There has been a lot of buzz around two pieces of news –in one case, lack of news—in the past week. Last Thursday, HHS Secretary Kathleen Sebelius responded to heavy pressure from the American Medical Association and announced a delay to the ICD-10 implementation deadline, currently set for October 2013.

Meanwhile, the health IT universe continues to wait with baited breath for Sebelius and/or leadership at CMS or ONC to publish the proposed regulations for Stage 2 of the “meaningful use” EHR incentive program. The proposal was supposed to have been out before 35,000 or so health IT industry types descended on Las Vegas for HIMSS12, but it was not to be. As with any major federal rule-making, the White House’s Office of Management and Budget has to vet every word, so it is out of Sebelius’ hands for the moment.

Rumors spreading through the Sands Expo Center and the adjacent Venetian and Palazzo hotels have pegged Wednesday or Thursday for the release date, since national health IT coordinator Dr. Farzad Mostashari is leading a session on Stage 2 meaningful use with other ONC and CMS representatives Wednesday morning, then delivering a keynote address the following day.

In the wake of the ICD-10 bombshell last week, HIMSS itself and other IT-related groups are telling their membership and anyone else who will listen not to slack off when it comes to ICD-10 preparedness. HIMSS CEO Steve Lieber noted in his annual press conference Tuesday that the official HHS statement said the department would “initiate a process to postpone the date by which certain healthcare entities” must meet the requirements. That, to Lieber, suggests the possibility of a delay for physician practices or perhaps small hospitals, but not for larger organizations.

Indeed, HIMSS on Tuesday released a survey of hospital CIOs showing that 89 percent expect to be ready for ICD-10 by the current deadline of Oct. 1, 2013.

Regulations aside, social media is a big deal at HIMSS12. Monday, pediatrician-blogger-author Dr. Wendy Sue Swanson, a.k.a. Seattle Mama Doc, excited the pre-conference CIO Forum by showing how social media can help doctors keep up with medical knowledge in a culture where the public and media are often discussing new medical research before practicing physicians hear about the discoveries.

“The more knowledgeable a physician is, the less likely they are to explain what they know on national television,” Swanson said. She started her blog at Seattle Children’s Hospital to help reassure parents of her patients about the safety of childhood immunizations after actress Jenny McCarthy went on the “Oprah Winfrey Show” to argue against vaccinating youngsters. Swanson has applied social media to refute what she called irresponsible statements from the controversial but popular Dr. Mehmet Oz, too.

“We’ve got to be far more careful,” Swanson said. She since has embraced Twitter, LinkedIn, Facebook and physician network Doximity, as well as YouTube. She uses the latter to post short, one-minute videos to educate parents and her adolescent patients rather than merely giving verbal instructions that people will forget as soon as they leave the doctor’s office.

Swanson is a bit of a social media star, but certainly not as widely known as the opening keynote speaker at HIMSS 12, namely Twitter co-founder Biz Stone.

Stone predicted that wearable health technology will become commonplace in the near future as consumers take a greater interest in their own care. He referenced FitBit—more fitness than healthcare, really, but who’s counting—perhaps providing the opportunity for people who know better to take a cue from Swanson and set the record straight via, say, this blog post?

Stone advised innovators to do a better job designing their technology to “degrade gracefully” so things become more accessible to poorer populations once more wealthy people have moved on to something more advanced. He also urged the HIMSS12 audience to take chances.

“To succeed spectacularly, you need to be willing to fail spectacularly,” Stone said. His words echoed those of former Apple CEO John Sculley.

Last month at the Digital Health Summit at 2012 International CES—also in Las Vegas—Sculley said that Americans usually are more than willing to give second and third chances. “Failure doesn’t mean you’re finished. It means you have to pick yourself up and start again,” said Sculley, himself the architect of one of the greatest failures in tech history when he ignored Steve Jobs’ advice to pull the plug on the Apple II computer in favor of an up-and-coming product called Macintosh.

Innovative thinkers and influential healthcare leaders aren’t relying on the decisions coming out of HHS to determine their strategy.  Despite the fact that many healthcare organizations were on target to transition from ICD-9 to ICD-10, Health and Human Services (HHS) announced it would initiate a process to postpone the date by which certain healthcare entities have to comply with ICD-10.

The details of the delay have not been revealed, but industry experts are speculating that a one-two year delay is in the works.  With only 20 months remaining to the Oct. 1, 2013 deadline, this leaves many organizations in limbo.  Do they continue down the path of ICD-10 adoption, revise plans based on speculation about a new timeline or completely put the initiative on hold?

The leaders in healthcare never limited their thinking to a coding mandate.  They were aligning their ICD-10 efforts with quality of care initiatives- EMR adoption and improved clinical documentation.  They won’t hesitate, they won’t miss a step, and they will focus on providing exceptional care through improved processes, many of which will prepare them for a successful transition to ICD-10 and ICD-11.

The following areas of focus will improve quality of care, reporting and accuracy of reimbursement.

-        Lead with purpose- understand the long-term impact of a coding mandate and help providers understand the alignment of greater specificity in coding with quality reporting, improved clinical documentation and clinical decision support.

-        Take this time to improve clinical documentation- develop processes and feedback to improve how physicians and other providers document care.  This effort will reap financial benefits and directly impact quality of care and reporting.

-        Invest in educating coders- coders will benefit from increased knowledge in anatomy and physiology under any coding system.  Introduce the changes in coding structure that will come with ICD-10 and ICD-11.

-        Appeal to the provider’s intellect- roles and responsibilities continue to evolve in healthcare.  Help the provider understand their role in clinical documentation and responsibility for greater specificity in describing care.

Lead an effort focused on improved clinical documentation, not on coding.  Healthcare leaders who develop a purpose greater than a mandate path will be the clear winners from a quality reporting and reimbursement perspective.  Those who use the delay as another reason to “wait” put their organizations at financial risk and will lag behind the industry leaders with or without a delay.

Content underwritten by a grant from XEROX corporation.

Eric Topol was once a lowly (well not that lowly) cardiology professor at the University of Michigan, but he’s now without question the leading renaissance man in health care technology. Virtually every week sees him on some big stage disgnosing his own heart murmur with an iPhone app or showing off how his sleep brain waves and his genome interact or don’t.

