacetime expansion in history. But today we have a multi-Trillion dollar economy and a few hundred billion dollars in domestic spending here and there is not going to cut it. What is needed is a multi-Trillion dollar domestic spending bill for the direct employment of Americans for nationwide infrastructure improvements. Unfortunately, we’ve already used up our political capital with year after year of massive deficit spending regardless of crisis. At least World War II had an end. By 1946 we no longer needed thousands of tanks, planes, and ships to fight the fascist threat and so spending decreased dramatically to prewar levels. This fiscal rationality no longer applies. For three decades, nearly every Federal budget has been followed by an even bigger budget. We no longer have either the political foresight or will to constrain spending so that we can reserve massive spending increases for times of true emergencies.  We have been spending our “rainy day money” on sunny days and now we have nothing left.

New data show that total spending by insurers, government agencies and individuals amounted to $6,238 per resident in 2009, well below the national average of $6,815. That puts California on a bottom tier with Arkansas, Georgia, Texas, Utah, Nevada, Arizona, Colorado and Idaho.

God forbid that California be in the same category of anything with those red states! It must be like west coasters finding out that Newt Gingrich is a diehard 49ers fan. Then came the blanket statements that blames lower health care spending for a sicker population, less productive work force, and the general downfall of civilzation.

“The state is essentially under-investing in healthcare and ending up with an unhealthier population as a result,” he said. “If people aren’t healthy, they are not able to work or to be as productive as they otherwise would be.”

But it’s not at all certain how spending on health care directly or indirectly affects worker productivity and economic growth. The problem is one of being able to separate the variables from each other. For example, health care spending is well known to directly correlate with older and wealthier populations.  States with a higher percentage of older citizens such as those in the North East and Florida spend more on health care than states with a younger median population like California and wealthy countries spend more on health care than poorer countries.

The overall health of a population (as measured in higher life expectancy, lower infant mortality, lower rates of disability, etc.)  certainly does correlate with better productivity.  But economically advanced and productive populations tend to be healthier which promotes increases in productivity which increases wealth and so on. Ergo, this self defining metric is not very useful and it not at all the same as the level of health care spending.

Another problem with trying to study population health and health care spending is determining cause and effect. Obesity is a good example. There is very good evidence that obesity and obesity related health problems directly leads to $40 Billion per year in excess costs to the Federal government. But there is no good evidence of the reverse.

Indeed, health care spending in this country is almost all reactionary and not preventative. States with older populations spend more. States with higher rates of unhealthy lifestyles such as obesity, smoking, and substance abuse spend more to deal with these miladies. The primary philosophy of US policy makers regarding health care spending appears to be little more than, “the squeaky wheel gets the grease.” And right now California has the benefit of being one of the healthiest states with low rates of obesity and smoking as well as being one of the states with the youngest populations.

In the same way that lower spending on fire fighting equipment and supplies is due to the fact that there were fewer  rather than more fires, the total level of health care spending should not be confused with worsening public health. Better metric analysis should focus on the numbers of and access to primary care providers, basic and affordable medications, neonatal and women’s medical care, and efforts to reduce pain and suffering in the elderly and terminal patients. Right now the US spends far too much on expensive and often frivolous medical care.  A smarter question should be, “are we spending enough on the right things” and not just “are we spending enough?”

Enter the late Senator Ted Kennedy who advocated for a government run long term care insurance program and thus CLASS (Community Living Assistance Services and Supports program) was born as part of the mega health care reform of 2009. Except it was stillborn.

Basically, liberals looked at the long term care of rich retirees or at least those who had the foresight to purchase a long term care policy and decided that this is a new entitlement that everyone should be able to get regardless of financial ability! So they decided that they could perform a magic trick and create a government sponsored and run long term care insurance program with monthly premiums as low as $5, a short 5 year purchase period before becoming eligible for benefits, no apparent age or time limits for benefits, and no underwriting in the selection of beneficiaries. Basically it was an insurance plan without any of the rational limits and restrictions that real insurance companies use to prevent themselves from going bankrupt.

CLASS didn’t even provide all that great a benefit compared to most private policies which usually provide $200-400 per day coverage. But even a $50 a day in-home care assistant to help with cooking, cleaning, and bathing would cost over $18,000 a year.  Nursing home care would cost even more. And with no signup restrictions and no increased premiums based on overall health and age at the time of signup, the possibility that the vast majority of beneficiaries in this program would be the sickest and most infirm was too much to be able to assure that the program would be solvent in 75 years. Thankfully, an amendment was added to the act that required the department of Health and Human Services to prove to Congress that they could perform magic and create a stable and self sustaining program.

