The Black Liszt

How to reduce the cost of medical imaging and PACS

Medical imaging devices like MRI's, CT and X-Ray machines are extremely valuable. They're also extremely expensive. So expensive, in fact, that health insurance companies typically require a pre-authorization for an MRI scan to make sure that it's "medically justified." The market is currently estimated at about $40 Billion a year, with more spent on proprietary PACS (Picture Archiving and Control Systems) for storing and managing the systems.

The medical imaging market is highly regulated, with the design and construction of the devices subject to detailed requirements for how the hardware and software should be designed and built. The result of the regulations is that a small number of large companies control the market, effectively preventing innovation and new companies from entering the market.

There is a proven path towards opening the market to innovation and dramatic cost reductions, while improving quality. We should break the iron grip of monopolistic companies and harmful government control to enable a medical imaging revolution.

The Software industry case

Something similar happened in the software industry. IBM mainframe computers and software once owned the world. Everyone bought from IBM, and were then required to buy IBM software and applications. They worked, but were incredibly expensive. A government anti-trust suit broke some of their monopolistic power, and new mini-computers changed the game. Then with computers built on multiple microprocessors, low cost, high quality and performance with intense competition ruled the roost in the computer industry. Separate companies built each part of the new world; each competed to be the best.

The crowning touch was that for important parts of the software such as operating systems, open source software emerged and became the norm. Even IBM acknowledged this by porting the Linux open source operating system to its IBM mainframe computers.

What should happen in medical imaging

Medical imaging machines are like specialized mainframe computers. In addition to the physical hardware that does the scanning, there are processors with operating systems and application software. Software controls each step of the scanning process, collects the data, stores it and displays it. Today, every bit of that computer hardware and software is built by the hardware supplier. Just like it was for IBM mainframes before the anti-trust suit.

The big difference is that no government agency exercised control over the details of how the IBM software was designed and built. Sadly, ignorant bureaucrats at the FDA exercise total control over this process, as I detail here. They require the use of methods that are so old and bad that even giant corporations have long-since moved on for their unregulated software.

The argument is that this is about your health. Do you want imaging devices that don't work or give bad results? The FDA performs the essential function of guaranteeing quality and safety, they say.

What they actually do is the equivalent of demanding that only hand saws be used for turning trees into lumber and refusing to allow nails or hammers to be used in house construction. Of course it can be done. But people using modern tools get far better results faster at lower cost. There is a simple way the FDA can assure quality, by shifting from lengthy HOW style regulations to simple WHAT style regulations as I explain here.

The Result

The result of this change will probably resemble what happened to IBM once their monopoly power was broken. IBM continues to this day to manufacture the successors of mainframe computers, now called the Z series. They support both their own operating system and a leading open source one. Applications that run on their systems are available from a wide variety of companies.

Similarly, major vendors such as GE and Siemens will continue to do what they do, but all of the hardware and software will be open to competition by both new and existing vendors, and possibly also by open source efforts. It's likely that Linux would be ported.

Image storage systems for imaging continue to cost many billions of dollars a year. They don't do much more than what you could with Dropbox or AWS S3 storage, for example. Each patient would have cloud folder that would hold all their records and images. The system would store each new file in the cloud, which would securely store it with full multi-site protection and backup. Sharing can be accomplished simply by creating and sending a link, something that can be done with a few lines of code or manually in seconds. The huge problem of medical imaging records storage and sharing that I demonstrated here would go away! Yes, you'd put some UI on top of the cloud storage to make it super-easy and not dependent on any one cloud storage vendor.

Conclusion

The essential and growing world of medical imaging and supporting systems form an indispensable part of modern medicine. It's long since time for them to catch up to the transformation of the computer industry four decades ago, dispense with harmful regulation and allow healthy competition to flourish. We would all benefit by the resulting increase in availability and dramatically lower costs. And yes, with better quality.

 

Medicine as a Business: Medical Testing 6: Another Test

When you have a tumor that's supposed to be vanquished by radiation therapy but refuses to go away, you're supposed to check on it periodically to see if it's resumed rapid-growth mode. While experience hasn't made my heart grow fond of MRI's, I reluctantly decided to give it another go, since I still have lumps I shouldn't have..

Here's what happened last time. I'm reluctant to dive into MRI-world again because even simple medical scheduling like for a covid test is a big problem -- but small compared to the nightmare of scheduling something like an MRI. Why don't I just go somewhere else where it's done well? Hah! Fat chance. And even then the burden would be on me to pry what are supposedly MY records from the iron grip of the multiple EMR's of my current system.

This time was an adventure -- a new kind of screw-up!

Scheduling the test

You would like to think that a doctor would keep on top of his/her patients and notify them when they're supposed to do something. Like my vet does for my cat! The rhetoric is that they do. It's possible that some of them do -- though how they manage it when having to spend nearly half their time entering an ever-growing amount of stuff into EMR's that are supposed to make things better is a testament to dedication and likely early burn-out.

The burden was on me to remember to schedule this standard-protocol follow-on test for my cancer. Clearly the big-institution medical center wasn’t up to the job. Neither was my insurance company, which is glad to pepper me with reminders to get my blood pressure tested by a doctor, something I regularly do myself at home. Test for cancer? It’s beyond them. A straightforward workflow software system would handle it all automatically.

I was supposed to get the next test a year after the prior one. I let it slip. No one reached out to me, of course. It's now nearly two years. Sigh.

I reached out via email on Nov 16, because I know calling is pointless. After many interactions on Dec 22 I was told I have an appointment -- ignoring of course my request to make it myself. At least I got it and could arrange things to be there on January 8.

Two days before the appointment I got a brief reminder voicemail and an email. The email didn't happen to mention a time or place. I guess they trusted me to know -- unlike any normal scheduling reminder system. But it did give me a ton of words about covid and safety, and requested that I spend time filling out forms online, which I did. Including uploading my driver's license and insurance card.

Taking the test

I arrived on time. After 45 minutes of claustrophobic rigid motionlessness to assure a good quality MRI while being bombarded by loud noises, the tech stopped things and asked me about my tumor and its location, which is under my shoulder blade. His reply: "We have to stop the MRI test. I'm following the test order, but I just looked at the prior scans and they're different! This order says "shoulder," which means around the joint. What past scans did was scapula, including all the way to near the backbone. This machine can't capture that. We'll have to restart you with the other machine here that can."

There was more conversation, all polite on my side, since the tech took initiative and was saving me from thinking everything was fine and having to come back to get the scan done correctly.

Even better, the facility wasn't busy, and the tech took the initiative to get me scanned at the correct machine. I was delayed by an hour and had extra practice at remaining immobile under aural bombardment, but OK. I warmly thanked both techs for their initiative and flexibility and went on my way.

Simply copying and sending in the same order as before was apparently beyond the esteemed radiation center director and/or his staff. I guess I should have gone elsewhere after the time I was in for an appointment after a scan had been done and he carefully examined … the wrong shoulder blade. And then only changing after the second time I politely mentioned he was on the wrong side.

Seeking the test results

What you're supposed to do is make a follow-up appointment with the director of the radiation oncology center to get your results. As in the past, I want to see the results myself. I have previously made an account on the system's patient access portal to do this. I entered the login information and got told this:

Less than a year after my prior access, they de-activated me. Do banks inactivate accounts for lack of use? How about email accounts? Or anything else? Exactly what horrible consequence is being averted by prompt de-activation? Right.

I read through all the material. Only by downloading a PDF file was I able to get the phone number I had to call, which was the only path back to activation. I called and after much of the usual nonsense I got through to a person who, after learning everything about me except my favorite flavor of ice cream gave me a code to enable me to enter a new miraculously complex password and have access to ... my own data, blankity-blank it!

The Surprise Appointment

Remember when I asked to make my own MRI test appointment so I could be sure it was at a time I could make? And one was made on my behalf? Imagine making a reservation at a restaurant and they TELL YOU when the appointment is that you may have -- because we're nice; after all, we don't have to let you come, so we'll fit you in when it suits us. This is what the MRI appointment was like.

Now, having logged into MyChart -- finally -- I discovered I had an appointment to see the director of radiation oncology! Surprise! When were you going to tell me, guys? I was nice and called the number, wove my way through the phone maze and found someone who claimed he would "tell the director." Not cancel the appointment; tell the director. Is some form of after-school detention coming my way to punish me for this refusal of an appointment? We'll see.

Why are they so insistent in me having an appointment with the director to "go over my results" with me? Simple: they want to be able to generate a claim for a visit.

Trying to get my test results

Given that they made an appointment for me to see the doctor two days after the test, it’s a fair assumption that the test results have been filed. I’ve been on the system’s patient access system and the radiation center’s separate (of course) system every day. They clearly have the results. They refuse to let me have them.

Refusing to provide patients timely access to their test results should be a crime. Why? In the most basic way, they are my property. Suppose I go to a tailor and get measured for a custom suit. I pay for the suit. Then the tailor refuses to give me the suit, and ignores my requests. If you go back to the tailor shop, the tailor says “I don’t deliver the suits. I just take measurements, make a suit, and give it to my team.” How do I get my suit then? “Go to MyTailor.com, sign in and it will be there.” What if it’s not? “Sorry, it’s not under my control.” Is the tailor shop committing a crime, taking money and refusing to deliver what was paid for? Of course! But in the wonderful world of medical business, this is standard practice.

Beyond the crime issue, sometimes those test results are health issues that the patients can be incredibly anxious about! Like me. I’m writing this making liberal use of my right arm and fingers, which the cancer could kill. Could it be worse? Yes. But am I anxious to see those results? You betcha!

All the rhetoric is that patients have the "right" to have full access to their own records. Wonderful modern medical record systems crow about how they support this full access. Lies. Blatant and pernicious. And no one does anything about it! Not only isn't it a scandal, it isn't even news.

Read here about the break-through in hospital EMR electronic data exchange. Read here, here, here and here about prior adventures on the same subject. Summary: Compared to past experiences, this was pretty good!

Getting the pre-auth

I’d kind of like to see the actual pre-auth so I can see the test order, a thing that the insurance company should have denied because it was wrong. I went to their website, which is of course down.

They say I can get what I need from their wonderful app Sydney, but it doesn’t have the information. Of course. Forget it. I have better things to do. I already know that the armies of highly paid IT professionals at Anthem can't build software, so beating a dead horse..

Getting my test results

After finally gaining access to MyMountSinai I log in. Of course the test isn't there. Given that they made an appointment for me to see the doctor two days after the test, I'm pretty sure they have it. They're just taking their sweet time to let me see it. Because patient satisfaction is important to them, you know.

I check the next day. The next. Next. Next. A couple more. I finally email the doctor who ordered the test, politely asking if he would send it to me. A couple days later I got an email from Mount Sinai:

Amazing! The results for "David A. Black" are in! I wonder who that is? A long-lost relative? I'm David B. Black. No wonder matching patient health records is a problem.

I carefully read through the report. Here's the punch line:

"No convincing evidence of progression..." is definitely "appreciated" by me! While I'd much rather that it was gone, sullenly sitting in my body not growing I'll gladly take.