His new book, The Creative Destruction of Medicine is a tour de force romp through basically every type of cool new medical technology. He covers the Cloud/Web/Wireless/Sensor phenomenon from both a social, transactional and diagnostic  point of view–leaning heavily on his connection to the West Wireless Health Institute which he helped persuade Gary & Mary West to fund. He’s the creator of a new medical school program at Scripps focusing on the genomics and proteomics revolution, and the book covers in great detail the evolution of the human genome project and its impact on disease discovery (coming eventually) and matching patients to the right drug (available more or less now). Finally he was of course the head of Cardiology at the Cleveland Clinic where he not only was heavily involved in the testing of tPA (the drug that built Genetech) but also in unveiling the problems with Vioxx not limited to the drug itself but also concerning Merck’s behavior at the time. (Remember Dodgeball?)

In fact if not for Merck putting pressure on Cleveland Clinic to get him fired (or at least Cleveland Clinic reacting as if that happened), Topol may not have become the medical renaissance man he is today. The San Diego air clearly agrees with him. And we’d all be much poorer for that.

I’d encourage everyone to read the book. It’s a remarkable and relatively in depth (for a speed read) analysis of the state of the art in three areas in medicine (IT, genomics & clinical/disease) and it has several very interesting ideas–all with a strong dash of health services research and cost-effectiveness analysis mixed in.

I come from a pretty strong background on the IT side, so I’m judging the other sections by the currency of what Topol said about that. His analysis of the development of the cell phone/Internet is comprehensive but also very current indeed. The book is smoking hot off the press and includes numerous products that are either just out or not on the market yet (AliveCor), and only one or two times when recent facts have overtaken him and look like poor choices (e.g. he features fading physician community Sermo which has just lost its CEO rather than QuantiaMD). Of course that’s the problem with a book about something that’s changing so fast, but in general his work on the IT side is very recent and relevant. The genomics and disease chapters required a little more concentration and the fast skimming reader (i.e. me) might get a tad lost in the DNA letter sequences, but the general gist is important and clear.

So what does he say? The brief synopsis is that medicine has been aimed at curing average diseases among average people, and therefore most treatments are ineffective. Worse, most clinical trials have to have huge numbers of people in them to see the difference in a small number of people. Topol and I recently tweeted back and forth about the mid-1990s GUSTO trial which showed that using tPA instead of Streptokinase saved just over 1 in a hundred heart attack victims at about 5 times the total cost. Topol defended the use of tPA then, and still does but points out that what we thought were big numbers in the 1990s ($2,200 a dose versus a few hundred) are dwarfed by say use of cancer drugs that can exceed $100K for a course and may only extend life a few months on average. So clearly playing by the old rules with the new medicine is unsustainable.

What Topol calls the creative destruction of medicine (getting all Schumpterian on us) is that we need to use the three tools of IT, genomics and clincal effectiveness research (i.e. big data) to blow up the current way we accumlate medical knowledge and make decisions over treatments and drugs. And also to lower the cost.

Instead we should allow the use of drugs identified as being likely positive for people with specific genotypes much earlier in the process, and we should be using wireless (and implantable/swallowable) sensors and other Health 2.0 tools to measure as much as we can about what’s happening to the patients in those smaller cohorts–which would still be much bigger numbers for people with particular diseases than those in the current broken clinical trial model.

It’s this personalization of the clinical trial model and its extension into everyday care that’s probably the biggest idea in this book but it’s one among many.

All in all this is a great read and points the way to lots of possibilities for the future of medicine. Which doesn’t mean that they’ll all happen, but it would for sure be good if most of them did!

(I wish the “Too clever by three quarters” title was mine but it was said first I think by Briitish critic Melvyn Bragg about actor, director, and medical doctor Jonathan Miller)

With unsustainably high costs and tremendous gaps in quality and patient safety, the health care system is ripe with opportunities for improvement. For years, many have seen quality measurement as a means to drive needed change. Private and public payers, public health departments, and independent accreditation organizations have asked health care providers to report on quality measures, and quality measures have been publicly reported or tied to financial reimbursement or both.

Throughout the Affordable Care Act (ACA), quality measures are tied to reimbursements in multiple programs.  It is critical that the Department of Health and Human Services (HHS) move forward with a strategy for measure harmonization that will accommodate local and national needs to evaluate outcomes and value.  Additionally, a standard for calculation measures such as the use of a minimal data set for the universe of measures should be considered.

The field of quality measurement is at a critical juncture. The Affordable Care Act (ACA)—which mentions “quality measures,” “performance measures,” or “measures of quality,” 128 times—heightened an already growing emphasis on quality measurement. With so much focus on quality, the resource burden on health care providers of taking and reporting measures for multiple agencies and payers is significant.

Furthermore, the field itself is being transformed with the continued adoption of electronic health records (EHRs).  Traditional measures are largely based on administrative or claims data. The increased use of EHRs create the opportunity to develop sophisticated electronic clinical quality measures (eQMs) leveraging clinical data, which when linked with clinical decision support tools and payment policy, have the potential to improve quality and decrease costs more dramatically than traditional ones.   Innovative electronic measures on the horizon include “delta measures” calculating changes in patient health over time and care coordination measures for the electronic transfer of patient information (i.e., hospital discharge summary or consultant note successfully transmitted to the primary care physician). Additionally, traditional data abstraction methodologies for clinical data require labor intensive, chart review processes, which would be eliminated if data could be electronically extracted.

The Measures Application Partnership

Recently, the National Quality Forum (NQF), the steward of the Measure Applications Partnership (MAP), released its final, pre-rulemaking report to the HHS on February 1st.  Section 3014 of the ACA mandated the creation of the “pre-rulemaking process,” which includes the annual public release on December 1 of quality measures under consideration for HHS programs, as well as sufficient time for multi-stakeholder comment on the proposed measures. HHS contracted with the NQF to convene the multi-stakeholder group (named MAP by NQF) to provide analysis and strategic guidance on performance and public reporting measures, including on increasing alignment within HHS and between public and private payers. The pre-rulemaking report is one of several reports created by MAP to improve and streamline quality measurement and reporting. The pre-rulemaking report provides HHS with analysis and feedback for over 350 measures under consideration for almost 20 of its programs.

