Protecting Identity in the New Digital Age

Now that HITECH has been able to increase the adoption of electronic medical records (EMRs), the focus is on interoperability. The market has been flooded with various EMR and PM (practice management) systems but how do they communicate? The challenge of interoperability is being addressed aggressively as we go into Meaningful Use Stage 2 and Health Information Exchanges. However, according Jitesh Chawla, MD the piece that might be forgotten is maintaining patient privacy in this new digital age.

As the nation progressively implements electronic healthcare records, stakeholders have uncovered an elephant in the room – how to implement patient identity and integrity solutions. Linking an individual’s electronic health records across disparate systems, many suggest, will more likely than not require a unique patient identifier. Yet from a policy perspective, implementing this identifier has been extremely difficult. Medical banking, or the convergence of banking and heath IT systems, is spawning new ideas that could impact this difficult area. New forms of efficiency in payment processing may yield a technology platform for managing digital identity by banks that could also be used for healthcare.

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Dr. Jitesh Chawla reviews smoking cessation trials

Dr. Jitesh Chawla's clinical trial research shows that the first anti-nicotine vaccine to enter Phase 3 clinical trial, NicVax, was in it’s the last stage of testing before hitting the market. The product works by inciting the immune system to produce antibodies that bind to nicotine in the bloodstream, much as antibodies would attack an invading microorganism. Once bound, the nicotine cannot cross the blood-brain barrier to enter the brain. It is the neurotransmitters in the brain that cause chemical reactions leading to addictive behavior. The vaccine was therefore expected to diminish the pleasure of smoking and make it easier to quit. Unfortunately, the failure of the vaccine serves as major set-back to harness the immune system’s power to fight additions such as tobacco abuse.

Figure 1.
Trial paper posting by Dr. Chawla

Nevertheless, Micro-electric  current therapy shows a lot of promise. In one trial studied by Dr. Jitesh Chawla, 1,000 cigarette smokers treated between July 2006 and January 2008, 972 (97.2%) lost their craving for cigarettes within 1 to 5 minutes into a 20 minute session of CES. In those who were in the process of quitting and often at the height of their withdrawal symptoms, cravings started to diminish within 2 minutes of initiating CES and usually disappeared within 10 minutes. Several were 2 or 3 weeks into quitting and still experienced craving.

There may be many reasons for the difference between success and failure including the solidity of the product, trial design, lack of capital, tough FDA reviewers but clinical trials. Even after successful trials and FDA approval some smoking cessation products, like the Nicotrol Inhaler, are not adopted well, as the side-effects and limited efficacy with mediocre outcomes serves as a stumbling block. It is time to try something new. Micro-electrical current therapy has a different mechanism of action than any other therapeutic agent for smoking cessation, currently in the market, and is worth a shot. Next time you are searching for a new doctor make sure he or she keeps up with latest research regarding medical treatments for important common problems such as nicotine addition.

Also, keep following this blog for more exciting clinical trial news from Dr. Jitesh Chawla.

Emergency Care under Obamacare

Dr. Jitesh Chawla speaks from personal experience as a physician who as frequently worked in emergency rooms/  

   "Packed waiting rooms and we will have to see 50 patients or more in a shift," answered one emergency room physician.  This was in response to my question of how the Affordable Care Act will affect the volume of patients that a provider in the ER will see.  Many experts speculate that the expansion of Medicare under “Obamacare” will allow more people in the country to access the healthcare system.  These same experts believe that the people who receive this access will flood emergency departments around the nation in record numbers for conditions that are not emergent, causing physicians to be overworked.  In this article we will examine claims from the experts and also specific examples in the bill that pertain to our subject matter.  Hopefully we will shed some light on the subject as we move forward.

     So why the panic over the expansion of Medicaid? Many commentators cite numbers in a recent CDC report ¹ that show that recipients of Medicaid visit emergency rooms twice as much as the uninsured.  The program is being expanded for people between 19 and 65 years of age that meet the required criteria and this will allow millions of new people the opportunity be covered.  With this, many believe that these new recipients will run to the ER anytime there is a problem that could be treated by a primary care physician. The question comes down to human nature and people can speculate but no one can accurately predict the future.

      What are the commentators saying? Well there seems to be many differing opinions, most based on political leanings.  The fact remains that the Affordable Care Act has been upheld and it is a reality.  Whether you agree with the bill or not, it will affect you and your practice.  According to a paper done in 2010 by John Goodman, CEO of the National Center for Policy Analysis, the rise in emergency room volume is inevitable.  Goodman concludes that the expansion of Medicaid under “Obamacare” will insure an additional 32-34 million people. Using past projections of emergency room visits, Goodman calculates the increase of patients. "Consequently, we project that insuring between 32 million and 34 million additional people will generate between 848,000 and 901,000 additional emergency room visits every year," Goodman stated in his article.

