Month: November 2010

Health Reform Won’t Fix the Real Problem: Unemployment

Nov 16, 2010• 6

By GEORGE PILLARI

While the effects of persistently high unemployment have surfaced in the shape of reduced consumer spending, shrunken tax rolls and a host of social problems, there is yet another harsh reality lurking in the shadows. Hospitals, already in precarious financial positions, are seeing their most profitable source of revenue fade away. Should the situation continue, even darker days for hospitals will surely be in store.

More than 150 million people in the U.S. rely on employer-sponsored health insurance to pay for the bulk of their medical costs. One of the more credible criticisms of health reform is the potential backlash against the employer pay-or-play provisions in the legislation, which could throw millions of today’s insured off their employer plans and into the streets with the chronically uninsured. Even if this did not occur, or at least not to a market-moving degree, it would be small recompense, literally, for hospitals relative to the boogeyman that no political party can legislate or filibuster in or out of existence at will: unemployment. Hospitals in our country rely on the privately insured and better-paying patients for approximately 35 percent of net revenue. Given the already compressed profit margins in the hospital industry, any deterioration in the supply of its best customers could seriously threaten the financial solvency and operational viability of many hospitals across the country. Health reform will not prevent this from happening. Reform targets the un- and under-insured and provides only a base level of coverage (Medicaid), coverage that traditionally add nothing to hospital margins and in many cases erode them.

HUB’s List

Nov 16, 2010• 2

By HERBERT MATHEWSON, MD

1). CELL PHONES DON’T CAUSE CANCER–

Despite ample scientific evidence to the contrary much buzz continues about cell phone usage causing brain cancer. Why is that ? A recent review in Scientific American magazine points out how hard it is to prove a negative. I am reminded about the story of the English farmer spreading purple dust over his fields last year. When asked why he did that he replied “To keep the lions away”. The questioner pointed out that there had been no lions in England for at least four centuries. “Works pretty well doesn’t it,” was the proud rejoinder.

A $24 million study (2) of 12,000 regular cell phone users, half of whom already had brain cancer, found no correlation between cell phone use and the two most common brain tumors. A recent article in Skeptic magazine stated that the non-correlation was because, as my oldest son the engineer often says to me, “It’s just physics.” X-rays and gamma rays can cause cancer because their radiation energy can disrupt chemical bonds inside cells, about 480 kilojoules per mole (it’s just a physics energy term). A cell phone generates radiation of less than 0.001 kilojoules per mole. Whatever kilojoules per mole are, it is clear that cell phones don’t generate very much of them; no where near enough to disrupt chemical bonds. The article’s author notes that probably the only way to hurt someone’s brain with a cell phone is to throw it at his/her head. I would add that since HPV (a virus) is associated with cervical cancer and is more apt to be present in sexually active women, I guess you could cause cancer with a cell phone by sexting!

Hospital Discharge Without a Net

Nov 16, 2010• 1

By JESSIE GRUMAN, PhD

By the time I reached the sixth day of my hospitalization for stomach cancer surgery, I was antsy to go home and I quizzed each nurse and physician who came into my room about what must happen for me to be liberated the following day. Their responses were consistent: my surgeon would visit in the morning and write orders for my release. Then I would have a comprehensive discussion with my nurse about my discharge plan, after which I could leave.

I was pretty curious about getting that discharge plan. The Patient Protection and Affordable Care Act raised the stakes for hospitals to reduce high readmission rates and new data on those rates are available. The rates and approaches to reduce them through improved discharge planning are the subject of news reports, journal articles and conferences. And I, a patient in a modern, quality-conscious hospital, was going to experience this process myself!

Here’s a rough transcript of my discharge discussion:

Nurse: Good news! The orders came through! You can go home.

Me: (in the corner untangling wires from my cell phone and iPod chargers) Wonderful. What do I need to know?

Nurse: Here are a couple prescriptions for pain medication. Don’t drive if you take it. Call your surgeon if you have a temperature or are worried about anything. Go see your doctor in two weeks. Do you want a flu shot? I can give you one before you leave. If you need a wheel chair to take you to the door, I’ll call for one. If not, you can go home. Take care of yourself. You are going to do great!

That was it: 8:45 a.m. and I could leave.

EHRs in Surgical Practices

Nov 16, 2010

By JOHN HALAMKA, MD

I was recently asked to offer advice about implementing EHRs in surgical practices. Here are the lessons learned from our Massachusetts EHR rollout experts.