The doctor later responded to my email saying he would forward the test results, which arrived. The substance was the same, but Mt Sinai had gone to the trouble to omit lots of information from the report released to me officially and the one forwarded from their own internal system to me. For example, the name of the doctor who wrote the report. Instead of simply copying the information they have to enable me to access it, they've taken trouble to create software to pick and choose exactly which -- of my possessions! -- they will deign to allow me to have. When they feel like it.

Conclusion

In the overall scheme of things, everything I experienced was small potatoes. I'm healthy and alive. This doesn't come close to being in the ball park of the deaths and serious issues resulting from medical error and the costly, health-harming impact of standard medical practices that have been proven to be wrong, but which the authorities refuse to change because it would mean admitting error.

My experience is nonetheless a good example of the business-as-usual gross inefficiencies of the medical system that drive up costs, cause endless patient trouble and generally make things far worse than they should be. This isn't about exotic new biomedical discoveries. It's about things that should be plain, ordinary common-sense processes and software of the kind widely used in fields like veterinary medicine that should be the standard in human medicine. But aren't. One is tempted to think in terms of self-absorbed heads-in-the-clouds elites, but all I've got is mountains of mountains of anecdotal evidence, no serious, RCT's (random controlled tests, the gold standard of medical studies) in favor of that hypothesis, so I'll just put it aside.

The Nightmare of Covid Test Scheduling

Oh, you want to get a Covid test, do you? Little did you know that the clever people who do these things also give you endurance, patience and intelligence tests at the same time! Our wonderful healthcare people and helpful governments have somehow arranged a diverse number of ways to make you fill out varying forms in varying orders, only to find out that there are no available appointments.

Don’t you think the highly paid experts who created these services could have done something simple, like following the model of dimensional search used at little places like Amazon, travel sites and other places that care about customers? I guess that would have been too easy or something. And besides, medical scheduling in general is a nightmare, why should this be different?

Looking for a test: CVS

Search told me that my local CVS has testing. I clicked to the website of my local store. I clicked “schedule a test.” Although I had come from the local store, I guess the people who built covid testing didn’t manage to get the local site to pass on its location, so I entered my location again as requested.

Now I have to “answer a few questions” for no-cost testing. Eight questions. Then when I say yes to recent symptoms, 12 more questions plus the date my symptoms began. Then clicking that I was truthful.

Next, pick a test type, look at a map of local stores and see a list of dates starting today. I pick today. There’s a list of each store, with a button under each to “Check for available times.” Click on the first store. Here’s what appears:

There are no available times at this location for Tue., 12/21. Try searching for availability on another date.

Wow. I go up and pick the next day. Click. No times. Pick the next day. Click. No times.

CVS has pioneered a whole new way to help customers pick a time! You pick a date, pick a store, click and hope you get lucky. Then pick a different store and/or a different time and click again. And keep rolling until you hit the jackpot! Assuming there’s one there…

Since there was no end in sight, I tried something different.

Looking for a test: Walgreens

No questions first. Hooray! Just put in a location, pick a test type and see a list of locations. … Almost all of which had “No appointments available.” Let’s check out the one nearest to me, which said “Few appointments available.” I click. First I have to agree to lots of things. Now I have to enter my full patient information: name, gender, DOB, race, ethnicity, full address, phone and email. Then review and click that it’s correct.

Then, it’s the covid questions: my symptoms, contacts, medical conditions, pregnancy. Have I had vaccines? For each, which one and the date given. Have I tested positive in the past?

Now, after all that, I can pick an appointment. Back to that bait-and-switch first screen with test types and locations. I pick the location. Now a calendar shows up. Today’s date is highlighted. This message in red is below: “No time slots available within the selected date. Try a different date for more options.” The next 7 days are in normal type, beyond that they’re greyed out. Do any of them work? I try each day individually. They each give the same message! Why couldn’t you have told me that NO DATES WERE AVAILABLE!?!? Maybe even … BEFORE I filled all that stuff out??

Looking for a test: The state of NJ

Since I live in NJ, I get regular dispatches about how the state government cares about my health in general and covid in particular. So I went to the state site.

Which it turns out is operated by a private company, Castlight.

I put in my zip code. They list places that offer testing, one of which is the Walgreens I just tried. But I click on it anyway, and they link me to Walgreens testing … in a town 10 miles away instead of my town, which was explicitly the one I clicked on. Good job!

They got my hopes up by listing Quest Diagnostics, which has a location in my town. I answer a long list of questions and am told that I quality for a test! Hooray! But then …

I have to sign up and provide loads of personal information before even knowing I can get a test. That’s it for Quest.

Looking for a test: The local county

Maybe my local county would have done it better? Let’s check it out.

I get a long list of testing places. How do I find one near me? After a few minutes of confusion, I discover that the sites are listed alphabetically! Now that’s helpful!

CVS of course is near the top, with a line per location. My town isn’t listed even though I already know that the local CVS claims they do tests. Crap.

Looking for a test: Digging deep

I found a private place, Solv, that claims to link you right to testing places. I tried. They had a clinic not too far from me. Clicked. I’m still on Solv, which is potentially good. After more clicking It turns out that no appointments were available today or tomorrow, the only choices. Gee, Solv, maybe in the next release of your software you could possibly only show choices that were actually, you know, available??

I finally tried a little pharmacy that is local and has remained independent. They offer tests. I clicked and got to a page dedicated to the pharmacy under a place I’d never heard of, Resil Health. Right away they list dates and times available. Just a few days out.

I pick a date and enter the usual information on a clean form, but also my insurance information and a photo of the front & back of my card. Click. The time is no longer available! But at least picking another time was easy. I was disappointed that it was a couple days out. They sent an email with a calendar invite. I accepted. There was a link to reschedule. I tried it. To make a long story short, sometimes when I clicked reschedule the dates available changed, and earlier ones appeared. After some effort I snagged one the same day! Then I went. All I had to do was show my driver’s license – since they had everything else, neither I nor anyone at the pharmacy had to do paperwork – Resil health did it all, including the reporting.

It was a pain, but by far the best. Hooray for small-group entrepreneurs, getting a service up and running that makes things easier and better than any of the giant private companies and certainly any of the pathetic ever-so-helpful governments.

Looking for a test: Is it just me?

I had to wonder: is New Jersey particularly bad, as snotty New Yorkers like to joke about, or is it just the way things are? It turns out that, even in high-rise Manhattan, covid testing is tough. This article spells out the issues.

Mayor Bill de Blasio keeps telling New Yorkers frustrated with long waits and delayed results at privately-run COVID testing sites to use the city’s public options — but his administration’s incomplete and bulky websites make that exceedingly difficult.

It’s not just me.

Conclusion

I got my test. I’ll get the results soon. Let's hope getting those results is better than it often is in medicine. What’s the big deal? I’m only writing about it because it’s a representative story in the life-in-the-slow-lane of typical software development. It’s possible to write good software. Thankfully there are small groups of motivated programmers who ignore the mountain of Expert-sanctioned regulations, standards and processes that are supposed to produce good software. These software ninja’s have a different set of methods – ones that actually work! For example, in New York City:

The complaints echo the problems New Yorkers encountered when city officials first rolled out their vaccine appointment registration systems this spring — prompting one big-hearted New Yorker with computer skills to create TurboVax to workaround the mess.

“We don’t have a single source of truth for all testing sites in NYC,” tweeted the programmer, Huge Ma, who was endearingly dubbed ‘Vax Daddy’ by grateful Gothamites. “Tech can’t solve all problems but it shouldn’t itself be a problem on its own.”

One guy – but a guy who actually knows how to produce effective, working software in less time than the usual software bureaucracy would take to produce a first draft requirements document. This is one of the on-going stream of anomalies that demonstrate that a paradigm shift in software is long overdue.

Here's How the FDA Can Reduce Medical Device Costs While Improving Healthcare

The FDA wants to keep us safe. They want the drugs we take to be what they’re supposed to be, and they want the medical equipment used on us to be safe and without fault or error. We all want that!

However, the way they choose to achieve the goal for the software that is an essential part of most medical devices is deeply flawed, and leads to huge expense with only a small number of companies willing and able to follow the FDA’s regulatory regimen for software. The net result is medical equipment and software (which is increasingly a key component of medical equipment – think MRI machines) that is wildly expensive and uses seriously outdated technology.

There is a simple, easily understandable reason for this horrible state of affairs, which the grandees of the FDA refuse to acknowledge or even understand. The root of the problem is that they don’t understand software. Which doesn’t stop any of them from being certain they can regulate it. Because of this inexcusable ignorance, they take the regulatory approach developed over many years for drugs and manufacturing and apply it with only cosmetic changes to software. Safety is safety, they probably say to themselves. We’ve proven our approach for drugs; why start from scratch for software?

The mistake made by the FDA, along with nearly all the hard-charging graduates of MBA programs, law schools and bureaucrats everywhere is in thinking that the process of manufacturing is like the process of building software, except not as visible or physical.

In manufacturing, you have a factory with raw material arriving, being processed in a series of steps, with quality checks along the way, and emerging as finished goods at the end. The important thing is to check the quality of the raw materials as they enter and the results of each step of processing to make sure it’s up to snuff. At the end all you need is a cursory quality check, because so long as everything is done right along the way, the result is probably good.

Similarly, they think, in software you have a set of requirements, with lines of code and software components being produced along the way, with careful unit testing being performed at each stage, and more tests as the components are woven together. The end product is subject to more testing, but the important testing has already been done. The idea is that quality is designed in.

This method for building software is exactly what, in gruesome detail, the FDA requires. It’s spelled out in highly detailed regulations. Sounds good, right? Why would anyone want crappy software, particularly when it comes to our health?

The trouble is that this whole way is thinking is based on a blatantly false analogy.

What they think is that the manufacturing process of converting raw materials to finished goods is just like the process of creating lines of code and combining them into a finished software product. People even talk about “software factories,” and how important it is to churn out quality code, on time and on budget. Still sounds good, right?

Here’s the problem: a factory that produces finished goods, whether they’re drugs or cars, is making copies of a design that’s already been created and tested. In the drug development process a drug is created and validated through testing. All that’s done in the drug factory is assure that the copies that are made of the already-designed-and-proven drug are exactly and only what the drug creators intended.

Designing and building a new piece of software is like the drug development process, not the drug manufacturing process. The software is created for the very first time, with changes made along the way. The software equivalent of a drug factory is trivial: it’s taking a piece of executable software and making a copy of it. There is a universal software “factory” that works on all software: the copy utility. It’s what happens when you go to the Apple or Google software store and download the software you want. The download makes a bit-for-bit-100%-accurate copy of the original software for your use. That is software “manufacturing!” There’s even a universal quality check – a checksum is always incorporated in the original prior to copying that the receiver can check. The checksum tells you whether the copy is perfect, just like all the drug manufacturing quality checks do, only with software, it’s easy. Yes, because software is different. Here is more about software factories.

What the FDA regulations do is specify and control in gruesome, expensive and time-wasting detail the process of building the very first, original copy of the software – like creating the drug in the first place. This is a complete and total waste. The methods and processes of building software are constantly evolving, with the most innovative companies, the ones that actually create new software, at the forefront. These companies have small, focused teams who crank out great software, and do it quickly. They use what can be called “wartime” methods of building software.

