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HIMSS11 Live: Meaningful Use

What can be said about “meaningful use” of electronic health records that hasn’t already been said? Actually, plenty, if the events leading up to Monday morning’s official opening of HIMSS11 are any indication.

Last week, HIMSS honcho Steve Lieber told me in an interview at his Chicago office that most of the confusion about Stage 1 meaningful use has subsided, but that there still was plenty of “uncertainty” about the future. As in, uncertainty about the transition from Stage 1 to Stage 2 of the federal EHR incentive program and uncertainty about leadership, as national health IT coordinator Dr. David Blumenthal prepares to return to Harvard in April. (Yes, it is April. Blumenthal apparently spilled the beans to former Sen. Dave Durenberger a few weeks ago.)

“Everybody’s real clear on Stage 1,” Lieber said. The uncertainty is about future stages of meaningful use, particularly in the transition from Stage 1 to Stage 2. The fact that there will be a new national coordinator is another source of uncertainty, but it just means that there could be further refinements to existing regulations.

Vendors seem anxious to see the Stage 2 regulations so they can begin modifying and recertifying their products to help customers meet the next round of requirements. (Yes, everything will have to be recertified to meet Stage 2 criteria.)

The College of Healthcare Information Management Executives (CHIME) late last week formally asked for more time to transition from Stage 1 to Stage 2 because it’s unclear if many physicians and hospitals are even ready for the first stage. “CHIME believes that it would not be prudent to move to Stage 2 until about 30 percent of (eligible hospitals and eligible providers) have been able to demonstrate EHR MU under Stage 1,” says CHIME’s comment letter. “We believe this approach would strike a reasonable balance between the desire to push EHR adoption and MU as quickly as possible, and the recognition that unreasonable expectations could end up discouraging EHR adoption if providers conclude that it will be essentially impossible for them to qualify for incentives.”Continue reading…

Let’s Face(book) the Hard Truth About Healthcare

‘In the time when new media.

Was the big idea.’

These two lines at the end of the album track  ‘Kite’ earned U2 a place in a recent list of suspect popular song lyrics. Some Health 2.0 vendors are also struggling to get ‘social media’ to rhyme with  ‘healthcare’ but will no doubt carrying on trying to do so. With Goldman Sachs throwing $1.5 billion in Facebook’s direction it makes sense for anyone in the online health business to position themselves as close to the social media company as possible, on the off chance that they will be able to pan a few nuggets out of the fast flowing stream of cash.

While no doubt some of the funds the bank is putting together will be used for healthcare related applications it is not immediately obvious what Facebook can do that Google and Microsoft have not already tried. Both these companies are trying to sell to healthcare providers whose business models if they do exist are confused and, in some cases failing. One way to gain a better understanding of the healthcare market is to view it as a mathematical equations that can be solved by eliminating one variable at a time.

So What If The UK’s National Health Service Did Not Exist?

You log on to NHS.uk and are greeted with a message saying “Sorry, this service has been discontinued. The UK government can no longer afford to provide you with healthcare.” And that is it, apart one last piece on advice. “Please take care.” This presumably aimed at Darwin Award candidates who were hoping to break the land speed record using fireworks and a skateboard and fully expect the local hospital to fix any resulting damage. Also perhaps directed at anyone with a grumbling appendix thinking of entering a baked bean-eating contest. (More about these people later.)

So what difference would it make if there were no healthcare provider? For a start everyone in the UK, apart from the 1.3-million ex-NHS workers, would be £1600 a year better off. A young person leaving school would have saved enough to pay for their university education. A young couple in their mid twenties would have saved enough to put a down payment on their first house. OK average life expectancy would fall and the last couple of years (or most likely months) of a person’s life would probably be more unpleasant, but the proceeding sixty five or so years would be a lot better. There, two of the government’s major economic headaches eliminated in a stroke – an unfortunate turn of phrase in this case. With an extra £100 billion per annum sloshing around in the economy most of the 1.3 million former NHS employees would be able to find new jobs.Continue reading…

Computers in 2020

It is 2020.   Computer evaluation of patients before they visit their doctors has come a long way.

Medical records containing  demographic  data,   personal histories,  medication use,  allergies, laboratory results,  radiologic images,  electrocardiograms, rhythm strips, and even the chief complaint and symptoms of the patient ‘s  present illness, as spoken and digitized by the patient,  are available prior to the visit.

These records, synthesized, summarized,  algorithmized,  and otherwise massaged by massive computer banks,  give doctors everything they want to know before seeing ore examining the patient.

