Tech

Tech

Stephen Curry’s Health Care Plan

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The 3 point shot has revolutionized basketball and turned the NBA upside down. The smartphone has revolutionized health care and turned the doctor-patient relationship upside down.

Let’s examine those two statements.

In a recent Wall Street Journal article, Martin Johnson describes the dramatic changes that the creation of the 3 point shot has created. The prior era in was dominated by a dominating big man-  Bill Russell, Wilt Chamberlin, and Kareem Abdul Jabbar.  As Johnson writes, “This made intuitive sense: The better a team is at protecting its basket, the better its defense should be.”

Suddenly, the rules changed and the 3 point shot was created.

With new rules, new values.

With new rules, new math, new economics for the NBA.

What had been valuable- the dominant big center to defend the basket- is no longer as valuable.

What had not been as valuable- a small, quick, long distance shooting guard, and those best suited to defend against them- now are a valued resource.

The evidence of this ‘transformative innovation’ is everywhere; from Stephen Curry, a small nimble, excellent shooting guard, winning the NBA MVP award to the NBA finals between the Cavaliers and the Warriors- where the defense is as fierce at the 3 point line as it is right under the basket.

So the  new rule establishing the 3 point line has turned the game inside out, shifting the focus from the ‘big man’ to a new type of player – as John Hollinger, the Memphis Grizzlies vice president of basketball operations, states in the Journal, “It has completely changed the way players are valued on the market.  Now we put a premium on length and basketball IQ.”

Straight Talk About Direct

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Those of us who have spent years arguing in favor of standards based health information exchange (HIE) have just had a few good months. The federal government has asked IT vendors and providers what it can do to advance health information sharing across organizations. This has drawn new attention to “interoperable” health IT systems and the quality and economy of care delivered to Medicare and Medicaid beneficiaries.

In late March, the Office of the National Coordinator for Health IT (ONC) awarded cooperative agreement grants to two non-profit trade groups working to certify and credential electronic health records (EHRs) and health exchange service providers whose products are capable of secure data sharing — that is, of “talking to one another.”  (Disclosure: I am the President and CEO of one of these alliances, DirectTrust.)  The tone of the conversation has definitely changed.

My sense, though, is that most people still don’t have a firm grasp on the issues. They remain uncertain or confused about what interoperable health information exchange really means to providers and patients, how it can be achieved, the barriers that remain to be overcome, and who is making the decisions about these matters. So this seems like a good time for both an update and a refresher of sorts on the nature of health information exchange, and to explain why this is not a good time to reduce spending on health IT in America.

Let’s start with what is probably the most important thing to understand: we are very, very close to national deployment of a relatively simple standard, known as Direct, that enables secure Internet transport of health information between people, organizations, and software. Direct exchange permits users of any EHR to send and receive messages and files from any users ofany other EHRs, regardless of operating system or vendor. In fact, Direct facilitates secure messaging, with attachments, to and from anyone with Internet access. It makes EHRs interoperable with one another, but also facilitates secure communication with providers and patients using Internet devices of almost any kind.

Internet Self-Diagnosis: Mapping the Information Seeking Process

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We’ve all been there. It’s early morning, and you wake up feeling groggier than usual, sensing the onset of a sore throat and a runny nose. Before crawling out of bed, you grab your smart phone and, naturally, Google “groggy sore throat runny nose symptoms.” Hundreds of results pop up, suggesting various illnesses and links to seemingly promising remedies. How could anyone filter through page after page of links, ranging from everyday allergies to deadly diseases?

Many of our health choices are made outside the doctor’s office. The simple decision of whether symptoms are severe enough to warrant visiting a healthcare provider is one of them. For some patients, that decision is easy, because regardless of the severity of symptoms, from a simple cough to leg pain, getting in to see a healthcare provider is easy. Unfortunately, many people still struggle to find a healthcare provider, get an appointment, and/or obtain transportation. These individuals are left to turn to other health information resources, such as the Internet, to determine whether their symptoms are severe enough to navigate these barriers.

The “digital divide” has become a catchphrase for how differences in educational, social, and economic backgrounds can affect access to web-based tools and services, as well as the general ability to use the Internet.

That divide has serious healthcare consequences: Though the web is not intended to replace traditional medical care, it may offer one of the few available sources of information for those with limited access to health services. While patients who regularly visit a provider are privy to the diagnostic processes of medical professionals, web-based tools may be critical in weighing the severity of symptoms for those with fewer resources and less access. 

