Steven Zuckerman, MD

As we move into April 2011, several dates are likely foremost in the minds of all neurologists:

·      April 9-16: The American Academy of Neurology annual meeting in the conveniently and centrally located state of Hawaii

·      April 15: Usually the deadline for filing federal income taxes that is postponed this year because of Emancipation Day until April 18 giving us seventy two whole hours to further procrastinate

 The Attestation System for the Medicare EHR incentive program opens

For some, this third event does not carry the significance of the others. However, this red-letter day represents the first opportunity eligible professionals have to report on the meaningful use of their certified EHR. I know what most of you are thinking: the 18th couldn’t come soon enough. For the vast minority of you who are thinking, “Huh?”, the date marks when those clinicians who have implemented an EHR in their office can report on which of the 20 meaningful use measures they have successfully completed to qualify for incentive monies.

According to the Office of the National Coordinator and CMS, one of these measures is the capability of your EHR to report on clinical quality measures. Three “core” measures must be reported by all eligible professionals. In addition, three out of 38 potential quality measures must be selected and reported upon. For each of the total six measures, the number of patients who you successfully fulfilled that quality measure (numerator) divided by the total number of patients who qualified for that measure (denominator) must be able to be reported by your EHR. This almost seems reasonable, until you look at the actual measures that are being requested.

2.     Tobacco use assessment and tobacco cessation intervention

3.     Adult weight screening and follow-up

You might think that these measures do not really reflect the scope of your practice and so would not really be relevant. Have no fear; our government, in its infinite wisdom, has anticipated this and allows for the selection of “alternative core measures” instead:

1.     Weight assessment and counseling for children and adolescents

2.     Influenza immunization for patients >50 years old

That should certainly cover all the bases. The other quality measures are no more relevant to neurology. They mostly apply to primary care physicians for the care of diabetes, congestive heart failure, cancer screening, etc. Probably most relevant to patients cared for by neurologists would be the ischemic vascular disease quality indicators, which call for the successful control of BP and LDL cholesterol—usually not the purview of the treating neurologist.

In order to qualify for the EMR incentive money, neurologists will need to report on quality measures that are mostly irrelevant to the scope of our practice. Fortunately, there is no requirement to satisfy a minimum value for the numerator or denominator for any of these measures, either the core or additional. As long as you have a certified EHR that can calculate these values, you will not be penalized in Stage I reporting years (2011-2012) for not accomplishing the goal of the specified measure.

However, it is anticipated that future stages of meaningful use will require that you demonstrate not only the capability of your EHR to calculate the frequency of quality compliance, but that you have successfully accomplished the measure in question. Therefore, it becomes more important that the AAN adopt quality measures that reflect important and practical indicators of best neurology practices. Quality indicators no longer represent an academic exercise in evaluating existing literature. Adherence to suggested quality measures may actually determine our rates of reimbursement.

As I head off into the sunset in Hawaii, I am looking forward to learning more about the latest hot topic: accountable care organizations and how neurologists fit into the scheme of this new reimbursement model. More to come.

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As we move into April 2011, several dates are likely foremost in the minds of all neurologists, but one might be overlooked.

The Neurologist's April

It’s like comparing Chevrolets to Porsches. They both get the job done, but one has extra features for a large difference in price. Of course, I’m referring to the recent article in 

that estimated the cost of implementing an EMR in small (2-12 people) primary care groups. The authors concluded that the first year fixed and “non-economic” costs came to $46,300 per physician. This was a well-designed study to track actual costs, as well as calculate personnel costs. Fleming, et al. estimated the time spent implementing the system by various personnel and multiplied those hours by the hourly wage of those workers to arrive at the “non-economic” costs. Unfortunately, this figure may become the new standard of what physicians should expect their EMR implementation to cost over the first year. Yet the study results are strictly limited to the particular circumstances of the 

. Any attempt to generalize their results would result in gross inaccuracies. As a result, the article may be more misleading than informative.

The article gives a passing mention that the results generated “may mean that our results are not generalizable to small, isolated practices or other practice settings.” I will expand on this understatement.