  • the differential diagnosis,
  • the most likely cause of the visit,
  • optimal treatment options,
  • a review of recent medical literature in the last 24 hours on the subject,
  • the best current medical practices,
  • the best value for the dollars in the immediate region and at national centers,
  • the best, most cost-effective and results-effective,  specialists  and medical centers  where  to go should further evaluation be needed.
  • the tests and procedures to be done before the patient leaves the office.

This barrage of information is available to consumers and physicians alike before and immediately after the visit.   Furthermore,  with advances in speech recognition,  patients and doctors will be able to talk to the computer in each other’s presence, ask questions, and settle any lingering doubt.Continue reading…

New Cures! Faster! Faster!

I wrote here the other day about the NIH’s new translational medicine plans. The New York Times article that brought this to wide attention didn’t go over well with director Francis Collins, who ended up trying to disabuse people of the idea that the NIH was going to set up its own drug company.

But there’s been an overwhelming negative response from the academic research community, largely driven (it seems) by worries about funding. Given the state of the budget, flat funding would be seen as a victory by NIH, so this isn’t the best environment to be talking about putting together a great new institute. The money for it will, after all, have to come out of someone else’s pile. Collins spends most of that statement linked above denying this, but it’s hard to see how there won’t be problems.

I think, though, that there’s an even more fundamental problem here. In the latest BioCentury, there’s an interesting sidelight on all this:

In comments submitted to NIH, Joseph Zaia, associate director of the Center for Biomedical Mass Spectrometry at the Boston University School of Medicine, argued against setting timetables for research results. “I do not believe that running medical science on a short sighted business time schedule will produce more cures faster. It will, however, deplete NIH resources very rapidly and possibly tear down an infrastructure of knowledge that took decades to create.” Zaia complained that the NCATS “process seems to be driven by the FasterCures movement sponsored by Michael Milken,” which he said has “been masterful in manipulating the political system for their purposes, and forcing NIH into this reorganization.”

FasterCures’ Margaret Anderson, executive director of the non-profit group that advocates for accelerating medical innovation, submitted a letter strongly endorsing NCATS, which she said “will provide a significant stimulus to moving ideas out of the lab and into the clinic.” Continue reading…

Employers as Doctors

Unless you spend a lot of time around health policy wonks, you’ve probably never heard of the term “value-based health insurance benefits.”  In fact, you may not even know that it’s the hottest new fad in the field.

Here is my layman’s summary: If you are like most people, you are not a very good consumer of health care. Odds are, you will fall for the latest fad advertised on TV or follow the advice you get at the bridge club instead of buying the care that has been scientifically shown to be better for you.

So as a corrective, a lot of employers are finding ways to “nudge” you into better decisions through financial incentives. Say you have a chronic condition and need to take certain medications. Your employer might drop your deductible down to zero (or may even pay your to take them) to encourage your compliance. But for services where there appears to be wasteful overuse (such as MRI scans), the employer might impose a hefty $500 deductible.

This idea intrigued me, so I turned to a rather lengthy article in the Washington Post, which informed that value-based insurance benefits are incorporated into the new health reform law, “including the requirement that new insurance provide free recommended preventive services such as mammograms and colon cancer screenings.”

In the world of big business, this idea is all the rage. One in every five employers employing at least 500 people is already doing it. Four in five employers who employ at least 10,000 workers say they are interested.

So if big business is for it; the government is mandating it; and health policy wonks like it; how could anyone possibly obj-……..Continue reading…

The Individual Mandate: Another Look at the Penalty Trade-Off

Most of the recent attention on the 2010 health care reform legislation has focused on the individual mandate. After two federal court rulings upholding the mandate, a third federal judge—in Virginia—ruled that the Constitution does not allow the government to require the purchase of insurance as part of regulating an interstate commerce market. Simultaneously, Congressional Republicans have reiterated their intention of preventing the individual mandate from being implemented, regardless of the constitutionality of the provision.

One interesting response to the resulting media coverage came in the form of a Kaiser Health News article [http://www.kaiserhealthnews.org/Columns/2010/December/121410laszewski.aspx] suggesting that the issue might be overblown since, even if the mandate were implemented, it would be relatively unsuccessful in leading the uninsured to purchase coverage. Unfortunately, the article misinterprets some of the legislative language, not entirely surprisingly given the complexity of the mandate provision. Following are clarifications of the mandate and associated requirements, and a somewhat more careful look at the mandate’s possible impact.

A Brief Summary of the Mandate

The individual mandate requires almost all legal residents of the United States to have at least a defined level of health care coverage. Those lacking such coverage will be subject to a penalty to be paid as part of tax filing. Exclusions are made for members of certain religious groups, Indian tribes, incarcerated individuals, and those whose income is below the tax filing threshold or inadequate to pay for coverage. To assist those with lower incomes but not eligible for Medicaid or SCHIP, the legislation provides for both premium credits and cost-sharing subsidies.Continue reading…

Getting an Estimate

A couple of years ago my primary care physician suggested that I have a colonoscopy at the age of 47. My father died from Hodgkin’s disease at 34 and my mom survived breast cancer in her 40’s. I suffer from irritable bowel syndrome so she suggested that I have my colon checked out just in case. She recommended a very experienced gastroenterologist at a major Boston hospital.

