Month: April 2011

The Patient-Centered EHR

Apr 12, 2011• 7

By MARGALIT GUR-ARIE

The term patient-centered has become a serious contender for the most flippantly used term in health care publications and conversations. Of course meaningful use is still #1 on the popularity charts, with ACO quickly moving up, but even meaningful use and ACO are almost always accompanied by patient-centered as a way to add legitimacy and desirability to the constructs.

Even Paul Ryan’s new recipe for fiscal Nirvana is touting patient-centered health care as one of a litany of fictional achievements made possible based on an array of wishful thinking assumptions. But perhaps the most common usage of patient-centered terminology is the Patient Centered Medical Home (PCMH), which is touted as the ultimate patient friendly solution to our health care difficulties. Since PCMH is heavily reliant on Health Information Technology (HIT) to achieve patient-centeredness, and since Meaningful Use of Electronic Health Records (EHR) is being increasingly aligned with this goal, it may behoove us to explore the features and functionality that would qualify an EHR to support a patient-centered approach to health care delivery.

But first, what exactly is patient-centered health care? From reading the NCQA medical home specifications, the Meaningful Use definitions, the HIT suggestions from PCAST and the brand new ACO regulations, all of which assert a patient-centered approach, one would conclude that patient-centered care is made possible by providing all patients with timely electronic access to the entirety of their medical records including lots of patient education, electronically coordinating a multitude of transfers of care, empowering non-physicians to provide most medical care, measuring a bewildering array of health care processes and constantly evaluating and reporting on population metrics, while somehow allowing patients and families to express their wishes regarding the nature of care within the boundaries specified by each proposal. I am excluding the Ryan budget proposal here, since other than having “patient-centered” typed in various spots, there is no reference to actual health care delivery, or what is left of it after most seniors, sick and disabled folks are reduced to begging for medical care. Computers and EHRs can, and to some extent already do, support many of the above activities, but is this truly patient-centered (singular) care, or should we add an “s” and refer to a plurality of patients-centered, or population-centered, care?Continue reading…

To the Barricades!

Apr 11, 2011• 5

By DAVID DRANOVE

Last week, Republican Congressman Paul Ryan unveiled his plan to save Medicare and Medicaid. Supporters hailed the plan as revolutionary; critics decried the plan as revolutionary. For something so revolutionary, it sure is based on some old ideas.

In 1978, Stanford Business School professor (and my soon to be advisor) Alain Enthoven published an article in the New England Journal of Medicine in which he described his “Consumer Choice Health Plan.” Enthoven proposed tax-funded vouchers that all Americans could use to purchase health insurance. The amount of the voucher would be tied to income and individuals could use their own money to purchase a plan that cost more than their voucher. Enthoven even included some rules limiting the ability of insurers to cream skim healthier enrollees; new and improved versions of these rules are written into the insurance exchanges as part of the Affordable Care Act.

In 1986 I published a paper that described how states were trying to control Medicaid expenses by regulating the prices they paid to hospitals. I pointed out that states had surprisingly little interest in reining in hospital costs because the federal government paid for half or more of the Medicaid bills. The solution was apparent to any economist – convert the “percent of Medicaid spending” formula to a block grant, so that the states are 100% responsible for the costs of Medicaid expansions.Continue reading…

HIT Trends Summary for March 2011

Apr 11, 2011

By MICHAEL LAKE

This is a summary of the HIT Trends Report for March 2011. You can get the current issue or subscribe here.

Government drivers. Federal communications dominated this month’s news. ONC defended its core EHR strategy through a report published in Health Affairs analyzing the most recent studies to prove the benefits. It found that 92% of studies reported positive or mixed but predominately positive results. The study updates prior research by Chaudhry (2006) and Goldzweig (2009).

It also released its 5 year HIT strategy that is more of a comprehensive tactical plan of the work over the next years. The plan seems generally aligned with most industry expectations. (Adopt EMRs. Exchange patient info. Make it secure and private. Get patients empowered. Measure everything.) ONC is asking for public feedback. Early comments wish the plan contained more on fraud prevention and innovative solutions and architectures.