MAP’s work begins to lay the foundation for advancing quality measurement and reporting. As eQMs are developed and gradually replace more traditional measures, measure alignment will become paramount. To calculate and report an eQM requires the ability to capture structured data, extract those data elements from multiple sources within the EHR, and then run a measure logic engine to apply the rules of the measure. This is a complicated process fraught with many challenges and requiring appreciable investments by providers and EHR vendors. The life-cycle of these measures (development, validation, testing and programming of measure reporting tool) does not allow for rapid adaptation to provider workflow or the rapid incorporation of changing evidence.

Moreover, vocabulary standards for eQMs are currently being evaluated. The Office of the National Coordinator for Health IT (ONC) is working with NQF on developing the vocabulary standards for the electronic specifications for these eQMs. One of their goals is to create a standardized model (the Quality Data Model) to turn measure specifications into computable value sets, which then can be used for quality measurement.

The following are some suggestions to mitigate some the mentioned barriers to the rapid and efficient use of quality measures to improve performance:

1) Harmonize, harmonize, harmonize. As mentioned, measure harmonization is critical to the future of quality measurement and reporting. In a health care system with increasingly limited resources, it is important to shift resources from quality measurement and reporting to quality improvement, which is the ultimately goal of measurement. The burden on providers and vendors is immense, and harmonization among private and public payers, public health departments, and independent accreditation agencies will enable providers to focus on increasing value in the most high impact areas. Providers and hospitals will participate in a multitude of national, state and local programs such as PQRS, Value Based Purchasing (VBP), Inpatient Hospital Quality Reporting System, Patient Centered Medical Homes, Accountable Care Organizations (ACOs), HEDIS, state initiatives and commercial private payer initiatives. It seems logical to find a common set of measures based on common clinical priorities such as the Million Hearts Initiative or Partnership for Patient Safety.   Meaningful Use Stage 1 has used a core plus menu model, which allows for a combination of standardized and customized reporting.

2) Develop a standardized minimal data set to enable calculation of 80 percent of the measures. Another challenge is the discrepancy between the data captured by various EHRs. The MAP’s pre-rulemaking report and many others in the measurement community often speak of the need for a “core set” of measures that could be broadly applied across multiple settings and providers.  For an eQM to be part of this core there must be a standardized, minimum set of data that all EHRs capture. Much work is needed in identifying this data set and then integrating data capture seamlessly with workflow. With hundreds of certified EHR products in use, a standardized minimal data set will enable the calculation of 80 percent of the measures and will allow for rapid implementation and extraction of data within provider workflows. It will also allow State and local measure reporting requirements be aligned with Federal requirements.

3) Use data intermediaries to report quality measures. Even if strides are made toward measure alignment and data capture, there still will likely be a significant reporting burden placed on health care providers.  Given the potential complexity of calculating eQMs, one solution would be foster the creation of data intermediaries. These organizations could import data from disparate sources from providers, calculate quality measures, and then feed the results back to the provider for quality improvement and to the relevant third parties. The Physician Quality Reporting System (PQRS) currently has a feedback loop to providers using claims data that averages 18 months; this lengthy delay impedes on any real time quality improvement. Data intermediaries could be piggybacked to State Health Information Exchanges, Regional Extensional Centers, or Quality Improvement Organizations to service ACOs and health homes enabling real time improvement while helping providers/hospitals report to Federal and State agencies.

The field of eQMs is still in its infancy, but we believe it is the future of quality measurement. ONC, CMS and NQF deserve accolades for their extensive work creating the foundation for this future. The realization of the potential of eQMs will require a number of challenges to be addressed through creative and innovative solutions. Measure harmonization, the creation of minimal data set, and fostering the development of data intermediaries are steps toward this realization.

Ahmad F, Tsang T, The Melody of Quality Measures: Harmonize, Standardize, Health Affairs Blog, 21 February 2012. Copyright ©2012 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

Faraz Ahmad, MD is a third year internal medicine resident in the Healthcare Leadership in Quality Track at the University of Pennsylvania and a member of the Center for Healthcare Improvement and Patient Safety.

Thomas Tsang, MD, MPH, FACP, is currently the Senior Advisor to the Governor of Hawaii for Healthcare Transformation and a CMMI Innovations Advisor.   He was formerly the Medical Director, Meaningful Use and Quality at the Office of the National Coordinator for Health Information Technology and served on the Committee on Ways and Means.

North Carolina Medicaid recently reported, for the third time, using a third consulting firm, the achievement of massive savings through its patient-centered medical home (PCMH) program, now called Community Care of North Carolina (CCNC). Among other things, CCNC pays the physicians more money in order to encourage and compensate behaviors and processes, including enhanced access to care and case management, to hopefully reduce the need for emergency and inpatient services. (A brief summary of this and past consulting reports appear in the current issue of Modern Health Care. http://www.modernhealthcare.com/article/20120218/MAGAZINE/302189938/1140)

However, the third time is not a charm. Notwithstanding these consultants’ reports — which paradoxically support my contrary conclusions by choosing to ignore the overwhelming data contradicting their own claims – the program is a total failure as far as reductions in cost and inpatient utilization are concerned.

Fact #1: According to the Medicaid and CHIP Payment and Access Commission (MACPAC) report to Congress http://www.macpac.gov/reports, North Carolina is by a significant margin the highest-cost state per capita in its region for adult and for child Medicaid spending. These are the two categories in which the PCMH has been in place the longest. In the “aged” category, in which PCMH had barely been started when the MACPAC data was compiled (and would not affect medical costs noticeably because the state is a “secondary payer” following Medicare, and most Medicaid “aged” spending is custodial anyway), North Carolina is the lowest cost state in the region.

Further, North Carolina is high-cost only for its <65 population covered by Medicaid: according to the Commonwealth Fund, commercial coverage (premium + annual deductible) costs only slightly more than the average for the region. http://www.commonwealthfund.org/Publications/Issue-Briefs/2011/Nov/State-Trends-in-Premiums.aspx

Fact #2: None of the originally projected and subsequently claimed utilization changes are discernable at all in the statewide Medicaid data, let alone on a scale (perhaps 40,000 – 50,000 avoided admissions avoided/year out of 240,000+) required to save the claimed billions. From 2000-2009 (complete calendar 2010 data is not publicly available yet), even as more and more members were enrolled in the PCMH to avoid more and more admissions, the total admission rate for North Carolina was basically unchanged, almost exactly paralleling the experience of low-cost South Carolina, which uses a classic managed care model. South Carolina enjoyed a slightly lower admissions rate in each year, with an even better absolute and relative performance as the decade drew to a close. (Despite the large amount of data for South Carolina, the consultants didn’t use it or any other state as a control for North Carolina.)

