# Electronic Medical Records



## Fern Modena (Nov 4, 2012)

Doctors' Offices are moving towards an electronic world.  I have several doctors and they all do things differently.  Some use laptops, some have a networked computer in each office.

Some of the nursing assistants put your vitals and update your medicines right in the computer; some of mine do not, they do updates on paper and there is still a paper chart in addition to an electronic one.

If your doctors do this, do you feel that they are spending more time looking at the computer than talking to you?  One of mine did at first, but no more.  I they are using paper *and* computers, do you worry about miscopying information at all?

Now all my prescriptions are sent electronically as well.  Some go to Medco/Express Scripts (mail order) and some are sent directly to my local pharmacy.  I don't see any of them beforehand. I should know what they are because the doctor discusses any new meds with me before he or she prescribes them.

A couple weeks ago I went to a new doctor's.  Actually I had to go to a PA, which I prefer not to do (but I didn't seem to have any choice). While he told me briefly what he was prescribing (three different items), when I got home from the pharmacy I wasn't sure what I had.  All I knew was that it didn't seem to be what he had told me.  I had two tubes and one bottle of pills.  All three said on the labels "as directed,"  nothing more.  

It turned out that one was definitely wrong.  Whether the PA prescribed the wrong thing (he said he didn't) or the pharmacy filled the wrong thing (they said they didn't), I don't know.  From now on, I will ask the doctors to at the least place specific prescribing info and what it is used for on the label.

This never used to happen before. I I had seen the prescriptions and taken them to the pharmacy myself, the misprescribing wouldn't have happened, because I would have seen the prescriptions.  

I believe that the electronic prescriptions law was to cut down on people forging prescriptions, yet at least two medical offices I've heard of have had employees use the new system that way.  

A friend of mine and her sister go to different doctors in the same office.  About a year ago, one of them went to a local lab for blood tests.  Somehow the doctor's office transcribed the records electronically to the other sister's chart (some of my doctors do it manually, but most scan info in). Last I heard, over nine months ago, it still wasn't straight, and the originating doctor was trying to make it the patient's fault!  How, I have no idea. But it is scary.

Have any of you had any problems with the new medical records system?

Fern


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## Talent312 (Nov 4, 2012)

I once did a follow-up with a doc at his second office, but he didn't have my file. The first thing he asked was, "Why are you here?" IMHO, electronic files are far more efficient.

My current doc faxes or phones in my Rx's to the pharmacy. I have not had an issue with this. However, they've started giving me a printout listing my scrips before I leave their office so I know what I 'sposed to get. I think it's an excellent practice.

If they simply say, "I gonn'a give you 'something' for that," I suggest that you ask them to put 'something' on paper, just to make sure there is no mix-up.


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## bogey21 (Nov 4, 2012)

My take so far is that my Doctors spend more time on their computers than communicating with me.  They also seem to have trouble locating history.  The prescription thing seems to be going ok.

George


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## SmithOp (Nov 4, 2012)

I've had similar experience with HMO, have to see PA for Meds.  She prints a copy, just ask for one they can easily hit print, if you notice most of them are Windows machines. She printed a page from Wikipedia for my son about tonsil stones he had, sheesh I coulda googled that


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## Passepartout (Nov 4, 2012)

Our records and visits have been electronic for years. I haven't seen a paper chart or 'script for at least 6-7 years. The nurse takes my vitals and it's entered into my file. The doc comes in and there is the history of labs going back all those years. It helps to spot trends if something is out of whack. My record shows visits to specialists in the network- but not if I go to a doc outside it. 'Scripts automatically go to my pharmacy, and are properly labled- brand name, generic name, origin, dosage.  DW and I are not the biggest consumers of health care around (thank goodness), but we are very satisfied.

I think that as practitioners get used to the equipment, and as we all have records that are portable and show our individual histories spanning lifetimes, it can't help but improve health care.

Jim


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## pwrshift (Nov 4, 2012)

My GP resisted going computer until it was made mandatory by his clinic.  It took him a lot of time to get totally familiar with the process.  Now he loves it, and says its given him much more patient time.  However he's using that time to see more patients each day, not spend more than 10 minutes with you...after keeping you waiting 45 minutes after your appointment time.  Grrrrr. I respect his time...but he doesn't do the same for me.  Specialists are much better at being on time than GPs in Canada.  But still better than waiting hours in ER at a hospital.

The thought of sending your private health info around the Internet in an age of Google and identity theft does frighten me.  There will one day be a big public disclosure, I feel.

Brian


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## DaveNV (Nov 4, 2012)

Fern, I work in IT at a very busy hospital and medical center that uses electronic medical records. 

When they first went to this system several years ago, there was the issue of how to handle the tens of thousands of paper records being stored in the basement.  There were rooms filled with shelves of paper stacked to the ceiling.  Some records were just a few pages thick, others had hundreds of pages in them.  The medical records staff has spent untold hours scanning and uploading all the pages in each of those individual paper records to the electronic record for the patient.  The (now) empty shelves are being removed, as the staff moves on to the remaining piles of records.  This process is normal, so at some point, you can expect your paper records will end up merged into your electronic record.  Your doctors will have access to your history, but may have to dig a bit within the program to access the information electronically.  Transcription of treatment notes is fast and accurate, and the information is downloaded back into your record very quickly.  Given the easy way paper pages can be lost or misplaced, electronic medical records is actually a much better way to store information.

Another advantage to electronic medical records is prescription history.  Your Provider should be able to see what you've been prescribed before, and be able to ensure there aren't any conflicts with new prescriptions.  In the case of the prescriptions you just got that were incorrect, it should be easy to find out who was wrong - your electronic record will show what the PA prescribed for you, and the pharmacy can prove what they received.  But your Pharmacist should have discussed the new medications with you when you picked them up.  I get things from Express Scripts, and they send paperwork with my new prescriptions.

One thing you can request is a copy of the prescription information, so you'll know what to expect.  Providers are supposed to provide a written treatment plan, telling you what they're doing to treat your illness, and explaining the prescriptions you're being given.

One of the reasons it may seem your Provider is spending so much time looking at the computer is because they're reading your treatment history, and making sure information is being entered accurately. MediCare is now pushing "Provider based billing," where the Provider has to document the exact treatment you've been given.  So there is a lot of new accountability for what they do.  

