Almost from the moment the HITECH Act was passed, various pundits and industry experts have been trying to convince physicians that they should submit to the Act’s mandates and provisions so they can earn the promised $44,000 grants. I disagree with these incentives, because despite what some vendors and politicians may think, for physicians it’s not all about the money; even if it were, $44,000 is not nearly enough to cover the costs associated with implementing a full-featured EHR. Large practices with large Medicare panels may realize significant bonus payments, but smaller practices may find it impossible to make a profit. What is at stake is the autonomy and viability of the small physician office. 

I think that there are many good reasons why physicians should think twice about complying with the new mandates, and possibly reconsider their association with Medicare. Medicare often rejects or delays payment on a significant portion of claims due to computer glitches, changes in payment methods, and outright incompetence. Years ago, a whistleblower even admitted to the use of a machine referred to as “Jaws,” which shredded thousands of letters (

The HITECH bonus payments may be difficult to attain. In past PQRI projects, the majority of physicians and offices have failed to receive payments, and those who did received low payments for all of their efforts (

). The bonuses will not be given up front, but rather as rebates based on meeting exact performance parameters. An important hurdle is the required minimum patient panel size (see the HITECH Act for particulars). I question whether CMS/Medicare will provide sufficient and timely feedback, leaving providers unable to correct a submission of data in time. There is also little physicians can do to appeal a CMS ruling that a practice incorrectly submitted sufficient data to be eligible for a full bonus payment (

In my practice, Medicare patients can make up 20% of a typical schedule, but since these patients are older and typically more complicated than non-Medicare patients, seeing them can require 30% of my time, expended for about 10% less pay. The workfl ow changes associated with capturing and coding quality data will be significant, and the new administrative burdens will be costly (

The HITECH Act mandate lacks important details. CMS has not set a specific date or method for issuing bonus payments, and is still modifying the definition of “significant use” of an EHR system. On July 16, 2009 HHS announced that it would not use the Certification Commission for Health Information Technology (CCHIT) as the agency that will determine what qualifies as a “certified EHR”(

). Unfortunately, the “ONC certification” scheme is not set up, and it is unknown whether “CCHIT-certified” EHR systems will be grandfathered. 

The central core of “significant use” is interoperability, which has yet to be codified by EHR vendors (

). Many states are trying to set up health information exchanges (HIEs), but most of these centralized exchanges have suffered from major financial difficulties (

Many current EHR systems have poor user interfaces, which has resulted in a 50% installation failure rate (

) and a reported 8% de-installation rate. In some early adoption spots, the de-installation rate has been higher, as is now being seen in Arizona, where physicians pressured to purchase expensive c-EHR systems have found themselves unable to economically survive ownership of their systems (

The government wants to electronically collect “granular” data on patients, despite growing concerns about patient privacy, as required by HIPAA (

). The concept of PQRI quality reporting can be used as another weapon to control costs by limiting physician payments (

). This is on top of the fact that Medicare already reimburses $0.35-$0.50 per $1.00 of charges submitted for patient care, barely covering overhead costs. 

It is time for physicians, who still overwhelmingly accept Medicare, to take a close look at the HITECH Act and the potential consequences of continued participation in Medicare. Failure to evaluate your options objectively could be a big mistake. 

Alberto Borges, MD, is in private practice and is an associate clinical professor of medicine at the George Washington University in Washington, DC. Check out his website at 

Articles

Columns

Despite what some vendors and politicians may think, for physicians it's not all about the money; even if it were, $44,000 is not nearly enough to cover the costs associated with implementing a full-featured EHR.

HIT Realist: Does the Promise of HITECH Money Have You Thinking about Installing an EHR? Think Again.

Although there is widespread agreement that the direct and indirect costs of litigation and the threat of lawsuits are major contributors to spiraling healthcare costs, tort reform and other proposals to remedy the problem have been relatively minor components of the debate over healthcare reform. 

In the US, medical malpractice cases and personal injury litigation are handled on a contingent fee basis. Plaintiffs and their lawyers enter into an agreement that sets the legal fee as a percentage of the amount of the ultimate recovery. Although the plaintiff and the defendant are each responsible for their own legal fees and costs, in practice it is the plaintiff’s attorney (not the plaintiff) who shoulders all of the expenses of the case--court filing fees, expert witnesses, depositions, etc--in exchange for a percentage of whatever damages are awarded. Thus, a plaintiff’s attorney in a malpractice case is really involved in a business deal, risking total costs against a potential payoff. 

This means that attorneys have incentives to take on cases even when it is unclear whether the defendant is actually liable. The key issues for attorneys are the amount of the potential recovery (which usually depends more on the amount of damages or injury to the plaintiff than on the physician’s degree of negligence) and the likelihood an award will be collectible from either an insurance company or the personal assets of the physician. 

An attorney can “win” a case with uncertain liability because, if the injury to the plaintiff is serious enough, there is always the risk a jury will return a large damage award, which can help the plaintiff’s attorney to force a settlement. Potentially enormous damage awards and high defense costs can create a financial threat that the defense is unable or unwilling to withstand, regardless of liability. 

