Let’s focus more on caring, rather than coding [PODCAST]

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“With the shift to value-based care models, it will be more important than ever to give clinicians a diagnostically focused view for each patient and each of their medical problems. Clinicians need these details instantly, without having to randomly search through unrelated sections of the clinically inert EHR.

By empowering clinicians in this way, the EHR can become more than a static repository for an ever-increasing collection of codes. It will evolve into a true diagnostically interactive tool for care.”

Jay Anders is a physician executive.

He shares his story and discusses his KevinMD article, “Let’s focus more on caring, rather than coding.”

The Podcast by KevinMD is brought to you by the Nuance Dragon Ambient eXperience.

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Jay Anders. He’s a physician executive. His KevinMD article is titled “Let’s focus more on caring, rather than coding.” Jay, welcome to the show.

Jay Anders: Thanks for having me.

Kevin Pho: We’ll get into the article in a little bit, but first off, briefly share your story and journey to where you are today.

Jay Anders: OK. Well, I’m a general internist by training. I practiced for 16 years in a large multi-specialty group practice and was president of that group for a while. I’ve also been a medical director of a managed care organization, as well as chief medical officer for five different EMR companies, all being acquired one after the other, like this business does all the time. So I started out in a small company called Integrate, went to a company called MED3000, went to a company called McKesson, which subsequently went kind of belly up in the health IT business, and wound up at Medicomp. And I really tell everyone I talk to, I think Medicomp is my dream job, short of practicing medicine. I do miss my patients. I don’t do that much anymore, but I do miss my patients. But this is a great job that I have with Medicomp, and with what we’re trying to accomplish.

Kevin Pho: So tell me, why is that your dream job?

Jay Anders: Well, it’s interesting. I got asked a question probably early on when I made the switch to health care IT. They said, “Well, why are you doing that?” And I said, “Well, think about it in a different way. As a primary care internist, I would touch 5,000 to 6,000 patient visits a year, and I did hospital and everything, so, you know, about 2,500 to 3,000 patients. In this job, I can touch the lives and help physicians in hundreds of thousands of patients.” So I saw the need to get it right. A lot of that’s been kind of lost, but that’s kind of what drives me. Physicians have, in my opinion, kind of been left behind in their ideas, in their needs, and in their desires of what they do and how they do it, and that’s been my goal since I got into the IT business, and especially at Medicomp.

Kevin Pho: When you say that you could touch the lives of hundreds of thousands of patients, give us an example of how you’ve moved the needle.

Jay Anders: Well, when I say that: When you create an electronic health record that is well designed and well integrated, and it has physician input into how they do it, all of a sudden that gets replicated throughout all of their practices, and that eventually starts to touch patients. And really, the thing about electronic health care, and health care in general, is it’s about patient care. It’s not about all the ancillary things we do, that we have to do; it’s about patient care. So enhancing that patient care has been my primary focus, and with our products, and others getting into this wide, broad range of other EMR products, we can start to do that.

Kevin Pho: Now, I happen to believe more and more physicians need to be involved in the health IT space, for the reasons that you just described. Now, how difficult is it for a practicing internist, for instance, how difficult is it for them to break into that space?

Jay Anders: It can be difficult. Mine wasn’t; it just kind of naturally flowed. I do have a computer science background from before I got into medical school and all that, so it kind of helped to make the switch. But you really have to have a focus and a desire that you’re actually going to accomplish something to make that change work, and if you have that, the transition’s not that hard. If you’re getting into it just to get out of medicine, the practice of medicine, I highly recommend that anybody who’s thinking that way not make the change, because you’re running away from something, not running to something.

Kevin Pho: All right, let’s talk about your KevinMD article. It’s something I deal with every day. It’s titled “Let’s focus more on caring, rather than coding.” Now, how did this article come together?

Jay Anders: Well, the article came together because of a lot of pressures that I get from practicing colleagues around the country, and from talking to my own colleagues back in Champaign, Illinois, where I practiced. Everybody today seems to be focused on getting the right code. And what I mean by that is, especially in Medicare Advantage, you have to have your visits coded very accurately so that scores can be calculated and that payment can come through the Medicare Advantage company and the insurance company and all those things. However, no one really focuses on the care of the patient, meaning that, with all of the coding aspects of what an EMR does today, and that’s fee-for-service, Medicare Advantage, other insurance vehicles, and payment schemes, the EMR needs to do something else. It needs to help the physician focus on the patient care and assist them in doing that, as opposed to, “Oh boy, I’ve got to get the right code. I’ve got to pick this code over here and that code, and oh, I’ve got to manage codes and the code updates for next year.” All of that, I call it clinical noise and nonsense, because it really doesn’t enhance the practice of medicine. All it does is track payment.

So my goal in the caring versus coding article is to start to bring that to the attention of the folks who can change it, and that’s EMR companies, that’s federal agencies, and the government. You know, think about what you’re asking us to do. They spent billions of dollars installing electronic health care across the country. Now 95-plus percent of practices have one, but it’s not focused in the right direction. Now it’s just another task; it’s not a tool. So that was my thought when I started to think about how to write about that.