Fact #3: Looking at the subcategory of ICD9s comprising the two largest categories of admissions in which the PCMH focused for most of the decade — asthma and diabetes — the same result held true, vs. South Carolina.

Fact #4: Likewise, looking at the subcategory of ICD9s comprising the AHRQ’s list of preventable admissions, the same was true.

Fact #5: “Preventable” is a term of opinion, not science, so that reasonable people may differ on what gets counted in that category. For the purposes of PCMH-preventable (as opposed to wellness program-preventable, for example), let’s define a “preventable” event as (1) a fairly common event (2) that is generally diagnosable and treatable, (3) where early access/intervention makes a major difference, (4) where many of the events are complications of a chronic condition whose management is already being emphasized, (5) where patients don’t have to change their lifestyle but rather just take a pill, and (6) where you don’t need to wait years for results. Perhaps the event most fitting those criteria would be cellulitis. Cellulitis admission rates increased by almost exactly the same percentage over the decade in both states. That was actually a slightly better performance for North Carolina than in the other three comparisons, in that they didn’t do worse than South Carolina.

To summarize the facts, there was no utilization change attributable to the program, and the increased costs of the program apparently cause or at least contribute to North Carolina’s status as the high-cost Medicaid state in the region specifically only for the Medicaid member categories most affected by PCMH.

Yet three well-known and highly taxpayer-compensated teams of consultants arrived at the opposite answer. One might ask, how did the consulting teams refute, address, distinguish or interpret this same data the opposite way, to conclude that billions of dollars were saved over the decade?

Rather than refute the data, all three consulting firms – Mercer, TREO, and Milliman – elected to omit the above data from their reports altogether, without a mention. In other words:

(1) They concluded that North Carolina had reduced its cost substantially without mentioning the federal data showing the relative cost position of the relevant population to be the highest in the region; (2) They concluded that Medicaid inpatient utilization trends had declined substantially without mentioning the federal database of Medicaid inpatient utilization trends showing the opposite.

Because both data sources are in the public domain, readily found and widely used (the AHRQ database from which the utilization statistics are derived is at http://hcupnet.ahrq.gov/HCUPnet.jsp ), one interpretation might be that omitting them implies these consultants know full well their conclusions are unsupportable.

The other interpretation would be that they didn’t know about these databases, though they are well-known to population health outcomes experts, which they held themselves out to be. Also, there had already been a well-publicized presentation by Mathematica on applying this data to North Carolina http://www.ehcca.com/presentations/MedHome20100526/peikes.pdf as well as several other reports saying exactly the same thing, including from the Kaiser Family Foundation http://www.kff.org/medicare/upload/7984.pdf.

What did these consultants do instead? Rather than look at the definitive databases of statewide utilization and cost, they used complex analytic models mostly to find outcomes that any trained observer would immediately conclude to be mathematically and epidemiologically impossible. For instance, Mercer found that the majority of the state’s dollar savings came from infants, a 54% reduction in overall costs in that age category.

This is blatantly wrong four ways, any one of which would be sufficient to reject Mercer’s 54% reduction finding:

(1) A 54% overall reduction in this age bracket would require a mathematically impossible >100% decline in neonatal utilization, since nothing else would be expected to change much;

(2) Mercer never analyzed neonatal utilization to find out whether it even came close to supporting their conclusion;

(3) It didn’t — neonatal utilization in reality was essentially unchanged, according to AHRQ data;

(4) According to the other consultants (Milliman), babies were not enrolled in CCNC in any case, meaning any savings from that category (there were none) would not have been attributable to the program.

Milliman found an overall savings of 15% for adults and children. Since admissions consume no more than half the total cost of adult/child Medicaid spending, and, as Milliman correctly points out, the savings are all in inpatient and ER (ER being a much smaller cost category in which – you guessed it – North Carolina’s utilization still exceeds South Carolina’s), that overall 15% decline would require about a 30% reduction in admissions. Since preventable admissions account for only about 10% of all admissions according to AHRQ, preventable admissions would have needed to decline by 300% (actually a bit less because some people are still not in the CCNC) in order to achieve this 15% overall decline. A 300% decline in anything is mathematically impossible, of course, but preventable admissions didn’t decline at all in any case. Nor did non-preventable admissions.

Two consulting firms, two mathematically impossible answers, two ignored federal databases supporting a contrary conclusion. (The TREO work is omitted for space reasons, but is also unsupportable.) These firms, in the immortal words of the great philosopher Ricky Ricardo, have a lot of ‘splaining to do.

But they’re not. Mercer has never addressed the issue of its impossible findings. Milliman was invited to next Sunday’s presentation of this data at the Thomas Jefferson University conference http://www.populationhealthcolloquium.com/agenda/bookclub.html#miniprecon. They declined, telling Modern Healthcare that they didn’t want to pay the $195 admission.

I then both publicly and privately (and with uncharacteristic grace) offered to finance their travel expenses plus pay them $2000/day to successfully defend their taxpayer-financed study, for which they were already paid more than I make in a year and for which they had access to the state’s data, against my own spare-time observations made without any proprietary state data. They declined again. I guess it wasn’t about the $195 after all.

Finally, how is this program “Medicaid’s Solyndra?” Just like with Solyndra, the federal government is making a “bet” on one project, heavily subsidizing this model, with a 9-to-1 match. The result is the same as Solyndra, except that North Carolina Medicaid will never go bankrupt because it can always get more funds from the state legislature, multiplied by Washington.

Some might cite this example as the poster child for block grants for Medicaid, while others might say in general that consulting firms to evaluate Medicaid outcomes should be hired by the state comptroller’s office rather than the department overseeing Medicaid. If nothing else, this case study suggests that allowing any state agency to hire consulting firms at taxpayer expense to justify its programs creates an inherent conflict of interest, especially when increased program expenses can be passed on to Washington.