There is a highly disproportionate degree of risk assumed by each side in a contingent fee case. If it looks like the costs of pursuing the case might go beyond what the plaintiff’s attorney is willing to invest, he can essentially “dump” the case, settling for less but avoiding a big financial toll. The plaintiff’s attorney controls his own costs and can manage the case with a view to properly balancing the risk/reward equation. 

Defendants in a malpractice lawsuit have no similar ability to limit potential loss short of settling the case. Unless the plaintiff agrees, the defense can’t simply decide to drop the case as the costs pile up. If the plaintiff’s attorney is well financed and a strong negotiator, the plaintiff holds all the cards and can demand a high price for a settlement. 

What if our tort system required the losing side to pay for the winner’s legal fees and costs? That’s how nearly every European country does it. Would that reduce the incentive to sue? Even with a contingent fee, a “loser pays” system would move the financial risk out of the plaintiff’s control—the defense’s risk of a jury damage award would be balanced by the financial risk and uncertainty assumed by the plaintiff. With “loser pays,” the two sides are more evenly matched: the defense is less likely to be forced into an unfavorable settlement, and the plaintiff can’t unilaterally dump the case to avoid financial risk. As their advantage is diminished, plaintiffs would be less likely to file cases for the settlement value without clear liability. With every filed case, the plaintiff’s lawyer would literally be betting the house on a successful outcome. Attorneys with poor skills and judgment would be weeded out of the profession in fairly short order. 

The inherent economic advantage (controlled versus uncontrolled costs) currently enjoyed by plaintiffs, even in cases of marginal liability, inevitably leads to frivolous malpractice litigation. A “loser pays” system would dramatically reduce the number of cases brought to court, yet still enable those who are truly injured to find an attorney to finance a legitimate case. The costs and the emotional impact of frivolous cases might be substantially reduced if these reasonable reforms were considered as a part of any healthcare reform. 

Robert J. Mintz, JD, is an attorney and the author of the book

To receive a complimentary copy of the book, call 800- 223-4291 or visit www.rjmintz.com.

 Asset Protection for Physicians and High-Risk Business Owners. 

What if our tort system required the losing side to pay for the winner's legal fees and costs?

Covering Your Assets: Loser Pays: How to Avoid Frivolous Lawsuits

Microsoft shot itself in the foot when it released Windows Vista in 2007. Windows Vista was widely derided as inferior to Windows XP, and to this day, many users have refused to upgrade or purchase a new computer with the Vista operating system. PC manufacturers like Dell and HP bowed to pressure from customers and dumped their Vista-only policies for consumer PCs by reinstating Windows XP as a “downgrade” option. 

Windows 7—derisively referred to by techies as “Vista done right”&mdash;is now widely anticipated for release in October 2009, about the same time this issue will land in your mailbox. Whether you choose to upgrade to Windows 7 will depend on a host of issues, including which OS you currently use, how happy you are with your current situation, and how badly you want to start using the new features of Windows 7. 

My software company, AmazingCharts.com, is currently testing our EHR system on Windows 7, and so far, the results have been good. We’ve had very few compatibility issues, and the Windows 7 platform has been remarkably stable. 

If you have a touch-screen monitor, the new Windows Touch feature will let you use your fingers to scroll, resize windows, play media, and pan and zoom. Windows 7 also introduces multi-touch technology—like the iPhone&mdash;so you can control what happens on the screen with more than one finger. For example, you can zoom in on an image by moving two fingers closer together, like you’re pinching something, or zoom out by moving two fingers apart. You can rotate an image on the screen by rotating one finger around another, and can right-click by holding one finger on your target and tapping the screen with a second finger. This is an exciting advancement for healthcare providers who work with imaging technology on a regular basis. Imagine being able to manipulate an X-ray or MRI image with just a touch of your finger. 

Another cool feature is the new Jump List, which lets you quickly reach the files you’ve been working with. To see recently used files, right-click on the icon on your taskbar. Right-clicking on the MS Word icon will show your most recent Word documents. If there are other files you want to keep handy, you can just pin them to the Jump List so they’ll always appear. On the Jump List for Internet Explorer, you’ll see frequently and recently viewed websites. You’ll even have quick access to tasks that were previously only available from within some programs, such as composing a new e-mail message. 

Other features fix issues that have bugged me for years. For example, when you wanted to compare two open windows before, you had to manually resize your open windows to show them side-by-side. With Snaps, you can simply grab a window and pull it to either side edge of the screen to fill half the screen. Snap windows to both sides to compare those windows. 

The View Available Network (VAN) feature in Windows 7 simplifies the task of viewing and connecting to all of your home or office networks. It provides one-click access to available networks, regardless of whether those networks are based on Wi-Fi, mobile broadband, dial-up, or your corporate VPN. These features are welcome and long overdue additions to Windows. 

Microsoft claims that Windows 7 is designed to make PCs start up, shut down, resume from standby, and respond faster. I’ll believe these performance improvements when I see them with my own eyes. If you use a netbook or notebook computer, Microsoft also claims power management improvements expected to extend battery life. Power-saving enhancements include an adaptive display brightness, which dims the display if you haven’t used your PC for a while. Other improvements include using less power to play DVDs, which is always handy on a long trip. 

