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Healthcare is Different

I’m often asked why healthcare has been slow to automate its processes compared to other industries such as the airlines, shipping/logistics, or the financial services industry.

Many clinicians say that healthcare is different.

I’m going to be a bit controversial in this post and agree that healthcare has unique challenges that make it more difficult to automate than other industries.

Here’s an inventory of the issues

1.  Flow of funds – Hospitals and professionals are seldom paid by their customer.   Payment usually comes from an intermediary such as the government or insurance payer.  Thus, healthcare IT resources are focused on back office systems that facilitate communications between providers and payers rather than innovative retail workflows such as those found at the Apple Store.

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The July Effect

“Don’t get sick in July!” We’ve all heard patients and family members say this – part declaration, part wishful thinking – in reference to the perceived summertime risks of teaching hospitals. When I hear it, I usually respond with comforting bromides like “robust supervision” and “cream of the crop.” But deep down, if I had the choice of entering a teaching hospital in July and April, I’d choose the latter.

This preference comes partly from my recollections of my own training experience. The day before I began my residency at UCSF, my entire intern class gathered to meet our new bosses. We were on pins and needles – laughing at jokes that weren’t really funny, suspiciously eyeing our colleagues, whose admission to the program (unlike our own) could not be explained by clerical error. The chief of service, Greg Fitz, a brilliant gastroenterologist with a disarming “aw shucks” manner and a Southern drawl (he’s now Dean at UT Southwestern), stood to address us.

“I know you’re all nervous,” he said, catching our collective mental drift. “But don’t worry. If we can turn bread mold into penicillin, we can turn you guys into doctors.”

I was only partly reassured.

The next day, I began my internship on the wards at San Francisco General Hospital. I picked up the service from a graduating intern. His sign out to me was pithy. “Sucker!” he shouted gleefully, as he jammed his beeper into my abdomen like a football. Panicked, I managed to survive my first few weeks on the wards without killing any patients.

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Let’s Hope ACOs Aren’t Our Last, Best Chance for Delivery System Reform

After reading the July edition of Health Affairs, I’m concerned about the impact of Accountable Care Organizations (ACOs) on cost trends in the US health care system.

In The Accountable Care Organization: Whatever Its Growing Pains, The Concept Is Too Vitally Important To Fail, Francis Crosson of the Kaiser Permanente Institute for Health Policy plays down the various criticisms of ACOs (that they may stifle innovation, unleash a torrent of regulation, and rely too heavily on fee for service payment methodologies) and argues that we need to help them succeed because there are no good alternatives. If not,

both public and private payers will probably be forced into across-the-board reductions in payment rates to providers, because the state of the economy will require cost reductions, and there will be no other obvious course to pursue. Reductions in quality and access may follow…

But the emergence of ACOs is driving hospitals to consolidate, buying other hospitals and physicians practices.

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Reduce Antibiotic Resistance: Get Your Flu Vaccine

A study published in the July issue of Infection Control and Hospital Epidemiology shows that antibiotic prescriptions tend to spike during flu season, even though influenza is caused by a virus and cannot be treated with antibiotics.

Some of these antibiotic prescriptions are justified – bacterial pneumonia, which must be treated with antibiotics, is also common during the winter months. And getting the flu puts you at higher risk for developing complications from secondary infections, including bacterial pneumonia.

Yet some people suffering from the flu virus alone may demand–and get–an antibiotic even though viral infections do not respond to antibiotic treatment.

According to Extending the Cure, a nonprofit project funded by the Robert Wood Johnson Foundation’s Pioneer Portfolio, between 500,000 to one million antibiotic prescriptions are filled each year during flu season for patients who have the flu and no bacterial illness.

Why should we care about how many antibiotics are prescribed?

When antibiotics are overused or inappropriately used, bacteria can develop antibiotic resistance, or the ability to withstand antibiotic treatment, making bacterial infections difficult to treat. Antibiotic resistance can develop quickly. Today’s antibiotics – the wonder drugs that transformed modern medicine – are used so commonly that we face the prospect of a future with a multitude of resistant bacteria and a shelf full of ineffective drugs.

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From EHR to HIE and Back

According to the latest count, there are 255 Health Information Exchange (HIE) organizations across the country, which amounts to an average of 5 in each State. If you are a practicing physician and have an EHR, chances are someone already knocked on your door offering to connect your practice to the local HIE for a small fee. If you don’t have an EHR, you may have had offers to access an HIE web portal, or maybe an HIE supplied EHR Lite, allowing you to at the very least view clinical data from other sources. Perhaps for free. If you are the proud owner of one of the full-featured EHRs, you may wonder what an HIE can do for you that your EHR is not already doing, and whether that service is worth your hard earned money.

In theory, a top-shelf EHR should be able to connect your practice to multiple facilities and allow you to exchange information to the best of all participants’ abilities. Granted most EHRs are still working on some of the connections, particularly to local facilities, but all in all, an EHR should be able to eventually provide for all your connectivity needs as shown in Figure 1. Note that for some types of connections, your EHR vendor can use a clearinghouse or portal approach to simplify and reduce costs of connectivity. For example, you don’t need a separate interface for each pharmacy – you use Surescripts as the clearinghouse and let them worry about it. You also don’t need an individual connection to each patient’s home – you communicate with all of them through one portal. With the exception of Surescripts pharmacy connectivity and a small number of reference labs, each connection, or interface, is costing you a pretty penny, and the more local the connection, the longer it takes to build.

 

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The Fallen Souffle Economy


It is increasingly clear that the United States’ economic troubles are far from over.