They couldn’t. And perhaps for the first time in history, a disastrous social program that would have cost the tax payers an additional $75 Billion per year was stopped before it could join the phalanx of entrenched entitlements. Once again, liberals have proven that you can’t pull water from a stone, create gold from lead, have your cake and eat it too, or buy something without paying for it.

CLASS failed for the same reason that Medicare is failing. The amounts that people pay into the system are falling short of matching the actual costs. Like CLASS, Medicare has few restrictions on the amount and types of care that beneficiaries receive. Liberal egalitarianism (“health care is a right”) demands that a severely demented 99 year old nursing home patient with terminal cancer receive the same life extending care as a 65 year old with no medical problems.

In a way, CLASS was even worse. It tried to create a new social entitlement where it’s debatable if there even is one. Despite hysterical claims otherwise, long term care boils down to one single benefit. Comfort. There is no proof that nursing home care or home assistance care or assisted living or adult day care increase life expectancy or prevents such old age maladies as falls, hip fractures, pneumonia, or strokes.

Severe cost over-runs raise the issue of whether Medicare should continue to provide for such aggressive care in those over 80 and CLASS raised the question of whether long term care is even the way to approach caring for our elders. Only about 50% of the population needs a nursing home stay at any point in their lives and the average nursing home stay is usually less than a year. The majority of elderly patients who do need assistance are cared for at home by family members or in some community care setting. Home and community care is far less expensive than facility care or having daily private assistance. More attention should be paid to assisting those families who do make the time and effort to care for an elderly loved one at home.

Then there is the rational approach to caring for the elderly. Statistically, a patient who has deteriorated in their ability to care for themselves and live independently as a result of advanced age and/or progressive medical conditions has a far shorter expected survivability than one who is relatively healthy regardless of aggressive medical care. The CLASS act does not appear to concentrate or particularly promote the option of hospice care (even for patients without a specific terminal illness) nor is there a provision to promote comfort over continued aggressive medical care. I can guarantee you that the vast majority of patients in a long term care situation continue to receive aggressive health care including blood pressure medications, statin medications to lower cholesterol, mammograms, colonoscopies, frequent testing and office visits, and frequent trips to the ER for any cough or fever or issue other than one strictly of comfort. Aggressive medical care accounts for a big part of the cost of caring for the elderly.

The Medicare lunacy of continuing to treat elderly patients in the last few weeks, months, or year or two of their lives with aggressive medical care designed more to extend lifespans rather than to promote comfort is a big part of what sank the CLASS act. Rather than concentrate on keeping the elderly alive and warehoused in facilities or with expensive home services indefinitely for the benefit of the working poor, the CLASS act might be still viable with a change in philosophy. The same goes for Medicare.

At some point (probably just before complete economic collapse becomes inevitable) the deficit will need to be paid back and right now that amounts of almost $50,000 per every single American.  Of course, this only applies to tax payers and inevitably those with higher incomes will be “called upon” to shoulder more of the debt burden. But beneficiaries will also have to pay the price of decades of deficit spending as social programs and entitlement benefits are slashed to bring spending under control. Essentially, everyone will pay in one way or another.

Fortunately, deficit spending can probably continue for many more years before the bottom falls out and we all end up taking night classes in Chinese. This is just what the current bunch of drunken sailors on a Tijuana spending binge that passes for the US Congress is counting on.  Re-election is more likely as long as members can continue the spending insanity and delay the inevitable hang-over until well after they have left office.

The health care industry and physicians in particular are doing almost exactly the same thing.

The current reimbursement system (as directed by Medicare) rewards volume over quality and invasive procedures over good medical management. Therefore and in the face of shrinking reimbursements, physicians have continued a pattern of high volume and high utilization of health care resources.

Currently there are absolutely no good incentives and fewer reasons for physicians to practice good resource utilization and try to contain health care costs.  A few managed health plans will “reward” their participating primary care providers by “sharing” a little of the savings from their efforts to reduce costs. But these kick-backs are usually a very small percentage of the over-all savings.  What about passing savings on to their patients? In my experience, patients infrequently ask their providers to help them out with less costly tests and treatments and any concerns are usually limited to medications. This is what happens in an insurance system. Costs are separated from the source. This disconnect impairs how both providers and patients understand and react to costs.

