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Commonly used interchangeably, “electronic medical records” and “electronic health records” have several critical differences. While technically only separated by a single word, that one word holds major implications for clinicians and patients. To better recognize these implications, it helps to understand the difference between an EMR and an EHR system.

What Is EMR

In essence, EMRs are digital representations of the paper charts in a practitioner’s office. The typical EMR will include the treatment and overall medical history of a particular patient. While basically just a digital version of a medical chart, a digital EMR does offer advantages over a traditional paper record, including:

• EMR allows clinicians to track data over time.
• A clinician can efficiently identify which patients are due for checkups or preventive screenings.
• EMR provides clear insight into vaccinations, blood pressure readings and other key health parameters.
• Clinicians can leverage EMRs to improve and monitor patient care.

Despite all of these benefits, however, EMRs do not travel well outside of a particular practice. In many cases, patient records may need to be printed and delivered to specialists or other providers by mail. In this regard, EMR has a big limitation that keeps it from being much better than a traditional paper record.

What is EHR?

To put things simply, EHRs can do everything EMRs can do and a whole lot more. Focusing on the total health of the patient, EHR systems go well beyond simple data collection and compilation. Because EHRs are designed to share information with specialists, laboratories and other health care providers, they help to create a broader view on a patient’s care. As information moves with a patient to a specialist, nursing home or hospital, the quality of care is improved, regardless of geographic borders.

EMR vs EHR

While EMR provides a basic structure for improved operational efficiencies, the benefits usually end at a provider’s front door. On the other hand, the advantages of EHRs extend outward in the following critical ways:

• Patient satisfaction: EHR systems allow patients to log in to their own medical records, so they can check lab results without having to wait for a call.
• Fewer errors: Because they can check lab results in real time, specialists are less likely to order unnecessary tests. Likewise, since electronic prescribing automatically checks for dangerous drug interactions, oversights are caught before they result in consequences.
• Informed decisions: Broader access to a clinician’s notes can help inform hospital discharge instructions and follow-up care.
• Real-time results: EHR systems allow clinicians to receive X-ray images, radiology reports and lab results electronically.

The Move toward EHR

Widely considered the future of healthcare, EHRs do more than collect and compile data; they help inform clinical decisions and coordinate care between all parties within the healthcare ecosystem.

Through streamlined sharing of updated, real-time information, patient care improves. As medical information moves along with the patient, the entire healthcare process becomes more accurate, more efficient and more cost-effective.

Dr. Robert Murry explains EMR vs EHRBob Murry joined NextGen Healthcare in July, 2012. Before his promotion to Chief Medical Information Officer (CMIO) in May, 2017, Dr. Murry was the company’s Vice President of Clinical Product Management, responsible for clinical oversight and workflow design.        Dr. Murry’s added responsibilities as CMIO include “Voice-of-the-Physician” across specialties, product safety, and government/regulatory affairs.

Dr. Murry is also the Medical Director of Ambulatory Informatics at Hunterdon Medical Center in New Jersey and practices Family Medicine at Delaware Valley Family Health Center and Hunterdon Medical Center. He is Board Certified in Clinical Informatics by the American Board of Preventive Medicine and Board Certified in Family Medicine by the American Board of Family Medicine.

Dr. Murry holds an MD from The University of Texas Southwestern Medical Center, Dallas; a PhD in Physical Chemistry from Boston College; and an MA in Physical Chemistry from the Massachusetts Institute of Technology.

I am not sure I can believe this outcome, we have come to the end of Trumpcare?  Consider the fact that the AHCA was introduced to the House on Monday, March 20, 2017 and was withdrawn on Friday, the same week its hard to view this as anything but an initial start, or a false start.  The AHA took years in the making including many rounds of legislation adjustments and then lengthy court battles.

Once you give something to the middle class its very hard to get politicians to take it back.  That is the core story that the Republicans seem so reluctant to learn, especially the Freedom Caucus.  But many moderates from Purple, Blue and Red States have had to take heat from of their constituents at anger town hall meetings. Further, the sound bits all have the same theme, “Congressman/Senator __________, I am a Republican, have been for ___ years.  But if it wasn’t for Obamacare ( I would be, my spouse would be, my child would be) DEAD!!!