One logistical point: The nature of a posting like this is that squeezing in all the exact information is impractical. Therefore I would ask the Usual Suspect THCB commenters who, being beneficiaries of PCMH, intend to defend the consultants’ impossible findings (and defend their choice to omit contradictory data) and, by implication, the lucrative PCMH model, to hear the entire presentation before commenting. Either stream it or show up in person at Thomas Jefferson University’s PCMH conference. Then you can get right on the permanent electronic record with your objections after seeing all the slides. Since the state’s consultants are not, as of this writing, intending to come defend their client on my nickel, you can do it instead on your own.

Al Lewis, widely credited with inventing disease management, is author of the forthcoming Why Nobody Believes the Numbers (John Wiley & Sons, June 2012), the introduction to which may now be downloaded gratis from www.dismgmt.com. He also runs the popular course and certification program for Critical Outcomes Report Analysis http://www.dismgmt.com/certs/cora/self-study and was named the “leading authority on care management outcomes measurement” by the 9th Annual Report on the Disease Management and Wellness Industries (Health Industries Research Co., 2010).

There’s a new movement in healthcare – and it’s growing from a surprising place.  Instead of emerging from government or industry, it’s budding from the grassroots –from everyday physicians. The movement is democratizing health information and giving birth to a new landscape: Interactive Health.

Interactive Health is transitioning clinical care from real-world, costly encounters to virtual, inexpensive, cloud-based care. And the view from the cloud is better.  This transformation is starting with the most fundamental interaction in healthcare: patient question, physician answer.

In late April of 2011, HealthTap decided to help facilitate this movement by bringing together physicians to engage online and create a roadmap for “care in the cloud.” Nine months later, the growth of physician engagement on HealthTap and beyond proves that Interactive Health is here to stay.

Today, HealthTap announced that 10,000 physicians have joined our Medical Expert Network, where they are sharing and evaluating the best health information online, dramatically improving care within a transparent meritocracy.

The Three Pillars of the new movement: Quality, Access, and Care

Interactive Health is supported by three pillars: quality, access, and care.

Quality

We live in a world of abundant heath information – but this information can create confusion, frustration and mistrust. The Interactive Health movement is changing this by ensuring quality through trust, pluralism, merit and peer review.  HealthTap is facilitating this movement in three ways.

HealthTap creates trust by allowing only U.S.-licensed physicians in excellent standing to join its Medical Expert network. Admission is even stricter than state licensing requirements.

HealthTap also supports pluralism by enabling doctors to add better answers to all patient questions, even if already answered by other doctors.  These, in turn, are being commented on by additional doctors adding multiple opinions and approaches to the available body of knowledge.

HealthTap supports meritocracy and peer review by ensuring that answers are not based on the assessment of a single individual or organization, but are based on the combined evaluation provided by the medical community, and by allowing participating physicians to review, rank, and evaluate answers.

Access

HealthTap makes the highest quality health information readily available to everyone for free. Physicians can also compare and contrast their own approach to that of other doctors.

HealthTap is built around transparency: when patients view answers, they can see who created them.  They can see the physician’s real name, learn where the doctor was educated and practices, and eventually follow up with an appointment.

In real Interactive Health, physician participation is voluntary, not dictated. The participating’s physicians’ goals are to improve care and to make the best health information available to all.

Care

HealthTap helps facilitate better care through creating a culture of gratitude and kindness between doctors and patients.  In addition to recognition from fellow physicians, HealthTap lets users “Thank” doctors when they appreciate answers.  Hundreds of physicians have written to us that the “Thanks” they receive from patients on HealthTap remind them of why they decided to practice medicine in the first place.

The second element of true care is availability.  Interactive Health makes doctor wisdom readily available 24/7 – without additional effort by physicians or cost to patients.

How HealthTap is leading the Interactive Health movement

The democratization of health information involves more than just bringing the best information to people everywhere – it also means giving an opportunity for top licensed physicians in good standing to have a real voice.

The Medical Experts participating on HealthTap include leading doctors from top institutions, as well as physicians practicing in rural areas, giving them all the same opportunity to have their voices heard, and to share their knowledge on equal footing.

Physicians on HealthTap are known both locally and nationally.  The fast-growing network includes respected medical practitioners in communities of all sizes. Doctors on HealthTap were trained in and practice at top institutions like Harvard (the #1 represented medical school for physicians in our network), Johns Hopkins, and UCSF, and have been published in medical journals, such as JAMA and the New England Journal of Medicine.  The network also includes experts who have served as department chairs or division chiefs at premier medical centers, including Cedars-Sinai, Memorial Sloan-Kettering, and Baylor University.

HealthTap’s Medical Expert community includes physicians like Dr. Barry Rosen, a surgeon listed as one of America’s Top Doctors in U.S. News and World Report; Dr. George Kalber, a Professor of Urology and Pediatrics at the Tufts University School of Medicine; and Dr. Cornelia Franz, a Pediatrician and author of Common Sense Pediatrics.

The HealthTap Medical Expert Network also includes physicians like Dr. R. Wayne Inzer, an OB/GYN who serves as the program Director for the Obstetrics and Gynecology Resident training program at Baylor University Medical Center; Dr. Latisha Smith, an assistant professor in the University of Texas Health Science Center at Houston’s comprehensive wound care and hyperbaric medicine center; and Dr. Bert Mandelbaum, the Chairman of the department of pediatrics at the University Medical Center of Princeton.

Together, these six doctors have answered more than 2,200 questions, which have received over 3,400 Agrees from the physician community, and which have helped almost 200,000 people to date (a number that will continue to grow in the future with no additional effort by these doctors as more users find them through their mobile devices and online).  This is what moving the best information to the cloud is all about.

By enabling doctors to compete with one another on the quality of their answers, and to assess the answers of other doctors, HealthTap has become both the voice of the most well recognized physicians and the voice of those who are most deserving of recognition. A true meritocracy, HealthTap is the podium for both the super-known, and for those who deserve to be—but are not yet as well known as they will be very soon.

An ancient maxim  of dinner party etiquette, which  I believe has been proffered  from more than one source,  is “never discuss politics, religion or sex in polite company”. In some ways, for me as a physician, entering the exam room with a patient seems to require some similar degree of discretion. But the consequences of straying outside the bounds of polite discussion in the doctor’s exam room are quite different from any awkwardness that might ensue after a social misadventure.