The Nurse Practitioner … Er, We Mean Doctor Is In

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flying cadeuciiA rash could be leukemia or idiopathic thrombocytopenic purpura. A sore throat could be glossopharyngeal neuralgia or a retropharyngeal abscess. A blocked ear could be Ramsay-Hunt syndrome, a self-limited serous otitis or sudden sensorineural hearing loss with an abysmal prognosis if not treated immediately with high doses of steroids. A headache or sinus pain could be cancer, and a cough could be a pulmonary embolus or heart failure.

Treating the Well:

In my early career in Sweden, well child visits were done in nurse-led clinics, some of them only open on certain days, with a local doctor in attendance. Parents carried the children’s records with them, containing growth charts, immunization records and so on.

These nurses had great expertise in differentiating normal from abnormal appearance of children, and would direct the attending physician’s attention to children with abnormal metrics, appearance or behavior.

With this arrangement, the physician time requirement was reduced, and limited to evaluating children attending the clinics who needed special attention. Physicians also performed specific examinations at certain ages, such as checking for hip clicks. These clinics freed up the local pediatricians to evaluate more sick children.

Well-baby visits are now the bread and butter of American pediatricians and family practitioners, and with the ever expanding mandates of politically determined items that must be covered in order for doctors to get paid for their services, we sometimes have trouble accommodating illness care demands.

Coming To a Decision On Decision-Support Technology

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Jaan SidorovFor more than a decade, a running joke among electronic health (EHR) record skeptics has been that its clunky “decision support” functions, defined as the on-screen provision of clinical knowledge and patient information that helps physicians enhance patient care , is condemned to always remain an innovation of the future.  Yet, while published studies like this continue to fuel doubt about the prime-time readiness of this EHR-based technology, a growing body of clinical research suggests that the science is getting better.  Jonathan Cohn, writing in The Atlantic, points out that IBM’s Watson has achieved enough of a level of sophistication to warrant clinical trials at prestigious institutions such as the Cleveland Clinic and Memorial Sloan-Kettering.

Unfortunately, there is an under-recognized threat to EHR-based decision support: the dysfunctional U.S. tort system.

The experience of Google’s “driverless car” may be instructive. According to National Public Radio, years of testing is putting this technology within reach of consumers.  Thanks to the prospect of fewer accidents, better transportation options for the disabled, reduced traffic congestion and lower hydrocarbon consumption, some states have responded by attempting to support this promising technology with “enabling legislation.”

Unfortunately, the legislation in some state jurisdictions is being hindered by the prospect of complicated lawsuits.  As physicians know all too well, when a single mishap lands in court, adroit attorneys can use the legal doctrine of joint and several liability  to tap multiple deep pockets to increase the potential size of the award. In the case of driverless cars – in which the owner is more of a passenger than a driver – the accidents that are bound to happen could metastasize upstream from the owner and tie up the driverless automobile manufacturers and all of their business partners in time-consuming and expensive litigation.

Ditto the EHR’s decision support technology. Even with Watson’s intelligence, medicine will remain imperfect and allegations of medical mistakes will be inevitable. When lawsuits arise, the defendant medical providers will likely argue that their judgment was clouded by the very technology that otherwise helped them better serve their other patients. Personal injury lawyers are unlikely to let that theory of liability go unused. Tapping the same kind of lucrative joint-and-several legal theories that have served them so well in decades of standard malpractice litigation, they’ll undoubtedly be happy to name the EHR manufacturer and all of its decision-support business partners in these lawsuits.

The Story Behind the CommonWell Story

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Arguably, the biggest news story coming out of HIMSS last month was the announcement of the CommonWell Health Alliance – a vendor-led initiative to enable query-based, clinical data sharing. So much has been written about CommonWell that there is little need to rehash what has been said before.

What has not been said, or at least has been sensationalized nearly to the point of irrelevance is the whole controversy surrounding Epic and how they were not invited to join the CommonWell Alliance until after the announcement. None other than Epic’s own founder and CEO, Judy Faulkner, has gone on record stating the Epic was unaware of CommonWell prior to the announcement. Faulkner has gone on to question the motives of CommonWell, in an effort to subvert it, in her highly influential role on the Dept of Health & Human Services HIT workgroup committee.

That was the last straw.

It is one thing to moan and groan at the HIT love fest that is HIMSS, where vendors commonly discount the announcements of competitors. But it is quite another thing to be a part of a highly influential body that is defining nationwide HIT policy and make the same claims over again, especially when they are frankly not true.