But not truly understanding and being separated from the economic consequences of their practice is only the background of how physicians are contributing to the escalating cost crisis.  There are so many other factors that “reward” physicians to totally ignore resource utilization and order more expensive tests and treatments for their patients. There’s ignorance among doctors that more expensive tests and treatments are better. There is fear of litigation and other reprisals and having to explain why they didn’t get the test instead of why they did. And then there is outright greed either to see a ton of patients a day (on the part of primary care docs) or to perform a ton of procedures (among specialists). There is even institutionalized greed among health care facilities to admit and treat the most patients and to perform the most expensive procedures which simply enables those aggressive, high cost physicians.

If you’re not part of the solution then you are certainly part of the problem. Unless physicians take responsibility and assume (or rather, re-assume) some leadership in our health care system the consequences of ever increasing health care costs will be ever drastic and larger funding cuts.  If physicians don’t stop responding to decreasing reimbursement rates by exploiting new revenue sources or simply increasing volume then the system will bring back managed care . . with a vengeance.

Our wild spending spree will have consequences. The problem is that no one knows when the tipping point will come. I’ve tried to talk to other physicians about this. The blank stare or shrugged shoulders they give me is similar to the responses I get when I talk to 20 somethings about the dangers of smoking.  The threat is currently too abstract. Like Congressmen, the hope is that they will be long retired and out of the profession before the proverbial excrement hits the fan. At that point, it will be someone else’s problem.

I’m not advocating for socialized medicine or some universal health care government scheme. I’m certainly not an anti-capitalist. The problem is that the current health care system is not so much capitalist as it is a gigantic privatized government program. As such, there are few  classic capitalist mechanisms as cost transparency and free markets in this system, which is great for recipients of the funding. It’s great, until the bottom falls out.

In concert with such actual and true reforms such as malpractice tort reforms and reimbursement reforms and stabilization, physicians need to convert from simple “consumers” of the health care system and start acting more like advocates, reformers, and preservationists of the good things about our system (freedom of choice, efficiency, advanced care) before the US gets it’s own National Health Service nightmare.

You know the score, pal! If you’re not a cop, you’re “little people.

Little People. Yea. In the realm of hospital politics, if you’re not a highly paid specialist . . then . . you’re little people.

Recently I was privileged to have had a conversation with the head of the emergency department of the big-national-conglomerate-owned hospital where I work.  One of the admissions to the medicine service overnight had turned out to be a patient with a fracture. The surgical specialist on call had requested that the ER admit the patient to the medicine service even though the patient was young and didn’t have any medical problems. The patient also had no insurance.

[Me on the phone to the ER director]: This was not an appropriate admission to the medicine service. There are no medical issues. Not even anemia. The patient’s blood pressure is better than mine right now! The only time the medicine service ever gets requested by the surgical specialists to admit a patient is when it’s an un-referred patient through the ER who doesn’t have any insurance regardless of whether they actually have any medical issues. They never ask us to admit their insured private patients! And unlike the surgical specialists, we don’t get paid to cover un-referred admissions from the ER!

[ER Director]: The surgical specialists don’t do their own admissions. They just consult.

That’s it. That’s the stark logic of reality that the ER director provided. But for those of you who missed it, I’ll provide a translation.

[TRANSLATION]: Federal law requires that we (the hospital) provide the same surgical services in the ER as we do in the OR regardless of the ability of the patient to pay. Therefore, we require the surgical specialists to be on call for the ER to provide this service. We pay them a fixed stipend (usually as much as $700 or more for each call day) because they also bring their private insured patients to this hospital for procedures that can make up to $25,000 to 30,000 for the hospital. We want to keep their business so we pay them to cover the ER. We pretty much give in to any of their demands like allowing them to consult only and not be the admitting physician on ER cases since this comes with more responsibility and paperwork than a consultant.  In contrast, you medicine people make the hospital far less money. We’re lucky to usually brake even on your patients. In short . . you’re not surgical specialists. You’re little people.

Often these types of admits are far simpler and quicker to do than the average Medicare, complicated, medicine patient so is it really that big of a deal? Yes, it is.

Bedsides the principle of being discriminated against without so much as pat on the ass, there are the issues of uncompensated time and effort being taken away from insured patients and needlessly and involuntarily taking on the increased liability. In the current system, the hospitals often get some type of reimbursement from Federal and state grants and programs to help pay for care of the uninsured while the doctor is usually the last one in line to receive any compensation. We can’t write this off as a business loss since the patient was not seen in the office. Nor can be write this off as a personal tax loss.  And far too many of the uninsured consider health care to be a “right”. I.e. something they are entitled to without having to pay for it.

