Public confession isn't always the best idea for people like you and me, who play a public role in our communities. On the other hand, letting slip a few fears and getting things off one's chest can be extremely relieving. So, I'm going to admit the monster in the closet of practice adaptation that scares me the most. My biggest fear is that you (yes, you) and your colleagues aren't paying attention to what's happening in the wider world of electronic health records (EHR) and clinical documentation; and that as a consequence, we're going to set chiropractic back 10 to 15 years. If you think that's crazy, perhaps you need better information on the EHR debate outside chiropractic. If you do, that's something I'd like to help remedy right now.
I'll start by qualifying my confession. I know your lack of interest in the EHR debates has mostly to do with a poverty of time and a wait-and-see attitude, not any purposeful derailment. I call it the "I'm-too-busy-to-move complex." Heck, you still may not even be sure what a true electronic health record is at this point. Why should the future of EHR intrude on your day-to-day activities? Fifteen years ago, were you one who said you'd never use a computer to do your billing? Now look in the mirror.
Why EHR should matter, and why it should matter now, has been the focus of my previous columns in Dynamic Chiropractic. We've covered the benefits of integrating EHR and digital documentation in our practices: namely better efficiency, better claims outcomes and the opportunity to improve our profile in the community with our patients, their other providers and the third parties who pay the bills. We've touched on the dark clouds that have spurred a new interest in EHR, largely the OIG report of 2005, which more or less told Congress that $280 million of taxpayer money could be saved if improperly documented chiropractic claims were not paid by Medicare.
Looking back, the catalyst for the recent discussions in our profession over EHR and the viability of chiropractic within Medicare can largely be laid at the feet of the OIG report. I've heard everything from, "I know I need to get an electronic documentation system," to "My documentation is terrible. I need help," to "All the EHRs I've purchased really weren't EHRs and they were slower than my paper system." Of course, some have remained a little more positive; I like to think of myself among them, largely because I believe there is a simple solution to a lot of our problems in the form of EHR and digital documentation.
The OIG report offered me, and others, a good opportunity to address the profession about our interest in widespread adoption of EHR. Consequently, this has lead many to think electronic patient management wasn't an issue before 2005. Some are tempted to think once the OIG report "fades with time" (a big assumption), controversies in clinical documentation, including EHR, will just fade as well. Now, thankfully, these folks aren't spelling out the doom of chiropractic under Medicare. But they are burying their heads in the sand, and their denial of the problem (i.e., chiropractic's questionable practices in the eyes of third-party payers) is not encouraging. While chiropractors aren't solely responsible for the environment that created so many documentation errors, we do have a responsibility to look and see what precipitated the OIG report. And, in reality, we need to look at the larger picture of improving documentation in health care, period. I think looking at the development of the EHR debate will explain/reveal why ignoring electronic patient management will send us in a backward spiral.
If the OIG report somehow gets swept under the rug, the issue of improving documentation and EHR isn't going to leave the public square any time soon. Political forecasting can be tricky, but as we get closer to 2008, major press stories about EHR are likely to increase. I believe the repeated question asked of the up-and-coming political candidates will be: "EHR is going to save me and my family money, so why isn't my doctor paperless yet?" Remember back in 2004? Incumbent George W. Bush promised nationwide EHR by 2014. John Kerry was throwing around the possibility of 2008.1
Just recently, our clinic received a visit by probable 2008 presidential hopeful, Iowa Governor Tom Vilsack. We welcomed him on a fact-finding tour related to health care technology and showed him our facilities here in Carroll, Iowa. These guys always come prepared with talking points, and the one he shared with me is the government's speculation that the cost of health care in the U.S. can be reduced by one-third through the implementation of EHR alone. That's somewhere around $77 billion a year. Nationwide, EHR is going to be a momentous task, but it's one that's very feasible and has already been proven effective in a number of circumstances. In other words, it makes an easy stumping point for presidential and congressional candidates, and it's one both parties can find reasons to endorse. There are also some "feel good" elements of EHR that really are hard to resist.