If you feel you aren't being given the attention you need, tell them.  Most Providers see so many patients a day, they don't have the luxury of spending lots of time with a single patient, and then trying to remember afterwards what they found.  (Not defending them, just explaining that's how things are scheduled.  It's not uncommon for a Provider to have patients scheduled every ten to fifteen minutes throughout the day.  It can be brutal.  I honestly don't understand how they can do it every day.)

I hope your treatment is easy and successful.  Being sick is never fun.

Dave


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## Glynda (Nov 4, 2012)

*doctor*

My doctor used to come in with a chart and upon leaving, went to a small room to dictate.  Now she and her assistant come into the room and the assistant records everything in the computer before and as I talk to the doctor.  The doctor still gives me attention but I'm not as comfortable talking to her with the other person in the room.  Also, as the system is new to their practice, she stopped a couple of times to look at computer screen and asked assistant how she did something.  The assistant gave her a lesson.  I like looking at my record on the internet but the prescription service doesn't work with my insurance company.  I have mixed feelings about all of it.


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## Kay H (Nov 5, 2012)

My cardiologist has used computerized records for a few yrs now but when i went in August, for the 1st time my ekg was recorded  immediately on the computer, no paper printout. I guess their expensive ekg machines are outdated now.


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## Phydeaux (Nov 5, 2012)

Yes, the times they are a changin. We live in a digital world. My physician and dentist offices went digital years ago, and I’m very thankful they have. I work in the medical profession, and I embrace the technology. The fact of the matter is, whether it’s with pen & paper, keyboard or stone tablet & chisel, input of information or data still require a human being to make the input. This being the case, it is incumbent on us to ensure the data is correct. Example – since in the past you were handed a prescription that you could read, if you were able to decipher your physicians’ penmanship, you could have caught an error, if you knew what the error was. Since your prescription is now sent without the paper, it is up to you to know what was being sent, the dosage, and to ask any/all questions you have at the time you are face to face with your physician.
My experience is patients do not ask enough questions of their caregivers.


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## dougp26364 (Nov 5, 2012)

Electronic files are efficient when a couple of things happen.

#1 The information is entered correctly. There is still the human element.

#2 Systems need TALK to each other. There is a big problem with hospitals in that there is not one system that does everything efficiently. We have at least FIVE different systems in our hospital, not all of them talk to each other. That creates problems. Then there's HIPPA, which is meant to protect patient confidentiality but also has a chilling effect on what information can be shared electronically and how fast that information gets shared. Penalty's can be large enough that one doesn't share information without all the i's dotted and t's crossed. Because the law can be difficult to understand, better to be err on the side of caution and NOT share that file than be fined for breaching confidentiality. IMHO, an unintended consequence of the law. 

In theory, electronic records cut out errors by removing the inablity to read someone's hand writing and by making information available in short order. If that information is not entered correctly, it can cause more problems than it solves as getting bad information out of a system always seems to be nearly impossible.


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## bogey21 (Nov 5, 2012)

Phydeaux said:


> to know what was being sent, the dosage, and to ask any/all questions you have at the time you are face to face with your physician.
> My experience is patients do not ask enough questions of their caregivers.



I agree with this although I have had a mixed reaction from my Doctors to asking questions.  Some appreciate them, others seem to think I am questioning their competance.

George


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## Phydeaux (Nov 5, 2012)

bogey21 said:


> I agree with this although I have had a mixed reaction from my Doctors to asking questions.  Some appreciate them, others seem to think I am questioning their competance.
> 
> George



You need to determine if this is only your perception, or if it is indeed accurate. If accurate, you need to fire that physician and get a different one. When it comes to *your* health, you're the boss.


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## dougp26364 (Nov 5, 2012)

bogey21 said:


> I agree with this although I have had a mixed reaction from my Doctors to asking questions.  Some appreciate them, others seem to think I am questioning their competance.
> 
> George



If they act as if you're questioning their competance, then maybe you should.


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## PamMo (Nov 5, 2012)

Our large hospital-based medical system incrementally switched to electronic medical records over the last 5-6 years. Learning to use the new system was initially very stressful and frustrating for staff, and at the beginning there was some push back. It took a tremendous amount of money, time, training, and effort to change the existing system. Now that all the hospitals and clinics are up and running, everyone appreciates how complete and accessible patient records are. Communication among health providers and between doctor and patient has gotten much more efficient.

As a patient, I like how I can pull up my medical records online and review medications, labs/tests results, health notes, appointments, etc. I can reach my doctor (or her nurse) through email to get a prescription refilled, or ask a question. It's MUCH better than playing phone tag. As the general population becomes more computer savvy, I think it will only get better.


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## bogey21 (Nov 5, 2012)

dougp26364 said:


> If they act as if you're questioning their competance, then maybe you should.



It is not that simple.  The Doctor I have the biggest problem with is my Electrophysiologist.  IMO she is absolutly brilliant just hard to deal with.  I have decided I would rather deal with the interpersonal issues  than put myself in the hands of an easier to deal with but less competent Doctor.

George


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## Phydeaux (Nov 5, 2012)

bogey21 said:


> It is not that simple.  The Doctor I have the biggest problem with is my Electrophysiologist.  IMO she is absolutly brilliant just hard to deal with.  I have decided I would rather deal with the interpersonal issues  than put myself in the hands of an easier to deal with but less competent Doctor.
> 
> George



Certainly your prerogative. I just prefer to deal with professionals that are both very competent _and_ easy to deal with. It's my money - why should I compromise? Having a great personality and similar bedside manner shouldn't have any relevance on their professional competencies.


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## pianodinosaur (Nov 5, 2012)

According to the Stimulus Bill, all physicians must have a government approved Electronic Medical Record System by January 01, 2014 or the doctor will suffer severe penalties.  That is how the law is worded.  Therefore, we are all being forced into a government approved EMR.  Part of the requirement is that prescriptions be sent by email.  This is to ensure that the government can keep track of every prescription and see if you filled it or not.  Furthermore, according to the Affordable Health Care Act, the IRS will now have access to all our medical records.  This is because a hip prosthesis or a breast implant has cash value.  If you get one of these medical appliances, you need to pay taxes on it.  This is not a political statement.  This is the law as it is written and as it is being implemented.  

The EMR does have certain advantages but the transition is very painful.  Getting accurate information into the EMR is difficult but once it is in, the information is very easy to access.