The take home point here is that this is just another reason to avoid going into primary care if you or a loved one are thinking of becoming a doctor. Avoid it like the plague.  Money (or sex) begets power and primary care physicians are at the bottom of the reimbursement totem pole.  Not only do we not get paid well, we don’t even have the power to avoid becoming modern indentured servants.

Chart rack: Not very secure

Both forms of data have weakness and strengths. One of the benefits of electronic data is that it can accessed from multiple sites  unlike a single paper chart. But this feature makes it easier for hackers to access electronic data. Then again, unlike paper charts, electronic data can be encrypted and password protected.  I have yet to see a password protected or encrypted copier or fax machine in use at a health care facility.

And paper charts are ridiculously easy to access (or lose).  The majority of hospitals still rely on paper charts openly stored at the nurses station for easy access and most hospitals have extremely loose security requirements such that anyone with a white coat or scrubs and a fake ID can have more than enough time to peruse a chart or even make copies before anyone notices.

The HHS inspector general is rightly concerned about the security of electronic medical records after two recent government reports found many security lapses and potential problems with electronic medical records. But many of the security problems appear to be bonehead screw-ups by facilities in not utilizing the security features available for electronic data.

“The second audit examined computer security at seven large hospitals in different states and found 151 security vulnerabilities, from ineffective wireless encryption to a taped-over door lock on a room used for data storage.”

There are cases in the early days of the use of wireless networks where hospitals didn’t know how or bother to use the encryption options when setting up their networks. Such negligence is odd since hospitals can be fined up to $50,000 per incidence of a breach in patient privacy. Maybe the Federal government should start enforcing it’s own laws rather then just creating reports and audits. And the processing and storage of electronic data is changing such that data is now being stored off site (yes, the cloud)  in facilities that should be able to provide much better security for storage servers than an easily taped-over door lock.

And while Luddites and detractors of electronic data still complain that the system can never be 100% secure, one has to question whether the entire issue of the security and vulnerability of  electronic patient records is another case of sensationalism looking for a problem. As of now, there does not appear to be a large criminal black market in stolen medical records nor any potentially large advantage to going through all the trouble to hack into medical facility networks to steal patient data. Though a lack of logic didn’t prevent the Associated Press from making ridiculously sensationalist claims that an illicit market for stolen health information is “booming”. What is their proof? Don’t laugh. It’s stolen celebrity hospital records.

The market for illicit health care information is booming. In recent years, the case of a former UCLA Medical Center worker who sold details from the files of actress Farah Fawcett, singer Britney Spears and others to the National Enquirer gained notoriety.

I’m not sure I understand the point of this paragraph. Does the writer imply that the issue of secure patent records is not a concern to the 99.99% of Americans who are not celebrities? And do we know for sure that the breached medical records of Farah Fawcett were exclusively in electronic form while her paper chart was perfectly safe at the nurse’s station?

Ironically, none of the celebrity medical information was accessed by outside third parties by hacking into hospital networks which is the entire point of the AP article. Maybe the slant of the AP writers should have been that hospital employees need to be better vetted and instructed about patient privacy?

But as if sensing the ridiculous claims and examples put forth in their previous paragraph, the AP writer(s) appears to back off from the celebrity security claim and instead claims that electronic medical records are valuable because they contain social security numbers.

Most cases don’t involve celebrities or get much attention. Yet fraudsters covet health care records, since they contain identifiers such as names, birth dates and Social Security numbers that can be used to construct a false identity or send Medicare bogus bills.

But almost all personal records contain information such as a name and date of  birth. This is what makes them personal records. Your name and corresponding date of birth are on everything from department of transportation records to voting records to marketing reports to client lists to sales records to school records etc. etc. and many of these are in electronic form.

And as for Social Security numbers, well, that’s an entirely different issue. The SS# was never intended to be used as a de facto national ID number but it is.  Hospitals assign medical record and account numbers to patients that are unique to their facilities and Medicare and private insurances assign their own number identifiers. In my opinion, there should not be any reason for private facilities to record or use a patient’s SS# or they should accept liability if the SS# is ever stolen from their system and used in a case of identify theft.