Dr. Henry Lee, the well-known Connecticut State forensic medicine expert likes to relate a tale of his own introduction to dinner party etiquette, which I will try to relay somewhat faithfully. His English was poor when he arrived in the U.S. and, invited to a party in which guests were seated in the traditional “boy-girl-boy-girl” arrangement, he knew he would be pressed to make conversation with the women on each side of him. A friend reassured him, “You’ll have no problem if you can just get the woman talking about herself and then all you have to do is listen politely. Simply ask  ‘Are you married?’ and then ask “Do you have any children?’. This should get things going just fine.” Armed with this strategem, Dr. Lee was seated and turned to an attractive young woman on his left and asked if she was married. She replied “No”. So of course, he went on to the next question, “Do you have any children?”. He was surprised when she reacted with a look of indignation and quickly turned her attention to the guest on her other side. Puzzled at her reaction, he surmised that he must have gotten the sequence out of order. Trying out the other way around, he turned to an older woman on his right and asked confidently if she had any children. “Three!”, she replied happily. Delighted with his progress, he then inquired if she was married. Dr. Lee says he spent the dinner conversing with his soup and salad.

I have also had exam room encounters come to grief because of sex, politics and religion, but nothing has caused me more regret than politics. I will explain.

Sex is not taboo. In fact, it is something I am expected to inquire about as part of the medical history.  A sexual history is essential if one is concerned about infectious diseases, reproductive health, domestic abuse, and even what drugs are prescribed and which are proscribed. I was taught even back in the dark ages of medical education in the 70′s that one should take a careful “non-judgmental” stance in taking a history. Students are taught to ask first, “Are you active sexually?” If the answer is yes, we ask “Do you have sex with men, women, or both?”. Then the question is asked in a way that allows the patient to discuss past behavior that he or she might be ashamed of: “In the past, did you…?”

Nonethless, if at all possible, I avoid asking about sexual activity as part of a history unless it is essential to the diagnosis. Why? Because I have only so much time to see the patient, and time spent on sex is time lost to discussing bowel habits, which is essential if you are a gastroenterologist. A few years ago it was found that women with irritable bowel syndrome (IBS) have an increased incidence of childhood abuse, emotional or otherwise. We were encouraged to add that element to our discussion about emotional factors in IBS.  I found that a colleague at the other practice in our hospital added that question to his interviews, at least for a time, because I had the pleasure of having to review the charts of several of his former patients who took offense to that line of questioning. Even if sexual abuse was an easy topic to discuss, I would not want to go there. If I did I would have become a Freudian psychiatrist. It’s tedious enough as it is, listening to detailed descriptions of stool from people who think they are suffering from a rare and unusual type of excretory syndrome, not to add to it tales of childhood trauma.  In sum, discussions of sex are appropriate in the exam room, but I avoid them because they take too much valuable time.

On the opposite end of the scale, religion is no problem because it is rarely a necessary aspect of the medical history unless it has some bearing on dietary habits. I like to know if my patient is a Hindu and follows a vegetarian diet. If my patient is a worried older Jewish woman, I like to blame her symptoms on having eaten trafe (spelling?), i.e. non-Kosher food, just to get a laugh and break the ice. But as far as I know, the Presbyterian diet is not too different from the Episcopalian, and beyond that I really have no interest. I never bring up my patient’s religion unless it is germane to our discussion, as in “Are you certain your communion wafer is gluten-free?”.  Occasionally a patient will ask me if I happen to be Jewish. When I say “Yes, although not very observant.”, they will sometimes even betray that they subscribe to an old prejudice that is as amusing as it is false: “Jews make the best doctors, you know.” I reply that good doctors come in all shapes, sizes and colors. So much for religion.

But politics in the exam room, that’s a pitfall and a booby trap that makes me wary as soon as I sense the subject is about to come up! I try to avoid politics whenever I can, because it is the biggest time-waster of all when it comes to getting through my day. It would only take three minutes per patient to set me back 30 minutes by the end of the morning, and that would be in addition to the extra 5 minutes taken up by additional unexpected complaints and reports about my patients’ jobs, families, social lives and other circumstances which are the glue that holds our relationships together in a way that simply prescribing medications cannot. Keeping on time is already a challenge I have described in my last post, and politics is yet another impediment.

Even so, politics comes up. Mostly it is because my patients want to know my political opinion. They especially want to know what I think about medical care and how our elected (and don’t forget, appointed!) officials are handling it.  Many of my patients want to discuss “Obama-care” and my attitude toward how it will affect me, although I think their concern is  how it will affect our relationship. Some of my patients want to discuss “socialized medicine”, or how care is delivered in Canada. Some just want to know who I plan to vote for, or who I think will win the Republican primary. Maybe they want to get to know me better, or maybe I am the first person they have encountered since they read the morning paper and they want to air their strong feelings about who said what.  Whatever the reason, if I allowed myself to be drawn into political discussions, my schedule would be an even greater disaster than it often is.

Suprisingly, many of my patients assume my politics are conservative because I am a doctor. Because so many doctors are Republicans they assume I am too. Many patients assume that I am fiercely opposed to socialized medicine, since surely I don’t want to be told how to practice or what I can earn. Some people even presume that I must be angry at the government laying claim to such a large share of my income.  When they bring it up, I never hesitate to tell them that I think the financing of medical care in this country is a disgrace and we should have a single-payer system.  Some people react with shock. A doctor in favor of socialized medicine?!  I confess, when I get that reaction I take a certain amount of malicious amusement in following up by a provocative statement such as medical care in Canada has a great deal to recommend it and we might be better off here if we adopted such a system.  I am especially amused at the story of the Tea Partier who held up a sign at a rally two years ago, “Government Hands off Medicare!”. For all its faults, I tell my patients, Medicare is the most generous insurance plan out there. Why not extend it to everyone? Of course, we would have to control utilization. Upon hearing that, some of my patients seem almost apoplectic.