First, personnel costs included several layers of personnel that are simply not present in most practices. 

·       Network implementation team: $28,000 per practice (> $7,000 per physician). This expense is unnecessary outside of a large health care system.

·       Practice implementation team: About $8,000 per practice

·       Practice end users (ie, physicians and clinical staff): about $10,000 per physician. The largest part of this figure comes from the estimated 42.5 hours of physician time entering information from paper charts (at $150.00/hr). Why physicians would even be involved in this part of paper to electronic transition is not clear.

Therefore, the combination of training and implementation was calculated to be about $19,000 per physician. These are not actual costs, however. Since the people doing all of this are already employed by the HealthTexas Provider Network, these figures do not represent additional expenditures. 

: $25,000 per physician for switches, cables, and wireless Internet connections. Seems like a lot of money for items that aren’t very expensive. In addition, it was calculated that expenses included $7,000 per physician for computers, printers, and scanners. Most practices, even without a current EMR, already have the majority of these components. It is puzzling how this money was expended.

estimated at $17,000 per physician per year. How much is attributable to 

 and how much was due to the additional costs incurred by licensing with the two other entities described is not listed. HealthTexas Provider Network felt it necessary to augment the GE Centricity software capabilities with two other products—

’ advanced forms and clinical messaging and 

. The latter two additional content providers are not necessary for small practice EMR implementation, but how much cost they add to the HealthTexas Provider Network calculated figure is not provided.

I think it is significant to note that an article that purports to provide an exact calculation of the costs associated with the implementation of an EMR did not evaluate any potential practice savings realized by that implementation. Perhaps the personnel costs incurred by EMR implementation are more than balanced out by the savings realized by eliminating chart pulls, automated patient reminder calls, and improved workflow efficiencies (eg, electronic prescribing and test ordering). It would certainly have been interesting to see differences in physician productivity as well as the practice profitability before and after EMR implementation.

I have reviewed the pricing structures of several of the most popular commercially available EMRs. I assumed a SaaS model in each of these determinations. This means the EMR software and data is housed at a distant site and available with any Internet connection (apparently the model of GE Centricity used by the HealthTexas Provider Network).  For both the EMR and practice management software packages, the average cost of both training and Implementation is about $8,000 per physician. This figure does not include the “non-economic” costs that were included in the HealthTexas Provider Network study. The average monthly fee for licenses, maintenance, and support is approximately $6,00.00. This would render an annual cost of $7,200. Therefore, the average actual cost per physician to get a state-of-the-art EMR and PM system (qualifying for meaningful use and ARRA stimulus funds) is actually about $15,000 the first year.  This is approximately one-third the quoted figure of $46,659 as the calculated figure derived from the study. Of course, those practices without the requisite hardware would incur those specific costs—unlikely to exceed $5,000 as a worst-case scenario. 

Therefore, for the vast majority of practicing neurologists (as previously noted are in solo or small group practices), the conclusions of this study simply do not apply. It would indeed be a disservice if this study becomes the standard quoted cost of EMR implementation. Perhaps further studies need to be performed in a more representative practice environment.

What really are the actual first-year costs of implementing a state-of-the-art EMR in a small group practice?

How Much Is that EMR in the Window?

I read with great interest the recent article in the 

Secrets of a Mind Gamer: How I Trained My Brain and Became a World-class Memory Athlete

Having dabbled in the mnemonic arts myself, I was curious as to how this individual related the topic. It is interesting and well written but is actually a teaser to a book written by Mr. Foer that will be released next month. The article, however, falls short on two accounts:

a)     It does not pay proper homage to the recognized modern master of memory techniques, Harry Lorayne.

b)     The memory technique description is not always accurate or sufficiently detailed and may be somewhat misleading (perhaps a deliberate attempt to create more interest in the book).

