By Michael Painter, MD

From SFO, I carefully followed my Droid Navigator’s directions off Highway 101 into a warren of non-descript low-slung office buildings—non-descript except for the telltale proliferation of Google signs and young adults riding colorful Google bikes.  I drove around to the back of several of those complexes and finally found the correct numbered grouping.  It really could have been any office or doctors’ office complex in the U.S.  The Khan suite is on the second floor.  There’s a simple brass plate saying “Khan Academy” on what looked like oak double doors. I let myself in and immediately encountered a large, central open space—with long dining tables, food, an ample sitting area with couches conducive for group discussions—and a friendly greeting by programmers and staff.  Oh, and computers—there were lots of computers.  As far as I could tell, nobody had their own office—though maybe Sal does.  Everyone was also open, friendly and passionate about the great work happening there.

After some trial and error, Rishi and I found an unused office and huddled around his Mac for a Google Hangout interview with a Bay Area reporter about the Khan/RWJF health care education project.  Later, I met with Shantanu, the Khan COO and former “math jock” high school friend of Sal, as well as Charlotte, external relations, and Matt, software engineer. They’re all long termers at Khan—that means they’ve been there for about two years.  Overall, the energy was pretty electric.  One other small thing—do not be fooled—these incredible people are, how should I put it—ferociously—intense and focused.

Pioneers in flipping the med school classroom

The next morning, Rishi and I met at Stanford Medical School—in the Li Ka Shing Center for Learning and Knowledge—an enormous and beautiful building off Campus Drive near the hospital that did not exist back in my days as an earnest Stanford law student.   We were there to observe some pioneers in medical education attempt to use Khan-like videos to flip the medical school classroom.  This work at Stanford is part of the current Khan Academy and RWJF collaboration. We’re trying to understand what happens when a medical school attempts to use the Khan-style videos to change the classroom interaction.

Continue reading “What the Khan Academy Teaches Us About What Medical Education Will Look Like Ten Years From Now”

By Michael Painter, MD

I am a family physician, but one who doesn’t currently practice and importantly, one who isn’t slogging day after day through health care transformation. I do not want to be presumptuous here because the doctors and other health professionals who are doing this hard work are the heroes. They are caring for patients while at the same time facing tremendous pressure to transform their life’s work.  That includes overwhelming pressure to adopt and use new information technology.

This level of change is hard, difficult and confusing—with both forward progress and slips backward. Nevertheless, doctors take heart because you are making progress. It may be slow at times, but it’s substantial—and it’s impressive. Thank you.

The Annals of Internal Medicine today published a study (I was one of the authors) finding that more than 40 percent of U.S. physicians have adopted at least a basic electronic health record (EHR),  highlighting continued progress in the rate of national physician adoption of EHRs. The study, also found that a much smaller number, about 9.8 percent of physicians, are ready for meaningful use of this new technology.

Some might say, “Wake up, folks!”   Look at those small meaningful use numbers.  Change course, now.  After all of this time and tax-payer expense, less than 10 percent of doctors are actually ready to use these important tools meaningfully. What’s up with that?

To me, though, this study is good news. All who care about health care transformation should be heartened by the progress—but also impressed by the enormous challenge that our health professionals have undertaken.

Continue reading “Electronic Health Records. Are We There Yet? What’s Taking So Long?”

By Michael Painter, MD

A little more than 13 years ago, the Institute of Medicine (IOM) released its seminal report on patient safety, To Err is Human.

You can say that again. We humans sure do err.  It seems to be in our very nature.  We err individually and in groups — with or without technology.  We also do some incredible things together.  Like flying jets across continents and building vast networks of communication and learning — and like devising and delivering nothing- short-of-miraculous health care that can embrace the ill and fragile among us, cure them, and send them back to their loved ones.  Those same amazing, complex accomplishments, though, are at their core, human endeavors.  As such, they are inherently vulnerable to our errors and mistakes.  As we know, in high-stakes fields, like aviation and health care, those mistakes can compound into catastrophically horrible results.

The IOM report highlighted how the human error known in health care adds up to some mindboggling numbers of injured and dead patients—obviously a monstrous result that nobody intends.

The IOM safety report also didn’t just sound the alarm; it recommended a number of sensible things the nation should do to help manage human error. It included things like urging leaders to foster a national focus on patient safety, develop a public mandatory reporting system for medical errors, encourage complementary voluntary reporting systems, raise performance expectations and standards, and, importantly, promote a culture of safety in the health care workforce.