1) . Surgical practices are challenging in general because they frequently use dictation and the most obvious benefits of EHRs do not apply to them. They do not have substantial amounts of structured data to enter and they do not have a high fraction of recurring patients so a large fraction of records are “new” records. The highest benefit areas for them require interoperability, which takes time to accomplish. A significant fraction of the information they need for documentation comes from hospital operative notes, referrals/consults are the biggest element of workflow, and they rely on electronic lab and imaging test results.

2) . The most successful workflow change approach requires shifting more responsibility to mid-levels so that basic structured data entry (like vitals, history, etc) and billing related entry do not fall on surgeons who can be resistant to doing that type of documentation. Unfortunately shifting practice roles/responsibilities is not easy.

3) . Working with the practice to build structured procedure templates in advance of go-live and setting up voice-recognition to allow surgeons to continue to dictate are key workflow/adoption steps.

4). Some EHRs such as eClinicalWorks have templates for Operative Notes as well as SOAP notes, which are key to EHR adoption.

5). Interoperability should be implemented as quickly as possible: diagnostic results delivery (especially imaging results) and hospital document push (operative notes, discharge summaries) should be integrated into workflow during implementation.

The Road to Wellville: Pilots and Demos?

Nov 15, 2010• 15

By ROGER COLLIER

As might be expected of reform legislation, the Patient Protection and Affordable Care Act places a lot of emphasis on innovation. Reasonably enough, most of the potential changes—at least in Medicare—are to be preceded by pilot or demonstration projects designed to test their feasibility. In fact, according to one health care blogger with time on his hands, PPACA includes no less than 312 mentions of demonstrations and 80 mentions of pilots.

Just how important are all these pilots and demos? Harvard’s David Cutler, who served as a key advisor to the Obama administration in developing the reform strategy, clearly believes they are vital. Writing in the June Health Affairs, he stresses the need for rapid implementation of the pilots and demonstrations in order to help achieve eventual savings of “enormous amounts of money while simultaneously improving the quality of care.”

How realistic are Professor Cutler’s expectations?

CMS’ Medicare chronic care demonstrations provide some clues. With data showing that the costliest 25 percent of beneficiaries account for 85 percent of total Medicare spending and that 75 percent of the high-cost beneficiaries have one or more major chronic conditions, the demonstrations were expected to show big benefits from care coordination—the major theme of PPACA’s proposed demos.

The outcomes were decidedly discouraging, as noted by MedPac’s 2009 report to Congress:

“Results suggest that some of these programs may have modest effects on the quality of care and mixed impacts on Medicare costs, with most programs costing Medicare more than would have been spent had they not been implemented….In almost all cases, the cost to Medicare of the intervention exceeded the savings generated by reduced use of inpatient hospitalizations and other medical services.”

Unhealthy Skepticism

Nov 15, 2010• 5

By JOHN MOORE

There remains an unhealthy level of skepticism in the market as to whether or not consumers will use a personal health record (PHR). While a certain level of skepticism is healthy in any market, the level to which it is laid towards PHRs is unwarranted and likely more a function of ignorance then malicious intent. Following is a brief PHR case study that provides validity to the mantra that a patient who is provided access to their personal health information (PHI) via a PHR can become a more engaged patient in self-managing their health. What is particularly striking about this story is that it is does not take place in middle-class America, where many have targeted their PHR initiatives, but rather among the urban poor.

Last week, I met with Dr. Nunlee-Bland, Director of Howard University Hospital’s (HUH) Diabetes Treatment Center, who graciously provided the context and content for this remarkable story.

Empowering the Urban Poor to Self-Manage Their Diabetes:

In 2008, HUH received a grant from the Dept of Health, DC to launch a diabetes treatment program primarily targeting urban poor. As part of this grant, HUH launched a PHR initiative creating a patient portal using NoMoreClipboard (NMC), linking NMC to their clinical diabetes EHR, CliniPro from NuMedics. The PHR provides patients with access to their problem list, vitals (height, weight, blood pressure, BMI), medication lists, basic lab results, A1C results (can be charted for track and trend) and basic demographic information. While Dr. Nunlee-Bland stated that HUH has no reason not to provide patients with full access to all PHI, they have purposely kept the PHR simple and focused on the treatment of diabetes.

Massachusetts has the best health care in America?

Nov 15, 2010• 9

By PAUL LEVY

A well regarded local hospital administrator last week said, “There is lots of evidence that Massachusetts health care is the best in the country.”

The context was a discussion in which it was pointed out that health care costs in Massachusetts are above the national average, even adjusted for wage differences. The statement was made to suggest that it is worth paying a bit more if what we actually get is better.