     What does this mean for emergency room physicians? It means that in an average 12 hour shift, physicians may see 30-35 patients at a busy hospital and many consider this a busy night.  Some fear that with the projected rising number of patients, doctors will be spread too thin and the quality of care will decrease as physician fatigue increases.  As it is with many issues in the United States, a problem presents itself and businesses and society responds.  Many states have opened Osteopathic medical schools, with a desire to train new physicians to practice in rural or underserved areas.  The thought process is that if more physicians are trained with an emphasis on these areas, they will meet the demand that the increased numbers cause.  Many allopathic medical schools are now offering rural health programs.  The University of Alabama offers a rural physicians program in which a qualified student can train to practice in an area where healthcare is not usually abundant.  This can be in rural farming communities or lower income neighborhoods.  The hope is that by training the physicians to serve in these areas, more patients will seek help at these clinics than flock to the emergency room.

    It may be inevitable that emergency rooms will have an increased number of patients under the expansion of Medicaid.  All signs seem to be pointing in this direction.  However, maybe the attempts at filling the physician shortage in certain areas will funnel the patient load away from ER's around the country.  We will continue to examine how the Affordable Care Act will affect certain aspects of our healthcare system.

 Stay tuned from more health information from Jitesh Chawla, MD.
Reference:

1. http://www.cdc.gov/nchs/data/hus/hus10.pdf

Medicaid Expansion Debate

Dr. Jitesh Chawla felt from the outset that the Medicaid Expansion effort part of the Affordable Care Act was going to be an uphill battle.

The 26 states have refused the are home to about half of the country’s population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country’s uninsured working poor are in those states.

Every state in the Deep South, with the exception of Arkansas, has rejected the expansion.Opponents of the expansion say they are against it on exclusively economic grounds, and that the demographics of the South — with its large share of poor blacks — make it easy to say race is an issue when it is not.

Dr. Chawla found out the North Carolina practices who take Medicaid didn’t really even much of an opinion of the expansion in the first place. In Mississippi, Republican leaders note that a large share of people in the state are on Medicaid already, and that, with an expansion, about a third of the state would have been insured through the program. Even supporters of the health law say that eventually covering 10 percent of that cost would have been onerous for a predominantly rural state with a modest tax base.
“Any additional cost in Medicaid is going to be too much,” said State Senator Chris McDaniel, a Republican, who opposes expansion.
The law was written to require all Americans to have health coverage. For lower and middle-income earners, there are subsidies on the new health exchanges to help them afford insurance. An expanded Medicaid program was intended to cover the poorest. In all, about 30 million uninsured Americans were to have become eligible for financial help.
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Health Insurance Exchanges - Working Through the Kinks

Dr. Jitesh Chawla feels that health insurance exchanges are a honest attempt to fix all the on-going problems with trying to provide the proper access and coverage to Americans that were created by insurance companies. But, like any new initiative, there are kinks that need to be worked out as this article explains.

The Health Insurance Exchanges, central pieces of the Patient Protection and Affordable Care Act (PPACA), opened as scheduled on October 1 amid debate in Congress and a government shutdown over the future of the law. The launch of the Exchanges along with open enrollment for Americans came just after the government released premium rates for 33 federal Exchanges.

Technical Problems in Accessing Exchanges

Consumers seeking online access to federally-facilitated Exchanges (FFE) faced intermittent outages and error messages throughout the first day of enrollment. Some state-based Exchanges, including those in California, New York, Maryland and Colorado had similar issues with their websites. Traffic to these sites was very high, leading many of the sites to slow down considerably. Similarly, those seeking assistance by phone also encountered long wait times.

Many proponents of the law, including those who are helping to develop the Exchange systems, have warned of glitches as the Exchanges roll out over the next several months. Many of these predictions proved accurate as large numbers of Americans logged on to the Exchange websites to browse coverage options. As initial curiosity over the Exchanges subsides in the coming weeks, it will be easier to more accurately assess the functionality of the websites.

Rates Announced

On September 24, the U.S. Department of Health and Human Services (HHS) released an issue brief outlining the premium rates in the 36 states with either an FFE or a partnership Exchange. Since data concerning premium rates is complex and ambiguous, supporters of PPACA hail the rates as a success for the health reform law, while opponents view them as a major failure.

