In the healthcare system, such a “powershift” is occurring within the walls of hospitals. Archaic hospital systems are using paper charts and paper prescriptions. Physicians must hand sign an order book which then gets faxed to the pharmacy. A courier then runs up the medicine to the patient’s room. All charting is done on paper and record keeping rooms are enormous. Medical transcriptions are done on a typewriter and placed in the patient’s paper chart.

In the second wave of medical informatics, the electronic network came about. Orders were allowed to be filled electronically. Medical transcriptions of dictations were outsourced to transcription companies who typed these out and they appeared electronically. Physicians could edit, verify, and sign electronic records and transcriptions. Computerized vending machines on the hospital floors could electronically document the use of supplies for the indicated patient. The second wave of medical informatics cuts costs and dramatically improved things and brought us out of the dark ages.

It appears that we are starting the third wave of medical informatics. “Going Live” is the concept where the electronic record is completely “live” and “online” and always being edited. Laboratory and diagnostic results appear real-time; doctors dictations, nurses notes, medical orders, and prescriptions are all done online and appear real-time. Transcription software allows the physician to dictate his note which uses voice recognition and speech transcriptions software to transcribe the note instantaneously where the physician can edit. If he so desires the doctor can electronically type his notes if he likes. There is no paper chart.

“Going Live” is the third wave of medical informations. Gone are the outsourced medical transcription companies. Gone are the paper charts. Gone are the electronic notes that indicate that a dictated note is “pending.” There are no gaps in the care or documentation of the care of the patient. The laptop or PDA-toting physician is here to stay.

As in the global powershift, hospitals and healthcare systems who “Go Live” early on will win more business and thrive. They will be more profitable and be more efficient and thus more effective in the delivery of healthcare.

If you’re interested in other works by Alvin Toffler, read Greg Beatty’s review of Revolutionary Wealth: How It Will Be Created and How It Will Change Our Lives by Alvin and Heidi Toffler.

Medicare, in its effort to cut costs, has balked at reimbursing for these scans. However, many cardiologists continue to order these tests because they make money (up to half of the income of some cardiologists) and patients demand the scans. Last year 150,000 of these scans were done at a cost of more than $100 million. All data trends indicate that their use is increasing significantly.

In the best case, having a CT-angiography that reveals significant occlusion of vessels may indicate the need to increase medications or undergo a procedure to unblock coronary arteries. In the worst case, having a CT-angiography can reveal that there are no blockages in a healthy and asymptomatic patient.

What is interesting about this issue is that the economic and political lobby for CT-angiography is extremely strong and was able to get Medicare to back down from their coverage reversal. Obviously, cardiologists, who may own the machines or have a financial interest in the machines, are going to fight all they can to keep this industry alive. Some people feel that the lobby is driven by capitalism under the guise of “improving patient care.” It is the rare cardiologist that refuses to order scans, own scans, or have financial interests in scanning facilities. Most other cardiologists feel that they might as well own or else they will be leaving money on the table.

At the heart of the issue though is whether these scans affect the actual outcome of the patient. There is very little evidence to suggest that it affects or does not affect patient outcomes. There are many patients in whom asymptomatic disease has been detected. There are also symptomatic patients where the scan confirms what previously was a sound clinical diagnosis based on history and examination.

It does not appear that CT-angiography is going away. The demand is just too high from patients and the lobby is too strong. This is yet again another example where the utilization of healthcare and the discovery of medical advancement are incongruent with the payment and reimbursement mechanism in this country.

In medical speak, ancillary services are services that are part of medical care but not the actual treatment or procedure. For example, if a patient has an injury and needs further evaluation to help decide to have surgery, a diagnostic study such as a CT scan or an MRI may be needed. The surgeon probably will make less doing the surgery than the cost of the actual diagnostic study. How can this be? Well in medicine, technology pays. Insurance companies don’t think that surgical or procedural skills are “advanced technology.”

Thus, as you can imagine, the lucrative segment of the industry known as ancillary services is a huge source of revenue for physicians who invest in these services. These ancillary services include imaging centers, surgical centers, diagnostic labs, dialysis centers, infusion centers, physical therapy and rehabilitation facilities, etc. The list really can go on and on. Some doctors actually make more money off these ancillary investments than they do from their own clinical care of patients!

The era of ancillary services does not come without its own set of moral and ethical challenges for the physician. The physician must always do what is best for the patient. The patient’s interest must come before the financial interests of the physician. The Stark laws against self-referral clearly highlight the point that the government will not allow a physician to get paid for a service or treatment or procedure via a self-referral where the physician has a financial interest. For example, he cannot order an MRI for a patient and send the patient to an MRI center that he owns.

The era of ancillary services clearly indicates that we are at an inflection point in healthcare finance. Perhaps the continued reimbursement difficulty will attract individuals into the field of medicine who are not money driven. Perhaps the era of ancillary services will attract individuals who are interested in the business of medicine. One thing is clear – the era of ancillary services will pose signficant ethical and moral challenges for physicians looking to capitalize on those services to make up for meager clinical reimbursements.

The AMA has certainly voiced their reservations about this practice. The push for these types of sites seems to be coming from insurers in tiered networks.

“In such networks, health plan members pay less out of pocket for seeing physicians who meet the insurer’s quality criteria, which doctors generally have criticized as faulty.”

-P. Dolan (http://www.ama-assn.org/amednews/2008/06/23/bil10623.htm)

The author goes on to say,

“Much of the growth in physician ratings sites have come from health plans pushing a consumer-driven approach to health care.”

Also of concern, according to Dolan, are insurer-based sites that allow patients to post unproven comments regarding their doctors, a practice that seems dangerously close to the definition of libel. The legal definition of libel is “a false and malicious publication printed for the purpose of defaming a living person.”

Patients should be aware that there might be ulterior motives to these sites before taking advantage of the information contained within. It is doubtful that insurance companies are sponsoring some of these sites simply for altruistic reasons; rather, they are hoping that they will be able to steer their customers to doctors that fit into their system in terms of cost-efficiency.

As for whether or not it can be considered libel to make potentially career-altering statements about physicians online, patients should take these statements with a grain of salt, as they must for a lot of information found on the web that is often misleading or blatantly false.