Month: July 2010

Checking in with BenefitFocus

It's been a little while since I checked in with the folks at BenefitFocus. They essentially create a system that allows employees to sign up for benefits all at once. They market it via a lead health plan in each area, and then give the employer HR department the ability to glom their other benefits plans onto it, saving lots of time and trees during open enrollment and for new employee hires. (The really old reader may remember that this was the very first business model of Healtheon in 1996 and funnily enough Healtheon's first "client" for that version of their business model, Blue Shield of California, is a decade and a half later using BenefitFocus for the same thing).

They also have an interesting side business making videos and selling that service to HR departments for internal education, and have a public side to their video business, a sort of Youtube for health called ICYOU, who of course come to every Health 2.0 Conference (Hi, Nina & crew!)

Last week I caught up with Shawn Jenkins, the CEO of BenefitFocus. This is a guy who started a business in the middle of the dotcom bust in the technology backwater of South Carolina (cue abusive emails!), and now has 500 employees, lots of clients and a very profitable company. And of course they are well positioned to be at the hub of the forthcoming exchanges–the state of Maryland has already signed on the dotted line. And now they're moving into analytics.

Interested in what they're up to? Listen in.

Shawn Jenkins, BenefitFocus

Kenneth Buetow and caBIG

SUBTEXTAt Health 2.0 Goes to Washington on June 7, 2010, Kenneth
Buetow, Associate Director of BioInformatics for the National
Institute and Founder of caBIG, talked about the launching of a large
scale effort called Cancer Biomedical Informatics Grid (caBIG).

Open access scheduling at the doctor’s office

I’m quoted in the Boston Globe today (A new practice: The doctor will see you today) on open access scheduling. (I’m all the way down at the bottom of the article.)

Open access is one of my favorite innovations because it improves customer service and quality levels. As we add patients to the system open access provides a way to preserve or improve access to the physician. It’s better—in my view—than other solutions such as using more mid-level practitioners and trying to boost the total number of doctors.

Open access means seeing today’s patients today rather than forcing them into a slot far in the future or trying to squeeze them in to a crammed schedule. The example given in the Globe article is a more extreme version than what I’m used to. I’m not sure such a radical shift to open access is optimal. It might be best to preserve a lower percentage of slots for same-day access rather than forcing folks in today who’d prefer to wait a bit!

What’s required to make open access work?

  • Working overtime to chip away at the existing backlog (otherwise there’s no free time to offer up)
  • Varying number of hours worked per day to accommodate fluctuating demand
  • Having the right sized patient panel—something that’s somewhat hard to assess in advance, since the true demand is unknown (offices usually just know how far out they are scheduling)

Why does it work?

  • There’s a high no-show rate from appointments made weeks or months in advance

David E. Williams is co-founder of MedPharma Partners LLC, strategy consultant in technology enabled health care services, pharma,  biotech, and medical devices. Formerly with BCG and LEK. He blogs regularly at Health Business Blog, where this post first appeared.

A Reply to the Cato Institute

This week, the Cato Institute released a 52-page report on health care reform titled: Bad Medicine: A Guide to the Real Costs and Consequences of the New Health Care Law.

The tract was written by Michael Tanner, a senior fellow at the Institute, and it rests on the thesis that the Patient Protection and Affordable Care Act (ACA) is both Unaffordable and Unfair. Inevitably, Tanner’s claims about affordability are shaky; in truth no one can project how much reform will cost over ten years—and how much it will save. There are too many variables involved. Nevertheless, Tanner seems sure: the legislation will add to the deficit, he asserts, and force insurance premiums higher. Moreover, he stamps the legislation “unjust”: it would turn private insurance companies into regulated “public utilities,” forcing them to insure sick people, while “redistributing income” from families earning “over $348,000” to families earning “$18,000 to $55,000.”  Ultimately, he argues, reform represents yet another step toward turning the U.S. into a “Nanny State.”

Why a 52-page report on health care reform now? Tanner makes his purpose clear in the Introduction where he suggests that conservatives will make the new health care legislation the “centerpiece of Republican campaigns this fall,” as they lobby for repealing the Affordable Care Act, or at the very least, replacing it. Bad Medicine is meant to serve as a playbook for those who hope to kill reform.

With that in mind, The Century Foundation decided that the document deserves scrutiny. In the weeks ahead, I will be analyzing and rebutting the report’s many arguments against individual and employer mandates, insurance regulation, subsidies, reductions in Medicare spending, and the CLASS Act, a much-needed national long-term care program.Continue reading…

So I’m on TV, unfortunately in piece of crappy reporting

So last month the nice people from KTVU (the local Fox affiliate in SF) came by to interview me and last night it aired. They’d been over at web-based EMR vendor Practice Fusion and had found out about EMRs. Then they came to interview me. I should probably have got the hint when reporter John Fowler kept on asking me about privacy concerns. I spent 20 minutes giving a balanced nuanced view about the advantages and problems of adopting medical records which is not exactly represented by the 6 second soundbite I get.