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## Bucky (Nov 6, 2012)

I read this article a few days ago in our local paper that I thought interesting.

http://www.newsobserver.com/2012/11/03/2457379/some-doctors-find-switch-to-electronic.html

WHAT’S BEHIND THE PUSH FOR ELECTRONIC MEDICAL RECORDS
Electronic medical records, a major part of the Obama administration’s strategy to cut medical costs, are driving a massive technology shift in the health care field.

The American Recovery and Reinvestment Act of 2009, commonly known as the federal stimulus bill, includes bonuses for doctors and hospitals that achieve “meaningful use” of electronic records with Medicare and Medicaid patients. Failure to meet the federal goals with Medicare patients triggers penalties.

For doctors, the maximum federal incentive for electronic records is $44,000 under Medicare and $63,750 under Medicaid. Failure to use achieve “meaningful use” targets triggers penalties in 2015. The penalties start with a 1 percent reimbursement reduction in the first year, and increase to 5 percent over time.

The Medicare incentive is available to dentists, podiatrists, osteopaths, optometrists and chiropractors. The Medicaid incentive is available to nurse practitioners, nurse midwives, physician assistants and other types of medical providers.

Under the “meaningful use” standard, the majority of prescriptions, diagnoses and other procedures must be processed and stored electronically.

Hospitals could receive incentives worth several million dollars. The hospital incentives are based on complex formulas, starting with a base minimum payment of $2 million a year that is adjusted on a range of factors.


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## bogey21 (Nov 6, 2012)

If the Government is truly driving the train on all this and providing incentives and penalties for compliance and/or non-compliance, it is bound to be a screwed up mess.

George


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## Texasbelle (Nov 6, 2012)

*Intensive Care?*

Our experience was that the personal attention varied with the nurse on duty.  Some spent more time "ticking away" on the computer than checking the person in ICU.  This was especially annoying to our daughter.  After her dad had no response to ringing for a nurse, she loomed over the ticker and demanded care for him.  It did not appear that they were understaffed just busy with "paperwork."  DD said the nurses in Tyler were much more attentive so she didn't see why Houston would be different.


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## Fern Modena (Nov 6, 2012)

I haven't seen the text of the law, but if you have, I'd like it if you can point out to me where it would require me to report a prosthesis or implant so that I may be taxed on it (or that the IRS would know and assess a value on it for tax purposes).  I really doubt that this is true.

Fern



pianodinosaur said:


> According to the Stimulus Bill, all physicians must have a government approved Electronic Medical Record System by January 01, 2014 or the doctor will suffer severe penalties.  That is how the law is worded.  Therefore, we are all being forced into a government approved EMR.  Part of the requirement is that prescriptions be sent by email.  This is to ensure that the government can keep track of every prescription and see if you filled it or not.  Furthermore, according to the Affordable Health Care Act, the IRS will now have access to all our medical records.  This is because a hip prosthesis or a breast implant has cash value.  If you get one of these medical appliances, you need to pay taxes on it.  This is not a political statement.  This is the law as it is written and as it is being implemented.
> 
> The EMR does have certain advantages but the transition is very painful.  Getting accurate information into the EMR is difficult but once it is in, the information is very easy to access.


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## pianodinosaur (Nov 6, 2012)

Fern Modena said:


> I haven't seen the text of the law, but if you have, I'd like it if you can point out to me where it would require me to report a prosthesis or implant so that I may be taxed on it (or that the IRS would know and assess a value on it for tax purposes).  I really doubt that this is true.
> 
> Fern



The devil is in the details.  Kathleen Sebelius has written all kinds of rules and regulations to go along with this legislation.  The new law grants her the ability to write these rules and regulations without the approval of Congress.  Some of these rules are currently being challenged because they violate freedom of religion.  The IRS is now in charge of all medical care.  Our medical records are now immediately available to the IRS.  You would not have to notify the IRS.  Your doctor and hospital would be required to notify the IRS through the EMR as part of a quality assurance program.  Sebelius herself told us that the main purpose of her rules and regulations is to redistribute wealth.  All you have to do is attend a medical meeting where these people speak.  If you are a member of the medical society, you get a report of what she said.  If all the Sebelius rules go into effect, you may find yourself being taxed on a cardiac pacemaker or defibulator or even your coronary artery stent.  Our cardiologists came back from a medical meeting this year absolutely furious about these new regulations about to go into effect in 2014.    

The death panels are very real.  The death panels are being created right now.  I have been asked to represent our surgery department in just such a panel.  Unfortunately, very few people outside the medical community understand what is taking place and why.  Even more unfortunate is that our leadership in the AMA helped create these problems.  This is one of many reasons why so many physicians have resigned membership from the AMA.


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## Passepartout (Nov 6, 2012)

This entire post reeks of so much more partisan politics than distribution of factual information that I can't possibly comment. What I read in your post is purely hearsay. Lets see some chapter and verse here, Doc.

I get that you are not on board with ACA. Couldn't have something to do with provider payments being trimmed to implement ACA, could it?

When I got my 'Welcome to Medicare' Physical a few months ago, my PCP said to the effect "OK, I'm your 'Death Panel'. Have you made any 'end of life' decisions?" Like a living will and advance directive for health care, and had them entered into my electronic chart- so MY wishes would be carried out, not someone else's. This is not about rationing health care.

As to taxes on medical appliances, why should they be tax free. These things vary by state- with the exception of excise taxes which are Federal. Heck, you pay Federal Excise tax on your car tires, why not medical appliances?

Jim



pianodinosaur said:


> The devil is in the details.  Kathleen Sebelius has written all kinds of rules and regulations to go along with this legislation.  The new law grants her the ability to write these rules and regulations without the approval of Congress.  Some of these rules are currently being challenged because they violate freedom of religion.  The IRS is now in charge of all medical care.  Our medical records are now immediately available to the IRS.  You would not have to notify the IRS.  Your doctor and hospital would be required to notify the IRS through the EMR as part of a quality assurance program.  Sebelius herself told us that the main purpose of her rules and regulations is to redistribute wealth.  All you have to do is attend a medical meeting where these people speak.  If you are a member of the medical society, you get a report of what she said.  If all the Sebelius rules go into effect, you may find yourself being taxed on a cardiac pacemaker or defibulator or even your coronary artery stent.  Our cardiologists came back from a medical meeting this year absolutely furious about these new regulations about to go into effect in 2014.
> 
> The death panels are very real.  The death panels are being created right now.  I have been asked to represent our surgery department in just such a panel.  Unfortunately, very few people outside the medical community understand what is taking place and why.  Even more unfortunate is that our leadership in the AMA helped create these problems.  This is one of many reasons why so many physicians have resigned membership from the AMA.