Unfortunately, the process of upgrading to Windows 7 will be neither simple nor straightforward for most users. Next month, I’ll take a look at the upgrade process, how it differs for XP and Vista users, the many fl avors of Windows 7, and hardware requirements. 

Dr. Bertman is Physician Editor-in-Chief of

He is a Clinical Assistant Professor of Family Medicine at Brown University and president of AmazingCharts.com, a leading developer of EHR software. He is also the founder and president of AfraidToAsk.com, a consumer website focusing on personal medical topics. He is in private practice in Hope Valley, RI.

Microsoft shot itself in the foot when it released Windows Vista in 2007. Windows Vista was widely derided as inferior to Windows XP, and to this day, many users have refused to upgrade or purchase a new computer with the Vista operating system.

Tech Talk: What's Cool in Windows 7?

“He’s 11 but very mature, so this year, we let him onto Facebook,” a dad told me recently. 

I asked one simple question: “How did you deal with Facebook’s minimum age of 13?” 

“We used our e-mail and changed his birthday,” noted the dad. “We’re always around when he goes on. That’s the rule. So, he’s safe, and it’s all ok.”

This is no anecdote or journalistic manipulation of the facts. This is not only a true story, but it is becoming a common occurrence in families with “tweens,” despite the fact that in order for members of this age group to get a Facebook account they must do things that we tell our kids never to do online: lie about their age and lie about who they really are. 

Parents listen to our every word of “anticipatory guidance” when kids are small, but when it comes to tween and teen issues online, parents somehow start mistakenly thinking they don’t need us as much. With visits becoming less frequent and time in the office shortened, physicians have to work even harder to get their points across and help parents understand that we are still experts in their children’s worlds. But, how can we accomplish it all in one visit? It’s simple. Use one analogy for both worlds: driving. 

I ask teens and parents if they’d ever drive without a license. They, of course, say “no.” I then casually inform them that social media sites all have age guidelines in place that are really considered online “graduated” laws and that it’s our job as parents to enforce those laws. Just as we wouldn’t allow our teen to drive a car without proper information and experience, we shouldn’t allow a child on Facebook or similar sites before the stated age and without proper experience on sites meant for their own age group. 

I address maturity issues up front. Tweens are wired to follow directions, but that changes in teen life as the brain becomes rewired to get ready for adult life. I explain that the reasoning frontal cortex doesn’t kick in until late in teen life, and before then it’s all refl ex, driven by a section of the brain called the amygdala. I then refer them to the 

, which has a wonderful explanation. I explain that the formerly rule-following tween will become a risk-taking teen. 

I also explain that socially, tweens are not ready to hang with teens. I ask parents if they’d ever let their 11-year-old go to a party with 18-21-year-olds. The “no” answer helps them understand that being on Facebook is the online equivalent of just such a party. 

Finally, I gently point out that using a parent’s e-mail to sign up for any site and changing the dates of a birthday gives the impression that it’s acceptable to engage in this type of behavior… even after we spend a lot of time telling kids never to lie about that sort of stuff. By this point, parents start to see the light. 

You can accomplish all of this in a matter of minutes by chatting casually during the physical examination or while entering data in your EHR. The more ways you find to raise these issues face-to-face, the more your families will begin to recognize how important they are and that the online world’s rules are as important to follow as the offl ine world’s laws. 

Being a savvy Health 2.0 physician also means not stopping at face-to-face chats! Use your online venues to reinforce these messages. Blog about age issues associated with online use. Create a list of sites that you hear your patients are using, and remind people of the ages of use for those sites. You can even create a handout that you can give to families in the office or post on your office website. Being a physician in 2009 means being as online as our patients and understanding what that means. Our families want that from us, and all of us are capable of providing that level of outstanding care. 

Gwenn Schurgin O’Keeffe, MD, FAAP, (aka “Dr. Gwenn”) is a pediatrician, health journalist, parenting and social media expert, and is CEO and Editor-In-Chief of

 an online health and communications company dedicated to providing reliable information for today’s busy families. She also writes the blog 

Parents listen to our every word of "anticipatory guidance" when kids are small, but when it comes to tween and teen issues online, parents somehow start mistakenly thinking they don't need us as much.

Social Media Notebook: Do You Have a License to Drive that Facebook Account?

High costs, unreliable vendors, lengthy installation and transition processes, disruptions to workflow, reduced productivity—it’s no wonder that so few practices have adopted full-featured EHRs. Will new federal incentives for adoption combine with legitimately useful products to provide a much needed transfusion of interest in the EHR market? Or will rates of use continue to pale in comparison to the possibilities of this technology?

	Challenging the notion that physician practices have been slow to adopt EHRs is quite difficult. According to 

 published in July 2008, only 4% of medical practices had implemented a full-featured EHR product, whereas another 13% of practices had implemented a basic system. A closer look at the practice-level use of EHRs provides sobering evidence of the difficulty of implementing and benefiting from a full-featured EHR. From increased costs to decreased productivity and, in too many cases, continuing use of paper records while paying for an EHR, many practices have failed to capitalize on the promises of EHR technology. 

	In reality, many practices that have EHRs actually are computer-assisted paper operations. One often encounters practices that record everything on a piece of paper and then scan the paper into the EHR. Other practices will print relevant pages from the EHR upon patient arrival. The paper follows the patient around the office to support the visit and patient care. Other practices record information in the EHR but print the report, which is placed in the paper record. Are these the type of practice models that would compel you to go to the trouble and expense of using an EHR? 