So to me, when I practiced medicine, back before electronic health care, of course, everything was dictated. So you just sat down, you did your work, you dictated a note, you filled out a little piece of paper that had what you did as far as the level of coding, and off it went to the coders, and off it went to other people for billing and all that. Now all of that is pressed right up against the visit itself. So not only do you have to do all that, you have to do it all and search for things that you didn’t have to search for before. So interestingly, one of the major difficulties is not just the coding part of this but the way electronic health care is designed today. There is not a lot of assistance in finding things in electronic health records. They’re all siloed; they’re scattered all over the place. So if I want to see a patient with diabetes, and I want to know everything in that medical record about that diabetes, I’ve got to search all over to get that. That has nothing to do with the code; it has everything to do with the care.

The other thing we’re seeing in the industry right now: There’s been a big insurance company come up and have a little problem with enhancing their coding without enhancing their care. If people want to contact me, I’ll gladly talk about them, but I’m not going to name them out loud. But anyway, it was a multimillion-dollar fine for what they did, and it was basically fraud. It was fraud on the provider side, and it was fraud on the insurance side. So that’s an example, I believe, of how they put the codes ahead of the care. So that’s the thing. When I read about it and when I see it, it really gets my attention, and that’s when I start to get really focused on telling folks there’s another way. We can do it better than this. And how do we actually do that and get out of this rut we’re in now?

Kevin Pho: Before talking about the way that could be done better, take us into the exam room. Tell us what some of your physician colleagues are saying in terms of that burden of coding after they see a patient. You mentioned they have to search through lists and lists to find the right code, to make sure it’s the right complexity. Just paint us a picture, for those who aren’t familiar with what we do in the exam room. How burdensome is that?

Jay Anders: You know, it’s interesting. When I first got into practice, I had no clue whatsoever how to do that kind of stuff, so you kind of learned it on the fly. But in an exam room, not only do you have to treat the patient correctly and do what you have to do with them, but you also have to figure out the level of service, and that depends on the insurance company and the type of insurance. You have to figure out the diagnosis code. You probably will write a prescription that will have multiple codes associated with it. For instance, there are 60 different kinds of amoxicillin in the world, all with a different NDC number. So if I write amoxicillin, OK, let’s search down that list, let’s find the right one I want, and put that in. So it’s that extra layer of stuff that physicians have to do in addition to just documenting the care. Once you’ve done that, you’re about, I would say, a third of the way over. The rest of it is: Did I code everything right, the right level of care, the right insurance company? Did I send this lab test with the right code to the right place? Those kinds of things. And that’s where EMRs, if they’re well designed, can actually help. Right now, they really don’t do it very well. So that’s what I mean about all the codes.

And if you get it wrong, most generally, in most larger practices, there’s someone checking on you, and you’re going to get a phone call. They’re going to say, “You saw Mrs. Smith. We’re looking at your records, and we think this level of service is a 99213, and you put a 99214. Did you miss anything? Do you want to go back and read it again?” So it’s that rework that’s code-focused. So there’s that aspect as well.

Kevin Pho: And in general, how much training do physicians get when it comes to coding?

Jay Anders: Zero. Very close to zero. I have a nephew who’s in his second year of medical school at a very prestigious medical school, and I asked him about that. I said, “Are they starting to talk about, you know, when you’re doing your work, are they talking about any of the business aspect of a practice? Because someday you’re going to have to do this.” And he said with a straight face, “No, we haven’t talked about that at all. This is the second year of medical school; we still haven’t had it.” He’s only got three and a half years; he’s in a medical school that has that advanced program. So will he get it at the end? I don’t believe so, because I’ve talked to the graduates of that medical school, and they don’t get it either. I graduated from the University of Illinois, a great land-grant university, and its medical school in Chicago had zero training, zero, in the business of medicine. I learned it by example, talking to others who have done it for a while. So they just don’t get training to do this kind of work, and it’s overwhelming when you start practice.

Kevin Pho: So what kind of answers do we have? Because I think what you described is something that I face every day: those lists and lists of codes that we have to pick. And there’s a lot of pressure on the physicians to pick the right one, or else you do get that phone call or message saying, “Hey, are you sure about this code?” What ideas do you have to make this process better?

Jay Anders: Well, there are technologies available now. My particular company has one. There probably aren’t any close to what we do, but there are people trying to do this. If you focus on doing all of that automatically by the computer, you know, people talk about AI and machine learning and things like that. OK, maybe; we’ve been talking about it for 15 years, and it hasn’t happened yet. But if I can just focus on the care of the patient, and have the computer strip out all of that information that it needs to supply all of those codes, either by learning, or by programming, or by me teaching it with favorites, things like that, there’s an answer to that.