My insurance would not cover the procedure because I am younger than 50, so I called the hospital to investigate how much it would cost me to have the procedure. Their first answer was that they did not know because no one had ever called in with that question before. This is a hospital which probably does more than one thousand of these every year.

I was transferred to someone else who was more helpful. She said it would depend quite a bit on what they discovered while I was undergoing the colonoscopy, but gave me a range of $2,000 to $4,500. I asked if there would be other charges and she said that the physician screening could cost $770 or more.Continue reading…

Watson: A Computer So Smart, It Can Say, “Yes, Doctor”

Game Show Watson wants to be a doctor. Well, almost.

Fresh off a commanding victory on Jeopardy, IBM will try to demonstrate that the combination of advanced natural language processing and sophisticated algorithmic decision-making capabilities involved in its extraordinary Watson computer can help humankind, not merely humiliate human competitors.

As I wrote on a previous blog, IBM began eying the medical marketplace more than 45 years ago. IBM CEO Thomas J. Watson, Jr. – son of the IBM CEO for whom this computer was named – put it this way in 1965: “The widespread use [of computers]…in hospitals and physicians’ offices will instantaneously give a doctor or a nurse a patient’s entire medical history, eliminating both guesswork and bad recollection, and sometimes making a difference between life and death.”

Now, IBM is ready to turn that vision into reality. At heart, Watson is the world’s most sophisticated question-answering machine. The company is collaborating with Columbia University and the University of Maryland to create a physician’s assistant service that will allow doctors to query a cybernetic assistant. IBM will also work with Nuance Communications, Inc. to add voice recognition to the physician’s assistant, “possibly making the service available in as little as 18 months.” For Nuance, it could be a major business line, and promises to carry over in the not too distant future to the mobile phone market, such as Apple’s iPhone, where Nuance is a major presence.Continue reading…

Replace The RUC

A few weeks ago, my writing partner David C. Kibbe and I ran an article on Kaiser Health News called “Quit the RUC!“ that has caused some turmoil within the physician community, particularly in DC.

First, it noted that the RUC, the informal specialist-dominated AMA panel, has made recommendations for 20 years about the value of medical procedures within the highly arcane and jiggered Resource-Based Relative Value Scale (RBRVS). As the Wall Street Journal recently reported, CMS (and its predecessor, HCFA) has accepted some 90 percent of its recommendations, apparently almost without question. It shouldn’t surprise anyone that the vast majority of recommendations involve payment increases to specialists that have come at the expense of primary care.

This combination – a highly conflicted advisory panel making methodologically questionable recommendations about payment to a blithely accepting regulatory agency – is at the heart of the American health care cost crisis and the greatest reason why the American economy is literally being bankrupted by its health care costs. This year alone, we’ll spend about $1.3 trillion on health care products and services that provide no value. This is two-thirds again more than we’ll spend over the next decade on the economic stimulus package.Continue reading…

How to Meaningfully Shop for an EHR, Part 2

Research and Observation

Here we are going to talk about the second stage of shopping for an EHR. We are going to assume that you did your homework, defined your goals and constraints and prepared a comprehensive list of requirements for an EHR (if you have not done so already, go back and read Part I). To continue our car shopping analogy, we are now ready to go kick some tires, and we start by calling on each of the three to six EHR vendors on your list. To your folder of lists, add a blank page for each vendor, to log your interactions with the various representatives you will begin encountering shortly. If the sales person is unresponsive and if it takes weeks to have someone call you back, most likely the situation will only deteriorate after they get a hold of your money, so keep good notes.

Calling an EHR Vendor
Whether you start by filling out a form on a website or by sending an email, eventually you will be on the phone with a sales rep. You should be the one directing the conversation. Inform the sales person of your specialty and practice size and explain that you are conducting an EHR search and his company is one of your candidates. Do not disclose the remainder of your list unless you are interested in a “confidential” long lecture on how horrible the competition really is. Your goal here is to obtain contact information (phone and email) of the regional sales executive, inform him/her that you will be sending out a Request for Information (see below) and set a date for your first clinical demonstration of the product. You can listen patiently, if you wish, to the details of this month’s “special offer”, but stick to your agenda and commit to nothing other than a demo. Remember to log your impression from this call, including the vendor’s willingness to accommodate your schedule and the expediency of setting up a demo date.Continue reading…

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