	EHR adoption has been inhibited by a number of issues, with many practices refusing to use the technology. From the cost of implementation to the questionable benefits of these tools, there is a wide range of reasons for physician EHR trepidation. 

	Many practices are not confident in the longevity of EHR vendors and are confused by the conflicting messages from the industry and their care partners. For example, a number of practices have been pressured to purchase an EHR supported by their hospital, physician hospital organization (PHO), or other healthcare provider group. More challenging is when one group wants a practice to use a particular product while another related group is pushing use of a different product. Indeed, some practices have been told to use a different EHR for each office, based on the preferences of the local hospital. In other cases, practices are being compelled by their more powerful hospital and PHO partners to use an EHR that is not appropriate for the practice size and/or the area of medicine. It is difficult to discern which of the 400 active EHR vendors will be able to survive and meet a practice’s long-term needs. 

	The cost issue is complicated by a number of factors. In general, EHR acquisition will cost a practice more than it has spent on almost anything else. Additional barriers to adoption are the spotty return on investment and war stories about lost productivity and revenues. Why should a physician invest a substantial amount of money for a questionable future return? Physicians can expect to spend $1,000 to $2,000 or more per month for an EHR system. If there are few savings or revenue opportunities enabled by the EHR, what would compel the physician to invest such sums when there are competing investments in new equipment, staff, and locations? 

	Indeed, the benefits of EHR investments are typically harvested by healthcare organizations that did not contribute to the investment. For example, electronic prescriptions certainly decrease errors in the pharmacy and save the pharmacy staff time that would be spent entering data. Similarly, electronic lab orders, surgery information, and patient demographic information are maintained and captured by a physician practice before transmission to other providers. In fact, the 

 that physician practices that pay for EHR systems only see $0.11 of each $1.00 saved. The other $0.89 accrues to the benefit of insurance companies, hospitals, pharmacies, and other healthcare organizations. 

	The EHR timeline is challenging. Even after spending the six months it frequently takes for a focused selection and decision process, the practice is faced with an EHR implementation process that can take another six months or more. Larger practices could be facing a rollout period across offices and areas of medicine that could take longer than a year. An additional 4-6 months may be needed to implement a practice management system that can support the EHR. Even after all of this effort and expense, the typical practice still faces the time needed to fully transition patients to the EHR. From potentially scanning some or all of a patient chart to backloading important patient information such as immunizations, prescriptions, or previous procedures, physician practices could be working on patient chart transition for 6-12 months after initial use of the EHR. 

	Unfortunately, achieving success is a long and challenging process. First, a practice must have the governance and management capabilities to support and empower the project. In many cases, EHR projects lack the total, staff-wide commitment that is essential for a successful implementation. Practices may allow staff and doctors to opt out of using the EHR or use it in ways that undermine efficiency and effectiveness. Then, the practice must choose an appropriate product that can manage documents, service patients, facilitate workflow, and provide appropriate structures for the relevant areas of medicine. Not all products provide adequate tools to meet the needs of every practice. Next, the practice must redesign every process and activity in order to integrate the EHR into the workflow. Redesign of the practice and implementation of the EHR product occurs at the same time that the practice continues to serve patients; medical practices cannot shut down for redesign. Finally, the practice must support the ongoing use of the EHR as the practice evolves and as the EHR changes. These keys to success are daunting for many practices that seriously examine using an EHR. 

	A significant barrier to EHR adoption is the existing information in a patient’s paper chart. Practices may have charts with 10, 20, or more years of information in the mass of paper that represents the patient’s paper record. Some patient charts may have 100 pages or more of a variety of forms from a number of sources. How do you get that information into the EHR? How does the practice deal with the legal requirement to maintain the patient’s chart as the practice moves to an EHR? 

	Newly practicing doctors today cannot remember a time when they were not using computers to work on school assignments or play games. These new doctors are often confounded by the paper-based systems used in most practices, while they are more than comfortable with computerized clinical tools found in many teaching hospitals and larger organizations. However, many doctors that have been working with paper charts for 10 years or more may lack the computer skills to effectively use an EHR to work with patients. In many practices, key physicians just don’t want to transition to EHRs after years of practicing medicine. 

	The American Recovery and Reinvestment Act (ARRA) has offset some of these factors and put EHRs on the agenda for many practices. The key issue facing practices is that ARRA will essentially force them to implement an EHR system. Practices that do not could be at a disadvantage and be forced to give up the incentives offered under ARRA. 

	Physician practices may have no choice but to use tools that are necessary to be an active player in the healthcare industry and, more importantly, to effectively serve patients. Patients are interested in interacting with their doctors over the Internet. Indeed, the ARRA-inspired “meaningful use” standards include availing patients of information over the Internet as well as the percentage of your patients that take advantage of that option. If other practices and healthcare organizations are serving patients through Internet connections, how will practices that keep patients waiting on hold, or leave cryptic HIPAA-compliant phone messages, be perceived? 

