Don’t you guys think that the modern EHR is a machine precisely for upcoding? Ask yourself (if you haven’t already) – what business would spend mid-seven figures on an investment with no ROI? Answer: None.

So then, there is an ROI. So what is it? It sure isn’t any of the things we have been promised. It’s longer days, less patient contact, more coding seminars, shorter visits, duplicated effort (spend time explaining things, then document the discussion on the EOV form), and so on. Everyone knows this.

The purchasers (hospitals) and their partners (payers) seem quite happy with their investments, however. Why is this?

It’s because “Pain US crying TM dusky red Dx OM Rx amox” is not codeable. A structured note which requires certain elements, even though they are unnecessary, is codeable, and it’s very easy for the PMs to identify newer and better ways to fill out that structured note so 75% of your 99212s become 992013s.

I do not know if anyone is tracking revenue streams per unit after EHR adoption (we do know total units go down), but it would be an interesting exercise.

Willam’s point is key in a couple of ways. One is that upcoding and billing fraud would likely be reduced if patients had convenient transparency on what was being billed. The second is that the policies that determine how patient data is accessed and used can be shifted to patient communities and other groups that are much smaller and more focused than today’s “integrated delivery networks” and governments.

But “downsizing the functional interactive units of medicine” as William calls them requires standards for how records are secured and accessed. We can’t expect the various health care professionals and provider groups to access and use independent and decentralized health records without having a secure single-sign-on technology and reasonable expectations for how information is laid out. Work on these standards is proceeding. Some is reflected in comments by Patient Privacy Rights to the Federal TEFCA regulations (due today) that will be posted soon.

As functional units become large, the instinctive love we have for our family members and similar small groups of friends disappears and we only seek return on investments. We also begin to fight and litigate and conduct wars. Our only interest becomes profit.

This is not hypothetical and psychologists and evolutionary anthropologists know the optimum and customary size of human tribes and groups over the last half million years….groups that had to trust each another intramurally—absolute trust was essential for survival— or they wouldn’t be here today.

A small example of policy change that might implement some of this would be that physicians mostly always explain and talk to patients about their bills and send claims to indemnity insurers who return money to the patient who directly pays the physician. Or not…if he was unsatisfied. Or partially return. The physician has to know the billing system and use it himself.

To bring about such a radical change in health care would require a revolution in power relationships, and is hardly doable today. Of course, as the authors above recommend, the patient must have much control of his medical records.

With large institutions running health care you can predict exactly what is now happening.