One of my most enduring “magic effects” has been a memory demonstration in which a four-by-four square gets filled in with random words chosen by audience members. For the finale, I not only remember the sixteen words and their exact locations, I demonstrate that I have constructed a “magic square” in which the sums of the columns, rows, corners, etc. add up to a number selected by an audience member 

the start of the effect. I had read about this effect in a magic journal, The 

, in 1965.  It was written by the magician Harry Lorayne, who has been described by 

magazine as the “Yoda of memory training.” In fact, Mr. Lorayne’s book (written with basketball great Jerry Lucas) “The Memory Book,” published in 1974, was on the 

best seller list for 46 weeks.  Mr. Lorayne appeared on all of the popular TV talk shows of the era—Ed Sullivan, Johnny Carson, Dick Cavett, etc. He would remember each audience member’s name, frequently five hundred people or more, who he had just casually met before his appearance. He would then demonstrate how he had memorized entire magazines or books and could give detailed descriptions or quotes of each page.

I must admit to be somewhat biased in my esteem of Mr. Lorayne since he was my boyhood idol. He also wrote what is considered a classic in card magic “Close Up Card Magic.” The influence of this card magic treatise over the next generations of cardicians cannot be overstated. As a result, I was absolutely thrilled when later in life, as a humble neurologist, Mr. Lorayne paid me the compliment of talking to me regarding the benefits my Alzheimer’s patients had using the techniques described in “The Memory Book.”  He told me his epic book “Ageless Memory: Simple Secrets for Keeping Your Brain Young” was about to be released. Imagine my surprise when I purchased the book and looked on the back cover and saw testimonials for such luminaries as Mel Brooks, Alan Alda, Dick Cavett, and yours truly!

It is certainly understandable that Mr. Foer chose his own guru of mnemonics, a psychologist named K. Anders Ericsson, who has apparently made very important contributions to studying memory and how to exceed the previously accepted limitations of memory. However, to not even mention the name of the recognized modern master mnemonist (and other alliterations) is like discussing the general theory of relativity without mentioning Albert Einstein. Perhaps he meant to include Mr. Lorayne in the article but just forgot.

Watch the video below to see Mr. Lorayne perform the mathematical part of his magic square.

If you are interested in learning more of the memory techniques the following websites are useful:

For those interested in learning how to perform the full magic square effect with memorizing the sixteen words and creating the numerical magic square, some work is required—but it pays off infinitely in the long run. You first have to learn the mnemonic system for remembering numbers. Each digit from 0 to nine gets represented by a consonant sound (please follow any of the above links or even the 

article for a full description of this system). After you have learned this system, you need to memorize the words in each of the sixteen squares from A to P (see square below for the words used in the 

article).  These words (and the corresponding numbers) need to remain permanently in your memory as your “pegs.” When your audience gives you their random word, you make an association with the peg word. The more unusual, outlandish, or raucous the association, the more memorable it will be (again, refer to above links on best association methodology). In order to perform the magic square:

1.     Draw the 4 X 4 square and label each box in the upper left corner as A, B, C etc.

2.     Ask someone to give any number from 34 to 100 and write this above the square

3.     Ask anyone to call out any letter from A to P.  Instruct them to write the number you give them in the top center of the box.  If they say “34,” no change in numbers from those given is needed. Otherwise, you need to calculate how to modify the number you have “pegged” by a formula that will be described later (Step 10).

4.     Once you give them the number to write in the square, they are to give you any word that comes to mind. It does not have to start with the same letter as the box it is in.

5.     Go through all sixteen squares in this fashion.

6.     At the end, they can call out any word or letter and you can give them the corresponding information. Actually, if you like, they can call out any letter, word or number, and you can give the other two pieces of information.

7.     After a few of these demonstrations, I will go through the 16 letters from A to P and give the correct word associated with that letter. That is usually fairly impressive, but I then show them:

8.     The numbers add up to the pre-selected numbers

       f.      Adding Four “Mirror Image” squares (see video above for demo)

9.     By this time, your audience is in shock and awe, so you can inform them that there are 64 different ways that you can total the number they selected.