	For example, Doctor A has an EHR and produces a note that includes complete information about the patient service and exam. Doctor B does not have an EHR and receives a paper copy of the complete report that many doctors consider excessive. The length of the paper report is daunting, and the important information is difficult to identify. Doctor A also transmits an electronic version of the report to Doctor C, who uses an EHR. Doctor C can view the report and transfer the prescriptions, conditions, and selected information into her practice’s EHR. Doctors A and C will be able to immediately access their patient information and share it with others. Doctor B will continue thrashing through pages of patient charts to find pertinent information. Why should a patient wait for an hour in an emergency room bed for Doctor B’s staff to accumulate the list of drugs and fax them to the hospital when Doctor A and C can send over the patient’s prescriptions through their EHR on demand at any time? The same lack of EHR support for patients could inhibit a practice’s ability to receive referrals, manage patient treatment orders, and even communicate with other providers in the local referral network. 

	A number of legitimate issues and challenges have stalled the adoption of EHR tools in physician practices. However, the combination of legitimate EHR products that address real physician needs and the ARRA incentives for EHR adoption should prompt your practice to take a second look at EHRs.

, is an independent EHR consultant and the author of the HIMSS Book of the Year Award-winning

Feature Articles

High costs, unreliable vendors, lengthy installation and transition processes, disruptions to workflow, reduced productivity--it's no wonder that so few practices have adopted full-featured EHRs.

Why Is the EHR Market So Anemic?

The Joint Commission, the Institute for Healthcare Improvement, and other organizations have identified medication errors and the points of transition during patients’ care that increase their likelihood as promising targets in the push to improve quality outcomes. Communication, coordination of care, and the effective application of health IT hold the key to reducing errors and improving patient safety.

 that medication errors continue to be one of the most frequent causes of preventable harm in healthcare. 

 at transition points in patient care is responsible for as many as 50% of all medication errors and up to 20% of adverse drug events in the hospital setting. The Joint Commission also notes that its 

 (accurately and completely reconciling medications across the continuum of care) has been exceptionally difficult to score since its introduction in 2005. Because of this difficulty in scoring, as of January 1, 2009, findings will be evaluated during the on-site survey; but, “given the difficulties many organizations are having in meeting the complex requirements of this goal, they will not be factored into the organization’s accreditation report.” This difficulty in scoring makes it all the more necessary to have electronic systems and other technologies in place to meet and exceed expectations not only for when the Joint Commission comes to visit, but also for the betterment of our patients. 

	Technology solutions to medication errors continue to evolve on a number of fronts, including simplified dispensing, direct order entry, PCA pumps that are programmed to be both patient- and drug-specific, and even experimentation with “polypills,” capsules that may contain up to seven drugs (all in low doses) for a variety of adult maladies. The Institute for Healthcare Improvement has been a leader in promoting advanced medication reconciliation at all transfer points, having identified early on that medication errors are one of the leading causes of injury to hospital patients. Chart reviews reveal that more than half of all 

 occur at the interface of care. As I see it, IT solutions hold the greatest promise to eliminate these errors, with programming that will focus on care transitions and any discrepancies or disruptions in medication management. 

	It is across the continuum of care that the reconciliation process has its greatest impact. According to the 

, “transitional care is defined as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location.” These locations and their transfers include hospitals, subacute and postacute nursing facilities, the patient’s home, the office practice (both primary and specialty), and longterm care or assisted living facilities. As we begin to evaluate the quality and safety of each movement and point of handoff, we see that proper management of medications and medication lists will fall under the rubric of medication reconciliation. 

	The integrated medical record has great potential to put all of this information “on one page”--or at least to have it reside in only one location. Even when care is provided across multiple sites and services (as is often the case), only one medication record need exist. It can be used to prescribe, populate clinical notes, handle admission orders and refills, and be included in discharge summaries. At a minimum, required fields include drug name, dosage, frequency, and route. The record system we use at the Mayo Clinic also requires amount and date of last refill, and it does an exquisite job of identifying drug—drug interactions. With our system, all providers who are addressing medication needs can access the electronic record at each site of service and update the medication list in real time. The medication history can also be brought up to discover when a drug was discontinued, and perhaps why (there is a voluntary field of entry for this information at my institution). 

	As we pursue a patient-centered approach to care, the medical record and the individual it reflects should be able to travel together. Moreover, medication lists are becoming available to patients, home care providers, and families as medical practices make patient-specific information available on the Internet. 

 (PQRI) allowed 119 measures that were published in the Physicians’ Fee Schedule to be used for reporting and additional reimbursement. Of those, 117 were clinical performance measures and two were structural measures that focused on either the use of an EHR or e-prescribing technology. The savvy practice will utilize its EHR to not only report clinical performance, but also to advance the care and safety of each patient and be rewarded along the way. 

	With the transition of care measures at various stages of development both at PQRI and at the National Quality Forum, medication reconciliation is the keystone for measure development. The current focus is on hospital discharges and how well the handoff goes. One way to judge is how well the medications were reconciled—what was omitted, what failed to restart following transfer or discharge, what has been duplicated, and what dose or dosages are incorrect. The next frontier, subject to the same analysis, will be how well nursing homes and home health agencies pass or receive the baton of responsibility. It behooves all of us to work as quickly as possible to integrate hospital and outpatient records along with pharmacy records in order to eliminate errors of duplication, omission, and transcription. 