Meet Propeller Health: Digital Health’s Poster Child for Invalid Savings Reporting

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We’ve seen shorter abstracts, and we’ve seen abstracts with more curious findings, but we’ve never seen a shorter abstract with more curious findings than this one, done by Dignity Health and Dr. Rajan Merchant, and financed by the California Healthcare Foundation, evaluating a gadget made by Propeller Health.

The study group’s use of inpatient care for asthma declined by a whopping 62% vs. the control group.  You might think this result violates Dr. John Ioannidis’ well-known conclusion that large treatment effects are usually wrong, but you’d be mistaken.  You see, there was no treatment here.

There was only an effect.  Dr. Ioannidis’ result applies only to actual comparisons of effects due to different treatments, not to random changes in effects using the same treatment.  In this study, the actual treatment protocol was the same and the inhalers were the same.

The only thing different was frequency of drug use.  Whereas the conventional wisdom for disease management states that hospitalizations can be avoided by more adherence and hence more drug use, in this case the study group used less medication than the control group, reaching for their rescue inhalers 25% less– once every 6.3 days vs. every 4.7 days for the control group.

Death of an Evangelist

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It feels like part of me is dying. I am losing something that has been a part of me for nearly 20 years.

I bought in to the idea of electronic records in the early 90′s and was enthusiastic enough to implement in my practice in 1996. My initial motivation was selfish: I am not an organized person by nature (distractible, in case you forgot), and computers do much of the heavy lifting in organization. I saw electronics as an excellent organization system for documents. Templates could make documentation quicker and I could keep better track of labs and x-rays. I could give better care, and that was a good enough reason to use it.

But the EMR product we bought, as it came out of the box, was sorely lacking. Instead of making it easier to document I had to use templates generated by someone else – someone who obviously was not a physician (engineers, I later discovered). So we made a compromise: since it was easier to format printed data, we took that data and made a printed template.

User Fees for Electronic Health Records?

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President Obama has released his 2014 budget proposal, which includes $80.1 billion in spending for theDepartment of Health and Human Services (HHS), an increase of  $3.9 billion. The proposed budget for The Office of the National Coordinator for Health IT (ONC) would increase its $61 million budget to $78 million, a 28% increase. The plan also includes a $1 million fee for electronic health record vendors that would almost certainly be passed along to users of the systems.

“In addition to the expanding marketplace and corresponding increase in workload for ONC, much of the work to date has been funded using Recovery Act funds scheduled to expire at the end of FY 2013. Consequently, a new revenue source is necessary to ensure that ONC can continue to fully administer the Certification Program as well as invest resources to improve its efficiency,” the ONC explains in the budget proposal appendix.

In particular, the fee could be used to fund:

  • Development of implementation guides and other forms of technical assistance for incorporating standards and specifications into products
  • Development of health IT testing tools that are used by developers, testing laboratories and certification bodies
  • Development of consensus standards, specifications and policy documents related to health IT certification criteria
  • Administration of the ONC Health IT Certification Program and maintenance of the Certified Health IT Product List
  • Post-market surveillance, field testing and monitoring of certified products to ensure they are meeting applicable performance metrics in the clinical environment

A Little Advice for Karen DeSalvo

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Karen DeSalvo started as the new National Coordinator for Healthcare Information Technology on January 13, 2014.   After my brief discussion with her last week, I can already tell she’s a good listener, aware of the issues, and is passionate about using healthcare IT as a tool to improve population health.

She is a cheerleader for IT, not an informatics expert.  She’ll rely on others to help with the IT details, and that’s appropriate.

What advice would I give her, given the current state of healthcare IT stakeholders?

1.  Rethink the Certification Program – With a new National Coordinator, we have an opportunity to redesign certification. As I’ve written about previously some of the 2014 Certification test procedures have negatively impacted the healthcare IT industry by being overly prescriptive and by requiring functionality/workflows that are unlikely to be used in the real world.

One of the most negative aspects of 2014 certification is the concept of “certification only”. No actual clinical use or attestation is required but software must be engineered to incorporate standards/processes which are not yet mature.   An example is the “transmit” portion of the view/download/transmit patient/family engagement requirements.

There is not yet an ecosystem for patients to ‘transmit’ using CCDA and Direct, yet vendors are required to implement complex functionality that few will use. Another example is the use of QRDA I and QRDA III for quality reporting.

CMS cannot yet receive such files but EHRs must send them in order to be certified.   The result of this certification burden is a delay in 2014 certified product availability.