I think there’s something else that has happened in the public mind that neither the press nor the politicians understand.  Now that the public has seen what the Republicians have in mind for their version of healthcare policy, as in 20 million less people with insurance over the next 10 years. Obamacare, has become a hardened brand!

The Grass is Greening for Obamacare – For Now, the End of Trumpcare

The public will look at an attack on Obamacare as an attack on healthcare and related entitlements.  Wait, the grass is greener but on our side of the fence.  Trump/Ryan/Price are bunch of chintzy gardeners that are trying to tell us that we should stop watering OUR lawn, let it brown out, pay more for our water AND send that same water over to our richer neighbors.  Yes, this is what the Democrats are saying but its coming out of the mouths of Republican voters.

OK, so I said I would take a deeper dive into the new bill just introduced in the House to replace the ACA.  The bill to replace Obamacare is HR1275.  It is actually called in the bill:

SECTION 1. Short title; purposes; table of contents.

(a) Short title.—This Act may be cited as the

“World’s Greatest Healthcare Plan of 2017”.

Meanwhile at the announcement by Speaker Paul Ryan and other house leaders they had a banner and announced it as:

“American Health Care Act”

Here’s a picture from the official launch by the leaders in the house:

If you examine the other section of the bill, there seems to be another title.

“TITLE I—ENERGY AND COMMERCE

Subtitle A—Patient Access to
Public Health Programs

SEC. 101. THE PREVENTION AND PUBLIC HEALTH FUND.
(a) IN GENERAL.—Subsection (b) of section 4002 of
the Patient Protection and Affordable Care Act (42
U.S.C. 300u–11), as amended by section 5009 of the 21st
Century Cures Act, is amended”

So that’s three different titles.

Where is the Patient

I thought this was interesting.  Within the two bills I did a search on the word patient and if you take away the use of Patient in the full name of the ACA, “Patient Protection and Affordable Care Act”  and you get rid of inpatient and outpatient you find:

The Word “Patient” doesn’t Occur Anywhere in the Document in HR1275 and once in the Energy portion

AMA Rejects the World’s Greatest

The American Medical Association, the largest association of doctors warned Speaker Ryan and the rest of the House Management team that the Obamacare replacement plan introduced earlier this week is “critically flawed” and puts millions of Americans at risk of losing their coverage.

Andrew Gurman, President of the AMA, said that insuring as many people as possible keep healthcare.  Dr. Gurman complained this impossible with the “World’s Greatest Healthcare Plan of 2017”  That it presently impossible to determine who many people would get or loss coverage, echoing earlier complaints about the lack of grading by the OMB.

Paul Ryan and the rest of the Republican House released their Obamacare replacement Draft (3/6/2017) for the Affordable Care Act (ACA)

Having a more conservative vision for the country’s health care system, replacing national insurance subsidies using a fresh type of individual tax credits and grants to assist states shape their particular policies.

People would not be penalized when they forgo health insurance. But the bill would make an effort to support individuals to keep coverage by enabling insurance companies to levy a surcharge of 30 percent for people who have a difference between health plans, when they drop and then later on get a new health insurance policy.

There are actually two bills that encompass the total plan.

Obamacare Replacement Draft in a Nutshell

Here’s what’s kept :

• Coverage can’t be denied coverage for preexisting conditions.
• Young adults keep coverage till they are 26.

As the House Releases its Draft, Here’s what lost:

• There’s no more penalty for not getting healthcare, instead there’s a 30% levy based on differences between plans???

The healthcare tax credit got changed in the final draft:

• The original plan was to have credit increase only by age.  That mean a millionaire got the same tax credit as a fast food server, even if they are both 60 years old.  This is adjusted by some degree by income in the last wording.
• Some conservative want it back to being income neutral.  Of course, any chance of getting Democrats on board would want the tax credits to be income based.

Yet to get numbers from the OMB:

• Office of Management and Budget estimates keeping demonstrating the credits will be both too little to provide enough help to lower-income individuals and overly expensive general to get a GOP decided to slash federal spending the ACA has required.
• Several House Republicans expressed worries the committees might begin to work with no whole financial evaluation on the laws. To be qualified to receive special budget rules known as “reconciliation” — letting bills to pass with a simple majority in the Senate — the deficit increases .