When it comes to finding medical information, there are computer programs out there that allow you to do that. So I can take a medical record, using one of the products that we create, and I can go into a medical record and give you everything there is to know about a particular disease, and strip all the rest of it out and present you with just that. So if you look at one of my typical patients, who has probably got three or four different diseases, it allows you to focus, and it allows you to practice better medicine because you are focused, as opposed to it being scattered everywhere. So there is technology available. I see more EMR installations adding things on top of existing systems to make those things work, when the existing system doesn’t have it or fails to try to develop it.

Kevin Pho: So take us into the exam room. If a clinician was using one of your products, how exactly would your system strip out the essential data and help us with the coding?

Jay Anders: Well, because of the way it’s constructed, we can take an entire medical record. I’ll give you a couple of examples. We can take an entire medical record and, like I said, strip it and match the information inside that medical record to a particular disease. And if you’re looking at problem-oriented medical records, it’s perfect for that. So you’ve got diabetes: Here’s what I’m doing for that. Hypertension: Here’s what I’m doing for that. They’ve got osteoarthritis: Here’s what I’m doing for that. So the aspect of actually documenting, focused documentation on particular diseases, is enhanced.

Let’s flip it over to the actual business aspect, for the Medicare Advantage patient or somebody like that, if you have the reminder at the point of care, in the room with the patient. So you’ve got somebody that’s coming in, like I said, with three or four diagnoses, all of which have to be addressed in that world, in the managed care Medicare Advantage world. But if you’re not reminded that they have these things, you’re going to sometimes get lost, sometimes just forget, sometimes get rushed for time, whatever. Put that information right there in front of the clinician while they’re in front of the patient. So if you’re missing your mammography for that year, give me a reminder, and I’ll order it, because I don’t know what’s buried in all of that other stuff in that medical record. So if we put that type of very focused, very succinct clinical information in front of the provider, in front of the patient, I believe care will be enhanced, and there’ll be less pushback from all those messages, phone calls, “you didn’t get it right,” all of that, because you will get it right the first time. It’ll help you do that, and that’s focused on the caring, not the coding.

Kevin Pho: Now, I’m sure you’re aware that a lot of physicians, we’ve been complaining about electronic medical records for decades now, for as long as I can remember. Now, you’ve worked in multiple iterations of EHR companies. How important is it for these EHR companies to make life easier for the clinicians?

Jay Anders: Well, I think personally it’s very important. The problem has been that physicians, for whatever reason, we haven’t had a strong enough voice into these systems. And to be honest, one of the largest systems in the world told me, “We don’t really care about physician input. We’ll do what we’re going to do, and they’re going to accept it.” As long as we as clinicians are willing to accept that kind of stuff, then we’re going to get what we get. It’s going to be up to our organizations to actually enhance that with other products if that EMR company is not going to listen.

Kevin Pho: So what are some ways that we could push back? Because let’s say you have that largest EHR company in the world saying they literally do not care about physician input. What scenarios do we have? How can we get these organizations to push back if these EHR companies already have such a big market share?

Jay Anders: Well, two things, I believe. If you are loud enough and consistent enough in your feedback, sooner or later someone’s going to listen to you. The other thing is, when these systems start to get a little bit out of date, or they’re not designed well, and people start to look for other systems to replace them, then you’ve got leverage. We’re paying millions and millions of dollars to these companies to do this. The other thing is to look for what I call add-ons, or some other way of getting the things done that you need. So physicians can go out there in their organizations and say, “OK, it doesn’t do this, it doesn’t do that. Is there anything out there that I can add on to this to make that happen?” It’s the involvement, and it’s consistent involvement. And even if they don’t want to listen, money talks, and when you start to move away from that particular conversation with some of these companies, it’s, “OK, well, you know, maybe we ought to do something about that.” So I think that’s a couple of ways to do that. But if you’ve got somebody that flat won’t listen, it’s harder. It just flat is harder.

But we’ve accepted what I would say are substandard things for so long now that it’s just like, “OK, that’s routine.” We’re just going to throw another version of the same thing. And we just saw Oracle and Cerner come together, and we’ve got another whole, “We’re going to fix health care.” OK, to do that, get the physicians that are using Cerner in there and have them tell you how to do it, not the persons that have been sitting in a programming center for a while, building.

Kevin Pho: We’re talking to Jay Anders. He’s a physician executive and an internal medicine physician. His KevinMD article is titled “Let’s focus more on caring, rather than coding.” Jay, what are some of your take-home messages that you want to leave with the KevinMD audience?

Jay Anders: I would say a couple of things. Don’t be discouraged about technology. It has improved in my lifetime, so it will get better. And be loud, be vocal, be consistent. Don’t accept substandard things shoved at you that you have to deal with. There are solutions, and if you push forward or move along getting to those solutions, your life’s going to be better. So be loud, be consistent.

Kevin Pho: Jay, thank you so much for sharing your time and insight, and thanks again for being on the show.

Jay Anders: Thanks for having me.

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