For example, newspapers have reported that many Hurricane Katrina evacuees were helped by the fact that their medical records were 100 percent electronic. Who were these special patients, whose full medical histories arrived in a week and whose pharmaceutical records arrived in one day? Were they patients of a trend-setting hospital for the insanely wealthy? Nope. They were only your average veterans in a Louisiana VA hospital.2 That's right, an institution which conjures images of a cumbersome bureaucratic beast actually is a rather efficient user of EHR, which the Veteran's Health Administration began to implement and develop in the early 1990s. The VA credits the use of digital records for allowing them to functionally double their capacity, but limit their budget expansion by 50 percent. Can you imagine what that would look like for you in your own clinic? You hear the pollster's questions now: "The government has already integrated electronic medical records nationwide into all VA hospitals, helping to defray significant medical costs. Are electronic health records something you would like to see in your community?"
There also is the widespread belief that EHR can significantly reduce costly medical errors and redundancy in services, which third-party payers and consumers both want to see. Insurance companies want you to have an EHR for immediate record retrieval and immediate proof of medical necessity, removing the snail-mail system and faxes. They want the data electronic for filing and transport reasons, saving them millions of dollars. And when consumers and managed health care lobbyists agree, you can imagine that the only real opponents to EHR are going to be MDs and other providers who are more than comfortable with the status quo.
The Institute of Medicine (IOM) recently released a pre-published copy of its 2007 report on preventing medical errors. The report states that the ideal for clinical/hospital safety requires "a single, electronic medical administration record that is broadly accessible" together with e-prescribing of drugs, etc.3 This is the same organization that made waves in 1999 with the estimate that medicine's errors cost the lives of 98,000 Americans a year in the report, To Err is Human. I'm sure you're all aware of the 100,000-death-a-year statistic quoted by chiropractors who wish to critique the legitimate deficiencies in American health care. While EHR isn't the only solution offered by the IOM, it's foundational to its plan for saving lives from human error. Now, whether this can actually be done in a system that is overly reliant on prescription drugs is another question, and open to debate. I believe it is absolutely within the purview of chiropractic to advocate for technology that hopes to reduce dangerous and redundant use of pharmaceuticals. Attempting to hold other providers to the oath of "do no harm" in order to protect our patients' interests is a noble act, even if it doesn't always make us a lot of friends.
What's interesting about the IOM's new report is that it repeats a call for widespread EHR which was first initiated in 1991, more than 15 years ago. If you think EHR only just arose as a major health care initiative, think again. It's been around for a while and will be around for years to come ... which brings me back to the monster in my closet.
I believe (as do others) that what's happening in the wider world of health care in regards to electronic patient management is directly relevant to the future of chiropractic as an independent, widespread system of care. Rather than allow managed care lobbyists and medicine-based information technologies to determine our place in the information data flow, I think it's imperative that chiropractors demonstrate a willingness to adopt EHR in order to remain in the planning stages of the coming wave of new legislation on technology and clinical practices - or at the very least, to understand the issues at hand. Our practices are different and our concerns over long-term EHR will be different. We need to figure out what those concerns are before a mandate catches us unaware and we have to spend years playing catch up with our patients' other providers. They're larger, have more clout, and will effectively influence the nationwide development of EHR information technology without much concern for the input of those of us who practice what's called "physical medicine."
By acting now, even if it's simply entering the debate, we can avoid a professional setback in the future. In fact, I think I'll draw inspiration from my previous column and state that we could be even on the cusp of starting a trend that revolutionizes how we do chiropractic in our communities. As many MDs continue to drag their heels and question the advantages of digital documentation,4 we can find ourselves ahead of the curve and demonstrate how a paperless model can benefit everyone involved. After all, our profession has made the claim that we're all about cost-effectiveness in regards to our treatment. It's time we understand our documentation affects delivery of care. It's time to look at all aspects of health care delivery and demonstrate that chiropractors are leading the industry with efficiencies in both the delivery and cost models.
References
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
Spearheaded by burgeoning scientific and clinical research literature, psychedelics have reached a level of media coverage and popular interest that has not been seen for over half a century. By “psychedelics,” we are referring to the unique class of substances that includes psilocybin (the active compound found in so-called “magic mushrooms”), LSD, dimethyltryptamine (DMT), ayahuasca, 5-MeO-DMT, and mescaline – each of which occurs in the natural world (except for LSD, which is a semi-synthetic compound).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