The FDA should scrap its mountain of software regulations and replace them with a simple set of regulations that achieve the same goal, more effectively. I describe this in detail here. The new regulations amount to something like “We don’t care how you build your software, but its your responsibility to assure that the software performs its stated job each and every time, without fail. If the software has errors that cause medical harm, you are responsible for the damage it causes, and you may be barred from supplying software to the medical market in the future.”

This of course, shifts the entire burden onto the software creators – as it should. Inspections are no longer required. Employment at the FDA should go down, but of course, since it’s the government, it probably won’t.

Changing the medical software regulations in this way will unleash a wave of innovative, low-cost medical software. It will be as though runners were required to carry 100 pound backpacks and walk on stilts; as soon as they can dump the pack and use real running shoes, just watch them set records! They will be a race with each other to see who can cross the finish line in style the fastest, with no stumbling along the way.

Adventures with Health System Software: Customer Feedback

If you want a cheap laugh, go to the Mount Sinai medical system website and hope they ask you to complete an opinion survey. It’s stupid and ridiculous, deserving lots of snark. But try not to think about what it means or the underlying reality, or you might get kinda depressed. Like I did, because I went to the website because I needed to get something done! I needed a phone number. Sounds simple, right? Until you understand I had already talked with someone at Mount Sinai, and that person gave me the wrong number. But I really needed the number -- I needed to make an appointment for a medical test that is crucial to my health. After a great deal of searching, I finally found what appeared to be the right number. Except it wasn't, as I found when I called.

This was part of my epic struggle to schedule an appointment -- something that I do with a couple clicks for my favorite restaurants, my cat at the animal hospital, or ... yes, my primary care provider. But at that powerhouse medical institution, Mount Sinai? Only the best people who really, really, really want an appointment are graciously granted one. See this for the story.

In this post, I'll confine myself to glancing at the carefully constructed Mount Sinai website and the extraordinary steps they are taking to assure that it is the best it can be. It's clear they're in a race for the top with the health insurance companies on this subject, see this.

Major companies that build websites have a problem, a problem they share with lots of companies that build software. The executives in charge are required to say that they care about quality, and do everything in their power to track and improve it, along with important metrics involving customer satisfaction. They take concrete steps to measure quality, using the best firms out there to help them.

There's just a little problem: they can't get it done.

The Mount Sinai website

I recently encountered a typical example of hopeless executive incompetence while trying to get a simple phone number to schedule a visit to Mount Sinai Hospital in NYC – scheduling that any institution whose software had successfully made the wrenching transition to the 2,000’s would have made long ago. I tell the story of the scheduling adventure here.

It was a long slog to get my MRI appointment made, including a number of calls and emails. You might think that when a window popped up near the end of my ultimately unsuccessful trek through the Mount Sinai website to extract a simple phone number that I would ignore it. After all, the website is a carefully-crafted, attractive-looking piece of useless fluff, impressive perhaps to the important people who are shown images of it in a Powerpoint presentation during some meeting, but in fact annoying, error-filled and generally useless to real people. Silly me: here I am thinking that the hoi-polloi, the real people who have health issues, are the relevant people here – when in reality, it’s the executives, jockeying for ever-growing power, prestige and money among themselves.

If you’ve read any of my other posts on software quality, you may suspect that I’m a glutton for punishment. Your suspicions are correct. So I agreed to take the survey. When I left the site, I expected the survey to pop up, but it didn’t. After all, the request told me, in no uncertain terms, “it will pop up when you leave the site.” OK, I thought, your loss, not mine. But darn! The survey I recently got from my health insurance company was so juicy!! I would have loved to see who wins the race for most dysfunctional survey between a major provider and a major payer!

It turns out, I just needed to wait. Before long, the survey arrived in an email:

I was a bit surprised to get the request in this way, but OK, they’ve obviously got all my information, so fine. As usual, I hover over the link to make sure it’s legit. The URL was portal.gsight.net with some codes after. I quickly discovered this was a domain owned by the company that sent me the email, Greystone.net. Hmmm, who are they?

Wow, a whole company devoted to healthcare marketing and the internet! They must be really good! I wonder if they know about the web?

It appears they know about the Web. And look at this:

It’s a whole process to make the website great! Smart folks, those people at Mount Sinai, turning to professional specialists to figure out how well their website is serving their customers! Though I can only assume that Greystone has only recently been engaged, since the Mount Sinai website is, after all, a pretty-looking pile of stinking crap…

So let’s dig into this expert opinion survey. Click. Here’s where I land:

OMG!!! My jaw has hit the floor so heavily, I’ll probably be scarred for life. I wonder if I can sue Greystone to cover the costs of plastic surgery for my deformed, floor-mangled jaw??

Why is my jaw hurting? Because the link these consummate professionals sent me was to a completely generic landing page! There is this thing known as “deep linking,” in which the custom URL you click brings you right to the place in question. It’s widely used. The landing page knows who you are and why you’re there. I guess the folks at Greystone hired a bunch of interns for this project, ones who hadn’t gotten to that chapter in the “Internet Linking for Dummies” book. And no one with the slightest bit of experience, like the average internet user, had tried it out.

After I gave the right answer, I was thrown into a completely generic survey about the website, utterly uninformed about who I was or any smidgen of knowledge about my site visit – putting the lie to the user tracking they supposedly do. Had they done elementary user tracking, they would have known who I was and which pages of the site I had visited. But no, they decided to ask completely generic questions.

Is this hard to do? Nope. For example, my bank, USAA, notices when I go to the “wire transfer” section of their website and then call them. A recorded voice says something like “I see you’ve recently visited the money transfer section of the USAA website; would you like to wire money today, David?” If I answer “yes,” they transfer me to the relevant department. Not hard! Maybe the Greystone.net interns will eventually get to that chapter.

The survey itself was endless, irrelevant awfulness.

Here’s an example of why the survey was awful:

If they had tracked me and made the survey specific, they would have known that I hadn’t filled out a form. Instead, they present me with a question about form-filling, and then require an answer. Most of the questions were like this. By the way, this question was about ... the twentieth question -- all of them response is required. See the progress bar that says 25%? At some point, it jumped to that, and then, question after question, it didn't changed.

Then at the end, I was invited to give some input. Which I did in calm language, mentioning that it might be nice if the phone numbers on the site were, you know, correct numbers. Of course, since they hadn't deep-linked, they had no way of contacting me to get further information.

Just to be sure I wasn't completely nuts, I went onto the Mount Sinai website again. I got lucky -- an invitation to complete an opinion survey popped up again. I carefully chose "take it after leaving the site," and this time it worked, though in a remarkably clunky way, indicating that whoever built the code had flunked Javascript 1.01. So I get the survey, and was blown away by seeing the very same "how did you get here" question I got from the email link. Any competent web programmer could know how I got there, by looking at exactly how the original URL was invoked. Clearly, performing this elementary task was beyond the collective genius of Greystone and Mount Sinai.

Then as I went farther into the brain-dead survey, I discovered that it just didn't work. Look at this:

Look at the percent completion bar just below the black line under the Mt Sinai logo -- it's still at zero, even though I'm many questions into it, as you can see by the scroll bar on the right. Programming and QA 1.01. Fail. And of course, it was a survey designed so that no normal person would march all the way through to completion.

Discussion

There’s a concept in math and computing, and also in real life, called “recursion,” or sometimes self-reference. It’s a simple concept; it’s been around for literally thousands of years, as we know from fun statements ancient Greeks made involving lying Cretans. In this case, it applies to the question of the quality checkers: who checks the quality of the quality checkers?

The answer is evidently “no one.” The most basic principles in surveys, common sense but also proven by experience, are “keep it short” and “Make every question matter.” We know these are the relevant principles because everyone who hasn’t failed the “survey 1.01” course knows that the most important metric to measure is drop-out rate. Of the people you invite, how many accept? Of those who accept, how far in the survey do they get before dropping out? What’s the completion rate? Any tracking along these lines would have shown minuscule completion rates. I’d love to have a recording of the executive meeting at Mount Sinai in which the survey results were presented, to see whether the issue was even raised.

But beyond that, let me ask: when was the last time you got a survey from Google? Or Amazon? Never, right? Another thing: have you read even a little bit about opinion polling, about how it's long-since been proven that people give one answer when asked, but then act differently? What people who are moderately educated web professionals know is that surveys are useless! That's why folks who know a little about websites watch what you do! If there's a lot of information on the site, they make it search-based, with lots of suggestions. They look for drop-outs.

Yes, I've made fun of how badly the survey was constructed and executed. It was the electronic equivalent of a paper survey from 50 years ago. Which makes sense, because the Mount Sinai website is the electronic equivalent of  a glossy brochure from 50 years ago. That's the killer observation. Mount Sinai could make a huge advance by leaping forward to the state of the art of roughly 20 years ago. The very fact that they're using obsolete technology like surveys -- and on top of it doing it incompetently -- shows that they are clueless. It's the equivalent of using a steam-powered car instead of an oil-powered one, and being unable to run the steam-powered car competently. The right response here isn't build a better survey -- it's use modern customer feedback techniques.

Conclusion

Well, it’s a wash. The hospital system opinion survey was pretty different from the health insurance one, but they each exemplified unique ways of being bad. I wonder how many dimensions of badness there are? The institutions I’ve had the pleasure of experiencing are clearly on the leaderboard of those most likely to get to the maximum. Neither of them has a clue about decades-old methods that are vastly superior for getting customer feedback than surveys, however well-constructed those surveys might be.

Postscript

Learning about the excellent survey work conducted by Greystone.net on behalf of Mount Sinai had an added dimension of amusement for me because I grew up near an institution named Greystone. Or more formally, Greystone Park Psychiatric Hospital.

It was, as my mother the R.N. called it when I was growing up, a ‘Looney bin.” If someone said something she thought was dumb, she would say “Did you just escape from Greystone?”

What’s Wrong with Medical Scheduling and Why it Matters

It’s easier by far to make a reservation at a restaurant than for a medical test. I guess having a meal at a restaurant is far more important than getting an MRI, given that the restaurant people have made the process simple and convenient and effective for all concerned. Getting a medical test must be rare and unimportant, since no one has bothered to make it work well. Sure. I guess that lie is more comfortable than the other possibility, which is that medical system administrators and software providers are too incompetent, lazy or unmotivated  to make things moderately convenient and up-to-date for their employees and customers.

Why this is an important issue

If you’ve gotten this far, you’re already an unusual reader. The vast majority of the leaders, innovators, experts and generally high-prestige people in healthcare would have tuned out and moved on as soon as they saw “medical scheduling.” Their guts tell them “medical scheduling isn’t important.” In terms of career growth and industry prestige, their guts are serving them well.  However, in terms of making a real difference that will positively impact most people involved in medicine, their guts are misleading them.

Medicine has a real prestige problem. I’ve described the medical innovation spectrum, in which the exotic, future-oriented end, like AI and Blockchain, gets most of the money, conferences, attention and career-advancing opportunities. The more you move on the spectrum to simpler, proven, non-exotic things that can make a difference here and now for lots of people, the more you’re moving to the back office or basement, where poorly-paid, invisible people while away their time and whine to no meaningful audience. Here are details and examples.

Scheduling is one of those proven winners that remains largely unimplemented in major medical organizations. The fact that scattered medical groups have implemented it beautifully shows there are no technical barriers.