Unfortunately—despite the producer’s stated desire to use Bay Area people—Texan nut job Deborah Peel gets almost half the piece including almost all the interview content. (Apparently Deven McGraw couldn’t be tracked down? Maybe DC is too far away) And what does Deb Peel say? Well you know what she says…

Continue reading…

How to Ration Health Care

Suppose you were in a triage situation and you had to choose between two patients, deciding who lives and who dies. Are there any principles you could rely on to make your choice?

Alex Tabarrok had an interesting post the other day at Marginal Revolution in which he asked readers to imagine standing behind a Rawlsian veil of ignorance. This is a thought experiment in which you are about to be born into a world, but you don’t know which person in that world you will be (e.g., you could be born smart, dumb; rich, poor; black, white; etc.). You can decide the rules governing the world you are about to be born into, but you must make your choice “position blind.”

What decision rules would you choose?

For his part, Tabarrok focuses on how to allocate kidneys among transplant prospects and his own solution is: allocate scarce organs so as to maximize remaining years of life:

In the current system, a 60-year-old patient can be given a 20-year-old kidney — that’s a waste because the life expectancy of the kidney is longer than that of the patient; it’s like putting a new clutch in a car that is rusting away.  If we had 20-year-old kidneys to spare, this wouldn’t be a big problem.  But we don’t have 20-year-old kidneys to spare, so we also give 20-year-old patients 60-year-old kidneys which means the kidney is likely to die early, taking the patient along with it.  If we want to maximize total life expectancy, younger people should get younger kidneys.

Continue reading…

Fantastic job: HHS ONC subject matter expert on consumer e-health

Josh Seidman has written from ONC telling us about a fantastic job opportunity. You get to work with the brilliant folks at ONC on fun stuff regarding consumer e-Health. What does that mean? From the posting.

  • Forge alliances with consumer organizations, technology and care delivery innovators and consumer advocates to further the consumer e-health agenda.
  • Develop consumer oriented strategies across the Office of the National Coordinator for Health Information Technology (ONC).
  • Serve as Project Officer providing project management oversight for contracts, including designing, developing and coordinating project management plans for policy initiatives in conjunction with the Division Director and the Office of Policy and Planning Director.

We’ve been very impressed by everything we’ve seen about ONC’s commitment to patient communication—not least the “sneaking-in” to the meaningful use requirements in Phase 1 of patient education materials (what Don Kemper calls Christmas in July). I can’t think of a more fascinating job for anyone who cares about online health.

So if you’re interested here’s the link to apply

Christmas in July: Meaningful Use as a Gift for the Consumer

Everyone was expecting the new meaningful use rules to include some important, but relatively basic advances for the consumer—and it did. However few of us expected meaningful use would include a real consumer gift: the requirement that EMRs help doctors deliver information prescriptions to each patient. That addition is a game changer for advancing the patient’s role in a patient-centered health care system.

Page 225 of the rules includes this Stage I Measure for demonstrating the “meaningful use” needed to qualify for the federal subsidy for EMR investments:

More than 10% of all unique patients seen by the provider are provided patient-specific education resources.

That simple requirement represents a sea-change in use of the EMR as a tool to advance the role of the patient. It will bring into mainstream American medicine a recognition that medical care is of high quality only if it includes relevant information to help the patient do appropriate self-care and better participate in treatment decisions.

The requirement gives mainstream life to the decade-old concept called “information therapy” or Ix for short. Ix promotes the need to prescribe the right information to the right patient at the right time as part of the process of care. The new rule promotes the exact same thing.

Continue reading…

My EMR Reality

OK, I am an EMR fan-boy, I will admit it.  I seem real “rah rah” in my approach to computers in the exam room, and to many I seem to have my head in the clouds; I seem to be out of touch with reality.  In response to posts I have written on the subject, comments have been thus:

“I couldn’t see as many patients if I had an EMR.  It would slow me down too much.”

“Using an EMR makes doctors ignore their patients and focus too much on the computer screen.”

“EMR is too expensive for the small practice or primary-care physician.  It will reduce their income in a time when it’s hard enough to function as a PCP.”

Yeah, yeah, yeah.  This is very familiar to me.  It’s also wrong.

True, there is a start-up period of getting used to the EMR in which you can’t see as many patients, but that goes away.  True, there is a time when you are uncomfortable with the computer in the exam room, but once you get used to it, it becomes as natural as having a paper chart.  True, EMR start-up expense is high enough to make doctors, especially PCP’s, wonder if they can afford the cost in this time of austerity.

I understand these things better than most people give me credit for, because I have lived through each of these troublesome sides of EMR personally.  Here is my EMR story:

I started thinking about using an EMR in 1995, when I saw how difficult it was for me to keep track of information in the record.  This came to a head in 1996 when the result of a test was missed, causing harm to a patient.  The problem wasn’t in the thought-process or in the intelligence of the doctor; the problem was from flaws inherent in a paper medical record.

