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Go Beyond Using Your EHR; Practice Heads Up Medicine

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Tom GuillaniWhen providers and their staff don’t have the time or tools to effectively communicate with patients, a slew of issues can result: from physicians missing important cues and misdiagnosing patients to preventable hospital readmissions and poor outcomes because patients didn’t understand or follow care guidelines.

The problem has become endemic. According to one study, 80% of what doctors tell patients is forgotten as soon as they leave the office. Beyond that, 50% of what the patient did recall is incorrect. In addition to impact communication and follow up have on care and outcomes, patients are expecting a different experience than they once had. Nearly two thirds of patients now say they would consider switching to a physician who offers access to medical information through a secure Internet connection.

Ridicule Mehmet Oz, Don’t Have Him Fired

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If I could invite four people for dinner, alive or dead, they would be Mark Twain, William Shackleton, Christopher Hitchens and Homer Simpson (Bart’s dad). If Mehmet Oz turned up with a bag of Garcinia Cambogia I would excuse myself.

Few things drive me to the abyss more reliably than the banality of status updates on Facebook and the monotony of health freaks. I would rather face the aftermath of Vindaloo followed by industrial strength Picolax than watch an episode of the Dr. Oz Show.

Did you catch that? Show. Like Dog and Pony show. Punch and Judy show. The Dr. Oz Show is a show. Not to put too fine a point, but physicians asking Columbia University to fire Dr. Oz are giving his show more profundity than it self-evidently deserves.

The obvious retort is that Oz is using his position as faculty of a prestigious university to promote dodgy metaphysical claims. Ah, the narcissism of academics! Priceless! As the saying goes, for everything else there is master card…

POLICY: More on Mass, by Eric Novack

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Sometimes (perhaps too often!) I agree with Eric Novack. Here’s what he writes about the pay or play version of the new Mass plan:

The recently passed bill in Massachusetts, well reported here at THCB, aims to provide ‘universal health insurance’ to state residents through personal and employer mandates, plus Medicaid expansion. It still has not been signed/ modified by Governor and future GOP Presidential candidate Mitt Romney, but the state legislature is already threatening to override any changes the governor might make.

I want to focus briefly on the employer mandate. The law, if unchanged, states that employers who do not provide health insurance would be assessed $295 per employee per YEAR. That’s right. Employers would pay about $300 per year per employee if coverage is not offered.

Does anyone see the problem? Most small businesses spend close to $300 per MONTH per employee now, for ‘good’ coverage.

Math never looks good in print, so I’ll make this example brief. Small business, ‘Matt’s Place’, has 20 employees. Currently, covering health insurance for those 20 costs 20 x $300 x 12 months = $72,000 per year. (That’s $6000 per month.)

Under the Massachusetts plan, if ‘Matt’s Place’ did not provide coverage, it would cost about 20 x $300= $6000 per year.

Hmmm. $72,000 versus $6000. And the employees would still be covered with insurance. And the company saves $66,000. A small business. Hmmm.

Any idea what is likely to happen?

I do not like predictions (my crystal ball is rather cloudy). But here is one. Within 3 years the number of small businesses offering insurance plummets. The ability of the state to cover expenses in a system that has no utilization controls plummets. And the state is forced to raise some combination of income taxes, sales taxes, property taxes, business taxes or completely revise the system.

But I am not against the experiment. I could be wrong.

Drug margins under fire

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Today’s NYT has an article (Reg Reqd) pointing out how vulnerable the PPI (ant–ulcer/anti-heartburn) drug market is to the oncoming generic versions of Prilosec.  Prilosec has been about the most successful drug in history (somewhere around $6 bn a year at its height) and catapulted Astra-Zeneca into the first rank of pharma companies.  They’ve also successfully switched their marketing focus to consumers and doctors over to its successor drug, Nexium, including moving the "purplepill" website. The Times reports that generic makers including division of Novartis and of P&G are going to come after the markets of Nexium, Protonix and the rest with generic Prilosec, and it’ll cost 1/5th the price. Wellpoint, the health plan which successfully got the FDA to agree to move Claritin and its allergy competitors to OTC status, is already planning to move as many of its members as it can to the generic Prilosec.

This is beginning to remind me of the early 1990s when there were few new blockbusters, and many old ones, including the first PPIs Zantac and Tagamet,  were coming off patent. Some companies then tried to manage a "brand to OTC" strategy, such as Syntex with the brand (Naproxen) that is now the OTC drug Alleve.  Syntex found that the sales for the brand fell off a cliff rather than rolled down a slope (and part of the result was their being swallowed by Roche). Then as now drug companies were concerned about the impact of a big new government program, and their stock prices were at bigtime lows. Look at this chart of Merck’s historic price and compare the 1992-94 dip to the one in the last 2 years)

However, overall drug companies have continued to be remarkably successful in both delaying the introduction of generics, albeit by using loopholes that have been partially closed, and at convincing doctors not to bite the hand that feeds them, even though some say they want to. What really will make the difference in their future is the next set of blockbusters.