How are we doing with those sensible recommendations? Apparently to delay is human too.

Continue reading “Doctor, I’m Not Comfortable with That Order”

By MICHAEL PAINTER, MD

Not everything about improving health care is breathlessly hanging on one high stakes decision.

The Supreme Court will rule soon enough on the constitutional challenges to the Affordable Care Act. Meanwhile, even amid the drama and bitter struggles, progress can occur in health care improvement—like the ever increasing adoption of health information technology. Believe it or not, there is broad agreement about using this technology in health care. Scott Gottlieb and J.D. Kleinke in a recent Wall Street Journal opinion said it well, “. . . promotion of health information technology is one of the only demilitarized zones in Washington—consistently attracting bipartisan support . . . .”

So, this rare consensus seems real and durable, but what is actually happening in the hallowed HIT ground where both sides have somewhat oddly come to a policy truce?

Since May of 2004 when President George W. Bush established the Office of the National Coordinator for Health Information Technology (ONC) we’ve witnessed a slow but relentless upturn in adoption. That progress dramatically accelerated with attention and funding in the American Reinvestment and Recovery Act in 2009. Since 2006, the Robert Wood Johnson Foundation (RWJF) in collaboration with ONC has supported an ongoing, independent effort to monitor the national adoption of the electronic health record.

Continue reading “Missive from the DMZ”

By MICHAEL PAINTER, MD

Picture a version of the Star Wars opening crawl:

A long time ago in a galaxy far, far away…. It is a period of enormous change and worry. The challenges are great. The status quo of poor health care quality and crushingly high costs is bearing down on the people—but that enemy is also under attack. A growing band of folk from all parts of the galaxy are attempting to bring every imaginable force—technology, market, government, people power—to the cause.  No one’s certain how it will all turn out…

Now, cue ominously Darth Vader’s imperial march theme… (Fade out).

Earlier this month, I participated in the 2011 HHS/IOM Health Data Initiative Forum and self-styled “Data-Palooza”.  It was exciting.  Lots of dynamic leaders attended —from the government, the software development world and other industries—lots of Twitterati—social media personalities.  The place buzzed, literally.  (It was just missing the Tatooine bar music.)

I couldn’t help but flash back to last year’s markedly more freshman, inaugural meeting and compare.  The differences one year later were striking—even startling at times.  The obvious progress could make one pretty hopeful.  The vision of creating tools that use previously moribund federal (and other) data in unique ways to solve real problems is already bearing some remarkable fruit.

During the “Data-Palooza” plenary session, a parade of app developers demonstrated technology that mines and harnesses data for very cool, practical purposes.  High points: PatientsLikeMe;  Asthmapolis; and Multistate Foodborne Disease Outbreak Investigation System (catchy name…).  The whiz bang, jaw dropping technology of these, and other, examples was impressive.  Last year, one really had to suspend to imagine how all this talk might actually have a major impact.  This year it could seem as if the vision isn’t keeping up with the technology.  In fact, perhaps we should be bolder, much bolder.

But, then, the enormity of the challenge brings one right back down to Earth—or rather—Endor.

Continue reading “A New Hope? (…But What About That Pesky Death Star?)”

By MICHAEL PAINTER, MD

First the good news—many are pushing the envelope on public reporting of health care information these days. For instance, last week the HHS/Health 2.0 Developer Challenge awarded honors to a new mobile app—using Hospital Compare data in new and innovative ways—try it. This application maps and provides some quality information as well as immediate ER waiting times for nearby hospitals. The idea of this app challenge, as you know, is to unleash moribund federal information, such as that sitting in the creaky Hospital Compare—to innovative types who will take it and create new—and, ideally, useful ways to present the information. That’s an exciting turn that makes altogether too much sense.

Then Wednesday, I had the good fortune to attend a very thoughtful AHRQ sponsored meeting on public reporting of care information for consumers.  The meeting included a good mix of consumers, employers, regional alliance leaders, health professionals, researchers and others.  Bill Roper provided the opening keynote.  The messages ranged from overt optimism about the important role of public reporting in the drive toward sustainable high value care—to the sober assessment that although public reporting has matured (some)—we may also be reaching limits.  As Steve Jencks commented—we’ve made progress—but let’s keep some perspective here—public reporting still needs some quick wins—it “isn’t quite covered in glory, just yet.”