The issue brief outlines the number of Qualified Health Plans (QHPs) offered in each state and the average premium rates that enrollees would pay for different plan tiers. Average premium rates are detailed for a 27-year-old (before and after tax credits are assessed), and a family of four with a specified income of $50,000 per year. Rates for the lowest bronze, silver, gold and catastrophic plans as well as the second lowest silver plans are described. The average number of QHPs offered in the 36 states is 53 with as many as 106 plans offered in Arizona and as few as seven in Alabama.

Update: On October 1, the U.S. Department of Health and Human Services posted premiums for over 17,000 plans being offered in the 36 states where the federal government is operating an Exchange. The premiums are listed for different geographic regions, age groups and different family sizes. Metal levels and plan type information is also provided.  This list provides people the ability to compare plans within and between states. Click here to access this resource.

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Purchasing an EMR

     So you have decided that it is time to purchase an EMR for your practice.  You are tired of the paper charting process and are ready to step into the 21st century, but what EMR do you buy?  So many practices are hurt financially and become frustrated from buying into the wrong type of equipment.  It is imperative that you take several factors into consideration before buying this costly piece of equipment, and find the system that is best for you.

     The first option you have is to hire a consulting firm to help you pick and set up the EMR. Consultants are well versed on all kinds of EMR equipment and can help you decide what type will help your practice the most.  More importantly than the guidance through the purchasing process, is the fact that many firms will help you set up the system and set it up correctly the first time.  With any technology, there will be bugs that need to be fixed and many consulting firms provide around the clock diagnostic service to help fix any problems that may arise with the software. The most important advantage of hiring a consulting firm to set up your EMR is the fact that they will teach you how to use the technology and get the largest benefit for your practice.

    Maybe you've decided that hiring a firm is ludicrous and you want to take on the task yourself.  If you decide to go this route, you have to first analyze what problems you want EMR to solve for you.  Do you want to cut down on the number of employees? Do you want to increase the productivity in your practice and eliminate the large volume of paperwork that you use? EMR can solve these problems but you must read unbiased reviews and do the research on each product to find the smartest option for the practice.

     You have to realize that buying an EMR is all about increasing your productivity which leads to increased profits for your practice.  Take this into account before purchasing your equipment because that swanky technology that one EMR might have may not help you accomplish your goals as well as a more basic and no-frills system will. The main idea in the article is "DO YOUR HOMEWORK", the same idea that carried you through medical school and got you to the position that you are in today.

 

Viewpoints about Doctors' Salaries

Really, how many porsches do you need?" has been a popular motto among proponents of Obamacare in response to objections by physicians at the possible pay cut brought on by the bill. This is a fair statement as most anyone would agree that if you are wanting to become rich, a medical profession is not the best option. However, physicians do have a reason to gripe in this case. After 4 years of med school and the loans that one can accrue over this period and the gigantic liability that a practicing physician faces, one would expect to be compensated at least enough to be able to pay off these fees once their residency is completed.

There have been many politically slanted opinions about the effect that Obamacare will have on doctors' salaries. Many in the medical profession are left wondering, "Will I be able to pay off my student loans?...Will I be seeing twice as many patients for half the amount of money and provide a lesser quality of care?" No one an really say for certain what will happen until the bill is fully implemented.

Many people fear that pay cuts will dissuade potential physicians from attending medical school and cause a great shortage of doctors in our nation. I think the best way for us to navigate this topic is to look at what the bill will do in theory to your salaries, without a political slant. First of all, it is important to understand what the goal of Obamacare is. It's goal is to lower costs of the American Healthcare system without lowering the quality of care. It resembles a European style of healthcare, and in this type of system, physicians make less money on average. In an issue of the journal, Health Affairs, the amount that French primary care physician makes was compared to what an American one makes.

PCP's in the United States on average netted around $186,000 while a comparable French doctor made $95,000. How will Obamacare affect the American pay? Well it is widely stated that the bill will cause physicians to be reimbursed at a lower than market rate for Medicaid. In other words, lower than what they are being paid now. This could spell doom for specialists such as general surgeons, who see many Medicaid patients for surgery.

With the lower pay an inevitability many believe that physicians will have to see a larger volume of patients to make the same amount of money that they do now. Many comment that this will cause a large decrease in care as doctors will rush to see as many patients as they can in a shift. We will continue to look at this issue in the coming weeks with more specific examples of how the ACA will affect you.