	I believe that we can only take quality measures so far. Although the science of qualitative measurement continues to advance, much still remains in the eye of the beholder. Medication errors, on the other hand, are quantitative and can be approached with methodical measurements toward Six Sigma. In the elimination of duplicate steps, we have less opportunity for error and also save time and money. Again, a unified record can give us the opportunity to keep track of who prescribed what, as well as when and even for what reason. 

	I know of no fully integrated programs that can follow patients across more than two or three sites of service. Nonetheless, progress is being made across the country as we explore the opportunities provided by the EHR. At Mayo, we have adopted a master medication list that is used by all outpatient primary and subspecialty practices. It is available to our two teaching hospitals and is also available to staff who are attending to patients in our local nursing homes. It is not yet integrated with pharmacies at any location other than Mayo for e-prescribing, nor does it populate the hospital or the nursing home record. However, it is a step in the right direction and has put far more physicians on the same page. 

	This integration also allows for instant review by the patient at every encounter. If adjustments are made, they are only made once and are stored in only one location. The medication list is maintained in its own repository and then loaded to the next clinical encounter. Institutions moving along these lines will be better able to follow patients across all transitions of care with a singular health record that recognizes only one medication list.

editorial board member, and a professor of medicine and co-director of the Robert & Arlene Kogod Program on Aging at the Mayo Clinic in Rochester, MN.

First, Do No Harm: The Role of Medication Reconciliation in Reducing Preventable Errors

Patients have embraced social networking tools that allow them to share information, offer support, and compare healthcare experiences. Physicians should also use these tools to connect with their patients and local communities and provide general medical information.

	Healthcare social networking has made impressive inroads into the mainstream, as like-minded folks find each other online and chat about their passions. From politics to personal, from professionals to patients, the Internet has exploded with people talking about their health and healthcare. Perhaps the economic downturn has rekindled peoples’ appreciation for those things that make life worthwhile—our families and communities&mdash;and refocused their interest in improving their health. I know from personal experience that a great shock can help you value what you have more&mdash;I recently successfully resuscitated an acquaintance’s child from near drowning and have been hugging my children every chance I get. I see friends reacting to the economic downturn in a similar fashion, reinvesting in their health as they watch their 401(k) and housing values shrink. Many of them are participating in online discussions as part of their investigations into how to improve their health. 

	President Obama’s proposal to overhaul the healthcare system unleashed a torrent of activity on e-mail lists, blogs, Facebook, and Twitter as citizens think that this time, something may really change. What’s amazing is that this energy has not been unique to the online space. You know that people are really worked up when they vote in record numbers and when large numbers of citizens show up to support or heckle in town hall meetings. This shows how effective online organizing can be; we’ve crossed the chasm from silly flash-mobs to impacting politics-as-usual. Maybe healthcare social networking isn’t just all talk. 

	Social media and social networking are not only about politics; they can also be about actual medical care. As people use social networks to ask about health, they find others with the same conditions, and at the same stage of treatment. Most folks are asking about what they can expect in terms of prognosis and possible complications. People tend to talk about common illnesses in public spaces like blogs and Facebook, but for more complex conditions, some patients often prefer private e-mail lists such as 

, where they feel more secure to reveal details. Others get very specific in public forums about how a particular treatment or medication could help them with their symptoms. Some patients choose to record online diaries that contain detailed data about their treatment and response, through online resources such as 

. With the latter two, records can only be viewed with the user’s consent; information stored in Microsoft HealthVault and Google Health is completely private. 

	The healthcare social networking format that I see used most often is quick updates from friends on their Facebook or Twitter pages announcing that they’re sick, which prompts other friends to offer comfort and suggest remedies. I’ve taken to commenting as well, offering suggestions on what friends can do at home to help with colds and other minor injuries. This is the same kind of health education you can find from books like the , or iPhone resources such as 

, but tailored specifically to what my friend has said online. I don’t practice medicine online—I don’t diagnose or prescribe or tell them what to do. I offer options based on their symptoms and point out things they should be more concerned about. It’s like what I imagine happened when our communities were much smaller and folks knew their local doc and asked quick questions at the grocery store or at church. Now, it happens online with more depth in places like the “Expert Forums” at MedHelp.org and at Yahoo Answers, where you can ask physicians these kinds of questions, sometimes for a fee. The great thing is that all of these conversations are archived publicly, enabling anyone with these conditions to benefit from reading about them. 

	I see the most questions of this sort in private e-mail lists, such as the 

, where more than 4,000 parents with children up to age five ask each other about local providers and how they care for certain illnesses. These parents with kids younger than elementary school age don’t yet have PTA networks on which to rely, and many of them have recently moved to the area and are looking for testimonials from like-minded parents. As providers realize that their reputation can be made or broken online, they’re starting to engage and respond to questions and complaints in these online venues. My own experience is that parents come and seek me out for urgent care since they know that I’ve been open online and am trusted by that community. 