Medicaid – States Split between ACA Participants or Not

Medicaid would be converted into a per capita limit on funds to states to anybody eligible from its present type of entitlement, based on exactly how many folks they’d registered. In states that expanded Medicaid underneath the ACA, the authorities for now would continue paying for nearly the whole price of the growth.

Thirty one states, in addition to the District of Columbia, have embraced that growth. Beginning in 2020, but, the GOP strategy would limit the authorities’s ample Medicaid payment — 90 percent of the price of insuring individuals in the growth group — exclusively to individuals who were in the program by then. States would keep getting that amount of federal help for every single of the individuals provided that they stayed eligible, together with the thought that many folks on Medicaid drop off after a couple of years.

For the other 19 states that failed to expand Medicaid, the laws would provide $10 billion spread over five years. States could utilize that cash to subsidize hospitals as well as other providers of care that treat many patients that are poor.

Some Republicans are not happy:

• States that elected to enlarge Medicaid underneath the ACA, four key Republican senators, said they’d oppose any new strategy which might leave numerous Americans uninsured.
• The four senators were split on just what their standards would be met by suggestions, but with 52 Republicans, McConnell wouldn’t have sufficient votes to pass repeal with no support of at least two of these.
• Senate Finance Committee Chairman Orrin Hatch, R-Utah, would not rule out changes in the measure where significant amounts of reasonable Republicans have expressed worries that too many voters could be left by the measure .

Here’s a political red flag:

• Planned Parenthood funding is totally removed, not just for abortions.
• Some Republicans are concerned that federal funds happens to be barred from financing abortions but Planned Parenthood provides routine medical care.

Remember as these bills move through the two chambers of Congress:

• Once the middle class gets a benefit there has never been a time when the Federal Government has renegaded and given that benefit back.
• The political sands have shifted.  People are now more in favor of Obamacare and are worried about getting they benefits taken away.

Most Important Point for Healthcare Professionals

No important changes, for patients or doctors, seems to be in the works until 2020.  Will explain those details in another post as the smoke starts to clear.

This is as promised the continuation of ongoing posts describing the transition from Obamacare to Trumpcare.  It is an attempt to get a heads up on the direction the Federal Government will take and how small to moderate size practices will be affected.

But this particular post is just as much as an observation of the POTUS and his political personally as it is a report on the events surrounding the political theater in the arena healthcare policy.

Let’s start with the latest headlines as shown by Google:

You can see all the major media outlets are making the headlines the POTUS quote and the following article focused on his supposed ignorance.  That his is just waking up to the fact that this is going to be very hard to fix.

I started by searching on what I remembered was what the President actually said.  Google, as usual, didn’t have to remember the exact quote.  But here are his actual quotes:

“nobody knew that healthcare could be so complicated,”

“I have to tell you, it’s an unbelievably complex subject,”

The media’s reaction to these remarks is to respond with a massive “I told you so!”  This is perfectly OK with Trump’s base and many independents.   Why is this, well it quite simple, lots of Americans don’t like a smart aleck.  They don’t just not like a smart aleck, they hate them.  There is a major thread of anti-intellectualism in American culture.

But Trump isn’t playing on this in an overt manner, it is part of his political personality.  He can completely compartmentalize his thinking, therefore claim ignorance on the matter.  The media is totally infuriated that he is  playing dumb.  But in his mind he is truly surprised.   The base actually doesn’t understand how complex healthcare is so they are happy that the POTUS is leaning something new.

In other words, Trump has a natural way to frame ANY SUBJECT.  It would be interesting to get George Lakoff’s take on this viewpoint about Trump, but it appears that progressives and the media are already shooting themselves in the foot.

In the meantime on Friday Governor John Kasich met with the POTUS and pitched more of a repeal-and-repair approach to changing the ACA.  During the meeting with Trump and Kasich they brought Secretary Price on the phone.  Kasich explained repeal-and-repair while Price explained Empowering Patients First Act.  To quote a summary of the meeting the President said, “I like his plan”, talking about Kasich and Representative Renacci’s plan better.

At this point in the game we might as well wait to see what the POTUS has to say tonight at his joint meeting with Congress.

