Care coordination

A number of pundits are citing the systemic failure of ACOs, after additional Pioneer ACOs announced withdrawal from the program – Where do you weigh in on the prognosis for Medicare and Commercial ACOs over the next several years?”

Peter R. Kongstvedt

KongstvedtWhoever thought that by themselves, ACOs would successfully address the problem(s) of [cost] [access] [care coordination] [outcomes] [scurvy] [Sonny Crockett's mullet in Miami Vice Season 4]? The entire history of managed health care is a long parade of innovations that were going to be “the answer” to at least the first four choices above (Vitamin C can cure #5 but sadly there is no cure for #6). Highly praised by pundits who jump in front of the parade and declare themselves to be leaders, each ends up having a place, but only a place, in addressing our problematic health system.

The reasons that each new innovative “fix” end up helping a little but not occupying the center vary, but the one thing they all have in common is that the new thing must still compete with the old thing, and the old thing is there because we want it there, or at least some of us do. The old thing in the case of ACOs is the existing payment system in Medicare and by extension, our healthcare system overall because for all the organizational requirements, ACOs are a payment methodology.

Continue reading “ACOs Are Doomed / No They’re Not”

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The Bowler Hats Come Marching Home

A recent report from the Commonwealth Fund places the US last amongst developing nations in healthcare. For self-loathing Americans, Christmas couldn’t have come earlier. Raptures of ecstasy were oozing from pores of self-satisfying righteous indignation.

Anyway that, and the shakiness of the metrics for another time.

For now I will focus on one of the conclusions. In analyzing the Britain’s high score on the management of chronic conditions the authors attributed this care coordination to the widespread adoption of health information technology.

That’s like someone saying Chinese food is tasty because chopsticks are widely used.

Sigh! Like quants so fastidious about decimal points they’ve missed the overall point.

Where do I begin?

I’ll start with Mesozoic era, i.e. before health IT was thrust upon Britain’s general practitioners (GPs). Then you had GPs and specialists. In Britain GPs are not optional ornaments for the mantelpiece that you pick up from Ikea when you feel like.

No, they are rather compulsory. Everyone needs to be registered with a GP. Ok, you don’t get fined if you don’t have one, but if you want a referral to a cardiologist you need to see your GP which means you must have one to see in the first place.

Read my lips: no GP, no cardiologist.

If your cardiologist thinks there is nothing wrong with your heart and your problems are supratentorial for which you need to see a shrink, then he must write a letter to your GP asking that he might consider referring you to the psychiatrist. The specialist can’t send you directly to another specialist, bypassing your GP.

Continue reading “It’s the GPs, Stupid. Care Coordination in Britain’s NHS.”

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One of the many challenges I face in my clinical work is keeping track of a patient’s multiple health issues, and staying on top of the plan for each issue.

As you might imagine, if I’m having trouble with this, then the patients and families probably are as well.

After all, I don’t just mean keeping up with the multiple recommendations that we clinicians easily generate during an encounter with an older patient.

I mean ensuring that we all keep up with *everything* on the medical problem list, so that symptoms are adequately managed, chronic diseases get followed up on correctly, appropriate preventive care is provided, and we close the loop on previous concerns raised.

This, I have found, is not so easy to do. In fact, I would say that the current norm is for health issues to frequently fall between the cracks, with only a small minority of PCPs able to consistently keep up with all health issues affecting a medically complex adult.

Continue reading “Zen and the Art of Charting”

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At some point, this gets to be ridiculous. Online, I can buy any item from anywhere at any price, pay any bill, watch any movie, listen to any song, order dinner, schedule car repair or read about any subject on Wikipedia.  I can determine the weather in Rio, sport scores of Barcelona, Parisian traffic or by GPS the location of my kids, just down the block.  However, I absolutely cannot learn anything at all of the health history of the flesh and blood cancer patient sitting right in front of me.

Today, I am seeing long-term patient, Thomas R.  Father of three and a really nice guy, Tom is a medical challenge.

He is immunocompromised and status post 20 years of complex chemotherapy, radiotherapy, a bone marrow transplant and several bizarre complications, we barely understand.  In the last two months, since his last visit with me, he has seen an internist, a dermatologist, a podiatrist, a neurologist, a dentist and an infectious disease specialist.  These doctors ordered X-rays, lab tests, blood cultures, an EMG, a skin biopsy and several new medicines.

These are confusing tests resulting in confusing diagnoses with confusing therapy in a confusing patient.

What records do I have of all this new complexity? Nada. None.  Moreover, based on our files, all these other physicians have none of ours.

Continue reading “Can Facebook Save Us?”

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Today I’m speaking at the ONC annual meeting as part of panel discussing interoperability.

For years, patients, providers and payers have complained that EHRs “do not talk to each other.”

By 2014, I expect this issue to disappear.

Why?

Do I expect that every state and territory will have a robust, sustainable healthcare information exchange by 2014?  No

Do I expect that every provider will be connected to a Nationwide Health Information Network by 2014?  No

Do I expect that a single vendor will create a centrally hosted method to share data by 2014 just as Sabre did for the airline industry in the 1960′s?  No

What I expect is that Meaningful Use Stage 2 will provide the technology, policy, and incentives to make interoperability real.