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## Talent312 (Nov 6, 2012)

I would not presume to dicker over details with someone apparently in-the-know, even if he has such an obvious axe to grind. But to avoid turning this into a debate over the Affordable Health Care Act, I'll just say this:

Any significant change which disrupts traditional way of doing things is scary to a lot of folks (see "Fiddler on the Roof")... especially so to those who lived most their lives in an analog/paper-based world. It's can be tuff teaching old-dogs new tricks.

When our office switched to an electronic filing system, doing away with paper files, a lot of the old-timers (myself included) were resistant and made their own paper files, duplicating  the ones in the computer. Whenever the system doesn't work like its 'sposed, they say, "See, paper files were better." But for the most part, the youngsters running Admin had their way. Now, a scant two years later, very few are left who would go back to the old-ways.


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## jlr10 (Nov 6, 2012)

Our doctor's practice started going electronic the last few years.  The nurse takes the vitals and updates some records. Then the doctor comes in reviews test results and reviews and compares my history, which is readily available to a point.  He asked me when I had my last tetnus shot, and I responded "Don't you have a record of that?"  He said their records didn't go back far enough for that question.  Luckily I could track it down to fairly close.  

Even with the computer our MD is great. He takes the time to ask, and listen, to "How are you?" He asks about work and the family and how I am doing,and more importantly, what am I doing.  He also records, on paper, all test results, complete with hand drawn graphs and diagrams.  He has always done that and I think he always will.  He is the stereotype people think of when looking for an 'old fashioned family doctor."   No matter what he always makes me chuckle.   I leave my results in hand and feeling like he took the time to stop and attend to just me and my needs.  I will miss him when he retires, which I hope won't be for a while.

I can't comment on the prescriptions. Pretty proud that at 52 I am still prescription free and working hard to stay that way.


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## pianodinosaur (Nov 7, 2012)

Talent312 said:


> I would not presume to dicker over details with someone apparently in-the-know, even if the has such an obvious axe to grind. But to avoid turning this into a debate over the Affordable Health Care Act, I'll just say this:
> 
> Any significant change which disrupts traditional way of doing things is scary to a lot of folks (see "Fiddler on the Roof")... especially so to those who lived most their lives in an analog/paper-based world. It's can be tuff teaching old-dogs new tricks.
> 
> When our office switched to an electronic filing system, doing away with paper files, a lot of the old-timers (myself included) were resistant and made their own paper files, duplicating  the ones in the computer. Whenever the system doesn't work like its 'sposed, they say, "See, paper files were better." But for the most part, the youngsters running Admin had their way. Now, a scant two years later, very few are left who would go back to the old-ways.



It is true that I have an ax to grind. My office EMR cost me a mint that I do not have.  The EMR does make it much easier to retrieve information.  However, I did spend two hours yesterday at a hospital meeting being informed about more new rules and regulations regarding our hospital EMR and how this information is to be supplied to the government and how it is going to be used.  I am on the committee responsible for implementing the hospital EMR and trying to get the other medical staff members to comply with the new regulations.  My previous post may have a political bias.  However, the EMR and all the associated rules and regulations are being forced upon us by the government.  I have to live with them on a daily basis.  It is the law.

I find it very convenient that a reference lab can send a report directly to my office computer EMR being flagged as abnormal.  I can immediately pull up the medical record and be reminded why I ordered the test in the first place.  The EMR will inform me about adverse drug interactions every time I write a prescription.  I can use my IPAD to look at a patient's  X-ray in the hospital EMR right now instead of using my IPAD for what I hope is interpreted as a friendly conversation on TUGBBS. (I am having trouble sleeping tonight.)  It helps me provide a better service to my patients in many ways.  However, I do have serious concerns about how the government is using all this information.


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## Talent312 (Nov 7, 2012)

pianodinosaur said:


> ... I do have serious concerns about how the government is using all this information.



I have a serious concern about how our front office is using our electronic filing system to look over our shoulders, track our workload, measure our client contacts, check our note-taking, and keep statistics on our performance. I find that I spend a lot of my time making my files "look good" for others.

What's next? GPS chips in our behinds? Pressure sensors on our chairs?


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## pgnewarkboy (Nov 7, 2012)

PamMo said:


> Our large hospital-based medical system incrementally switched to electronic medical records over the last 5-6 years. Learning to use the new system was initially very stressful and frustrating for staff, and at the beginning there was some push back. It took a tremendous amount of money, time, training, and effort to change the existing system. Now that all the hospitals and clinics are up and running, everyone appreciates how complete and accessible patient records are. Communication among health providers and between doctor and patient has gotten much more efficient.
> 
> As a patient, I like how I can pull up my medical records online and review medications, labs/tests results, health notes, appointments, etc. I can reach my doctor (or her nurse) through email to get a prescription refilled, or ask a question. It's MUCH better than playing phone tag. As the general population becomes more computer savvy, I think it will only get better.



That says it all very succinctly.   No system is foolproof but the upside on digital medical records is huge for much improved medicine care for the individual and society.   Breakthroughs in research on major diseases will surely follow because of the massive data that will be available to scientists.


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## bogey21 (Nov 7, 2012)

pianodinosaur said:


> The death panels are being created right now.  *I have been asked to represent our surgery department in just such a panel. * Unfortunately, very few people outside the medical community understand what is taking place and why.  Even more unfortunate is that our leadership in the AMA helped create these problems.  This is one of many reasons why so many physicians have resigned membership from the AMA.



Much of the population will get their information from the media and the politicans.  Only a few will listen to those on the front lines.  IMO to our detriment.

George


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## wilma (Nov 7, 2012)

pianodinosaur said:


> The death panels are very real.  The death panels are being created right now.



So you find it horrible to provide patients with end of life counseling, advice on making living wills and advance directives for health care and have Medicare pay for it?


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## Fern Modena (Nov 7, 2012)

Some of my doctors have it right; My cardiologist has an EKG machine which plots directly to my electronic chart.  In fact, other tests done in his office, such as ultrsounds and stress tests are also reported electronically to my chart.  His assistant also charts my vitals and a list of my meds electronicly.  In addition, most of my lab results are reported electronically, and those which are not (and are faxed instead) are then scanned into my record.  So everything is integrated into my chart and available for my doctor.  