So we have dueling data, Speaker Ryan releases a presentation on how bad the Obamacare signups are and the need to have it replaced. Here are the leading points:

“Obamacare has failed.

Six years after the enactment of Obamacare, here’s what we know: This law has failed the American people. Insurance markets are collapsing. Premiums and deductibles are soaring. Patients’ choices are dwindling.
The law has failed to deliver on its core promises.

The law is only getting worse.

While we could simply allow the law to collapse, that would not be fair to the American families struggling under Obamacare. The truth is, left unaddressed, the situation would only get worse – with even fewer coverage options and even higher costs.”

Closing data for signup for Obamacare per the HHS on how many those who used HealthCare.gov to enroll for health insurance plan through the Affordable Care Act’s (ACA) Markets during the 2017 (2016) open enrollment period support significant data the Markets as well as their near-term future, are doing fine.

Comparing registration shifts across states suggests that premium increases had little, if any impact, on ACA  signups, providing powerful evidence against claims that the marketplace would be sent into a death spiral per the concerns of Speaker Ryan and the administration.

While the little decline in signups may have negative effects for the individuals who would happen to be covered, the effect on the individual market risk pool will be modest. It thus remains likely that insurance companies will return in 2018, absent other policy changes to some nearly break even or slightly profitable standing.

Obamacare Signups Show Little or no Impact on HealthCare.gov Registrations

“The HHS snapshots provide point-in-time estimates of biweekly plan selections, call center activity, and visits to HealthCare.gov or CuidadoDeSalud.gov. The final number of plan selections associated with enrollment activity during a reporting period may change as plan modifications or cancellations due to life changes like starting a new job or getting married occur. In addition, as in previous years, the biweekly snapshot does not report the number of consumers who have paid premiums to effectuate their enrollment.”

Do you know the story of the Five Blind Men and the Elephant.  Go ask someone, you’ll know why this is such a trying discussion.

History seems to be repeating itself.  Just because you control the White House and both Houses of Congress doesn’t mean you can make legislative progress as Republicans Subdivide.   In the case of the Obamacare, the Affordable Care Act, the bill was signed by the President in March 23, 2010 the and upheld by the Supreme Court on June 28, 2012.   But it took a secondary role to dealing with the Great Recession and it took almost the whole first term of the administration to get it launched.

We now have somewhat of a parallel situation with the attempted change to Trumpcare.  First, there has been major backlash on the part of the public to the repealing of Obamacare. Many people have attended local meeting with their Representatives and have been very vocal about keeping the plan in place.  Some Congressmen have even skipped out of their planned meeting altogether.   Representative Jason Chaffetz of Utah met with an angry crowd of around 1,000 people to voice their concerns.

So where is the parallel to the earlier stages of the Obama administration.  I thinks is fair to say that at present the Trump administration has bigger fish to fry.  Two examples are the courts suspending the Executive Order regarding immigration and the resignation of General Mike Flynn as National Security Advisor.

Republicans Subdivide on Obamacare Direction

In the meantime Congress itself is also delaying its efforts to replace Obamacare. Despite efforts by Speaker Ryan to come up with a replacement no amount of whipping have come up with a voting consensus.  The most Freedom Caucus members aren’t willing to wait and insist on eliminating Obamacare whether or not there’s an replacement in place or not. Further, there is no real guidance from from the White House or Secretary Price.

There are other factors in play but it looks like Trump administration has had its hand tied in its immigration efforts.  It will have to be seen if the Judaical Branch weights in on Obamacare issues.

For example, the recent ruling on ACA Insurance Risk Corridors would confirm that those insurers that didn’t do well and have gone out of business or written off the costs will get some of their expenses returned.  But it is not sure if this specific ruling will be overturned.  Or even if Congress just changes the law the disallow the use of The Judgement Fund by enacting HHS Slush Fund Elimination Act.

Meanwhile I am listening to a webinar on the MACRA Merit-based Incentive Payment System Annual Call.  Point being, that in the belly of the HHS/CMS beast life is goes on.  There’s an actual Radiologist on the cal, the poor man, that is trying to figure out how to participate in the merit/performance standards.  The people from CMS are trying their best and they did direct the doctor to a good contact point at CMS, good stuff.

Who are the players that will take on the change from Obamacare to Trumpcare?  Before is an outline of all the players that come to mind.  In some cases there is a short description.