The bottom line is that identify theft is a national problem that is far bigger than the risk of security holes in electronic medical record systems and there is no evidence that medical records are a significant source for information used in identify theft. The fact is that electronic medical records are much easier to view, transfer, and store and unlike paper records, they can be password protected and encrypted. The benefits of electronic data outweigh their risks.

And apparently, this garbage is what now passes for mainstream journalism in the US. No wonder the Drudge Report linked to it.

Unfortunately,  far too many emergency room departments believe that it is still 1960 when it comes to patient medications. And it used to be worse.

The accurate and consistent documentation of medications for patients admitted to the ER and the hospital was unregulated and of low priority until early the last decade when the Joint Commission for Hospital Accreditation starting requiring all member hospitals to keep track of their patient’s home medications and to reconcile these lists while in the hospital and on discharge. As of 2007, only 66% of hospitals actually documented a patient’s home medications though this seems to have improved. But from personal experience, the effort is often substandard.

The documentation forms for medication reconciliation are often confusing and poorly designed. Sometimes there are 2 or more lists which often contradict each other. Medications are frequently misspelled and dosages given in the wrong units or route. Yet, the single worst aspect is that these reconciliation lists are often jaw droppingly inaccurate to the point of being mostly fictional and this is despite the fact that this information is acquired by licensed medical professionals (mostly nurses and physicians).

The inaccuracy of this documentation appears to be a combination of two factors. 1. The medical staff appear to put forth much more of an effort to acquire a list (any list) than in maximizing the accuracy of such a list and 2. Many patients and their families have a very difficult time keeping track of their own medications.

The second problem is a universal headache for most health care workers. Patients either forget their medications or bring outdated lists or only some of their medications and family members are too infrequently involved in the patient’s medical care to help give information or the one member who knows the most is never available. These are considerable problems but short of a national electronic database to keep an accurate record of each patient’s medication list in real time (more on this in a future post) there is not much that can be done on the patient side. Yet, many patterns and common pitfalls can be seen and dealt with to significantly improve the accuracy of this information.

For example, patients often put all of their medications in one container to bring with them to the ER. However, this fact alone does not constitute an accurate list. Patients will put both medications that they have discontinued in addition to their current medications into the same bag. Or they will put their medications into the same container with their spouse’s medications. I frequently see this type of error.  It’s as if the person recording these medications didn’t bother to read the name on the labels but simply assumed that every single medication in a specific container was currently being taken by the patient. In one case, a female patient’s medications were recorded to include doxazosin which is a medication taken to shrink the prostate in males. The doxazosin was the patient’s husband’s medication and the pill bottle label even stated “take nightly for prostate” and this line was included in the medication reconciliation list.

Patients frequently forget to include medications. They often do not mention medications that are not taken in pill form such as inhalers, injected insulin, home oxygen, topical patches, and eye drops. They frequently forget to mention non-prescription medications such as aspirin and the chronic use of such over the counter medications as non-steroidal anti-inflammatories  which can have profound clinical consequences.  Often, specific medications need to be asked about for patients with certain conditions, however, in my experience, if the the medication is not in the bag then it doesn’t go on the list.

This nit picking about the accuracy of medication lists is far more than cosmetic. There is a lot of data out there that medication side effects and complications result in a significant number of ER visits each year. A 2008 Canadian study found that 1 in 9 ER visits were related to medication problems; either adverse reactions, noncompliance, or wrong medication or wrong dosages. Obviously, the inability to get an accurate list of home medications can significantly impair the staff’s ability to recognize and treat for medication problems. Additionally, an accurate medication reconciliation list is important for discharge planning to ensure that patient don’t go home and start taking medications that they shouldn’t and that nobody asked them about.

The cynical reader would think that this lackluster effort to reconcile medication lists is mostly limited to big city public hospitals with mostly indigent patients but it’s actually a quite frequent occurrence in high dollar private hospitals belonging to huge national corporations. The priority in private hospitals is to move patients so as to facilitate higher volume and increased billing. The priority is not accuracy.   It’s obvious that the ER staff is simply documenting to satisfy the regulations in the same way that public school teachers frequently “teach to the test”.  In one incidence, the medication list appeared to be simply copied verbatim from the records for the patient’s previous ER visit about 3 months prior. This despite the fact that the patient was perfectly awake and alert and told me that her doctor had since discontinued those prior medications and started her on all different ones.