You can historically look at parts of health care where drugs have replaced hospitalization. For instance anti-biotics replaced TB Sanatoriums, which represented some 30% of health care spending in the 1920s and 1930s, and indeed the first PPIs essentially replaced ulcer surgery. You can also argue that the statins are doing a pre-emptive strike on heart surgery rates in 10-20 years time.  But with no imminent blockbuster class on the near horizon, big pharma is scrambling to discover which part of today’s health care system they’re going to replace with a pill, or which unrecognized "disease" they can convince people they can cure (think Viagra).  Because that’s the road to another stock run-up as we saw in the late 1990s. I don’t think it will be as easy for them this time, but don’t write this industry off!

HIT Newser: Big Win for Epic in San Diego

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 Epic Scores Another Big Win

Scripps Health selects Epic to replace its existing GE Healthcare’s Centricity Enterprise (inpatient) and Allscripts Enterprise (outpatient). The San Diego-based Scripps includes five acute-care campuses, 26 outpatient clinics, and 2,600 affiliated physicians.

No doubt that this is one that Cerner had hoped to win.

Marlin Equity Partners Acquires e-MDs

Marlin Equity Partners acquires ambulatory EMR provider e-MDs. Marlin will merge e-MDs with its existing portfolio company MDeverywhere, a provider of RCM and credentialing services for physicians. e-MD founder

HIT Newser: Millions and Millions for More Interoperbility

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Athenahealth Pushes Further Into the Inpatient World

Beth Israel Deaconess Medical Center partners with athenahealth to enhance its homegrown in-patient EHR. Athenahealth is buying Beth Israel’s clinical applications, which it will enhance and rebrand as athenaNet. The purchase comes just a few weeks after athenahealth’s purchase of RazorInsights, an EHR platform for rural and community-based hospital.

Never underestimate Jonathan Bush’s ability to disrupt the HIT world. Athenahealth may be a little late to the in-patient EHR party, but they wouldn’t be the first company to successfully transition from an ambulatory-only vendor to an enterprise vendor: Epic, of course, got its start as a provider of ambulatory solutions.

ONC Offers $28 Million to Advance HIE

The ONC will award $28 million in grants to advance the adoption and use of interoperable HIT tools and services to support HIE.

The announcement coincided with the ONC’s annual meeting – which reportedly focused heavily on interoperability issues – and on the heels of the agency’s release of its draft HIT interoperability roadmap. Though it’s still early, “interoperability” seems to be taking an early lead as this year’s top HIT buzz word.

MGMA Asks CMS to Reduce Portal Duplication

The MGMA asks the federal government to consolidate its reporting programs and eliminate its use of multiple Web portals for physician reporting.

MGMA says its best: “it makes not practical sense to have multiple systems which create unnecessary work by requiring duplicative registration with separate usernames and passwords for physicians and practices to access reports or report information pertaining to Medicare Part B programs.”

FDA Recommends Minimal Oversight for Medical Devices

The FDA finalizes guidance on data transmissions from medical devices, saying it doesn’t intend to regulate software that receives, transmits, stores, or displays data due to the low risk to patients.

That’s good news for mHealth developers and enthusiasts, who had been concerned that too much regulation might spur continued innovation in the space.

Wheeling and Dealing

  • CareTech Solutions wins an eight-year agreement with Maryland’s Adventist HealthCare to provide outsourced IT services.
  • Boulder Community Health selects Voalte’s smartphone mobile communication technology for its acute-care hospital and regional trauma center facilities.
  • Lehigh Valley Health Network’s 200 outpatient offices go live this month on Epic as the first phase of the health system’s $200 million implementation. LVHN’s regional competitor St. Luke’s University Health Network will also be switching to Epic at a later date.
  • Gulf South Quality Network in Louisiana selects Medecision to build a data warehouse based on Medecision’s Aerial platform.

Show Me the Money

  • Athenahealth reports Q4 adjusted EPS of $0.58 versus the previous year’s $0.57 and beating analysts’ estimates of $0.39. Revenue was up 24%. Despite the strong performance, analysts note that revenue from Epocrates services fell 32% from the previous year, and, general and admin costs grew more than 50% as a result of increased headcount.
  • McKesson posts Q3 EPS of $2.89, up from last year’s $1.48 and beating estimates of $2.62. Revenues grew 36.9% to $47 billion, beating estimates of $44.6 billion. Despite strong overall results, revenues from McKesson’s Technology Solutions segment fell 7.3% as the company continued its planned elimination of its Horizon hospital software product line.
  • Vital Medicals, a developer of a smart glasses application for surgeons, raises $925 million from angel investors and the Stanford StartX Fund.
  • Telehealth solution provider Kura MD secures $1.5 million from Moneta Ventures.
  • PB Capital Holdings invests an undisclosed amount in EHR provider ITelagen.
  • Under Armour acquires Enomondo for $85 million and MyFitnessPal for $475 million, establishing the company as the “largest digital fitness community” reaching more than 120 million users.
  • Workflow automation software provider Aventura closes a $14 million Series C financing round co-led by Safeguard Scientifics and Merck Global Health Innovation Fund.