Stage 2 requires that providers demonstrate, in production, the exchange of clinical care summaries for 10% of their patient encounters during the reporting period.   The application and infrastructure investment necessary to support 10% is not much different than 100%.   The 10% requirement will bring most professionals and hospitals to the tipping point where information exchange will be implemented at scale, rapidly accelerating data liquidity.

Continue reading “Are We Finally Seeing the Dawn of the Golden Age of Interoperability?”

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This is my new office. I signed the lease for this property yesterday – another big step in the process of getting my new practice off the ground.  I should feel good about this, shouldn’t I?  I’ve had people comment that I’ve gotten a whole lot accomplished in the 4 weeks since I’ve been off, but the whole thing is still quite daunting.  Yes, there are days I feel good about my productivity, and there are moments when I feel an evangelical zeal toward what I am doing, but there are plenty more moments where I stare this whole thing in the face and wonder what I am doing.

I walked through the office today with a builder to discuss what I want done with the inside; it quickly became obvious that there was a problem: I don’t know what I want done, and nobody can tell me what I should do.  Yes, I need a waiting area, at least one exam room, an office for me, a lab area, bathrooms, and place for my nurse, but since I don’t really know which of my ideas about the practice will work, I don’t know what my needs will truly be.  How much of my day will be spent with patients, how much will be doing online communication, and how much will be spent with my nurse?  I want a space for group education, but how many resources should I put toward that?  I also want a place to record patient education videos, but some of my “good ideas” just end up being wasted time, and I don’t know if this is one of them.

I come across the same problem when I am trying to choose computer systems.  I know that I want to do that differently: I want the central record to be the patient record, not what I record in the EMR.  I want patients to communicate with me via secure messaging and video chat, and I want to be able to put any information I think would be useful into their PHR.  So do I build a “lite” EMR product centered around the PHR, or do I use a standard EMR to feed the PHR product?  Do I use an EMR company’s “patient portal” product, or do I have a stand-alone PHR which is fed by the EMR?  I have lots of thoughts and ideas on this, but I don’t really know what will work until I start using it.

Continue reading “The Good Doctor Learns to Fly”

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What comes to mind when you hear the term “medical home?”  Perhaps you favor the definition put forth by our government (AHRQ):

The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care.

1. Comprehensive care
2. Patient-centered
3. Coordinated care
4. Accessible services
5. Quality and Safety.

The presence of these five attributes to care should then constitute a medical home, right?  It depends on who you get your definition from.

Continue reading “The Organic Medical Home”

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Health information technology has, in many ways, been a calling for me. I passionately believe in the ability of technology and information to reduce costs, improve quality and transform healthcare. For the last seven years (I won’t say the “better part” as my wife and kids would probably not appreciate that characterization…on the other hand, they would quickly confirm that it has consumed most of my waking hours), I have collaborated with hundreds organizations in healthcare and technology across the public sector and the private sector to try and positively influence the adoption and use of health information technology. By many measures, this work has been successful.

Awareness levels and perceived value of health IT among doctors, hospitals, policymakers and many other audiences has improved dramatically. A wide majority of physicians in the U.S. have by now adopted technologies such as electronic health records and e-prescribing. Playing a small part in this progress to date has been the most gratifying work of my career.

But then came Dad and his own personal experience with health IT. My father’s experience as a patient has left me questioning the level of progress that has been achieved.

Continue reading “Health IT and Dad”

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Once again, the Supreme Court was unsurprisingly surprising. The conventional wisdom was that at least part of the health reform law would be overturned, but in practice the court blessed the status quo we have known for two years: The reform law will continue to be implemented.

It’s the devil we’ve known. Washington will issue more regulations. Insurers will be buried in requirements on coverage and benefits, driving up costs. Physicians will have more oversight and report to the government. Hospitals will see Medicare cuts. Millions of individuals will either get a new federal subsidy for insurance or be enrolled in Medicaid.

States will have more interference from Washington. While the Supreme Court gave them some flexibility on whether to expand their Medicaid programs, states will still be forced to either build a new insurance exchange, like Expedia for health insurance, or have the federal government build it for them.

By upholding the law, the court also left untouched two huge problems looming on the horizon. First, as the law expands coverage there will be a tremendous increase in demand for medical services, but there will not be an increase in the number of doctors, nurses and other providers to deliver care.

Millions of people may have very generous coverage, but they will struggle to find providers to deliver it.

Second, as businesses face requirements in 2014 to offer federally approved health insurance or pay a fine, many companies will do the math and see that paying the penalty is far less expensive than continuing to provide coverage.

Continue reading “The Devil We Know”

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Don’t assume anything.

Assumptions can kill.  

Assuming something regarding your own health care can cost you money, cause you pain, and yes, even kill you.  Here’s my list of potentially harmful assumptions:

1.  No news is good news

If you have a test done and don’t hear anything about the result, do not assume it is fine.  This assumption kills people.  I have too many patients with too much information flying at me every day for me to catch every important detail.  Sometimes things are missed, but sometimes the results don’t come to our office.   We have trained our patients to expect an email or letter with their results within a certain amount of time, so they sometimes call when the test results don’t come in.  I tell them to do so in the clinical summary sheet I hand out at the end of each visit, but the assumption remains.

Continue reading “Zen and the Art of Not Thinking Magically”

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