Last time I went to my neurologist his office was just beginning to start electronic charting.  Because of this, when he requested that I have an ultrasound which my cardio doctor normally did, I told him I'd have it done there, with the results sent to him.  His office coordinator tried to convince me to have it done there, since they had a tech ready and willing to do it (the doctor didn't care if I had it done with the other doctor). I told the coordinator that I wanted to have it done at the cardiologist's since that was where I normally had such tests done.  

It is getting better, but part of my reason for posting was to remind people to make sure they know (and get a copy or printed list of) what the doctor is prescribing so you can check it with the pharmacy.  I didn't do that, and I should have.

Fern


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## pianodinosaur (Nov 7, 2012)

wilma said:


> So you find it horrible to provide patients with end of life counseling, advice on making living wills and advance directives for health care and have Medicare pay for it?



We do this already.  The death panels are to withold care from patients eventhough the patient and/or the patient's family want care continued.  This is so that the patient will die more quickly and save the government money.


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## wilma (Nov 7, 2012)

pianodinosaur said:


> We do this already.  The death panels are to withold care from patients eventhough the patient and/or the patient's family want care continued.  This is so that the patient will die more quickly and save the government money.


Insurance companies already do this.


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## pianodinosaur (Nov 7, 2012)

Fern Modena said:


> Some of my doctors have it right; My cardiologist has an EKG machine which plots directly to my electronic chart.  In fact, other tests done in his office, such as ultrsounds and stress tests are also reported electronically to my chart.  His assistant also charts my vitals and a list of my meds electronicly.  In addition, most of my lab results are reported electronically, and those which are not (and are faxed instead) are then scanned into my record.  So everything is integrated into my chart and available for my doctor.
> 
> Last time I went to my neurologist his office was just beginning to start electronic charting.  Because of this, when he requested that I have an ultrasound which my cardio doctor normally did, I told him I'd have it done there, with the results sent to him.  His office coordinator tried to convince me to have it done there, since they had a tech ready and willing to do it (the doctor didn't care if I had it done with the other doctor). I told the coordinator that I wanted to have it done at the cardiologist's since that was where I normally had such tests done.
> 
> ...



My office EMR automatically checks for adverse drug interactions every time I write a prescription.  The meaningful use requirements give my patients an updated review of all their medications with each office visit.  I find this to be one the most beneficial aspects of my EMR.


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## Passepartout (Nov 7, 2012)

pianodinosaur said:


> We do this already.  The death panels are to withold care from patients eventhough the patient and/or the patient's family want care continued.  This is so that the patient will die more quickly and save the government money.



Having had my mother pass in recent years, and FIL just last month, I think this statement is absolute male bovine waste! Based on what a patient's views on end of life care and advance directive are, a decision may be made to provide 'comfort care' or hospice when 'heroic measures' could prolong life. However this is based on quality of life issues, not whether the government saves money or not.


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## Clemson Fan (Nov 7, 2012)

Passepartout said:


> Having had my mother pass in recent years, and FIL just last month, I think this statement is absolute male bovine waste! Based on what a patient's views on end of life care and advance directive are, a decision may be made to provide 'comfort care' or hospice when 'heroic measures' could prolong life. However this is based on quality of life issues, not whether the government saves money or not.



Not to diminish your loss or your experience with end of life issues, but really they have nothing to do with what the future holds with the Affordable Care Act.  Much of the ACA has not come on line as of yet, so your recent experiences have no bearing and will probably be far different then from what they will be once the ACA becomes fully integrated and activated.  I’m also a MD, but I have no idea what the landscape might be like once the ACA comes completely on line.

I will say I’m an early adopter of EMR in my practice and I’ve been fully electronic for 5 years now.  I love my system, but I hate the systems in the hospitals.  I find the hospital systems difficult to use and they actually increase my workload because a lot of the administrative stuff I used to delegate to my staff is now placed on me because I’m not supposed to share my login information with anybody else.


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## pianodinosaur (Nov 7, 2012)

Passepartout said:


> Having had my mother pass in recent years, and FIL just last month, I think this statement is absolute male bovine waste! Based on what a patient's views on end of life care and advance directive are, a decision may be made to provide 'comfort care' or hospice when 'heroic measures' could prolong life. However this is based on quality of life issues, not whether the government saves money or not.



Your mother did not die under the supervision of the new laws.  Neither did my mother.  The moment I found out my mother had suffered an embolic event to the thalamus, I advised my father and her physicians to stop all life support.  As of 2014 these decisions are about to be made on the basis of how cost effective it will be to prolong life and how cost effective that quality of life will be.  The patient's views and the family's views are about to become irrelevant.  (In England these decisions are made based upon a mathematical formula that takes into account future economic productivity on the part of the patient verus the cost of providing the care.  If providing care is not considered cost effective, the care is denied.)  This is what we are attempting to implement at our hospital to become compliant with the new laws by January 1, 2014.  We will have a committe to tell patients that their life is no longer worth living and that we have made the decision to stop all futile care because it is not cost effective.  If the patient is not able to understand, we will give the bad news to the family and their concerns will be of no consequence once we have made the decision.  My job as the representative of the surgery department will be to tell families that we will not perform an operation because it is not cost efffective.   I am not happy about this but the department felt that I would be the best one to handle the job after so many years as chairman.  This is happening all across the country as the ACOs are being established.  I understand how horrible this sounds.  It is horrible.  However, our hospital activities are now being monitored by the government through the EMR.  I spent two hours at a medical staff meeting yesterday being advised of all the penalties we will suffer if we do not comply with these laws.   I spent two hours with the rest of the surgeons being advised how we will be punished if we try to save a sick old person just because the family or the patient wants us to make that attempt or if we keep them in the hospital too long.  We will also be punished if we send the patient home and the patient returns to the hospital within one month for any reason.  Obviously, my reality and your reality are not the same.  All I want to do is take care of sick people and relieve suffering.  These new laws represent a serious obstacle in my reality.  Live long and prosper in your reality. 

The EMR does help me take better care of my patients.  However, I remain very concerned about how the government is using all this information.


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## pianodinosaur (Nov 7, 2012)

wilma said:


> Insurance companies already do this.



I agree.  However, it is much easier to fight an insurance company than the government.