I was practicing with another PCP at that time.  We were employed by a hospital, but were growing increasingly frustrated with their lack of interest in running our practice efficiently.  So we left them in 1996, bucking the trend at that time of hospital ownership of practices for the sake of personal control.  It put us under far more financial pressure, but the control made it worthwhile for both of us.

Feeling the sting of the missed test result, and feeling the empowerment that self-employment brought, my partner and I set about to look at EMR products.  My brother-in-law worked in a nearby practice that had already been on EMR for a few years and was functioning far more efficiently than we could ever hope with our paper record.  We both visited his practice and saw just how much we could gain from a computerized record.  Once we saw this, the question was not whether we were going up on an EMR, it was which EMR product we’d choose.

We narrowed our choice down to two products: one that was well-known and well respected, but more expensive; and one that was cheap, slick, but had a very small user-base.  We were sorely tempted by the slick sales presentation, but listened to our better judgement and went with the more established product.  After buying the product, the cost would end up being $1000 extra per month per physician (given the terms of the loan we could secure for an $80,000 installation).  We both winced at this, given our short time of independence, but then my partner boiled it down very simply:

  • How much do we earn on average per patient visit? We shot low, and said $50 per visit.
  • How many days do we work each month? Both of us worked 20 days per month at that time.
  • How many extra patients would we each have to see to pay the $1000 monthly loan payment? One extra patient per day would easily cover our expense.

One patient per day?  That’s all??  It made the decision quite easy, and it made the ROI quite easy to grasp.  Our goal was to use the EMR in such a way that it would improve efficiency (something we had seen in my brother-in-law’s practice) and focus on other benefits of EMR once we had it paying for itself.  We reached that goal easily within the first 6 months of using our EMR, and exceeded it soon thereafter. Neither of us saw ourselves as slaves to the EMR, we saw the EMR as a tool.  Consequently, we found our own means of accomplishing our goals, using the EMR in ways that other users hadn’t considered.

  • We didn’t care about being paperless, the goal was efficiency and quality of care, not saving trees.
  • We didn’t like the standard templates supplied by the EMR vendor, so we made our own.
  • Whenever I became frustrated with a process, I talked to my partner and then changed the template to fix the process.  I soon became an expert at template development, gaining prominence among users of our product.
  • When the process inefficiency was not template-driven, such as the use of nurses, the process of answering phone calls, or other common situations encountered in our office, we talked with our office manager and staff and came up with a solution.  Our EMR gave us a bunch of options for solutions we would have not had without computers.
  • We quickly realized that fixing too many things at once created trouble.  I adopted the philosophy: “a good idea at the wrong time is a bad idea.”  So we worked to prioritize problems in terms of their seriousness and how easy the solution was.
  • Once we had an efficient workflow, we realized there were incredible gains to be had from a care-quality standpoint.  We were not paid more for good quality, but our efficient workflow afforded us the opportunity to focus on it nonetheless.  That may seem backwards for non-clinicians, but it is the reality of private practice.  In truth, our quality had already gotten significantly better simply from the improved organization of our records and instant accessibility anywhere, any time.

Forward to 2010, and here is where we stand:

  • I see on average 25 patients per day, working 4 days per week.
  • We have 5 Physicians and 2 PA’s.  The efficiency of our office has increased with each additional provider, as we haven’t had to increase overhead much at all with each addition.
  • We no longer see patients in the hospital (except pediatrics, which is a small number), and we don’t do many in-office labs or other procedures.
  • Despite this, our income has been very good – well above the national average for PCP’s.
  • On quality measures, our practice has excelled every time we’ve been measured.  We easily qualified for NCQA diabetes certification, and our measures for prevention are impressive – with colon cancer screening, childhood immunizations, adult immunizations, and cholesterol screening far above national averages.
  • Most importantly, I give my patients the time they need.  I make a point to not rush my visits.  Each visit is given 15 minutes, no matter of the type, but visits that require 30 minutes are given that time (which is usually offset by the 5 minute sinus or ear infection visit).

That is why the arguments against EMR ring hollow to me.  I see it like the arguments people give against exercise:

“I don’t have enough time to devote to exercise.”

“I hurt after I exercise, and basically feel lousy.  I can’t afford to feel that bad.”

“I need my sleep in the mornings and am too tired at night to exercise.  I’m doing OK without it for now.”

Yes, I sympathize with these arguments.  I have made them all myself, and still struggle to exercise regularly.  But anyone who says people are better off not exercising are just plain wrong.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

Keas Opens API for Health 2.0 Developer Challenge!

Keas_logo-one1 The fifth challenge for the Health 2.0 Developer Challenge has just been announced. Keas, the health and wellness data-driven platform, has opened up their API and a development environment to anyone who wants to author a "social Care Plan." In a fun play on a "Challenge to design a Challenge," teams will have access to tools and a robust engine to test new ideas that incorporate social motivation in health and behavior change through the sharing of health data and health results.

The winning team gets to discuss their work over dinner with Web 2.0 pioneer CEO Adam Bosworth, $3,000 cash prize, and the opportunity to feature the winning app at the Health 2.0 Conference in October. To find out more and sign up to compete, see the Keas' Challenge here.