Guest post: Richard Orlowski, M.D.

The following is a guest post written by the head physician at Carolina Oncology Specialists regarding the government “quality of service” reporting and its effects on EMR software.
The medical office now is encumbered by an overwhelming array of government regulations and hurdles. The government, as payer, is desirous of avoiding fraud and abuse. The government hopes that the EMR will make records more available to them for analysis of cost, appropriateness and ultimately rationing (which is inevitable in a government system–under some other name). Thus, the idea of “cost savings” pertains to the government and not to the practice.

There are aspects of the EMR that are wonderful, such as immediate access to data collected in a central repository in a timely manner without having to search for charts. Collecting and organizing all of the data is not an easy task and is a major challenge for programmers.

The data must be presented for thorough review and sign off. Also, the EMR is well suited to aid in scheduling events and tracking progress of plans of management and  documenting in detail what is happening in the office. To increase efficiency the EMR must help with these processes without imposing extra work for the medical staff that is under fire throughout the day dealing with living, breathing patients with innumerable real-time problems.

The EMR will not give the practitioner experience, knowledge, intuition, critical thinking, improved mental focus, proper diagnoses, proper treatment, and insight into human aspects of patient interaction or compassion.

The government, in their concern for containing costs, has devised a method of oversight that centers on coding and documentation for such coding. Actual clinical skills do not enter into this analysis. The government asks that MD charges be justified by an incredibly convoluted and complex system of  “bullet points” that testify that a certain level of data collection has occurred.

Computers are particularly adept at data collection so what is seen now is perversion of the patient encounter such that attention is diverted from thinking to data entry. Doctor notes generated under such requirements are voluminous. The notes lack focus such that it is impossible  sometimes to figure out what problem solving occurred during the visit. Despite this, it is certain that data collection has occurred and bullet points have been checked to justify charges. The computer spits out 6 pages of meaningless bullet points. The process is a major distraction. Nowhere in this construct is there the ability to determine if the practitioner acted appropriately and with insight. Nowhere is there a way to measure what was  NOT thought about. The whole process is demeaning and cumbersome and unproductive. It’s no wonder that EMRs are not saving offices money.

Now, in continued effort to reduce expenditures, there is a push by the government to measure what the regulators call “quality”. Excuse my skepticism, but this appears to be another sketchy scheme conceived by the same people who created the above monstrosity with bullet points. They will measure what they are able to measure and call it “quality”. It will amount to more garbage in–garbage out. The practitioners will learn the rules and the EMRs will adapt to spit out more verbiage to satisfy the rules. The measures will miss the mark in detecting and rewarding truly skilled physicians. The computer programs will adapt. Practice management will become more difficult. Efficiency will suffer. EMR’ will fail to result in cost savings in the doctor’s office because they are being used in the government’s game of cat and mouse rather than as a finely tuned tool to assist in evaluation and management. This is a reflection of the difference of perspective of someone in the trenches vs. someone in a government office shuffling papers and trying to control the massive, amorphous, and constantly changing world of medical care.

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3 Responses to “Guest post: Richard Orlowski, M.D.”

  1. Joy Hester Says:

    Very well said and hits the mark. It is about goverment control and not the quality of care people receive.

  2. Mark Jones Says:

    Sounds very pessimistic. Why can’t the software do both? Provide the physician with what they need to do a good job and show what was done.

    I know too often when I have gone to a physician, the service I get has been shoddy, my doctor was out of town for a week, so I explain the whole issue to her substitute, only to be told when I return I need to come back for another visit so I can tell her what I told him. That’s really unacceptable, but is something that happens. Why should the payer have to pay twice?

    In the code I work on we strive to present the medical personnel with what they need to do their job. And for billing we print out what is needed for billing. Computers are incredibly stupid, but they can do this, and it doesn’t take that much more to have two different presentations of the same data, much as what you get at the table in a restaurant vs the order the cook sees in the kitchen. Same data, 2 presentations.

    My biggest problem is finding a “Truly Skilled Physician”.

    I have a niece that has spent 20 years being misdiagnosed, 20 years of paying for specialist after specialist. Yes, she has a rare problem, but surely if the right bullet points had been in place, she could have been cured in under 20 years. Now she has to deal with what 20 years of the wrong drugs have done to her body.

  3. rorlowski Says:

    The complaint here is about meaningless government requirements that divert physician attention and consume physician time. Internists complain that 30% of their clinical time is now spent fulfilling meaningless requirements. It is not a programming problem; it is government requirement problem. So, it is not a matter of data presentation. It is a matter of consuming limited resources (physician thought and time) with data collection requirements that do not address the main clinical problem. The requirements ripple through the medical office as different employees must take extra time at multiple stops throughout an office visit. Preparing a note for such an encounter is not a simple process and takes time. Transcription struggles to keep up with the increasing demands and transcription of notes is delayed so one physician may not have immediate access to all information.

    The “bullet points” are inane data collection check points that the government uses in an accounting process to decide if the practitioner did enough “work” to justify a given charge. The bullet points are not conceived to aid in diagnosis or management.

    The record is forced to serve the government and their accountants and less so the patient and physician.

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