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## pianodinosaur (Nov 7, 2012)

Clemson Fan said:


> Not to diminish your loss or your experience with end of life issues, but really they have nothing to do with what the future holds with the Affordable Care Act.  Much of the ACA has not come on line as of yet, so your recent experiences have no bearing and will probably be far different then from what they will be once the ACA becomes fully integrated and activated.  I’m also a MD, but I have no idea what the landscape might be like once the ACA comes completely on line.
> 
> I will say I’m an early adopter of EMR in my practice and I’ve been fully electronic for 5 years now.  I love my system, but I hate the systems in the hospitals.  I find the hospital systems difficult to use and they actually increase my workload because a lot of the administrative stuff I used to delegate to my staff is now placed on me because I’m not supposed to share my login information with anybody else.



I am using Meridian, which is a urology specific EMR.  Meridian recently set up an agreement with CareCloud for exchange of information.  Meridian does all the E&M coding automatically and now sends the statements directly to CareCloud.  This has really streamlined my office in the past month.  

The hospital is using AllScripts.  I find Allscripts to be a very cumbersome EMR just as I found AllScripts to be a cumbersome billing system before going to CareCloud.  Allscripts will not do the E&M coding for hospital visits or consults.  The medication reconcilliation process is very painful.  However, I think it has cut down on medication errors.  I had formerly dictated all my progress notes because I have bad handwritting.  The Allscripts templates are not that friendly but if I use them for my progress notes and physician orders I no longer have to worry about signatures, dating and timing.  I still dictate when I am in a hurry, but, I can sign the notes from my IPAD.  Our hospital started with Allscripts in April 2012.  I have not hand written a progress note or physician order since before May 2012 at this hospital. Since I was the one of the first surgeons on our staff to go to an EMR in his office, I was selected to be on the EMR/IT committee. Most members of our staff are now very comfortable looking up information with Allscripts.  However, only about 1/2 of us are using Allscripts for entering orders and progress notes.  A major problem with Allscripts in the hospital system is that we cannot use it to print prescriptions or e-prescribe.

I was on the executive committee of The Harris County Medical Society when we first began studying how to implement the ACOs.  It is going to be a very difficult and painful transition.  However, we are also trying to establish a system where it will become easier for physicians to share information about patients.  Unfortunately, HIPPA has been the biggest obstacle to the easy transfer of information between physicians and hospitals in Harris County.


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## bogey21 (Nov 8, 2012)

pianodinosaur said:


> *The patient's views and the family's views are about to become irrelevant. * (In England these decisions are made based upon a mathematical formula that takes into account future economic productivity on the part of the patient verus the cost of providing the care.  If providing care is not considered cost effective, the care is denied.)  This is what we are attempting to implement at our hospital to become compliant with the new laws by January 1, 2014.  *We will have a committe to tell patients that their life is no longer worth living and that we have made the decision to stop all futile care because it is not cost effective.*............I spent two hours at a medical staff meeting yesterday being advised of all the penalties we will suffer if we do not comply with these laws.   I spent two hours with the rest of the surgeons being advised how we will be punished if we try to save a sick old person just because the family or the patient wants us to make that attempt or if we keep them in the hospital too long.  We will also be punished if we send the patient home and the patient returns to the hospital within one month for any reason.



*Ignore at your peril.*

George


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## pgnewarkboy (Nov 8, 2012)

pianodinosaur said:


> Your mother did not die under the supervision of the new laws.  Neither did my mother.  The moment I found out my mother had suffered an embolic event to the thalamus, I advised my father and her physicians to stop all life support.  As of 2014 these decisions are about to be made on the basis of how cost effective it will be to prolong life and how cost effective that quality of life will be.  The patient's views and the family's views are about to become irrelevant.  (In England these decisions are made based upon a mathematical formula that takes into account future economic productivity on the part of the patient verus the cost of providing the care.  If providing care is not considered cost effective, the care is denied.)  This is what we are attempting to implement at our hospital to become compliant with the new laws by January 1, 2014.  We will have a committe to tell patients that their life is no longer worth living and that we have made their e decision to stop all futile care because it is not cost effective.  If the patient is not able to understand, we will give the bad news to the family and their concerns will be of no consequence once we have made the decision.  My job as the representative of the surgery department will be to tell families that we will not perform an operation because it is not cost efffective.   I am not happy about this but the department felt that I would be the best one to handle the job after so many years as chairman.  This is happening all across the country as the ACOs are being established.  I understand how horrible this sounds.  It is horrible.  However, our hospital activities are now being monitored by the government through the EMR.  I spent two hours at a medical staff meeting yesterday being advised of all the penalties we will suffer if we do not comply with these laws.   I spent two hours with the rest of the surgeons being advised how we will be punished if we try to save a sick old person just because the family or the patient wants us to make that attempt or if we keep them in the hospital too long.  We will also be punished if we send the patient home and the patient returns to the hospital within one month for any reason.  Obviously, my reality and your reality are not the same.  All I want to do is take care of sick people and relieve suffering.  These new laws represent a serious obstacle in my reality.  Live long and prosper in your reality.
> 
> The EMR does help me take better care of my patients.  However, I remain very concerned about how the government is using all this information.



The problem with this post is that it will not be retracted when it is proven to be wrong on letting old sick people die and other inflammatory statements.   The law clearly does not permit what you think it does.   The fact that you or others you know think these things only proves that more than one person can be wrong at the same place and time.   And of course the AMA and all the medical professionals that helped write the law are conspiring with the government against old sick people.


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## pianodinosaur (Nov 8, 2012)

pgnewarkboy said:


> The problem with this post is that it will not be retracted when it is proven to be wrong on letting old sick people die and other inflammatory statements.   The law clearly does not permit what you think it does.   The fact that you or others you know think these things only proves that more than one person can be wrong at the same place and time.   And of course the AMA and all the medical professionals that helped write the law are conspiring with the government against old sick people.



About 88% of all physicians in Texas have resigned from the AMA over these laws.  I know all about it because I am a delegate to the Texas Medical Association.  The AMA now represents less than 18% of physicians nationwide due to the mass resignations that have taken place over the past two years.  The AMA does not make its money on the basis of membership dues.  The AMA now makes its money via ICDM coding and CPT coding.  These codes exist so that the government and insurance companies can track our activities and create individual physician profiles.  These codes determine reimbursement.  These codes are all about money.  These codes now go direct from the EMR to the government and the insurance companies.  My statements are not inflammatory.  They reflect my reality and the reality of most physicians who have resigned from the AMA.  (That happens to be most but not all physicians.)  You do not have to sit through the hospital meetings and be told how you will be punished for taking care of sick old people.  I do.  I also have a pretty good idea how most physicians will respond to the threat of punishment.  They will take measures to avoid the threat and to avoid the punishment.  I am upset because I went into Urology to take care of sick old people.  Obviously my reality is diffferent than your reality.  Your reality is similar to another member of this forum who has chosen to insult me.  I wish you both well in your reality.