I can hear it now. Scheduling. Sure. What award am I going to win by implementing something restaurants do? I’m breaking new ground in personalized medicine while I’m curing cancer on the side! Away with your trivial scheduling talk!

I get it. There’s just a little problem. As I’ve detailed here and here and here and here and more, time and money loss and serious medical issues are caused by nuts-and-bolts problems in the medical system. If just some of them were improved, the funding for your precious futuristic projects could be increased! And, by the way, loads of patients would be better off on multiple dimensions, including not dying prematurely! You know, little things.

As an example of the impact, consider just this aspect of scheduling: automated follow-up (yes, it’s part of scheduling). Failure of follow-up problems:

“The impact on patient outcomes included missed cancer diagnoses.” Journal of General Internal Medicine.

“In fact, almost a quarter of all medical errors occurring in outpatient settings can be attributed to poor follow-up of abnormal test results and are believed to represent 25% of malpractice lawsuits involving failures or delays in diagnosis.” AACC

The Scheduling problem

There are an amazing number of dedicated, skilled, hard-working professionals in medicine. There are patients who have health issues who are often grateful for the service and care provided by those professionals. But both groups, providers and patients, are burdened by ancient, dysfunctional and incredibly expensive processes and computer systems that make things that should be quick and easy into something that is cumbersome and time-consuming, often yielding poor results. Everyone involved feels trapped and needlessly harassed. What’s going on here?

This is the horrible general scheduling problem in health care. To illustrate the issues in a concrete way, I’ll focus on scheduling a test as a follow-on to a procedure, and use my own experience as an example – an example that, sadly, is business-as-usual in this world.

A Cat Scheduling Example

Before getting into scheduling a medical test for me, let’s see what happened when I had to schedule a test for someone more important than I am – at least she seems to think she is – my cat, Priss. The comparison between getting tests for Priss and me will be instructive.

I have a cat, Priss. Priss is pretty chill; here she is thinking deep thoughts:

I take Priss to a local animal hospital, where she is well cared for. I get regular notes and emails telling me when something medical needs to be done for Priss. For example, here’s the header of an email I received last year:

Note that the email arrived near the end of August, 2018.

Here’s the top part of the mail:

Note that there’s a picture of a cat in the email – they know who they’re dealing with! They know Priss’s name, and they know she’s a cat, and not one of those friendly but face-licking, slobbering dogs who are incapable of using a civilized thing like a litter box.

Here’s the rest of the email:

They make it hard to miss the phone number or the online scheduling system they support to make an appointment, don’t they? They also spell out exactly what needs to be done. And darn, the email was sent EXACTLY one month, to the day, before the service was due. Please note: this is THEM taking the initiative to follow up, TELLING ME when something needs to be scheduled.

If this were a human hospital we were talking about, I would say “to make a long story short …” but because this is an efficient, modern animal hospital, I get to say “to tell it like it is …” all I had to do was click on the email, buzz through their easy-to-use on-line scheduling system, make an appointment that worked for them and for Priss, get a confirmation email back right away, and I was done. That’s it!

On top of it all, the people there are great, and care for Priss really well. There was a problem with her fecal test -- results back in a single day -- and the treatment was immediate and effective, no more than a day's delay for any step.

An MRI Scheduling Example

Now we turn to hospital scheduling for humans, specifically for me at the world-class hospital system, Mount Sinai. I’ve had some medical issues that have required MRI testing. See this for a description of the issue, with details about the testing experience and the conclusions that can reasonably be drawn from it.

I had  30 days of radiation therapy in early 2018. I was supposed to have MRI’s to see the results of the radiation six months and a year after the treatment. This is standard practice. I know from experience that the grandees at Mount Sinai Medical System haven’t gotten around to sending a team to the Hudson Animal Hospital to learn from their cat scheduling system, so they can put a multi-year project plan in place to implement something similar for their human patients. In a human medical world that worked as well as my local little animal hospital, I would have gotten a reminder a month before my MRI should have been taken.

Being the patient patient that I am, I waited until after the anniversary itself. Then I sent a friendly reminder to my doctor:

He replied the next morning with a perfectly reasonable response – given that he had to do the work that a vet wouldn’t have had to do.

His prompt reply was Feb 4. I heard nothing for weeks, so I finally reached out again three weeks later:

Again, the doctor in charge of the radiation center, doing clerical work well and promptly, work that he shouldn't have had to do, responded right away:

What happened next? More fun wasting everyone’s time. Remember, with a reasonable on-line system like restaurants and vets have, none of this would be needed!

A couple days later I got a voice mail, with a friendly person giving me the date and time for which my MRI has been scheduled – of course, without consulting me! I guess I must be sitting around suffering, anxiously waiting for the first possible moment at which I can get my MRI, at which point I’ll drop everything and arrive two hours early. Or not. Even better, this call isn’t from the MRI center, it’s from my doctor’s office, where someone has made an appointment for me, a couple days after the most recent request, weeks after the original one. So I return the call, explain I can’t make the appointed time, and is there any way I could talk with the MRI center and make an appointment myself? Well, she tries to be accommodating, and says it’s OK, but I also need to make a follow-up appointment with the doctor by calling her. I think I can manage this.

I call the number she gives me, which was the wrong number. I consult the web, and it takes a typically long time to find the center and its phone number for scheduling on the website. Mount Sinai management, it goes without saying, is totally on top of customer feedback and quality management. So they pop up an opinion survey. What happened with the survey is a lesson all by itself in the profound dysfunction of our medical systems in general, and Mount Sinai in particular. I will treat this event in a separate post.

I call what the website says is the right number, and keeping sarcasm – however warranted it may be – to a minimum here, after a journey through automated VRU’s and other wrong numbers, I eventually get to the person who can schedule me. Sure enough, she finds the order for the MRI in her system, and makes an appointment that actually works for me. Phew! I then, as instructed, call back the main doctor’s office and schedule a visit with him to go over the results, as I had been instructed to do. Please note this visit with the doctor I scheduled; it will start its own little trail of incompetence and waste.

After way too much effort on everyone’s part, I thought things were finally set. Silly me. I got this call a few days before my MRI appointment:

After a couple of attempts, I get through. I’m told that the room where the MRI machine is suddenly needs to have major work done, work that apparently couldn’t be scheduled in advance, making the machine itself unavailable. So pick another time. We work something out. I then call the doctor’s office and re-schedule my visit with him, so that it’s suitably after the new date of the test.

On the morning of the date of my original doctor visit, the one I called and re-scheduled, I get a voicemail saying in effect, “you’re coming into today as scheduled, right?” I admit that the nasty thought of ignoring the call crossed my mind, but my better self took control. I called and got through after a couple tries and explained the re-scheduling. The person verified that the new appointment had in fact been made, but that “someone else” must have failed to cancel the old one. Done. Except that it wasn't really "done." See the associated customer service post to see what happened!

A week later something came up and I had to move the appointment with the doctor. I called. After explaining what I wanted, the person said, didn’t you just miss a scheduled appointment with the doctor? Nope. Apparently the last person I talked with, whom I told about their mistake, failed to correct it. Again.

Do you use a calendaring/scheduling system, for example the one in Microsoft Outlook? Have you noticed that you can click on an event and change the date/time, so that it moves to the new time slot? Of course, you can delete the old one and make a new one from scratch if you really want to, but why would you? The evidence seems to point to the possibility that such a feature, which is standard on modern calendar systems, doesn’t exist in the paragon of modern software used by the leading medical system, Mount Sinai.

Conclusion

Follow-up of events, both one-time and multiple recurring, is a standard feature of modern scheduling systems. Self-scheduling by software is a widespread feature. It’s widely used, and benefits everyone involved. It’s not as though self-scheduling by software is particularly difficult for medicine. For example, the primary care office I use, OneMedical, has a convenient system that takes account of the length of visit you need, and gives you choices of providers and locations so you can pick what works best for you.  Once scheduling is on-line, it is amenable to serious optimization techniques, which have been deployed with great success resulting in substantial savings and efficiencies in things like infusion centers and operating rooms. This is not possible with the primitive human-phone-based systems in widespread use.

It’s painfully obvious that the important people at medical centers prefer to spend time doing “important” things at the fancy future end of the innovation spectrum, rather than lowering themselves to implement practical, here-and-now improvements that benefit everyone. When will this change?

 

Medicine as a Business: Medical Testing 5: The Results

I've gone through quite a bit to get the results of my MRI. See here for the previous installment, and here for the start of the saga. I glanced at the report and it looked good. In this post, I'll describe the unsettling things I found when digging deeper. In sum: the whole baroque nightmare of scheduling, performing and delivering results of medical tests is not only inefficient and riddled with needless high cost and waste, but more important there are serious quality problems leading not just to delay and waste, but bad results.

I fully acknowledge that what has happened to me pales beside the waste, incompetence and fraud that pervades the worst medical systems. My point is that, even in the best healthcare systems, bad things are happening.

The Results

I glanced at my hard-won test results and felt OK, mostly because I had been told that radiation therapy took a looooong time to show results, and I shouldn't expect anything to change at the first MRI. There was no OMG or IT'S GROWN LIKE CRAZY in the notes when I glanced at them, so I let it rest. I was tired out from all the effort of getting the darn thing.

Then I looked more carefully. I'm still OK for my personal case, but on close examination, I realized that the final report of the MRI was consistent with the crazy things that led up to it: scheduling the test, taking it, and getting the results. It's all part of a bizarre system that has GLARING flaws that seem like they should be easily fixed, but nothing much happens.

Here is the key paragraph from the earlier of the scans, the one that led to the radiation treatment:

Here is the corresponding paragraph from the second scan, the one I struggled to get:

The first thing that jumped out at me was the simple observation that there are no standards! Radiologists are incredibly smart, well-educated people. College degrees. Super scores on GMAT tests. Degrees from incredibly-hard-to-get-into medical schools that have TINY numbers of students. Then more years getting further training to become medical imaging specialists -- usually five more years, on top of the four years of college and the four of medical school! 

If I showed you the whole report, you'd immediately see that even the paragraph and subject-matter organization was different. About the most glaring thing to me was that the second report gave actual dimensions of the tumor, while the first did not! Don't you think that when tumors were involved, specifying the actual size would be the standard?

There's lots more that could be said, but I'll leave it with these simple observations:

• There is no system in place to record and assure that the required location is being imaged. The key thing can be missed because it wasn't imaged.
• There is no consistency of exactly what is reported on and how it is reported. It is difficult to compare reports and assure that what you need is there.
• For tumors, there is no consistent positioning and measurement of size. You could miss a tumor altogether, and easily miss size/location changes.

Conclusion

I'm in remarkably good shape, having a scary diagnosis of an extremely rare cancer. I received great treatment from highly skilled professionals at every step of the way. I received chemo that had only 25% chance of working, but it shrank a rapidly growing tumor. Then, when it started growing again, I got right into radiation, which has at least prevented further growth, and should finally stamp it out. I have nothing to complain about, and a great deal to be thankful for, including all the professionals who treated me. 