It doesn’t much matter whether my political opinions agree or disagree with those of my patient; either way it’s a sticky wicket. Some will be particularly eager to have a discussionespecially if they find the least suggestion I share their beliefs. Who better to lend a sympathetic ear to your opinions on the absurdity of the term “death tax” than your doctor? After all, doesn’t he have  an intimate acquaintance with life and death? Who better to unburden your political prejudices to than the person who is paid and obligated to listen to your most intimate fears and anxieties about life? Surely your doctor would lend you a sympathetic ear, right?

Thus I have learned over the years that it is best to keep politics from intruding into my medical encounter, but recently I encountered a patient’s political views in a way I could not avoid. I was glancing through the letters-to-the-editor page of our local small town gazette when I came across a letter submitted by one of my patients who I have attended to for many years. He is a very pleasant, intelligent and appreciative gentleman in all respects and we have had many conversations about his career, family, hobbies and retirement pursuits. The letter was prompted by some issue about the town budget, if I recall correctly. I was dismayed to find it proceded to a reactionary and bigotted diatribe against immigrants, poor people, liberals, our President and his party, so laden with half-truths, vitriol and outright nonsense that even a Rush Limbaugh could not have concocted it! I could hardly believe it was written by my very same patient. I wondered immediately how that might affect the care I provide him in the future. Will I be less sympathetic? Will I unconciously skew my use of healthcare resources on his behalf? Will my advice regarding end-of-life issues be influenced by his views on the “right to life”?  Should I recuse myself from his care? But that would constitute a form of retaliation to someone who has entrusted me with his life, and what sort of person would I be if I only plied my skills with those I agree with? In fact, wasn’t it part of my Hippocratic oath not to be swayed by such considerations?  I have a few times cared for criminals and felt as though I was doing my duty, and they presumably havve committed far more egregious offenses than were committed by my patient.

In the end I decided to file it away and never mention I had seen the letter. But my relationship will never be quite the same, in the same way that one might be put off to find that someone we respect has committed some act that betrays  that respect. Sometimes patients find that their doctors have feet of clay, but it is a rude shock for me to learn that my patient is not all the man I thought he was. I guess this is just something else I have to accept: I have to maintain my role as a healer regardless of whether I have contempt for a patient’s substance abuse, legal problems, sexual misconduct, or abhorrent political attitudes. Somehow the last one feels uniquely difficult today.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut.

The numerous changes in the healthcare sector are forcing stakeholders to develop new business models to prosper, to survive. Among health insurers, this means one thing: diversification. Health reform was the nail in the coffin of yesterday’s business model, a model that had no restrictions on margins, a model where payers sold to businesses, not individuals. Tomorrow’s strategy for payers is still a work in process but one thing is clear, its foundational elements will be consumers, technology and data. The emerging world of big data in healthcare is providing payers with new potential ways to make profits. Beyond the promise of efficiencies, some payers are beginning to look closely at harnessing the flow of clinical, claims and administrative data to allow for the creation of stand-alone business opportunities.  Specifically, information exchange will grow in importance in 2012 and beyond as value-based payment models rely to increasing extents on the availability of diverse types of data at the point of care.

So why have payers been so cautious to jump on board and fund HIE’s?

The answer is multi-faceted. First and foremost is simply the issue that many a provider is uncomfortable with a payer having direct access to clinical data and is thus unwilling to share such data with an HIE that has payer involvement. Second is the business uncertainty at this early stage of HIE maturity. The HIE market remains very dynamic and there is a lot of uncertainty as to where this market will eventually lead. Before putting some parameters around the direction of payer-involvement in the HIE market, it bears a quick run-through of what the different models of payer involvement look like today.

Infrastructure Play
Axolotl and Medicity are the clear leaders in the HIE software market. Both were acquired in 2010 by big insurers (Axolotl by United Health Group, which was folded into the Optum Division and Medicity by Aetna) and continue to dominate the HIE landscape. Both UHG/Optum and Aetna are clearly looking to build out new lines of business, in this case healthcare IT, where the opportunities for future growth and expansion are promising. Their investments are already paying big dividends: In a telling sign of the direction of this market, Optum has actually begun to grow faster than UHG’s main insurance business.

The investments these insurers have made in HIT are significant and ones that only the biggest national players will have the appetite for. Kaiser’s walled garden, in-house approach effectively rules them out of this kind of play. Other payers have not shown signs of moving towards owning their own HIE solution, or making other major bets on HIT…yet. Humana and Cigna have only helped out by funding pilots to date. Despite a national brand and association, the Blues fit into their own category because of the state-based nature of their business structure. They are certainly not slouching in the HIE race though as the next section explains. Chilmark has also heard murmuring around the water cooler about some potential partnerships on a more national scale in 2012, so again only time will confirm these rumors.

Conclusion: It may be too late for other payers to get in on the HIE market via acquisition of a leading vendor as few independent vendors remain. Lumeris, with three regional Blues acquired NaviNet this week. This acquisition may provide a non-traditional route to the same end-point, purchasing the network to build-out future pipes for numerous data types. Further crystallization in the HIE marketplace as well as more evidence from operational systems will help them make a bet on a particular vendor.

Entirely Payer Funded
These are HIE’s that are exclusively funded by payers. As it stands now, this is a pretty lonely space, as providers continue to be skeptical of payer intentions and there remains a dearth of conclusive proof of return on investment (ROI), more studies like Humana’s with WHIE will only help. However, some early movers have already tasted success with this approach, the most prominent being Availity, a Florida-based collaboration between two Blues plans, Humana and WellPoint. Their business model is simple: Payer contributions help to get the data flow and integration efforts underway, providers receive a base set of information access services for free, and pay for premium business services such as revenue cycle management and practice management tools. The value equation for providers has been enough to keep Availity in the black to date. They’ve gone one step further and it looks like Availity will be licensing this to other Blues plans around the country as well. While this work is certainly laudatory, Chilmark is skeptical that this level of collaboration will occur widely today (Availity began in 2001). While it’s possible for a national payer to partner with local plans to get an HIE off the ground, these typically include other intermediaries for purposes of getting buy-in from other stakeholders (these are insurance companies, after all), skin-in-the-game and governance. Moreover, because the ROI in HIE can be somewhat invisible, appearing in efficiencies and reduced costs for payers and providers, payers feel more comfortable sharing the investment.