Patients need to be aware of this if and when they have to go to the emergency room. The best strategy is to double check the ER staff’s work. Try and make sure that you have all of the current medication bottles or an up-to-date and accurate list. Ask to see the medication reconciliation form after the staff have filled it out to verify to yourself or your family member that what is listed is accurate to the best of your knowledge. If you don’t know or are unable to get a full and accurate medication list then make sure that the staff are aware of this and that they document somewhere on the medication reconciliation that the list is not yet complete.

The reasons for this are varied and complex but in an article that spotlights several lows in the career of a software programmer, Scott  Reynolds writes about one experience with coding software for the next generation of electronic health records and what happened after it was finished, shipped to the customer, and went live.

You didn’t know what to do with yourself so you sat there all day refreshing a view on the database to spy on what [the first few customers were] doing. Answer: not much. The things they did do, they did wrong. They found bugs. They found ways to circumvent all of your carefully constructed system rules and validations. Not because they were master hackers or brilliant technicians…but because they were just stupid.

They clicked on things they shouldn’t click on. They typed things in that they shouldn’t type in. They didn’t read simple instructions. They didn’t listen in training. They were personally insulting you by being terrible at using your software.

In a field labeled “Enter the number of specimens:” they typed “five specimens.”

In a field labeled “Social Security Number:” they typed “he doesn’t have one because he is an illegal.”

Instead of using the button labeled “Create New Patient Record:” they kept changing the information in a single patient record over and over and saving it.

Then the calls came in from the sales team demanding to know why the system was broken and why you had taken so long to develop something that clearly didn’t work.

There was nothing you could do but respond to the bug reports and issue system patches that added no value other than handholding people through the software. You wondered aloud how these people had managed to survive this long without drinking bleach by accident.

Sad but very true. Like many industries, the medical business is loaded with tons of paper pushers, unmotivated mid-level managers, mindless bureaucrats, poorly trained ancillary staff, and lucky professionals who slipped through the cracks and managed to get a degree despite being borderline bleach drinkers.  It’s far easier to conceal stupidity, laziness, and incompetence while utilizing a paper based documentation system than an electronic one.  Paper documents are regularly loaded with errors, inaccuracies, and out-right crap. Lucky, very little of this has any impact on patient care or is discovered until the chart is audited by insurance companies, Federal agencies, or malpractice attorneys.

It’s not until the paper form is replaced by a computer that can fact check and give instant feedback that the massive scope of all this crap documentation becomes known. It’s not just that people are “computer illiterate”. At the hospital where I work, forms are regularly incorrectly filed under the wrong tab in the paper chart, medications are misspelled, illegible test results printed long after the printer toner has run out, daily weights randomly documented using lbs or Kgs, blood sugar levels written in the blood pressure column, etc. etc.

Combine this fact that the health care industry is not immune to employing bleach drinkers with the fact that it’s inherently a very complex information system and we start to get an idea of just how daunting a task it is to design a software system for health care documentation.

But, then again. As the article makes obvious, why is a software programmer designing AND coding  a computer system for health care? Isn’t that like an oil company executive designing a formula one racing car or lawyers writing health care legislation? Yea. That.

Pediatricians’ pay took a tumble. Hospital nurses questioned why we took on so much responsibility and worked such long hours for paychecks significantly smaller than theirs. Insurance companies kept ratcheting back both on our reimbursements and on the level of patient care until there was little left.Patients naturally became disgruntled. They got angry about the insurance denials and took out their frustration on our office staff. We needed to see more patients to make ends meet, so the waiting room became more crowded and waiting times increased. I had nightmares about running hours behind, patients yelling at us to “hurry up!” There were days when we would skip basic necessities like eating lunch or going to the bathroom; we didn’t want patients to wait. Days “off” were often spent seeing patients, catching up on paperwork, and calling back families who had questions too lengthy for regular office hours. Lunch was typically spent tackling the accumulated stacks of charts and callbacks to patients from the morning, in addition to holding office staff meetings or attending meetings at the hospital. A typical call night would entail the beeper going off every five to 10 minutes throughout dinner, and my often spending a good part of the night at the hospital. In the morning we’d arrive at the office and try to smile through another full day of patients.

Sounds like a dream job. Yep, and a great investment: spending 7 years of medical training to make less than what an RN makes with 2 years of training (kudos to the happy RNs who figured this out before it was too late).

Dr. Li encountered the paradox of traditional high volume primary care. Insurance reimbursement rates fall so the provider sees more patients but higher volume means higher overhead costs and more non-reimbursable obligations (phone calls, medication refills, paperwork) and therefore less take home pay. Too bad Dr. Li didn’t consider changing to a concierge medical practice model.