Meanwhile, I used my EMR all day and it was helpful.  I was able to get into the hospital EMR and look at CT scans on patients who had been referred to me throught the Emergency Room.  I was able to use my snipping tool and import images from the hospital EMR into my office EMR.  I was able to email prescriptions so that the patients would have less waiting time at their pharmacy.  My patients were given a typed copy of a medical record that reflects not only their office visit, but all their current medications and past medical history.  I was also able to fax copies of their report to their referring providers.  I think this helps improve the quality of care that I can deliver to my patients.  I remain deeply concerned about how the government is going to use all this information.


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## pgnewarkboy (Nov 9, 2012)

pianodinosaur said:


> About 88% of all physicians in Texas have resigned from the AMA over these laws.  I know all about it because I am a delegate to the Texas Medical Association.  The AMA now represents less than 18% of physicians nationwide due to the mass resignations that have taken place over the past two years.  The AMA does not make its money on the basis of membership dues.  The AMA now makes its money via ICDM coding and CPT coding.  These codes exist so that the government and insurance companies can track our activities and create individual physician profiles.  These codes determine reimbursement.  These codes are all about money.  These codes now go direct from the EMR to the government and the insurance companies.  My statements are not inflammatory.  They reflect my reality and the reality of most physicians who have resigned from the AMA.  (That happens to be most but not all physicians.)  You do not have to sit through the hospital meetings and be told how you will be punished for taking care of sick old people.  I do.  I also have a pretty good idea how most physicians will respond to the threat of punishment.  They will take measures to avoid the threat and to avoid the punishment.  I am upset because I went into Urology to take care of sick old people.  Obviously my reality is diffferent than your reality.  Your reality is similar to another member of this forum who has chosen to insult me.  I wish you both well in your reality.
> 
> Meanwhile, I used my EMR all day and it was helpful.  I was able to get into the hospital EMR and look at CT scans on patients who had been referred to me throught the Emergency Room.  I was able to use my snipping tool and import images from the hospital EMR into my office EMR.  I was able to email prescriptions so that the patients would have less waiting time at their pharmacy.  My patients were given a typed copy of a medical record that reflects not only their office visit, but all their current medications and past medical history.  I was also able to fax copies of their report to their referring providers.  I think this helps improve the quality of care that I can deliver to my patients.  I remain deeply concerned about how the government is going to use all this information.



Whatever statistics you claim doesn't change the facts.. Facts are not determined by popular vote.   You and all the doctors in Texas can't change the fact that the law does not permit what you think it does.


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## bogey21 (Nov 9, 2012)

pgnewarkboy said:


> Whatever statistics you claim doesn't change the facts. Facts are not determined by popular vote.   You and all the doctors in Texas can't change the fact that* the law does not permit what you think it does*.



You may be right.  The problem will be in the Regulations implementing the law, many of which are not yet written.

George


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## pianodinosaur (Nov 9, 2012)

pgnewarkboy said:


> Whatever statistics you claim doesn't change the facts.. Facts are not determined by popular vote.   You and all the doctors in Texas can't change the fact that the law does not permit what you think it does.



I agree that facts are not determined by popular vote.  The people who write the laws are elected by popular vote.  It is not that the law does not permit what I think it does.  The law and its regulations mandate the changes that I am being forced to comply with against my will.  That is my reality and I think it is the reality of the 88% of all Texas physicians who resigned from the AMA.  The devil is in the details.  The road to hell is often paved with good intentions. 

Meanwhile, I had to spend an extra hour after an operation today because some clerk in the hospital entered information into the hospital EMR that was inaccurate.  Garbage In, Garbage Out.


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## pgnewarkboy (Nov 9, 2012)

bogey21 said:


> You may be right.  The problem will be in the Regulations implementing the law, many of which are not yet written.
> 
> George



All proposed regulations must be published in the Code of Federal Regulations before they become actual regulations.   Individuals and groups are entitled by law to object to any part or all of the regulations or suggest changes and sometimes file lawsuits.   The doctors from Texas, insurance companies, patient rights groups, conservative groups, progressive groups, hospitals,  and others will have the same rights to object.  Television stations and newspapers and blogs will all see the proposed regulations.   If old sick people have to die to save money we would have already or will hear the explosion of rage from all over the country.  The rage would focus on the exact language permitting such an atrocity.  It would be political and social and economic suicide for any politician, business, or group to support such a thing.


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## Fern Modena (Nov 9, 2012)

I wasn't aware that AMA developed or administers the ICDM/CPT coding.  I am not challenging you on this, because I don't know its origin.

I do know that it exists so that medical claims can be classified in an easy to use fashion in a digital world.  Of course, that means that if the wrong code is used, there may be no reimbursement (pay) or no preauthorization when needed.

As for your statement about the codes going directly from the EMR to the government and the insurance companies, I feel that your statement is inflammatory due to the fact that it is misleading.  Going to the government makes it sound like a scary, government overlord.  In fact, other than the fact that the codes are sent via the computer, nothing has changed. The "government" you are referring to here is Medicare and Medicaid, which have paid claims for a percentage of the population for years.

As for being punished for taking care of sick people, if you perform correctly, this should not happen.  What I read was that it is proposed tha hospitals will not get reimbursement for readmissions within a month for infections on previously hospitalized patients.  That makes sense to me.  When Jerry was in the hospital for weeks at a time, once a week a special nurse came to visit him and inspected every inch of his skin for infection, bedsores, etc. I'd never seen that before (this was almost three years ago), but it pleased us).

It seems to me that much of what you are posting are things you have heard, but are suppositions, rumors, guesses. etc.  We don't yet know how things will turn out.

I noticed you practice in Texas.  Texas is one of the states which is refusing to set up an Insurance Exchange for uninsured people under the ACA.  It will leave this to the Federal Government to do.  This suggests to me the sway of the information you are given.  