	Healthcare social networking can be particularly effective in getting the word out about hot-button public health topics. Information about H1N1 (the artist previously known as “swine flu” before being hog-tied), has flowed so much more freely than information about SARS did seven years ago. This time, the CDC updated its website regularly and provided webinars and conference calls for physicians and the public. Even local health departments started using Twitter to tell folks about the rapidly changing response. From this information, local schools and parents could understand the real risks involved (not terrible to date, thank God) and avoid further school closures and panic. I tweeted and used my Facebook updates to share guidelines for when it is appropriate to come in to be seen for urgent care, since so many people were coming in with very mild symptoms without fever, or with no symptoms at all, just because they’d recently traveled to Mexico. 

	Using social media to spread the word about public service announcements is particularly potent. I recently posted a shocking video depicting a gruesome accident due to texting while driving. In just a few minutes, hundreds of my friends viewed it, and a dozen commented and reposted it to their own friends. I connected with a fraction of the millions that have viewed it on 

, but in a much more personal way. A fellow physician commented that the video was “so 20th century. Nowadays, we should say ‘Don’t tweet and drive!’” 

	Health nonprofit organizations are also engaging the social networking enthusiasm of their members. Though applications like 

 allow for direct cash donations, you can make a greater impact by getting the word out about an organization’s message through online handouts, photos, YouTube videos, and invitations to events and fundraisers. The Leukemia & Lymphoma Society’s 

 has been especially effective in engaging supporters through social networks. 

	A day doesn’t go by without a local chapter of a nonprofit inviting me to a meeting, training, or fundraiser. To prepare for a debrief for the families who witnessed my resuscitation of a child from near drowning, I’m relying on 

 in order to encourage parents to watch their kids more safely and empower their kids to stay safe in the water. I haven’t even moderated the discussion yet, and parents are commenting enthusiastically online in anticipation of our meeting. 

	Exercise video games are a really fun way to use healthcare social networking. I may not have time to hit the gym most days, but I always seem to find time to play my Nintendo Wii, whether it be Wii Fit, EA Sports Active, Punch-Out, or just to compete to be the biggest loser with Jillian Michaels Fitness Ultimatum (God knows I need to lose a few...). Even if no one else at home wants to join me, by becoming online “buddies” with other Wii-owning friends, I can feel like I’m part of a larger exercise community. It’s more fun working out with EA Sports Active with one of my kids, but seeing friends working out seems to kick my butt into gear more effectively. Wii Fit, which focuses on improving balance rather than increasing aerobic endurance, can help elders who are at risk of developing balance issues resulting in falls and possible hip fractures. I dream of a future where elders not only chat about their golf handicap or how well their doubles game went, but also become Wii buddies and brag about their low “Wii Fit Age.” 

	New iPhone applications also offer an easy way to track your fitness goals and show your friends how fit you’re getting. I’d like to see iPhone apps that use the accelerometer in the iPhone to track your exercise. 

	Academics, however, are expressing some caution with regard to social networking and personal health information. In an e-mail to students and faculty of Harvard Medical School, Dean for Medical Education 

: “Caution is recommended . . . in using social networking sites such as Facebook or MySpace. Items that represent unprofessional behavior that are posted by you on such networking sites reflect poorly on you and the medical profession. Such items may become public and could subject you to unintended exposure and consequences.” For physicians, it’s clear that you should only practice medicine online through HIPAA-compliant private and secure portals that allow you to e-prescribe and provide care that is linked to your EMR, like we do at 

. What’s not clear is how your other public expressions, health-related or not, reflect on you. I only post things online that I’d be happy for anyone to know about, even when posting in a purportedly private place like a closed e-mail list or with Facebook friends. You never know who could copy some incriminating photo to send to your boss. (Not that I participate in any activities I want to hide, of course!) 

	With the anticipation of increased competition in the wake of healthcare reform, I believe physicians will have to engage online and become more transparent. An excellent example of what I believe to be the future is 

, the website of surgeons Drs. Calvin Lee and Tammy Wu, who publish their statistics so you can see their experience and success rates. Educated patients will increasingly demand to know complication rates, and will spread the word about great surgeons who embrace transparency like these two old college friends of mine. The future looks bright for patients in terms of learning about safety and quality, and healthcare social networking will be a central part of that future.

editorial board member, partner at Palo Alto Medical Foundation Urgent Care, and adjunct clinical instructor in internal medicine at Stanford Medical School. Connect with Dr. Choi at 

Is It All Talk? Healthcare Social Networking

Given that healthcare reform is such a contentious subject in the United States, it is not surprising that conflicts have arisen between physicians and patients who hold different views and who aren’t shy about discussing those opinions in the examination room. We recently posted on HCPLive.com 

 that addressed this issue and invited readers to share their thoughts and comments about whether physicians should discuss healthcare reform with their patients. 

As a physician who blogs on healthcare reform, I believe it is crucial for every citizen to become informed on the subject. Nevertheless, I consider it inappropriate for any physician to use clinical encounters to promote his/her own views on any potentially controversial subject. It may damage the rapport needed for best outcomes, and the doctor-patient interaction is not always viewed as equal. I applaud physicians for becoming active on this topic, whatever their views, but not in that way. 

It is totally inappropriate for a physician or practitioner to provide opinions, political information, or partisan materials to patients in a care setting, no matter the opinions of either party. This would constitute taking advantage of vulnerable patients in their weakest moments. If asked, the physician would have the right to answer honestly. But this response should not consume significant time needed for the patient’s care. There is no place for the “bully” exam room or the “bully” waiting room in our care of our patients. 