I was taken aback. I have never seen any evidence to support this conclusion. Would anyone care to offer quantitative support for the proposition — or against it?

Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that under Massachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.

The HIT Parade

Nov 15, 2010

By LISA SUENNEN

The Cleveland Clinic recently published an annual Top 10 list of what their leadership believes to be the most significant advances in medicine in each of the last five years. In 2007-2008 all of the items on the top 10 lists were either medical devices, clinical diagnostics,pharmaceutical or biotech products. These sectors were basically the Beatles of medicine, while healthcare information technology was more like the indie group Florence + the Machine: intriguing, but not likely to be called out on the Billboard Top 10 (or make Cleveland’s own Rock and Roll Hall of Fame) in the immediate future.

Interestingly, healthcare information technology (HIT) applications began to sneak their way onto the Cleveland Clinic Top 10 list over the last two years. In 2009-2010 HIT barely made it, coming in at number 10 in both years. In contrast to all previous years, however, there it was. HIT had made it to the list representing 10% of what one of the nation’s most prestigious medical institutions calls the most significant up-and-coming technologies that can have the biggest impact on health care. In 2011 HIT was number 6 with a bullet, moving HIT well up the Top 10 list.

I think it is fair to say that most people in the know about the healthcare field agree that the strategic application of HIT is essential to moving the quality, efficiency and efficacy of our healthcare system forward. However, it is particularly gratifying to see an organization such as the Cleveland Clinic broadening their view of what constitutes the most profound developments in our healthcare system.

The Road to Repeal?

Nov 13, 2010• 24

By RICHARD REECE, MD

Emboldened by their victory in the Midterms, many Republicans are calling for repeal of the Patient Protection and Affordable Care Act (PPACA). How likely is it that we’ll see changes any time soon? Probably not very. More cautious observers are expressing reservations about the prospect of any reversal in the near term.

Paul Ryan, R-Wisconsin, one of the Republican young guns, says, “You can’t fully replace this law until you have a new President and a better Senate. And that’s probably 2013, but that’s before the law fully kicks in on 2014.”

Michael Tanner, a senior fellow at the conservative Cato Institute, is more straightforward,”Repealing Obama care is just not going to happen while Obama is in office.”

In the meantime, expect the following events to play out over the next two years.

1. House Republicans will vote overwhelmingly to repeal Obama care, with modest Democratic support from those elected who opposed Obamacare.

2. Harry Reid, Senate Democratic leader, will refuse to bring the House repeal up for a Senate vote.

3. President Obama will insist, as he already has, that it is foolish to “relitigate” a law which he regards as set in legislative, historic, and ideological concrete.

4. They will call upon Kathleen Sibelius, Secretary of Health and Human Services, to explain why costs have risen sharply since passage and why so many insurers and businesses have dropped coverage.

5. They will summon Doctor Donald Berwick, Administrator for the Centers of Medicare and Medicaid Services, to explain his views and to justify why he should be reseated following his recess appointment.

6. They will seek to repeal the reform the provision calling for submitting of 1099 forms for every $600 of business expenditures – a possible item of compromise.

Paper Is Good … Pass It On

Nov 13, 2010• 8

By ALEX EPSTEIN

I nearly dropped my spoon into my fibery breakfast cereal last Sunday, because as I was reading the paper, I noticed a a full page ad that read in part…

“It’s Easier to Learn on Paper”

Seems a Paper Company – called Domtar, has been taking out full page ads in the New York Times Magazine, among others, to tell the world – words go better with paper.

I was reading about the virtues of paper, in a paper, printed on paper. A paper trifecta.

Another of their claims: Reading on Paper is 10-30% faster than reading online, plus reviewing notes and highlights is significantly more effective.

Now I don’t know if any of that stuff is really true. Or if it is the dying gasp of a dying medium.

Speaking of dying, did the guys who made papyrus tell the authors of the Dead Sea Scrolls that the scrolls would be an easier read if read on their vegetable based medium rather than the animal medium of parchment?

I remember way back when I was a kid growing up Brooklyn, and my teachers at P.S. 241 put our class on the subway for a class trip to visit the Gray Lady herself. That was when she still printed on West 43rd Street (and you wondered why it’s called Times Square – duh!).

And they gave us a tour and showed us the whole process – from the city room to the banks of men typing the stories on gargantuan machines that molded type out of lead – to the printing presses to the trucks.

Anyhow, I wonder whether the Linotype Operators union was telling its people then…words go better with lead?

Now people actually have to remind us – Paper is Good??