There’s also some pushback on its Stage Two and Three requirements. A CCHIT industry survey indicates some potential overreach in areas such as agency reporting, formulary checking, medication reconciliation, patient info access and other areas. Yet CMS put out its first rules on ACOs for comments, and the HIT requirements are ginormous. Writing in the NEJM, CMS head, Don Berwick says, “Information management — making sure patients and all health care providers have the right information at the point of care — will be a core competency of ACOs.”Continue reading…

PatientsLikeMe goes big, doesn’t stay home

Apr 11, 2011• 1

PatientsLikeMe has, since before we first featured them at Health 2.0 in 2007, been the patient online community continually pushing the boundaries for patients with rare diseases. It started with MS, ALS and Parkinson’s and slowly moved towards mental health. And along the way PLM developed some of the most unique reporting tools both for patients and for third party (read: pharma) researchers. However, it always stayed away from the really big disease categories, like diabetes. No longer. As of today anyone can start a community for any condition at PatientsLikeMe. As of right now there are 182 patients with type 2 diabetes. Of course this is minuscule compared to Diabetic Connect or dLife, but given PLM’s reputation and press coverage, the gloves are well off in the patient community contest.

The Massachusetts Mistake

Apr 10, 2011• 17

By ROGER COLLIER

A year after the passage of health care reform, fewer than half of Americans support it, a similar percentage believe that it has already been found unconstitutional or soon will be, health care costs are continuing to rise far faster than the CPI, and the Republican Party has seized on the issue as a sure election winner.

The Obama administration and congressional Democrats, now thoroughly on the defensive, are clearly surprised at the public and political reaction. But should they be? This post—on the reliance on Massachusetts as a model—is the first of three that will look at some of the miscalculations—and sheer bad luck—that have helped to undermine reform. When Governor Mitt Romney signed Massachusetts’ reform bill into law in 2006, it was widely regarded as a bipartisan political triumph, and one that was supported by the public and by most of the state’s insurers and providers. Massachusetts would be the first state to require virtually all legal residents to have coverage (with tax penalties imposed on those not complying), while providing subsidies for lower-income individuals not eligible for government programs, as well as to implement a state-administered brokerage function (the Connector) to allow competitive selection of health plans. By the fall of 2008, as congressional efforts to design national health care reform moved into overdrive with the election of Barack Obama, the Massachusetts legislation was widely regarded as a success. Public reactions were generally positive, the numbers of uninsured had fallen, and there had been no dramatic increase in costs. It was scarcely surprising that the Massachusetts model emerged from the field of competing proposals as the favorite of most Democratic lawmakers.

Unfortunately, the elected officials in Washington DC failed to recognize that Massachusetts was an exceptional state in terms of health care. Even before the state’s reform bill was enacted, the percentage of uninsured was very low. It was also a socially very liberal state, far more likely than most to support reform efforts (in fact, Massachusetts had passed, but then revoked, a slightly different version of health care reform a dozen years earlier). And, of course, the economy was still in its boom period when the new law was passed. Massachusetts had other advantages that would not transfer to national reform. As a small state, with only a small percentage of the population likely to be directly affected by reform, implementation could be much faster—less than a year for most provisions of the state’s new law. Continue reading…

The RUC’s Defense

Apr 10, 2011• 3

By BRIAN KLEPPER

On Wednesday, 47 American medical specialty societies sent Rep. Jim McDermott (D-WA) a letter, with copies to all members of Congress, containing a detailed defense of the American Medical Association’s (AMA’s) Relative Value Scale Update Committee’s (RUC). For 20 years, the RUC has exclusively advised the Centers for Medicare and Medicaid Services (CMS) on physician procedure valuation and reimbursement. On its face, the letter responds to a seemingly minor piece of legislation introduced by Rep. McDermott, H.R. 1256, the Medicare Physician Payment Transparency and Assessment Act, that would require CMS to use processes outside the RUC to verify the RUC’s recommendations on medical services values.