Conclusion: Aside from emerging collaborations between Blues plans and some provider organizations (e.g. Catholic Healthcare West and Blue Cross of California), we foresee little progress here. For big payers considering an acquisition play, investing in one-off models is quickly becoming redundant; for local plans it makes more sense to share the load with non-payers.

This post first appeared at Chilmark Research.

I like health Web sites and tech start-ups. I think the democratization of medical information is a beautiful thing. It’s a cliche that you can find out more about a hotel than a doctor with a few Google searches. I love how that’s starting to change. I also think that electronic medical records will improve health care over the long haul.

But I am also cynical about the idea that technology is some sort of panacea all that ails the sector. I read Michael Lewis’s book The New New Thing when it came out in 1999. There’s a great anecdote in it about Netscape founder Jim Clark. He was looking for another big challenge and decided–this was 1996–that all that was missing from health care was good software. So he started Healtheon. To Clark it was just a matter of writing some really good code and all the inefficiencies and paperwork that bedeviled the industry would go away. His business plan was a flow chart showing how software cuts out paperwork. It was simple.

Flash forward and Healtheon is buried somewhere deep inside WebMD. There’s still a lot of waste and paperwork that hasn’t gone away.

Since Clark there has been a parade of other ambitious health-tech entrepreneurs. Do you remember the search engine Wondir? Or the comparison-shopping site Vimo? Or Carol.com? How about Steve Case‘s modestly named Revolution Health? What about Subimo?

Just like Healtheon they all failed to catch on, much less “fix health care.” Castlight is a more recently hyped entry in the field. Another is John Doerr‘s company Essence Healthcare. HealthTap is another one that’s gotten buzz.

Though people keep trying, the track record of trying to “solve” health care the Silicon Valley way is fairly uninspiring.

That’s why I cringed this week when I saw another company–and another reporter–fall into the “if we Webify health care we can fix it” trap. The Times profiled ZocDoc, a New York start-up that has raised over $90 million from big names like Amazon’s Jeff Bezos. Its business is an interesting one. It’s like OpenTable, but instead of helping you get a restaurant reservation, you use it to get an appointment with a doctor.

But here’s the money quote from the article that made me shake my head:

“We’re one of the companies that can help fix the health care system,” said Dr. Kharraz, a physician and ZocDoc’s chief operating officer. “We’re making doctors more efficient and helping patients find the hidden supply of health care.”

Uh oh. Why go there?

ZocDoc has a cool service that’s attracting doctors. It will hopefully make some money for its investors. But why does it also have to “fix the health care system?”

There are lots of interesting debates about whether our health system is broken, if so why, and how to make it higher quality, lower cost, less wasteful, and so on. But I promise you that nobody having these debates has pinpointed the inability to get a doctor’s appointment as part of the problem.

So why do start-ups fall into this trap of promising to fix health care? I have a couple theories.

The Apple Effect There’s an unofficial requirement that tech companies can’t just build a great product. They also have to make the world a better place. Remember how Steve Jobs recruited John Sculley from Pepsi by asking if he wanted to spend his life “selling sugared water? Or did he want to come with me and change the world?” The punch line, of course, is that Apple has changed the world. But that kind swagger has also raised the bar. Every other tech company must act like it’s doing something more than just engineering a cool product.

Everybody In The Industry Must Be A Reformer When you’re in health care, changing the world means “fixing it.” I’m someone who thinks that our country’s health care system works better than any other and that the crisis has been vastly overstated. But I’m in the minority. We wouldn’t have just passed a $1 trillion health reform bill. So if you are an entrepreneur it’s tempting not just to “change the world” by making doctors offices run a bit better. You shoot higher. You will fix the world! Apply the same rhetoric to OpenTable and the food business and it sounds kind of silly.

Overzealous Tech Reporters Usually technology reporters, not health care reporters, write these hyped up stories. They need a hook for why the company will be the next Facebook or Google. Health reform is staring right at them. They may get the quote simply by asking over and over again the “fixing health care” question. And for whatever reason, there’s little effort to hold previous companies accountable that had the same ambition.

Health Care Is Analogue Medicine is easy to diss for being a Luddite field. Doctors don’t use email like other professionals. The paperwork is out of control. Hospitals are big, messy service businesses. There’s a feeling that any service can be better with technology.

This diagnosis is true. But the cure is not necessarily as simple as adding software. (Although that is happening with the widespread implementation of electronic medical records.) What’s harder to grasp is that health care is not just a service. It’s an experience. And while many services can be replicated online, human experiences can not. There’s no real electronic replacement for being seen by your doctor. When you take a pill you can’t do it over the Internet. You obviously can’t get virtual surgery.

So it’s true that you can point a finger at health care and say it lacks tech. But it’s not because the technology doesn’t exist. It may be that technology doesn’t really fit. To make a comparison to another “experience sector”: the Web also can’t replace a vacation. It can enhance it, perhaps. But it’s a human experience existing in three-dimensional space.

Going After Bricks & Mortar Many of these health-tech start-ups have looked at a big hospital, or a doctor’s office, the same way Amazon.com once looked at Barnes & Noble. Make the industry faster, chaper, more transparent and disaggregate the market–and you’ll win. (I’m in favor of all those things, by the way.) But in health care it hasn’t been an easy road. Just ask Google, which had to shut down its Google Health product last year after nobody found much utility in storing their health information online. Microsoft HealthVault may be next.

If I were working at one of these health start-ups I’d be careful not to over-hype what I’m doing. (And not just because I’m a superstitious, jinx-minded guy.) I think health care needs more entrepreneurs. But a team of engineers coding all night, no matter how smart they are, how well they’re funded, how much publicity they get from the tech press, or how high their ambitions–is not going to “fix” health care anytime soon.

Matthew Holt, who hosts the Health 2.0 conference and has followed this space more comprehensively and for much longer than I have, makes a similar point in an article he wrote this week on THCB.

He was taken aback recently by the hype surrounding a start-up called CareZone. It appears to be a private Facebook for people taking care of sick loved ones to store information. It also has a certain hubris and a big-name founder from the software industry. It might turn out to be great. But as Holt writes convincingly: don’t act like this kind of thing hasn’t been tried before.

David Whelan is a contributing editor at Forbes, where he was a staff writer for 8 years covering health care payers, providers and policy. He’s currently studying and working in hospital administration. Follow him on Twitter @WhelanHealth