I've written this series of posts about Medical Testing NOT as an indictment of the individuals who have treated me, but as a serious indictment of the system in which they work. Here is a summary list of the things that "could be improved;" details are in the prior posts of this series:

• Scheduling and getting a pre-auth for a test can be a labyrinth and delay-filled nightmare.
• There are multiple issues with the wasteful, expensive and time-consuming blood test.
• There are multiple issues with specifying and following an exact procedure for the location and mechanism of the scan itself. Instead of being in the system, the nurse has to get information from the patient and guess about other things!
• The equipment and software is built in a regulation-protected bubble, which results in 10X or greater cost and trailing-edge technology.
• Getting results that have already been created by the radiologist can be an obstacle-filled maze, even if you try to use a “patient portal” that is supposed to make things to easy and transparent.
• The patient portal is mostly a sales pitch about how the hospital is wonderful – getting the information is a big problem, and then important information is wrong or just plain not there.
• Finally, the results produced by super-highly-trained doctors based on these expensive and questionable inputs don’t meet any modern standard for content.

Why doesn't anyone in management seem to care? I've often wondered this, and speculated about why several times. What's clear is that there's a hierarchy of prestige in every society, including ours, and that the top of the hierarchy is populated by people who focus on strategy, policy, direction and messaging. They are, for the most part, "above" getting "lost in the weeds." Sorry guys; the action is on the ground, where real things happen to real people. That's where you discover what's wrong, and when you "fix" something, that's where it's got to change.

Medicine as a Business: Medical Testing 4: Getting the Results 2

I've done everything I can to use the Mount Sinai patient access portal to access my test results, without result. (See here for the start of this saga, and here for the previous post.)

Now it's time for desperate measures. I finally take the radical step of picking up the phone and calling for help. Surely the results are there!

Here's what happened.

• I called.
• I was put on hold.
• I explained the situation.
• I was put on hold while the CSR checked something out.
• More questions. More holding. Rinse and repeat several times.
• Hold while I check with my supervisor.
• Rinse and repeat several times.
• Final result: we can't help you, call your doctor and have them help.
• But what can they do that you, the specialist can't??
• They have a number they can call to get help.
  

More than half an hour on the phone, and I get to ask my doctor to call someone who won't be able to help either. And I'm sure my doctor would jump at the chance to fix this problem, since he looooooves the EMR so much!!

Desperate and out of options, I call the doctor's office.

• I got transferred to a 5 minute wait before getting a dial tone.
• I got transferred to voice mail.
• I got transferred to nowhere again.
• Again.

Finally, someone picked up whose voice I recognized -- the office receptionist. I explain the problem, and he tells me that the Mount Sinai Radiation Center uses a different EMR than the rest of Mount Sinai!! Apparently one that doesn't send patient data to MyChart.

He promises to get me into the Radiation Center EMR patient portal AND send me the results. "What's your fax number?" he asks. "Umm, can you send it by email?" Pause... "Sure, I can figure out how to do that. What's your email?" I gave him the information, and five minutes later, I got an email with a PDF document attached. The document had the test results and instructions on how to get into the patient portal.Thank you!

Problem solved! I read the report, and the news was good. The thing that had been growing had stopped growing. But self-sacrificing guy that I am, I didn't stop there. What would have happened had I not persisted in my calling, and connected with a helpful and knowledgeable receptionist? After all, the report was supposed to be in the patient portal.

So I persisted. I decided to get into this special patient portal and finally see that the test results were actually posted there and available to me.

The Radiation-only EMR and patient portal

Leaving out all the details, I followed the procedure and after only a moderately odious amount of work (I had an access code!), I got into the portal:

 

Then I went to the test results, where my report should be:

It's not there, of course. Why am I not surprised?

The test results report should have been in My Mount Sinai Chart. It was not there, as confirmed by multiple levels of customer support people. It should also have been in the Radiation Oncology patient portal. It was not there, as you can see above. Given that an insider was able to access the report quickly and send it to me, the report was certainly in both EMR's. It was in the normal Mt. Sinai EMR, because that's where the doctor who wrote the report put it. It was also in the Radiation Oncology EMR, because that's the EMR of the doctor who requested the test -- and as I learned early in the process, it was easy for people in the radiation center to put orders into the "main" system.

Here's the key point:

Neither of the two EMR's at Mount Sinai that were involved with my test put a copy of it into the relevant patient portal so that I could see it. While I managed to avoid the usual doctor's appointment to find out the results, it's not clear how much time and frustration I saved in the end. Here's what was promised:

What was the reality?

• The test results were not available in MyChart. Is Mt. Sinai management unaware of this? Are they just lying and hoping to avoid embarrassment, as they do with other important "low-level" things? See this for a juicy example, and this for context. Either choice is unacceptable.
• The customer support service, when finally available, was unable to help.
• The original doctor's office was unavailable.
• The SURPRISE! special, different EMR used by my Mount Sinai department also didn't have the report.
• I only got the report because of repeated calling and a chance encounter with a kind receptionist.

Yeah, yeah. I'm computer and math guy, and I know statistics, and I know this is just one example. But can you really imagine that what I went through was a giant, almost-never-happens, tiny blip in a uniform fabric of excellence? Right. Wanna buy a bridge? I've got one real cheap for ya...

The E-mail!

Wait! There's more! After I drafted the saga of getting my greedy hands on the MRI results, something happened.

About a week later I got an email:

WHAT!!?? This test result was supposed to be on the radiation center's portal!

What's more, the only reason I got the email telling me the result was available on the Mount Sinai patient portal was because I was previously a patient and had signed up for it. If I had come into the Radiation Center directly, without having a history at the broader hospital system, I'd still be waiting.

On July 24 I'm told that the result was posted and available to me. A result from a test that was posted to Mount Sinai's system on July 3, 3 weeks earlier. It's a good thing we've got computers -- if it took 3 weeks to make a copy of a short document from one place in the Mount Sinai computer system and store the copy in another place in a related program in the same computer system, imagine how long it would have taken to do it manually! Years, probably!

I'm writing this on July 31, 2018, so by now the result surely will be posted on the patient portal for my doctor, nearly a month after the test was taken, right? Let's check:

Nothing is available. So much for the Radiation Center's patient portal.

Now I'm curious. Is the test really there, even though on the wrong portal? Here's the results list:

Yes, it's there, top of the list.

MyChart also provides a convenient to-do list, things I'm supposed to do, and there's something on the list. Better check it out, even though no one's told me there's something for me to do; this subject is important to me, to put it mildly, and I wouldn't want anything to slip through the cracks. Here's the to-do:

Oops. The MRI that was expected to be taken on June 11, actually taken on July 2 because of my initiative, and posted to the portal on July 24 is listed as a to-do item. The EMR evidently failed to connect the work order with the fact that the work ordered was performed and the results delivered.

This sounds benign, but it's actually scary. Deeply scary. The system doesn't match orders placed with results delivered, which means that orders could hang in space, ignored, with patient-essential work undone, unless a concerned and involved patient tracks it. In my case, there was a concerned and involved, not to mention detailed-oriented patient. What about the normal case? How many important things just hang out on a to-do list, undone, until they are "cleaned up?"

There's more trouble coming. When I glanced at the results, I got the impression things were OK. But when you dive in, ... see the next and final post in this series.

Medicine as a Business: Medical Testing 3: Getting the Results

If you went to the time and trouble of a medical diagnostic procedure, chances are ... you want to know the results. ASAP!

It's a perfectly reasonable desire. In most areas of life, getting the results of something you paid for is pretty easy. If the results are information, most organizations just send it to you -- by snail mail, email, text or whatever you've arranged. For example, think about the crucial tests you take that have so much influence on your schooling and career, things like the SAT, MCATS, LSAT, and professional certification tests. You take the test and they send you the results in a standard way.

Not so in the wonderful world of medicine! In that world, you go to considerable trouble to arrange the test, and once it's been taken ...the fun of getting the results begins!

Getting medical test results

The usual pattern of getting the results from a medical test appears to be based on the assumption that patients are both stupid and illiterate. No way can you just send the results! The patient has to make an appointment with highly qualified medical person, who then patiently explains to the patient what the results were and what they mean. Plus, there's an office visit to be paid for.

We are told, however, that there's a revolution going on with medical record transparency. In this wonderful new world, patients can access their medical records themselves!! The major EMR vendors now support a "patient portal" for making such results available online, and major hospital systems brag about it.

Hmmm, I wonder if that's how I could get my results. Oh, I remember now, Mt. Sinai has a patient portal! I'm even signed up for it! Oh, good, this should be easy...

Getting my results from the Patient Portal

The test was ordered at Mt. Sinai. It was performed at Mt. Sinai. I have a MyChart patient portal account at Mt. Sinai. This should be a piece of cake. I pull up the main screen:

Isn't it nice? The EMR software provider, Epic, has a patient portal module called MyChart, which Mt.Sinai has cleverly called My Mount Sinai Chart. All I have to do is login, and I'll surely be able to access my recent test result, just like they say!

I login. I'll spare you the details, and keep it short: the MRI report is not there.

How is this possible? What happened to "no more waiting for a phone call or letter -- view your results..."??

I have just one thought. Maybe the fact that my original doctor left Mt Sinai and that I signed up for the MRI with a new doctor at Mount Sinai confused the system. Maybe I was signed up under a different identity!?

I poke around on MyChart a bit more. In reality, I visited the Mt. Sinai radiation center 30 times over about a six week period, and had separate consults with the doctor in charge of my radiation at least four times. NONE of these visits are listed. In fact, the last visit recorded was from 2016!

MyChart is still a wonderful program, probably ready, willing and able to show me all my stuff, but probably human error resulted in me being entered as a new person. All I have to do is create a new account, and I'll find all my records.

Signing up for the patient portal account

I'll dive right in. Given how important this is, the portal is probably written to make this effective and efficient. Here goes! I click on set up new account and get to here:

What's this activation code business? I look around and find this:

Odd. "Sign up online?" I thought that's what I was already doing! At least there's something relevant for me to click. I click it and get this:

That's more stuff to enter than I've seen in a while. There's a lot that could be said about this form and how it works, but I'll just point out one unique aspect of it:

When was the last time you had to enter your county? Even better, even if you've already entered the state, you get a list of all the counties in the whole USA!

Once you get to this point in the form, you realize that the creative people who built this software have actually created an obstacle course, a long and challenging one, hoping that most people will drop out from exhaustion long before completing it. And we haven't gotten to the really good stuff yet.

Establishing identity for the patient portal

Apparently it's really, really, REALLY important to make absolutely SURE that only the person themselves signs up for chart access. After filling out the form you see above, I got my identity hammered at:

Next, where have I worked:

A home equity loan:

My bank:

My former home:
Finally, after accurately answered all of these questions, and risking totally awful 100% identity theft if their system is compromised, I get this:

 

At this point, a sensible person would have given up and tried to make an appointment with a doctor, so the doctor can access the results document and essentially read it to me. But convinced as I am of my ability to read documents (egotist that I am), I decided to plunge ahead and try another path to getting the document. The next post continues the story.

Medicine as a Business: Medical Testing 2: Doing the Test

This is the pinnacle post of the series on medical testing, which starts here.

It's the pinnacle because I've finally climbed the mountain of scheduling, and I'm going to the radiation center for my test. Hooray! I'm at the top of the mountain! It will be easy after this, just getting the results and the bill.

I've been to the imaging center before. I'm well aware of their attempts to hide behind misleading signage:

Its nearly-secret location is several floors deep in the basement -- only those who really want to get there, and have the persistence to get there, make it.