Fern



pianodinosaur said:


> The AMA now makes its money via ICDM coding and CPT coding.  These codes exist so that the government and insurance companies can track our activities and create individual physician profiles.  These codes determine reimbursement.  These codes are all about money.  These codes now go direct from the EMR to the government and the insurance companies.  My statements are not inflammatory.  They reflect my reality and the reality of most physicians who have resigned from the AMA.  (That happens to be most but not all physicians.)  You do not have to sit through the hospital meetings and be told how you will be punished for taking care of sick old people.


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## pianodinosaur (Nov 9, 2012)

pgnewarkboy said:


> All proposed regulations must be published in the Code of Federal Regulations before they become actual regulations.   Individuals and groups are entitled by law to object to any part or all of the regulations or suggest changes and sometimes file lawsuits.   The doctors from Texas, insurance companies, patient rights groups, conservative groups, progressive groups, hospitals,  and others will have the same rights to object.  Television stations and newspapers and blogs will all see the proposed regulations.   If old sick people have to die to save money we would have already or will hear the explosion of rage from all over the country.  The rage would focus on the exact language permitting such an atrocity.  It would be political and social and economic suicide for any politician, business, or group to support such a thing.



Indeed!!!   I am trying to compose a non political answer to a political statement.  Fox News, CNSNews, WorldNetDaily, The National Review, The Weekly Standard, Town Hall, FrontPageMag, The Heritage Foundaton, and of course, the EIB network have all been outraged by these rules and regulations.  The Texas Medical Association has been fighting this.  Lawsuits have been filed.  Certain hospitals and HMOs stand to make a fortune under the new law.  Hence, the big push to get everything switched over to an EMR so all the coding can be tracked more accurately.  I guess it all depends upon if you are a practicing physician who wants to take care of sick old people and participate in medical staff affairs and get your information from CMS or where you get your news. ( CMS runs Medicare for those of you who are not in the medical community. )


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## pianodinosaur (Nov 10, 2012)

Fern Modena said:


> I wasn't aware that AMA developed or administers the ICDM/CPT coding.  I am not challenging you on this, because I don't know its origin.
> 
> I do know that it exists so that medical claims can be classified in an easy to use fashion in a digital world.  Of course, that means that if the wrong code is used, there may be no reimbursement (pay) or no preauthorization when needed.
> 
> ...



You are quite correct that the use of coding is nothing new.  The problem is how it is being expanded and used.  My information comes from CMS which runs Medicare.  I am glad your husband received good medical care.  However, I don't think that limited experience is very much education in the problems we physicians face on a daily basis.  Elderly, chronically ill patients are are in the process of dying.  There is nothing we can do to prevent that.  We in the medical community have been so successful in treating disease, relieving human suffering, and prolonging life that few people outside the medical profession have any real familiarity with the process of death and dying outside the limited realm of their own personal families.  If an 82 year old man has a heart attack and survives, he will ultimately be discharged from the hospital.  If he has another heart attack or a stroke with 30 days of discharge, that does not mean he received bad medical care IMHO. However, under the new rules that would be defined as bad medical care.  The doctors and hospitals would be punished.  This radically changes the doctor-patient relationship in ways that I am afraid you do not yet understand.


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## bogey21 (Nov 10, 2012)

pianodinosaur said:


> If an 82 year old man has a heart attack and survives, he will ultimately be discharged from the hospital.  If he has another heart attack or a stroke with 30 days of discharge, that does not mean he received bad medical care IMHO. However, under the new rules that would be defined as bad medical care.  The doctors and hospitals would be punished.



I assume that the "punishment" would be financial.  If it gets bad enough, it is logical that  some doctors and hospitals will go out of business leaving fewer to treat the additional patients created by the new law.  

George


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## Tia (Nov 10, 2012)

pianodinosaur said:


> We do this already.  The death panels are to withold care from patients eventhough the patient and/or the patient's family want care continued.  This is so that the patient will die more quickly and save the government money.



Yes insurance companies already do this as said by wilma. I have also seen incompetent patients put through medical procedures that were senseless. Some families want life at any cost, they are not paying for it,  even if it's very low quality life.  Just my opinion.


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## SDKath (Nov 10, 2012)

pianodinosaur said:


> About 88% of all physicians in Texas have resigned from the AMA over these laws.  I know all about it because I am a delegate to the Texas Medical Association.  The AMA now represents less than 18% of physicians nationwide due to the mass resignations that have taken place over the past two years.  The AMA does not make its money on the basis of membership dues.  The AMA now makes its money via ICDM coding and CPT coding.  These codes exist so that the government and insurance companies can track our activities and create individual physician profiles.  These codes determine reimbursement.  These codes are all about money.  These codes now go direct from the EMR to the government and the insurance companies.  My statements are not inflammatory.  They reflect my reality and the reality of most physicians who have resigned from the AMA.  (That happens to be most but not all physicians.)  You do not have to sit through the hospital meetings and be told how you will be punished for taking care of sick old people.  I do.  I also have a pretty good idea how most physicians will respond to the threat of punishment.  They will take measures to avoid the threat and to avoid the punishment.  I am upset because I went into Urology to take care of sick old people.  Obviously my reality is diffferent than your reality.  Your reality is similar to another member of this forum who has chosen to insult me.  I wish you both well in your reality.
> 
> Meanwhile, I used my EMR all day and it was helpful.  I was able to get into the hospital EMR and look at CT scans on patients who had been referred to me throught the Emergency Room.  I was able to use my snipping tool and import images from the hospital EMR into my office EMR.  I was able to email prescriptions so that the patients would have less waiting time at their pharmacy.  My patients were given a typed copy of a medical record that reflects not only their office visit, but all their current medications and past medical history.  I was also able to fax copies of their report to their referring providers.  I think this helps improve the quality of care that I can deliver to my patients.  I remain deeply concerned about how the government is going to use all this information.



I could have written this post word for word.  The good, the bad and the ugly.  I have to enter into my EMR every Medicare patient's LDL cholesterol so that the govt now knows exactly what your level is.  They will judge us on how low or high your levels are (never mind that you think meds are not necessary for your 190 LDL) and our reimbursement will depend on this info being sent to Medicare and the govt.  They will have nice, complete databases of your health care, your blood tests, your last pap smear, etc.  OH, and they have of course all of your direct deposit and bank info too since Medicare is asking patients to pay their MCare bill electronically with autopay methods.  And if they don't like something, they will blame the doctors and cut our pay even more.  It's a great system for everyone.  NOT!


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