10.  To calculate how to adjust your peg numbers

       a.     Subtract 34 from whatever number they choose (must be between 34 and 100). It may be easier to do this in two steps: mentally subtract 30 from the number given,  

               then take four from that result.

       b.     Divide your result by four. If there is no remainder, just add the resulting number to each of the peg numbers. For example, if “46” is chosen, subtract 34 from 46 to get 12. Divided by 4 equals 3. So you add three to each of the memorized peg numbers. If the division by four is not even, you add the quotient and remainder to get another number. This second number gets added to only four squares—the O, I, F ,and D squares (13,14,15, and 16) while adding only the quotient  to the other 12 squares. For example, if the number chosen is “48,” 48-34 = 14. 14/4 = 3 remainder of 2. So, all squares with letters A through H would have 3 added to the peg number, but the O, I, F, and D squares would have 5 added to the base number (3 plus remainder of 2). 

Learn how to train your brain and master memory techniques.

Thanks for the Memories

…it delays the onset of Alzheimer’s disease

Sometimes it pays to be stupid. Let me explain. I recently became aware of an article in 

 that concluded that bilingual individuals may have a delay in the onset of the symptoms of their Alzheimer’s disease for up to four or five years (

). Well, since I didn’t have what it takes (especially a respectable GPA) to get into medical school when I graduated college, I spent my first two years of med school in Italy.  While there, I noticed that many people did not speak the same language as I did.  In fact, since the exams were all oral and 

, it behooved me to learn the language. So, now I count myself among the ranks of the bilingual and, as such, perhaps I am more resistant to Alzheimer pathology than those unfortunate smart people who got into medical school in the USA.

The reason bilingual people may not display the effects of the tangles and plaques until their disease is more advanced have to do with a concept called “

.” The older concept of “brain reserve” represented a passive model of describing how neural decline would not vary among individuals. There would be a threshold of neuronal or synaptic loss beyond which a disease state would become symptomatic. Therefore, in PD, a loss of a certain number of cells in the substantia nigra would result in clinically recognized Parkinson symptoms. In Alzheimer’s disease, when a limit of cholinergic neurons were lost, cognitive impairment would manifest.

However, a more active model of cognitive reserve postulates that brains can make adjustments and adaptations to an injury—whether it be degenerative, traumatic, or otherwise induced. Under this model, it is not just a fixed threshold that determines when symptoms occur, but rather the interaction between brain loss and compensatory mechanisms that determine the neurological effects. To summarize:

: Individual differences in the brain itself allow some people to cope better than others with brain pathology. These differences can be quantitative, such as larger brain, more neurons, or more synapses.

: Individual differences in how people process tasks allow some to cope better than others with brain pathology.

: Inter-individual variability—perhaps in the form of differing efficiency, capacity, or flexibility&mdash;in the brain networks or cognitive paradigms that underlie task performance in the healthy brain.

: Inter-individual variability in the ability to compensate for brain pathology's disruption of standard processingnetworks by using brain structures or networksnot normally used by individuals with intact brains. This compensation may help maintain or improve performance.

Therefore, people with a greater cognitive reserve will display less symptoms of a disease given the same amount of cerebral pathology.  This theory is represented with this graph:

It has previously been shown that educational achievement and occupational status are factors that can positively affect your cognitive reserves. However, it had not been previously demonstrated that being bilingual would also afford an individual the type of cognitive reserve that may result in the delay in demonstrating the cognitive impairment at similar degrees of Alzheimer’s pathology.                    

“Bilingual” was defined as“having spent the majority oflife, at least from early adulthood, regularly using at least 2 languages.” Two groups of AD patients were compared: mono vs. bilingual individuals (about 100 in each group). There was a 5.1-year difference in the age of onset of Alzheimer’s symptoms. Educational level was actually higher in the monolingual group, and so could not account for this remarkable difference. One confusing part of the article reports that immigration status was not shown to be a significant factor, though 75% of the bilingual patients were immigrants whereas the monolingual group had only 25% immigrants. It is not reported whether cultural/genetic factors were investigated. Interestingly, the most common second language was Yiddish, then Polish, Italian, and Hungarian.

So, if you are a middle-aged practitioner, you may want to start getting your affairs in order a little sooner than your bilingual colleagues. As for me, arrivederci.  A la prossima volta.

A closer look at how bilingualism can help delay the onset of Alzheimer's disease.

Steven Zuckerman, MD

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