Conspicuously absent from the letter’s signatures were the nation’s three main primary care societies: the American Academy of Family Physicians (AAFP) – which has formally endorsed Mr. McDermott’s bill – the American College of Physicians (ACP) and the American Academy of Pediatrics (AAP). Last week, the New Jersey Academy of Family Physicians sent a letter to its parent organization, AAFP, “strongly encouraging” it to quit the RUC. It is as though the long-compromised primary care physician community, that makes up one third of American physician and handles half of our office visits, is suddenly mobilizing.

The medical societies’ letter is more than a response to just Rep. McDermott’s bill. It also responds to the primary care physician community’s stirrings. Marshaling the influence and discipline of a medical establishment obviously distressed by the prospect of having its economic franchise disrupted, it was the third public defense of the RUC in a little more than a week, following a column on Kaiser Health News by the RUC’s Chair, Barbara Levy MD, and a letter this past Tuesday to Rep. McDermott by AMA CEO Michael Maves. After 20 years of easily-validated intentional obscurity – ask virtually any room of physicians what the RUC is and watch the majority’s blank responses – this open activity favoring the RUC is unprecedented.

The letter is also obviously orchestrated, using many of the same tactics and arguments that Drs. Levy and Maves employed in their defenses. It carefully avoids talking about the abysmal real world consequences of the RUC’s historical approach. It ignores the dramatic under-valuing of primary care, the plummeting rates of medical students choosing primary care, the over-valuing and over-utilization of a wide variety of specialty procedures, and the inherent incentive for the RUC to focus on under-valued rather than over-valued procedures.

Instead, it obfuscates. To counter the McDermott proposal that CMS should use means other than the RUC to assess the RUC’s recommendations, the letter argues that past efforts to use contractors have failed. Therefore, it is senseless to go down this path again.Continue reading…

Sekou & Steve: When Does Death Begin?

Apr 10, 2011

By MATTHEW HOLT

This was sensational when I saw it live at TEDMED and it’s even more amazing second time around. Sekou & Steve do 18 minutes of beat poetry & intensity–“we know when life ends, but when does death begin!

Why CMIOs Matter, and Why We Hired One

Apr 10, 2011

By JONATHAN BUSH

On Monday morning, April 4, we were proud to announce that Dr. Todd Rothenhaus has come onboard here at athenahealth to serve in the role of chief medical information officer, or CMIO. It’s a new position and we’re excited he’s joined us. Among many other tasks he’ll take on, he’ll be working on various product development and physician advocacy initiatives.

So now that we’ve got one on the payroll…you might ask: what exactly is a CMIO? And why do we now have one at athenahealth?

I have always known, at a gut level, that from a sales perspective, CMIOs are more important for us to engage with early in the sales process than a traditional CIO (no offense Halamka, I still wanna be friends). In fact, we became major sponsors of CMIO magazine long before I truly appreciated the role of a CMIO!

The CMIO is almost always a doctor, but a doctor in an executive position responsible for managing the health information in a medical organization. They lead implementation of EMR and other health information technology systems. And it seems there is a Lorax element to most. Remember that Dr. Seuss favorite? Well, in the way that the Lorax speaks for the trees, the CMIOs I know speak for the other docs in their organization where management of information is concerned.Continue reading…

The evolution of THCB

Apr 9, 2011• 3

It’s been a couple of months since we moved THCB to WordPress and added the channels you see at the top. As you may have noticed there have been some teething troubles, and for all its power WordPress does have some problems. We’re still working on fixing the right hand columns. However, we’re able to do some things that we couldn’t before–including this little mini-blog microbrew that allows me (Matthew) to write little pieces that I like without having to write enough for a whole post. WordPress also does much better on spam trapping;I literally just went through 1,000 spam comments and only 3 were false positives. If youve had problems posting comments try taking OUT any links (that tends to trigger the spam filter).

But overall you can expect more and better from THCB in the coming weeks…and we’ll be keeping you updated.

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Everything you always wanted to know about the Health Care system. But were afraid to ask.