The stock market plunge that began in earnest last week reflects the market’s belief that we’re not going to recover fully from the recession that began in 2007. As a Wall Street Journal commentator said mid-Monday’s plunge:  “The market is pricing in a double dip recession”. In reality, the 2007 recession (caused initially by $150 a barrel oil) never really ended.

Past remedies for recession basically involved nearly free money and Keynesian pump priming to stimulate demand with either borrowed or freshly printed money. The most recent (bipartisan) stimulus effort, nearly a trillion worth of extended Bush tax cuts, unemployment extensions, payroll tax cuts, etc. which Congress and the Obama Administration negotiated in December, seems to have disappeared into thin air, producing a whopping 0.8% economic growth in the first half of 2011 and a July unemployment rate of 9.2%. This Economist analysis argues that the political system has exhausted its remedies for our economic problems.

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A Legal Challenge To CMS’ Reliance On The RUC

This week in a Maryland federal court, six physicians based at the Center for Primary Care in Augusta, GA filed suit against HHS Secretary Kathleen Sebelius and CMS Administrator Donald Berwick. The complaint, spearheaded by Paul Fischer MD with DC-based lead counsel Kathleen Behan, alleges that the doctors have been harmed by the Medicare payment structure developed through the agencies’ reliance on the American Medical Association’s Relative Value Scale Update Committee (RUC).

The suit also claims that the agencies have functionally treated the RUC as a federal advisory committee. But they have not required the RUC to adhere to the Federal Advisory Committee Act’s (FACA) stringent management and reporting rules – e.g., balanced representation, transparent proceedings, and scientifically valid analytical methodologies – that keep the proceedings in the public interest. The plaintiffs request injunctive relief, which would freeze the relationship between CMS and the RUC until the advisory group complies with FACA’s requirements. Of course, compliance would drastically change the way the RUC conducts its affairs, something it is almost certainly loathe to do.

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The Year of Going Paperless

Seven months into 2011, things look very different than they did this time last year at my office. Not only have I been using an electronic medical record for nine months now, but I’ve also been submitting claims electronically (through a free clearinghouse) using an online practice management system. I’ve also begun scanning patients’ insurance cards into the computer, as well as converting all the paper insurance Explanation of Benefits (EOBs) into digital form. I’ve even scanned all my office bills and business paperwork and tossed all the actual paper into one big box. As of the first of the year I even stopped generating “daysheets” at the end of work each day. After all, with my new system I can always call up the information I want whenever I need it.

How did such a committed papyrophile get to this point? It is the culmination of a process that actually began last summer with the purchase of an adorable refurbished little desktop scanner from Woot ($79.99, retails for $199, such a deal!) The organizational software is useless for my purposes, but it does generate OCR PDFs, which makes copying and pasting ID numbers from insurance cards into wherever else they need to be a piece of proverbial cake. The first step was to start scanning the office’s administrative paperwork (phone bills, electric, etc), since that didn’t affect the staff’s workflow. Suddenly, instead of having to sort the increasingly teetering piles of paper bills into file folders in an upstairs desk drawer, I had a single file on my computer where I could access any document I needed with a click or two.

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Dropping the Price of Surgery

I would like to share a story about my son’s recent surgery that, while only one simple case, reveals the foundational problem with the U.S. health care system.

I write this story as a father of a 12 year old boy who has cerebral palsy. Jack is fortunate to be healthy and active with minor medical needs. As he has grown he experienced some issues with contractures in his right lower leg which recently required a minor 2 hour outpatient surgical procedure. That is where our saga begins.

When Jack’s surgery was scheduled I started the time consuming process of getting price estimates from the surgeon, anesthesiologist and the facility since we have a high deductible insurance plan. The physician fees were straight forward and relatively easy to obtain, not so with the facility. Jack’s surgery was scheduled at the local hospital’s outpatient surgical facility. I called the hospital to request a price for the surgery and they said they couldn’t really tell me. They offered to send the procedure codes to an external reviewer who would provide a general idea of the anticipated charges. Three days later the answer came back at $37,000. I reiterated that I had high deductible insurance and needed to know the actual price they would bill me after an insurance adjustment to the network fee schedule.

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The Economic Urgency of Health Care Reform

Watching the events of the past several weeks in Washington has been sobering. Decades of failed fiscal policy have finally come home to roost and Congress is tied in knots trying to find a compromise solution and avoid American default. Americans rightly are scared that our leaders can’t find a way out of this muddle. But the really sobering part is this: the solutions under consideration don’t fix the problem. Even if Congress enacts the most draconian spending cuts advanced by the Tea Partiers, and all of the tax increases advanced by the liberals, we will not be out of the mess. The crisis will still loom. Why? Because health care costs continue to increase at an unsustainable rate, and health care spending is the single largest category of federal spending. Without real, sustained health care cost control, we still face a crisis, no matter what package of cuts and revenues the new “gang of 12” develops.

As a Governor, I can’t ignore this problem. Health care spending more than tripled in Vermont between 1992 and 2009. Between 2000 and 2009, health care spending as a share of our gross state product rose from 12.9 percent to 18.5 percent.

We come face to face with the impact of growing health care costs every year in our state budget process. Health care squeezes out all sorts of other priorities, and we (state government) aren’t even paying our fair share of the increase. The state can’t afford to sustain a rate of growth that far exceeds growth in our economy and growth in our tax revenues. So we shift costs from state health care programs to the private sector. The private sector can’t sustain the growth, either, so they cut jobs and reduce insurance coverage for their employees. That’s why, despite aggressive efforts to expand government-sponsored insurance coverage in Vermont, nearly one in ten Vermonters is uninsured, and nearly a quarter of our population is underinsured — they have coverage, but could still go bankrupt if they had a major illness.

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