I arrive more than the half hour early they requested, to allow plenty of time for the front-office staff to do their work. What's there to do? I've been there before; how can there possibly be anything about me they don't already know?

First of all, it's an iron-clad tradition to give entering patients a clip board full of paper that needs to be filled out, with lots of boxes to check. Have I been through this before? Yes. Every single time I visit. There's a simple explanation for this. Think back to cop shows you've seen where there's a witness or suspect the cops think might be lying or leaving something out. Or where there are two people who they think have concocted a story, and they interview them separately, trying to trip them up. The cop usually starts by saying, "I know you've been through this with my doughnut-eating colleague X, but I need you to take me through it again slowly, step by step." If it works for the cops, it should work even better for the medical staff, right? They carefully check every answer I give and cross-check it with all the previous answers I've given and analyze the differences. This way they can tell when a patient is lying, or when their memory is crashing because of whatever is wrong with them. Or simply to gauge the patient's intelligence and memory, to rank all the patients and do something wonderful with the results that only members of the doctors' cabal know about. AlI I know is that I have to waste time on each visit, only to have the staff glance at the first page, and file it.

I end up waiting for about an hour. Finally someone calls my name, and I follow her out of the waiting room through the trackless maze of hallways. After a bit of walking, I'm introduced to a person who, she tells me, will take my blood for testing.

The pre-MRI blood test

I've been through this before, and nothing bad happened. It just caused, as usual, another delay in starting the MRI, because they wait for the results of the blood test. Which results (of course) no one gives to me, the person blood was tested.

But there are a couple things to note about this practice.

• The main purpose of the test is to see if I'm likely to have an adverse reaction to the extremely safe contrast material that will be injected for some of the images.
  • The main concern is with the few subjects who have abnormal kidney function.
    
  • I had an MRI with contrast just 3 months prior. How likely is it that my renal function went south during the interval?
  • Doing the test for everyone is just not needed. See this, for example.
  • Doing the test for me was a waste of time and money.
  • In any case, it's clear that there are no standards that are followed here!
• Given that you're going to do a test, of course my blood needs to be drawn.
  • My blood was drawn by ... an RN.
    • Registered Nurses are amazing people with years of training, often including an undergraduate degree and more.
  • My blood could just as well have been drawn by a phlebotomist.
    • You can train to become a phlebotomist by having a high school diploma, taking a month-long full time course, and taking a certification test. Boom, you're done.
  • I don't think I need to comment about the different in cost.

After more waiting in a special waiting room, I'm finally called into the MRI room.

The MRI itself

The MRI nurse/technician was courteous and professional, like everyone else I encountered during the testing process. But the process was inexcusably bad, wasting time and money and reducing quality.

First, the nurse asked me where the tumor was that was to be imaged. This could have been good. It's classic checklist, the sort of thing you should do to avoid error. See this for details. Why wasn't it good here? She wasn't double-checking to make sure the computer-based instructions were correct -- she was asking to find out!

Imaging studies have been done on me of this area. Multiple times. Including at Mount SInai. Mount Sinai has incredibly detailed information about exactly where the tumor is, more accurate by far than anything I know. Nonetheless, I was the nurse's primary source of information about exactly where the pictures should be taken! She placed pieces of tape on my body indicating the limits, and those pieces of tape were her only source about where to take pictures.

Next, I laid down on the MRI bed. The nurse had me slide my shoulder into a little compartment, something which had never happened on any prior MRI. Clearly the dial on my paranoia control was set way too low, because I just vaguely thought, hmm, this is different, well she must know what she's doing. After adjusting me a couple times, I got to enjoy the usual loud noises in a confined space during which I was to remain rock-solid motionless; this pleasure went on for 20 minutes or so. Then I got rolled out.

The nurse tells me that the compartment my shoulder is in is a "camera." Unfortunately, the camera wasn't capturing all the area of the tumor, so she would have to use a different camera and do everything again. She gets out a thick, flexible plastic sheet and places it on my shoulder. I recognize it immediately, because it's exactly the same device that has been used on each MRI I've had, regardless of the imaging center that has done the work.

Amazing. Frightening. When I go a hair-cutting place, they record my visit and the choices and selections I made for getting a cut. When I go again, even if it's a different person, they'll ask something like "same as last time?" And then they'll normally do the checklist thing of confirming their understanding of what last time was. The point is: they know what I got last time. They recorded it. A hair-cut place. The only thing I can imagine is that the advanced technologies that hair salons use for keeping information about their customers haven't yet made it to the world of medicine. The plain fact was that Mount Sinai had either not recorded (probable) or not used (possible) key information about the image that was taken and how to take it. I would use the word "inexcusable" for this, but without a few choice 4-letter words, such a word would be far too mild to describe what went on here.

About 3 hours after I arrived, the MRI had been taken and I was free to go.

The MRI technology and equipment

This isn't part of my test specifically, but it's on my mind every time I encounter medical equipment. I'm a computer guy since forever (see this for details of my background), and I know too much about the technologies and the companies that are used in this equipment, and the hardware and software processes that create it.

The highly regulated companies using highly regulated processes to build this hardware and software are unique in technology. The regulation is supposed to protect the public and assure high quality. In fact what it does is assure that only a couple companies can supply the equipment in a government-protected monopoly, at absurdly high cost.

The net result of this is that specialized equipment and software are built to meet the regulations, even when COTS (commercial off-the-shelf) equipment is widely available to do the job with high quality and great performance at a fraction of the price. A prime example of this is the PACS (Picture Archiving and Control System) that all medical imaging systems include. This is basically a standard file storage system with a database that logs everything put in and enables access to images.

At the heart of the MRI is a body of software that could be built, maintained and enhanced at a tiny fraction of today's cost -- a 10X improvement is the minimum one could expect under a rational set of rules. Here is a detailed post with examples of the insanity and, just as important, a specific proposal for how to fix it.

Conclusion

I got the MRI. Nothing awful happened to me. I'm grateful that medical science/engineering has gotten to the point that something as truly amazing as an MRI is even possible. I can certainly imagine things being much worse than they were.

That being said, the opportunities for improvement on multiple fronts are HUGE. The patient's time and inconvenience could be greatly improved. The operational cost of performing the MRI could be considerably reduced, and the quality and consistency improved. Finally, the capital cost and rate of innovation of imaging machines in general could be HUGELY enhanced by drastic changes to the regulations controlling the design and manufacturing of the devices.

Even more good news: my saga was not yet over. I don't have the results yet! Wait until you read about what I went through to get them...

Medicine as a Business: Medical Testing 1: Scheduling

Before you get a medical test, it has to be scheduled, right? Just like getting a reservation at a restaurant, both you and the place you're going have to agree on a time. Here's the real-life story of my recent MRI, starting with scheduling it. The point of this post isn't to whine about what happened to me, but to illustrate deep, widespread problems in the medical business by means of a concrete example.

Background

First some background. My doctor was at Mount Sinai. While he was treating me, I had several MRI's at Mount Sinai. Then he moved to another major hospital system in the NYC area, Northwell Health. Both are excellent places with modern, up-to-date systems. I told the story here of the amazing breakthrough in EMR electronic interchange that allowed me to get the MRI's that had been taken at Mount Sinai and get them to the doctors at Northwell so they could do their jobs. It was true breakthrough technology, since the interchange was almost completely electronic, with the truly minor annoyance of a dozen phone calls, a couple paper forms and faxes, and a couple packages carried by hand. I know it's hard to believe that such giant systems could be so modern and electronic, which is why I give all the facts and associated proof here.

I felt my tumor growing again. I quickly got an MRI that showed that, unfortunately, I was right. My doctor, the MRI and the follow-on to it were top-notch. The subsequent billing events are an object lesson in how the business of medicine can be improved, see the posts here for details.

My doctor, who had treated my tumor and greatly reduced it with chemotherapy, now felt it was small enough that radiation was the best approach for treatment. He recommended I go to a radiation specialist, who happened to work at Mount Sinai, my doctor's former employer, and where I had originally been treated. Naturally, I took his recommendation. I got radiated. 30 times.

It is standard practice to check the results of radiation 3 months after the treatment. In my case, that meant getting an MRI.

Scheduling the MRI

Here's what I went through to get the appointment. Nothing horrible here; I'm pleased that something so effective as MRI technology is available and that I was able to get it. But the cost, time and convenience all reflect a broken business model. Fixing the model isn't hard in principle, but would require serious change. This is an example of how it works today.

On my final visit with my radiation doctor post-radiation, he told me about the follow-up MRI I should have in 3 months. He told me his office would contact me and get it scheduled "shortly."

Nothing happened. I waited for the 3 months to pass. No one contacted me. Fortunately, I kept track of the time, so I got on it myself.

I started with my radiation doctor's office at Mount Sinai. Sure, they said, you can use the Northwell imaging center to get your MRI. It's convenient for you, so why not? We'll set it up for you.

I wait a few days. Nothing. I call again. Oh, sorry, we'll set it up. I wait a few days. Nothing. I tried again. Nothing. Finally I called the Northwell imaging center and explained the situation. Sure, no problem let's make the appointment. What about the pre-auth? Oh, don't worry, we'll take care of it. You've got all my information in your system from last time, right? Yes. Don't worry.

Two days before the scheduled MRI, I get a call. Hey, about this MRI you're scheduled for, there is no pre-auth for it, so we're going to have to cancel the appointment, there's not enough time to get one. Great. I don't bother complaining, what good would it do?

I realized that I had been totally wrong in my strategy about this. This medical stuff must be making me lose my mind. Or I'm getting colossally stupid. What was I thinking?? I was choosing where to get my MRI done based on what was best for me. WHAT an IDIOT I am!! I know that the smart thing to do is always do what's best and easiest for the medical system. Duhhhhhh!!

Having returned to sanity, I called the Mount Sinai radiation doctor's office. They said they'd set it up. The whole thing, pre-auth and appointment. A couple days pass. I call again. Same thing. A couple more days pass. I call again. Oh, sorry, excuse excuse excuse. I said, no problem can you just please send me the doctor's order? After more shenanigans, I get the order. Giving in completely to the world as it is, I call the Mount Sinai imaging center, where I've been a few times in the past, and make the appointment, making sure that they've got the doctor's order.

Conclusion

I got the appointment. That's the good news. I know that others have had it far worse. But I also know that this peculiar state of affairs, where there's no equivalent of, say, the Open Table scheduling service for making MRI appointments, is a HUGE time-waster for everyone involved. Do you want a job doing what the people I talked with on the phone sort of try to do? Would you want to cope with constant hassle and frustration?

My insurance company knows the treatments I've had. All the information is in the EMR's of the two major systems I've used. It wouldn't be hard to know that getting an MRI at my stage of treatment is something to authorize. The process could be completely automatic. And I could maybe even have made my MRI decision based on my needs rather than the peculiarities of a deeply flawed, broken system.

Next step: getting the MRI.

Medicine as a Business: Billing 4: What's Wrong

Making fun of medical billing, as I have done with gusto in the previous series of posts, is way too easy. Everyone involved knows it's a problem. But it's not getting better. Money that should be spent helping people be healthy or get healthy is instead being spent in completely unproductive ways, annoying and harassing everyone along the way.