New Blood

  • Kaiser Permanente names Richard (Dick) Daniels EVP/CIO. Daniels has served as interim CIO since September 2014; previously he was SVP of enterprise shared services for Kaiser.
  • Former Epic executive Dave Cassel joins Healtheway, a nonprofit collaborative focused on advancing interoperable HIE, to lead the company’s Carequality initiative.
  • RemitData appoints Laura Hescock (Public Consulting Group) director of strategy and operations and Stacie Bon (Rodgers Townsend) senior director of marketing, and, promotes Jason Whiteaker from director of sales to VP of partner strategy.
  • Specialty surgical hospital network Coordinated Health names Greg Flanagan, former COO for Advanced Health, CIO.

Etcetera

  • A spokesperson for New York City Health and Hospitals Corporation attributes its use of EHR for protecting the health system from record loss after a fire destroyed a warehouse that housed duplicate copies of archived patient records.

Unicornius Gorus – Theranos and Zenefits

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The Lab test reinvented – Theranos

So I have to ask Theranos; which lab test have you reinvented?  Is it the one where you do a full blood draw and send it off to UCSF to pay way more than the amount you charged the patient?  Is there something in that business model I am not getting?  Or did you reach back to the old “I’ll make it up in volume” approach.

The Nation’s First Modern Benefits Broker – Zenefits

And you Zenefits, if your idea of “Modern Benefits Broker” is that they are not licensed to sell insurance, I think I’ll go for the pre-modern broker.Yes I know, I’ve heard it soooooo many times, all it takes is a bit of silicon valley whiz bang and the whole world will be better, take that unique bravado and creativity and apply it to healthcare, change the world.

Only one small problem; as Esther Dyson said at Health 2.0 many years ago and I’m paraphrasing from memory:

I’ll come back in two years and most of you won’t be here, why because you don’t understand healthcare.  You can build all the great systems you want, but if they don’t work in healthcare, because you don’t understand it, you’re done.

The Self-Care Rx

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“The system only changes if we empower the one person who cares about their health the most – the patient. Over the next decade, I believe people will become the CEOs of their own health.” Vinod Khosla

Self care is the future for the simple reason that nobody wants to be a patient. Of course we want care when we need it. We want to be well. We want a good life. We want independence. We want control, and we certainly don’t want to need care nor to lose control.

And becoming a patient, for better or for worse, implies giving up control. Being a patient implies there are gatekeepers, there are limits, there are constraints, there are decisions we can’t make for ourselves. We can’t always get the access we want. Talk to patient advocates and you’ll find people fed up with the lack of control, lack of ownership and the lack of help from the health care system.

Statin Wars: Less-is-More versus Unlimited Medicine 

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flying cadeuciiIt is the beauty of evidence-based medicine (EBM) that a scientist can at once be a Pope and a Galileo. His transmutation is as effortless as it is discretionary. If you think you’ve met Galileo – a rebel, a free thinker, a rocker of the establishment – the following week he is a Pope, castigating detractors, censoring critics, and celebrating uniformity. He changes by a roll of the dice. His change is decided by a quirk in hypothesis-testing known as statistical significance. If the p value is 0.051 he is Galileo, if the p value is 0.049 he becomes the cardinal. He is one day a raging skeptic and another day a true believer.

The latest fight between orthodoxy and free inquiry is about the benefits and harms of statins for primary prevention. A review, and an editorial, in the Lancet said the benefits of statins are real, the harms are exaggerated, and skepticism of benefits of statins should be censored because doubt can harm the public who may not take their statins and thus die prematurely. Stated differently, skepticism kills. The lead author of the review once asked the BMJ to retract a study which he felt overplayed the harms and denied the benefits of statins. The editor compared the fear about statins to fear about vaccination. Statin skeptics, like vaccine deniers, are now medicine’s truthers.

A Letter from CMS to Clinicians in the Quality Payment Program: We Heard You and Will Continue Listening

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screen-shot-2016-10-14-at-8-43-48-amToday, we are finalizing policies to implement the new Medicare Quality Payment Program. Part of the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Quality Payment Program aims to create a more modern, patient-centered Medicare program by promoting quality patient care while controlling escalating costs through the Merit-Based Incentive Payment System (MIPS) and incentive payments for Advanced Alternative Payment Models (Advanced APMs).

After issuing our proposal for how to implement the new program earlier this spring, we held a listening tour across the country to hear your thoughts and concerns first-hand about the Quality Payment Program. Whether you formally submitted one of the over 4,000 comments we received, or were one of the nearly 100,000 attendees at our outreach sessions, there have been record levels of clinician engagement. The interactions reflect the importance you place on serving the more than 55 million individuals that have Medicare coverage.

We found an eagerness to help the Medicare program improve and an interest in being engaged in how we address the challenges and opportunities ahead. We also heard concerns, which is not surprising, given the challenge of changing something as large and important as the Medicare program. But, we found that there is near-universal support for moving towards a future focused on patient care that pays for what works, reduces clinician burden, and better supports and engages the medical community.