Meredith Rosenthal, in her plenary presentation, observed that public reporting is essentially about to graduate from high school—sitting in the guidance counselor’s office trying to decide whether to go to college or trade school.  Bob Galvin, in the closing session, added—that while public reporting is indeed in the guidance counselor’s office—and it clearly has a bright future—it’s a pretty confused student.

The problem? There seems to be near unanimous sentiment—at least in this group—that public reporting of quality and cost information is critically important to drive sustainable health care quality and value. Continue reading “Which Way Transparency Nirvana?”

By MICHAEL PAINTER

I distinctly remember the first time I heard the title, “National Coordinator for Health Information  Technology”.  It was 2004.  That’s, of course, the year that RAND released its important national report card highlighting the overall mediocre state of health care quality.  You know the one that told us “it’s a flip of a coin.”  I was an RWJF Health Policy Fellow working on the Hill with then Majority Leader Bill Frist’s health policy staff.

There was a flurry of staff activity regarding the president’s pending executive order pushing adoption of the electronic health record and creating a new federal health information technology, dare I say, czar. . . . But what to call this new position?  To be honest, when I initially heard folks say the words, “national coordinator for health information technology,” my first thought was, “Well, that’s a mouthful.”  My second was “It sort of sounds like a character from that TV show, ‘The Love Boat’”.  But I kept those smart remarks to myself and quite quickly got on board—and, to be honest, never looked back. Continue reading “Where were you?”

By MICHAEL PAINTER

An elderly family member recently received a devastating cancer diagnosis.  She gets her care in California from a team of health professionals in a large integrated delivery system.  We’re supposed to be reassured that her care team is working together in seamless accountability–dedicated solely to the best possible outcomes for her, right?  Unfortunately, that’s not entirely the case.  She, of course, has a primary physician and a surgeon.  She had a hospitalist who managed her inpatient post-operative complications.  She has a number of oncologists.   Guess what?  None of these five or six physicians were communicating with each other about her care until family members prompted them to do so.  She didn’t really have much, if any, choice in selecting her specialists.  She had minimal, if any, information about the performance of the various professionals she suddenly needed.

Continue reading “The opposite of that bridge to nowhere”

By MICHAEL PAINTER

Is it possible that the State Department is technologically bolder than the HIT Policy Committee?  On Tuesday, that committee convened by the Office of the National Coordinator as required by the American Recovery and Reinvestment Act released some initial recommendations on the definition of meaningful use of HIT.  Then yesterday the New York Times in an above the front page fold article reported that the State Department recognized an internet blogging service could change history–right now.

Compare that report about the State Department to the HIT Policy Committee’s recommended vision for the role of patients and families.  The committee envisions that someone would eventually “provide access for all patients” to populated personal health records and some self-management tools by 2015–about six years from now.  It’s not that this vision is bad; it’s just so underwhelming.  Let’s see–the State Department thinks that the Iranian people might be using Twitter today to regain control of their nation–and in our multi-billion dollar ultimate vision for the patient’s role with health information technology we’re still talking about “providing” a couple of interesting tools to patients by 2015.  Is it me, or are we possibly missing a powerful health reform player here–the consumer?

So, as you can see, I listened to this meeting on “meaningful use” and came away with some distinctly mixed impressions. Continue reading “The State of Meaningful Use”

By MICHAEL PAINTER

A recent Wall Street Journal editorial strongly challenged the notion that there is enormous waste in American health care.  In the article the editors acknowledge that dramatic variation in health care spending exists across the country–but point out that the precise reason for that variation remains uncertain.  They also note that much of the data about regional variation comes from the Dartmouth Atlas–and that work, they point out, is limited in that it only examines Medicare data.  And they cite work from Richard Cooper at the Wharton School that directly challenges some of the Dartmouth Atlas conclusions–essentially arguing that the Dartmouth observed regional variation is actually simply an artifact of Medicare.   They conclude that “Dr. Cooper’s assault on the Dartmouth Atlas is controversial but compelling. He argues that the less-is-more theory is based on the flawed premise that when a region’s outcomes did not improve as spending increased, the difference is simply classified as ‘waste’ – even if it isn’t.”

Continue reading “Op-Ed: It’s the Waste, Stupid.”