I would not broach the topic with patients unless they asked me my opinion, and then I would be careful with my remarks. I was trained in the UK, liked the NHS, and feel that the vast majority of Americans would benefit from healthcare reform that opened up access and offered a public option. However, I was very surprised recently when I went in for a routine endoscopy and, during the pre-sedation check, on hearing my accent, the anesthesiologist asked, in an aggressive tone, “When are you planning to go back to England to enjoy all that socialized medicine?” Now that is crossing the line! 

I have been in practice for 56 years and almost all of my patients are long-time friends. With few exceptions, these patients are against more government intervention in healthcare economics. When they bring up these issues, I wait until the professional session is ended and then talk to them like they are my best friends. They need to get their concerns (anxiety) answered truthfully, which is part of their medical care and needs. If I don’t do this, then I have failed my duty to do all that I can to be a medical servant to said patient. 

First, it is very interesting to me that HCPLive confuses “healthcare” (which to most, at least, means “clinical care”) and “healthcare coverage/reform.” It suggests how much the two very different issues have become conflated in the current debate. The practice of clinical medicine has become overtly politicized as we all worry about resources and agendas... Perhaps this is what PQRI is really about; we all worry, especially because many of us do not do a great job in defining and defending what we do. Second, I think that physicians must approach issues of healthcare reform in the office and wherever else they can. Physicians are now, and always have been, knowledge workers in the Drucker sense. Not flattering? Then doctors will pay in blood and treasure to maintain that artifice of “the profession.” 

We Know You Have an Opinion about This! These articles and blogs were recently posted to HCPLive.com. 

Vaccination for Cancer? Why the Controversy?

Warning: Working Long Hours May Rot Your Brain

Pulse

Given that healthcare reform is such a contentious subject in the United States, it is not surprising that conflicts have arisen between physicians and patients who hold different views and who aren’t shy about discussing those opinions in the examination room.

Second Opinions: Physicians Talk Healthcare Reform with Patients

Some patient advocates, tech-savvy physicians, and other Health 2.0 proponents tout e-mail, online forums, and social media technologies because they can potentially help strengthen the patient—physician relationship by providing patients with greater access to their physicians and facilitating more open communication. Yet, after seeing patients all day, do physicians really want to spend a significant portion of whatever free time they have in the evening answering informal, non-specific medical questions online and dispensing general healthcare advice to friends and patients? The time is quickly approaching when physicians are going to have to confront this and other questions prompted by patients’ evolving, technology-driven expectations regarding the extent to which they have access to their healthcare providers and how and when they can communicate with them. 

Not only are more people using online social networking tools in their personal lives, but now, even companies and professionals are beginning to understand how these technologies can be used for marketing, outreach, and other business applications. And, just as with any service or technology, the more ubiquitous that social media and other online connectivity tools become, the more that consumers will come to expect that they will have access to them. This may pose significant challenges for physicians for several reasons. If recent history is any guide, other businesses will likely adopt online social media tools faster and more extensively than will the healthcare industry. This, coupled with the example set by physician early adopters and the ever-expanding galaxy of online healthcare information resources (it turns out that patients are eager to read healthcare information online and then discuss it with friends, family, other patients who have the same symptoms and conditions, and medical experts), will inevitably lead patients to demand increased access to their own physicians, many of whom—already faced with a time crunch initiated by the financially driven need to see perpetually expanding numbers of patients&mdash;will balk at shouldering yet another responsibility. Throw in unresolved questions over whether and by whom physicians will be reimbursed for their time, and the situation becomes even more complicated, as providers try to figure out how to adapt to the changing times and balance their needs with those of their patients. 

This month’s cover story tackles many of these questions and issues. Written by editorial board member Enoch Choi, MD, it offers the perspective of a physician who has eagerly embraced the challenges of practicing medicine in an increasingly online world. Choi says that new technologies offer us a chance to replicate a time when “communities were much smaller and folks knew their local doc and asked quick questions at the grocery store or at church.” Interested physicians and patients can recapture those connections; only now it will happen online. Choi also suggests that instead of viewing this as a burden, physicians should realize that actively engaging their patients online will only enhance their reputation in their community and generate goodwill and business for their practice. 

Yet, for every physician like Choi who has found a way to make this work, there are many others who reject the personal or professional use of any and all social media tools. While that choice is understandable given all the competing demands on physicians’ time, social media technologies are not passing fads that can be ignored until they go away. While Twitter, Facebook, and their like can be used for mundane, even frivolous pursuits, they are also powerful tools that can be used to quickly and efficiently share information and create and sustain professional relationships and collaborations. And this is just the beginning; these tools will become more comprehensive over time, and then will be superseded by newer technologies with even more robust capabilities. This will happen faster than we think (it always does). Will physicians be ready, or will they gain a reputation for being antisocial in a social media world? 

Editor's Note

Some patient advocates, tech-savvy physicians, and other Health 2.0 proponents tout e-mail, online forums, and social media technologies because they can potentially help strengthen the patient–physician relationship by providing patients with greater access to their physicians and facilitating more open communication.

September 2009