It's amazing how many issues are illustrated by just two bills from one healthcare system. Sadly, this is not an isolated example: it illustrates business-as-usual in healthcare billing.

I make no claims to be comprehensive, but fixing the medical billing issues I've illustrated would be plenty!

Here are the prior posts:

http://www.blackliszt.com/2018/07/medicine-as-a-business-billing-overview.html

ttp://www.blackliszt.com/2018/07/medicine-as-a-business-billing-1.html

http://www.blackliszt.com/2018/07/medicine-as-a-business-billing-2.html

http://www.blackliszt.com/2018/07/medicine-as-a-business-billing-3-insurance.html

Here are some of the highlights:

• The first obvious issue that makes medical billing different from the rest of the world is that there are no price lists. You have no idea what you will have to pay. When you sit down at a restaurant, you get a menu with prices. Not in the medical office.
  
• The next glaringly obvious issue: unlike most other services you can think of, the bill was not presented at check-out time! Fixing this would fix a whole host of problems!
• A single health network has multiple billing systems, each amazingly different from the others, each with its own staff, software, costs, etc. It doesn't have to be this way.
• The bills can arrive months after the service was rendered. What service organization you interact with lets billing slide for months? It sure sends a message that they're not serious about collecting.
• When the bill arrives, the address that it comes from and the place to which you send the payment can have totally different names and places from the organization that served you.
• When you get a bill, you sort of expect to know exactly what the bill is for: what service was rendered, when it was rendered, where and by whom it was rendered. Without those key facts, how can you be sure about the bill? Both bills were a strike-out on this subject. Why is it hard to provide this simple, common-sense information?
• For many people, receiving bills and paying electronically is convenient. For many organizations, sending bills and receiving payment electronically is more efficient, and encouraged. As I've illustrated in these bills, the health system's electronic payment is like a programming 1.01 course project -- one that failed.
  • They didn't even try to have e-bills.
    
  • E-payment was offered on the paper bills, but the process was amazingly bad and error-prone.
  • In the end, e-payment simply did not work. Period. And of course, there was no electronic way to get help or even register a problem!
• The second the insurance company is involved, things get real baroque in the bills, with confusing additional information that, in the end, makes no difference to the patient. And without even the name of the insurance company correct.
  

Wow-za! Not that any self-respecting healthcare system manager will spend money on fixing billing instead of promoting innovation, AI and ML anytime soon! Why, if they stooped to merely making things better for patients while reducing costs, they would rapidly lose prestige among their peers in the industry!

 

Medicine as a Business: Billing 3: Insurance

In the prior post in this series, I dove into detail of the bill I got from a doctor visit. The doctor was wonderful. On the other hand, the billing amounts to a deep well of opportunity for innovation, innovation of the kind that doesn't involve blockchain, machine learning, AI or even Big Data! Merely the kind of innovation that reduces costs and makes things better for everyone. That's all.

In this post, we get to dive into a treacherous bay in the sea of healthcare billing the likes of which can be found nowhere else.

The doctor visit bill

Again, here’s the bill I got for a visit with the doctor:

The bill I got for the MRI was pretty discrete about the fact that an insurance company was involved. Here's what they said:

That's all. It flies by so fast, even assuming you read it, most people won't notice that according to the bill (I'm not sure I believe it), they were paid just weeks after the service was rendered. No talk about what was billed, who was billed and what they paid. I'm just a patient, I have no "need to know." What I do need to know is that I owe them $85, and I'd better pay up.

But this is billing for a doctor visit. Different department. Different software. Different bills. Different payment mechanisms. This bill makes clear that the insurance company is a major player here. Here's the first part:

Unlike the MRI bill, this bill tries to tell who was billed how much and for what. Who was billed? "BCBS OUT OF STATE." My insurance company is Anthem. Yes, I know the industry lingo that BCBS means Blue Cross Blue Shield, but the name of the insurer is Anthem. Sorry.

What was the bill for? This:

Remember, we're dealing with a HUGE IT department here, stuffed to the gills with experienced professionals. But I guess that looking at the bills and making sure they make sense is low on the priority list. Do you know what a "comple" is? Because I spend WAY too much time on this stuff, I do know what it means. It's truncated from "complexity."

This is our first glimmer of a fierce, take-no-prisoners war that's actually going on beneath the surface of these innocuous-seeming bills. What presents itself as a bill is in reality a communique from a war zone. The "high complexity," which is a translation of the ICD-10 code that Northwell put in their claim that they sent to the "BCBS OUT OF STATE" is their rocket launched over the trenches to the Anthem side to try to get Anthem to pay more for the 20 minutes the doctor spent with me telling me what I could have read from the radiology report, if the medical system had stooped to giving me the results of the reading of my images, paid for by me. But those trenches are already dug deep, and aren't going to change because a mild breeze of common sense wafts by.

Because of inserting the code for "high complexity" in the claim, Northwell is trying to get the enemy ... oops, sorry, the honorable insurance company ... to pay 641.00 for that visit.

An inquiring mind may wonder, what exactly does Northwell want, given that they're asking for:

Do they want Euro? Peruvian Peso's? Bitcoin? I suspect they want plain old US Dollars, but unlike any other bill you've ever seen, they can't be bothered to get it right.

(You may wonder why I trouble my pretty little head about such "trivial" issues. Simple. I wrote software for 30 years, and led the effort for credit card billing software that now processes half a billion accounts world-wide. I know software in general and billing software in particular. In the same way that an editor has trouble taking seriously a writer who doesn't bother to spell correctly, and that a conductor has trouble taking a candidate musician seriously who flubs lots of the notes, there is good reason to believe that a software group that lets obvious flaws like these appear on patient bills has far deeper problems, and that the "underground" parts of their software are probably nightmares. Which all the evidence shows that they are.)

Now let's shift to the right column. Here's what we see:

More than 2 months after my visit, Northwell claims that "BLUE SHIELD," not BCBS and not Anthem, paid them 232.89 Ether, or whatever currency they ended up agreeing to. So the response to the HIGHCOMPLE rocket was a grenade that, when it exploded, screamed "I'll pay you 36% of what your rocket demanded. BOOOM!!"

Northwell sadly reports to me how badly they lost the battle (they're used to losing), and cleverly inserts a "OK, we lost. Fine." line item of 358.11.

What the &*()&*() is that about? How did they ever arrive at that amount??!

This leads to our next juicy topic...

Insurance Co-pays

Medical systems have a myriad of ways of putting it. Some of them just say something like they did for the MRI bill: "This is what you owe. Really. Pay it. It's your responsibility." Others, like this branch of Northwell, handle it totally differently. They make a pathetic, flawed attempt to do the standard accounting/billing thing of "This is what you started owing, this is what you paid, and this is what's left. Please pay it." Except you haven't paid for a thing! The insurance company somehow decided to pay 36% of the bill, and then Northwell somehow decided to subtract an "adjustment," magically leaving the nice, round amount of 50.00 Yen, Bitcoin or whatever to be paid.

Just to be helpful, they put a line item in there "Patient Payments    0.00." Duhhh. Like, you haven't billed me, man. This is the first bill you've sent me for this, a mere 3 months after my 20 minute visit. Of course I haven't paid. And it's in bold, no less. I guess I'm supposed to feel guilty? Or perhaps just hurry up and pay (via the doesn't-work online payment website) the 50.00?

This whole thing is a fake, of course. As everyone who's dealt with insurance knows, way back around the time the Pope divided the New World between the Portuguese and the Spanish (which is why they speak sort-of Portuguese in Brazil and sort-of Spanish in the rest of South American), a group of genius-level experts, the kind of people who decide important things so that the world will work as it should, got together and invented the notion of "co-pay."

"Co-pay" is one of those ideas that only true experts, people who see farther and deeper than us mere mortals can see, could come up with. The core idea is to give patients an incentive to care about the cost of their health care. If they have to pay something every time they "consume" health care, they'll exercise caution and not use too much of it! That's co-pay. Sheer genius! Even better, we'll make the co-pay something that they owe to their doctor. Genius again -- it's the doctor who's providing services, so of course it's the doctor who should be paid. Insurance companies are hated enough as it is. By shoving the burden of billing and collecting onto the medical systems, maybe they can see what it feels like to be disliked. And get collectors involved. And see what substantial levels of double-digit payment defaults look like on the financials. It's all a good thing because we're influencing patients to be careful about what medical services they consume, and from whom! I really don't understand how this kind of galactic-level genius can sleep at night, quivering from the excitement and self-regard of being responsible for such a transformative idea.

Now back to reality. Do co-pays "work?" I mean, do they influence patient behavior in the way intended? No, of course not. But now they're deeply dug into the trenches separating the payer and provider armies, and extricating them will take a real act of courage.

In this example, suppose Northwell decided to bill 591 instead of 641. Suppose (humor me here) that BLUE SHIELD paid the same lousy 232.89. Suppose Northwell made the same 358.11 ADJUSTMENT. Net result: Bill paid. PAID IN FULL!!

Now was that really so hard? Of course, there are some awful consequences of this. A truce would have to be called on a major part of the front. There are jobs and important bodies of software at stake here, on both sides of the war. And support people. And collection agencies. What would they do with all their time?

Probably the worst consequence would be patient behavior -- patients would start consuming healthcare services like crazy because there's no 50.00 co-pay! Not. The second people respond with the same amount of serotonin to the phrase "don't worry, this giant needle won't hurt a bit, just a pinch" as they do to the question "what kind of massage oil would you like me to use," we'll know we have a problem. Until then, I think we're OK.

Conclusion

This post was supposed to focus on the insurance aspect of medical billing, using an example bill. The bill I used was a typical, benign example; not the kind of extreme example you'd expect when reading something that dives into a problem. I said nothing about pre-auth, denials, deductibles, insurance company coverage notices, or any of the other all-too-common joys of the medical business. That was the point! The transaction described here, with the on-the-surface messes and below-the-surface nightmares are business-as-usual!! And that's sad, for everyone concerned -- which includes pretty much everyone, except those of us who are looking at a small patch of grass from the side of the grass where the roots are.

Medicine as a Business: Billing 2

In the prior post in this series, I presented a couple bills and dove into detail for one of them. Now it's time to see what pleasures there are in the second bill.

The doctor visit bill

Here’s the bill I got for a visit with the doctor who ordered the procedure:

This bill is a bit of a relief compared to the one for the MRI. While the return address (some PO Box in New York) and the address to which payment should be sent (NSLIJ at a PO Box in New York) are opaque and confusing, at least the box in the middle of the page names the doctor I saw and gives the date of the visit. I know what I'm being billed for: a visit with this doctor on that date. That's good!

Let's look a little more closely.

First, there's something interesting about the date. The visit with the doctor was Dec 11. Now look at the statement date: 3/13/18. Yes, that's right: the statement was dated a full 3 months after the visit! Wow. Northwell has clearly optimized their systems to march everything through so they can bill and receive payment promptly, right? Sadly, no.

Second, I'd like to point out an important issue: paper vs. electronic. With all the noise, billions of dollars of federal subsidies, and the obvious fact that electronic is better than paper, you would think that a major NYC hospital system would be entirely electronic. You would be wrong. Here is a post about this. But about this bill:

I got the paper bill in the mail. They could have gotten my email from me at any time, but didn't.