Health Insurance Exchanges

The Affordable Healthcare Act may have not only changed the United State's  healthcare system forever, it also may have changed the insurance industry  forever.  The implementation of so called health insurance exchanges, or HIX for short, have helped change the industry forever.  The model is a consumer based  approach, where customers will be able to shop for the best insurance plan for  them.  President Obama focused on allowing states to set up the exchanges  instead of a blanket approach that would make one exchange for the whole  country.

Ideally, the concept will allow people with preexisting conditions to be denied  insurance.  Customers will have to satisfy a smaller amount of conditions in order  to receive insurance.  Lawmakers envisioned this change as a system in which citizens will be allowed to have the same type of variety that members of  Congress have in shopping for their health insurance.  At this point you may be saying, "Great, now how in the world will they  implement this and what does this mean for me?" Let's try to answer this  question! The exchanges can cover a whole state or be broken up in to smaller exchanges in one state.  For instance a state like California may have a Southern  California exchange and Northern California exchange.  As long as the exchange covers a certain geographic area they will be allowed to operate.

States can also partner with other bordering states to create an exchange. As for how the exchanges will be run and affect you, the consumer, lets look at the car insurance model. President Obama has repeatedly compared these  exchanges to car insurance purchasing.  People living in an area that has a HIX  will be able to compare plans online and buy which ever one fits them the best.

There will different levels of coverage, given a gold, silver, or bronze designation. Only companies meeting the standards set forth by ACA regulations will be able  to sell their insurance plans.  According to www.obamacarefacts.com, this alone  will lower insurance premiums 7-10 percent. 

Listed below are the criteria to be  an ACA-approved insurance plan.

All plans must include:

1. Ambulatory patient services

2. Emergency services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance use disorder services, including behavioral health treatment

6. Prescription drugs

7. Rehabilitative and rehabilitative services and devices

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10. Pediatric services, including oral and vision care

We have yet to see if these will in fact work in the United States.  In theory,  they sound like a great idea and that they will allow for variety in insurance  shopping.  The hope is that more people will be able to become insured in the  long run.

Mobile healthcare

 

            If you have been in a doctor’s office lately you may have noticed your physician grasping an iPad or some other tablet.  What you have seen is a new trend in the medical field in which health care providers are incorporating technology into their practices. Along with electronic medical records, the practice of medicine, much like most things in our world, is going digital.

            The hope associated with this trend is the fact that medical practices can become more efficient and cost effective in the long run.  The days of paper charting may be a distant memory in the upcoming years.  According to a survey done by Manhattan Research in 2010, 72% of physicians responded saying that they use mobile devices in their practice.  The report also went on to say that the number will only rise in the future. 

In what capacity these physicians are using the devices in their practice is undetermined, but it is safe to say that technology companies have taken note of the possible new market that they can tap.  Companies such as Apple and Dell are currently in the process of developing mobile devices that are equipped with specialized EMR apps.  Many hospitals have already ordered these devices and are hoping that they will someday replace the infamously bulky and awkward computers on wheels. One hospital that has bought in to the technology is The Ottawa Hospital, which services over 1.5 million people in eastern Canada.  The hospital ordered 500 iPads specially tailored for EMR to a portion of its over 1,000 physicians recently.

            EMR is a new trend that has caught in many parts of the country.  Physicians can now chart physical exams and check patient histories and labs virtually instead of logging through stacks of paper. Though paper charting will probably never be extinct, the advantages of getting real time lab results and radiology right at a physician’s fingertips are astounding.

So how exactly will EMR and mobile devices change healthcare? The question is very broad and has many answers.  One answer is that of accessibility. On one iPad a physician can pull up a patient’s labs, radiology, and medical history without leaving the bedside.  This allows for a large cut down on the time it takes for a physician to give a diagnosis on a patient and places the patient’s information in one place.                        

                                              Photo Courtesy of www.macris .com

            From the information we can gather so far, it is safe to say that a majority of clinicians support using some sort of mobile device and EMR in their practice.  However, there are some limitations to relying totally on this technology in a practice.  Tablets are not the best tool for writing long summaries. In terms of sitting down and writing a long history on a patient or physician’s note, the classic PC is hard to beat.  Though there are some limitations to what tablets can help health care providers accomplish in a clinical settings, the pros definitely outweigh the cons.

            With the dawn of these types of technologies, the days when physicians view x-rays on through standard fluorescent light in a darkened dictation room may be few and far between. The prospects on the amount of time that can be saved from using mobile devices and EMR are very large.  As is the trend in the practice of medicine, the science is always evolving to fit the needs of the patients more efficiently and cost effectively.