When there are other players that need to be added this blog will be revised.  If new people enter the picture we’ll try to add those individuals.

The Governments

Federal Government

The Executive Branch

The President – Donald J Trump   

Yes, we start off with Trump, he’s had other matter on his plate for the first couple of weeks but its still a major item on his plate.

HHS – Secretary Tom Price  

Before he was a Congressman he was a successful orthopedic surgeon for many years.  As a Congressional Representative from Georgia he was Pro-Life, Pro Gun, classic Southern Conservative.

We’ll do a separate blog post on the Secretary Price and he past legislative efforts involving healthcare, like Empowering Patients First Act.

If Dr. Ben Carson become Secretary of HUD we’ll have two Doctors in the Trump cabinet, that’s interesting.

Centers of Medicare and Medicaid Services (CMS)    

This is the agency that gets doctors paid for Medicare and Medicaid.  The present administrator is the acting head.

Elected vs Not Elected Officials

Really, Elected Appointees come and go but the bureaucrats are there until they retire. Who is in charge of CMS on a day-to-day basis will have a lot to do with when and how doctors are going to get paid.  This is especially true of the next year of two.

The Legislative Branch

The Senate

Majority Leader McConnell   

So the Senator worked the Senate parliamentary procedure to cut off the filibuster by the Democrats so Obamacare can be repealed.  That’s only the procedure, not the actual act of taking the funds away.  But again that was almost a month ago.

Chairman Lamar   

We’ve already mentioned that Senator Lamar Alexander has his toe in the water when it comes to Obamacare.  He wants to adjust it, not throw it away.

The House

    Speaker Paul Ryan

Chairman ???

The are a number of committees that have their hand in the Obamacare pie on the House.  Plus the committees are larger and/or more specialized.

But there’s a lot more concern at the House level about a radical repeat of the law.  Here’s another Congressman’s quote:

“I’m much more concerned about the content than the timing,” said Rep. Tom MacArthur (R-N.J.), a former insurance executive who voted no

State Governments

Important to realize that the States have as much to do with the major health programs.  Sometimes these programs have serious cross-talk with the carriers.  For example Blue Cross/Blue Shield is the prime contractor in New York State for Medicare/Medicaid.

Of course there’s the fact that many of Governors opted out of the ACA and how that reduced the pool of people that could have added critical mass to the number of the insured

K Street – The Lobbyists

There are lobbyists for the Insurance Carriers, Pharmaceuticals, Device Manufacturers just waiting in the wing to craft the actual legislation that is created.

It these special interest groups that tend to write the initial draft of most bills, not Congressional staff. 

The Public

Seniors/AARP        

Look the subject line from the email I JUST GOT:

Jxxxxx, Join the Fight: Tell Congress to Protect Medicare

Need we say more; Seniors are going to be looking over any changes that are made to the healthcare system.  Seniors did vote for President Trump but they are very suspicious of both Democrats and Republicans

The Doctors

Can the new administration make things any easier for physicians, in particular small practices.  Is it even possible for the small practice to continue to thrive?

AMA        

There are 100’s of associations for physicians to work with but the AMA is the biggest by far.  They will be working with and sometime working against the insurance companies.

Employers

As long as the healthcare system is centered on Employers it will favor large companies and make it difficult for people to switch job.  Taking your healthcare insurance with you is becoming more and more of an issue as freelancing becomes the norm in the economy.

Is the best that we can do in this economy is COBRA insurance?

Do most people remember that we ended up with an employer based healthcare system by mistake?  It is a remnant of 1930’s depression based marketing and then workforce shortages sealing the deal during  WWII.

But if its a bad habit its one that’s going to be hard to break.

The Media

Is the media capable of covering healthcare?  Will we end up with with another round of Death Panels or/and misstatements like You can keep your doctor.  Or on the other end that Medicare will cause the US to become a socialist dictatorship? 

Can the healthcare’s own trade press add to the discussion or the confusion.

Who are the Players – The Ones that Really Count

It’s the Insurance and Pharmaceutical Companies that are the gatekeepers when you objectively look at the chess board.

Summary

This post will be revised as more player fall in place.  Unlike a game of chess new players often come into the picture, and old players fall away.