There is no opportunity to sign up for paperless billing, unlike even notoriously backwards bureaucracies like utility and phone companies, which constantly harass you to sign up.

Two things on the bill are highlighted to make them stand out: The amount to pay and the URL to pay it:

I think it's fair to say they're trying to get me to pay online. So I tried. But what a pain! Copying that looooooong URL without error isn't trivial. Then once I entered it correctly, here's where I landed:

They re-directed me: that long string I copied could have been tiny, because it wasn't actually the place they wanted me to go!

But the fun has just started. Now I have to fill out the form:

Once I filled it out, here is the result (with my DOB cut off for privacy):

Fail!

Dutiful person that I am, I got out my ancient check book, revved up my hand-printing skills, and ... yes, put the check in the mail.

There is more joy and fulfillment to be found in this simple-seeming one-page bill, but that's enough for now. For the next installment, we can look forward to some only-in-healthcare wonders of billing.

 

Medicine as a Business: Billing 1

If you were to argue that my fascination with medical billing, including the endless-seeming minutia of it, is somewhat, well unusual, I could not dispute it. "Guilty as charged" (or billed?) would be my only response.

I've learned that the obvious, annoying uniqueness of paying for medical services, different than pretty much anything else in our lives, is the tip of an iceberg of financial pain, metastasizing bureaucracies and festering IT dysfunction for the institutions and people involved in it. See this for some context.

This is a strong, broad statement. Let's dive into some real-life, on-the-ground facts and see what we see.

Background

I’ve been under the care of an excellent doctor, now working at Northwell Health, for a super-rare, long-term condition. I called his office because there was evidence that the condition was worsening. His similarly excellent NP buddy responded to my phone call report by authorizing an MRI of the area in question, and making an appointment for me to see the doctor 4 days later. I truly appreciate how exceptional this accessible and responsive behavior was.

I went to the MRI and then had a consult with my doctor. Sure enough, the evidence I noticed was confirmed by the MRI, and he immediately started the appropriate treatment.

From a medical and scheduling point of view, this experience would be hard to beat. Anywhere, under any system.

This post, however, is about the hospital system billing, with the heavy involvement of my insurer. Every step of the process was chock-full of stupidity, waste, friction and “opportunities for improvement.”

The bills

Here’s a bill I got for the MRI:

 

Here’s a bill I got for a visit with the doctor who ordered the procedure:

 

Take a quick look at the two bills, each issued from the same health system for visits which took place in Manhattan a few days apart. Could they be more different?

Right from the get-go, we know we have a problem. Totally different systems producing bills that are radically different, involving different systems for generation, tracking, and collection. Wow.

Totally different systems

Even though both bills clearly have the Northwell Health logo clearly displayed at both the top and bottom of the page, nearly everything else about them is different. The return address is different, the address to which you send the bill is different, even the little box where the payment is defined is different. It blew me away that even the web page for electronic payment was different!

This means different software systems for generating the bills and collecting the payments, among other things.

The MRI bill

Let's look at that MRI bill. It's written in the form of a letter, which is interesting. It was amazingly prompt: the "service" was "rendered" on Dec 7, while the bill was dated Jan 13, only 5 weeks later. In terms of medical billing, lightning fast!

Who is the bill from? Clearly, Northwell Health. But that doesn't help, because Northwell is a giant system. The return address of the bill says "Lenox Hill Hospital," with a PO Box in New Hyde Park, NY. That's nice, except that there is no place called "Lenox Hill Hospital" in New Hyde Park -- though there is a huge complex that is part of Northwell called "Long Island Jewish Medical Center." So where is "Lenox Hill Hospital?" That's easy. It's a big place on E 77th St in Manhattan. The addresses they give aren't helpful. What about the letter itself. Maybe there's a hint there?

Now we're getting somewhere -- the letter clearly states when and where the service was performed:

Excellent, the service was performed at Lenox Hill, the place on the Upper East side of Manhattan. The trouble is, I didn't go there for my MRI!. Not there, and not LIJ. I went to an imaging center run by Northwell in the Chelsea neighborhood of Manhattan.

Maybe they're talking about something else than my MRI. Let's check out that bill again, and see for sure that it's a bill for my MRI. Uh-oh. Trouble. Nowhere is MRI mentioned in the bill, or medical imaging of any kind! Look again at the bill and the snip of it above. The words used are "services rendered." The wonderful people at Northwell go to the trouble of putting a Spanish-language version of the bill on the other side of the paper, but they can't be bothered to tell me what service was provided or where it was provided. Actually, it's worse. They clearly state in the snip above that the service was provided at Lenox Hill Hospital. Which it was not.

Now try to pay the bill. Hah! They give a website. Let's go there.

I have to guess that they want me to pick "hospital," so I do and pick the one on the bill, Lenox Hill. I hit "submit." Here's the result:

Software is wonderful, isn't it?? Saves trouble, filling out paper, stamps, and all that old-fashioned stuff. Just go on-line and pay. Except when the software doesn't work.

That's plenty for a single blog post. We'll have some fun with the other bill next.

 

Medicine as a Business: Billing Overview

If you break your arm, broken arms are suddenly at the top of your list of least favorite subjects. But after the arm gets better, the billing process for the arm-fixing services is probably pretty high on the list.

Medical billing is something too many of us are way more familiar with than we'd like, but nonetheless will serve as an excellent first subject for this series on the business of medicine.

Let’s start by putting medical system billing in perspective.

Going to a hospital or doctor to get a service is in most ways like going to any place and getting a service.

• You’re hungry, you go to a restaurant and get a meal.
• You’re shaggy, you go to a barber or salon and get a cut.
• You’re bored, you go to a movie or show and get entertained.
• You’re bored and hungry, you go a bar with a show
• You need a book or chair or laundry detergent, you go to the appropriate store.
• For most of the above, you just go. Sometimes, when the service is popular, it pays to make a reservation. You call or do it online, and your space at the place is assured.

A pattern is clear here. When you need something, you go to the place that has, does or serves that thing and you get it. Pretty simple, and universal. Same thing with medical issues!

• You broke your leg, you go to the hospital and get it fixed.
• Your skin gets weird and painful, you go to the doctor and get it checked out.

But there’s something really important that I’ve left out of the above list; I suspect you know what it is. Let’s see if you’ve guessed what it is. I’ll wait and give you some time. Click … click … click … OK, time’s up! Did you get it? You probably did, but just in case, here’s the answer:

The billing and payment are totally different! And the scheduling/reservations are often a nightmare!

Here's how it works for nearly everything:

• For the movie, the price is posted, you pay when you enter.
• For the restaurant, salon, and retail store, you choose from a menu or list or wander around picking things, and pay when you leave based on the services/goods you got.
• For the bar with show, you pay the cover charge when you enter, and your bar tab when you’re done drinking/eating.
• For all of these, you can pay with cash or card. The card could be a credit card, which enables you to pay later or make payments.

Now, let’s look at the big exception: medical billing.

• If it’s an emergency, you might go to the ER and wait for hours.
• If not, making that “reservation” may require a “pre-auth” and a variety of other things that are often painful, and sometimes denied.
• You don’t pay when you enter.
• There are no posted prices, unlike the salon or movie. No menu. No price tags.
• Some stores let you special order things, sometimes one-of-a-kind. Before getting it, you get a price and make a payment arrangement. Not in medicine!
  
• There is no “check-out register” where you find out what the total comes to.
• Unlike a restaurant, where no one has any idea what food and services you’ll receive when you walk in, there is no bill at the end.
• In medicine, it’s common to leave after services have been rendered, and eventually a flurry of bills may arrive from different places and/or notices from insurance wanting information or telling you what’s been “covered” and what they’ll pay.

Go. Get services. Leave. They're all the same. Schedule it and pay for it: it's totally different in medicine!

• “I broke my leg” is like going into a car repair shop knowing you want it fixed, but not being able to do it yourself or knowing what it will cost. It’s your only car, so it’s got to get fixed.
• The car place tells you about what it will cost and you agree to pay when done. Not so at the leg fixing place!
  
• Bills from the ER and a couple doctors could show up over the next couple of months, with lots of fine print. The insurance company probably joins the fun with multiple pages.There's loads of stuff that has no counterpart in the real world of product and service buying.
  
• “I have funny skin” is like going into a salon knowing your hair and makeup just doesn't work for you, and you don't know what to do. You need a new "look" and need help and advice. After a discussion you might look at some pictures and try a couple things out. A specialist may need to be called over.
  
  • You get your new look and pay for the products and services on the way out of the salon. Not so at the skin fixing place!
  • There might be "co-pays" that you owe someone, or maybe not if they're "in network." Letters about any "coverage" some family member may or may not have. Not to mention surprise bills. Nothing that any salon of any kind would ever try if they wanted to keep their customers.
    

All of this is bad. Really bad. It's terrible for patients, terrible for medical people and institutions, and no fun at all for insurance companies. Believe it or not, the behind-the-scenes, underlying reality is even worse! Which is part of why it doesn't get better.

In the later posts in this series, I will go into specifics with real-life examples. In each case, while there are clearly systemic barriers to improvement, there is a clear path to improvement.

Among the issues I'll cover are these:

• The delay between the service and the bill
• Bills from different places
• The difference between provider billing and insurer paying
• What service was provided, where and by whom?
• The challenge of paying the bill

This is going to be fun!

 

Medicine as a Business: Overview

Medicine is a business. It’s a big business. But it’s like no other business, often in ways that are not good for anyone involved.

The good news is that there are many amazing people who work hard, have compassion, and do their best to make things better for their patients. More good news is that dedication and hard work have created drugs and procedures that can cure or alleviate awful conditions, conditions that resulted in pain, suffering and premature death in the past. We are truly blessed.

It’s not news to say that the business of medicine could be greatly improved. When this subject is discussed, it’s usually done in terms of rocks and hard places, or irresistible forces and immovable objects. Then hands are waved, thrown up in the air, and nothing but desperate hopes are expressed.

I believe that the business of medicine can be improved. Greatly. From the outside, it’s impossible. But when I look at the computers and software systems and procedures, I find a particularly ripe example of something I’ve seen many times: decrepit software running on outrageously expensive hardware, surrounded by ineffective business processes, and run by experienced, well-meaning people trapped on a steam-age island in a world that has long-since gone electronic. While there is no magic wand to fix everything in a flash, the technology is available to make dramatic improvements. Today.

To a broadly experienced software person, the solutions are obvious – once the exact technical flaws have been precisely identified. Much of this series will be devoted to spelling out those flaws, not to wallow in them, but to put cross-hairs on them so they can be fixed!

As context for the rest of the posts in this series, let me observe that the issues I will raise are waaaay too "little" to engage the big minds and the great powers in the medical industry. These prestigious and powerful people much prefer to give talks, issue press releases and hang banners about how they and their institutions are "innovative," how they are leading the industry in their use of "cognitive computing" or "artificial intelligence." They hold and/or attend conferences on the subject, and pour money in those general directions, each of which is sure to deliver real results real soon now -- why, the trials are just so promising!!!

That's not my perspective, to put it mildly. See this for some plain words and facts on the subject of fancy-pants innovation in healthcare. And see this for facts and logic that help explain why this subject gets almost no interest or attention from the higher-ups in healthcare management.