Author Archives

lauramontini

Does ICD-10 Delay Create an Easy Opportunity for Coding Improvement?

Feb 16, 2012• 4

By Al Lewis

Implementation of ICD-10s has been delayed “indefinitely.” Rather than opine on whether that’s a good thing or a bad thing, I will note that it creates an opportunity for a simple but powerful improvement in the value of the coding.

Caveat: I am not a coding expert (I don’t even play one on TV) so there might be something wrong with this idea. The specific reason for the post is to find out whether there is some reason this can’t be done, given the value of doing it. (I am so unfamiliar with coding that it is possible this is already being done and I’m the last guy to find out about it, in which case perhaps John and Matthew would be kind enough to remove it.)

Quite simply, how about adding an optional “R” for “rule-out” after the codes? For instance, today if a patient gets tested for diabetes and it turns out that he HAS diabetes, he gets coded “250” in the ICD-9s. Whereas if it turns out the patient does NOT have diabetes, he still gets coded “250.” My proposal would code that (in ICD-9s) 250R.

By contrast, giving two opposite diagnoses the same code creates a cascading set of problems, in outcomes measurement, risk scoring, registries, disease management, reimbursement, and predictive modeling, problems that will be exacerbated as risk shifts down to the provider level and payors move to outcomes-based reimbursement.

The Creative Destruction of the News Business and Other Weird Stories

Feb 16, 2012• 8

By Dave Chase

Health system CEOs would be well advised to study what newspaper industry leaders did (or perhaps more appropriately, didn’t do) when faced with a dramatic industry change. Turn back the clock 15 years and the following dynamics were present:

Newspaper leaders knew full well that dramatic change was underway and even made some tactical investments. However they didn’t fundamentally rethink their model.
Newspapers were comfortable as monopoly or oligopoly businesses allowing for plodding decisions. Their IT infrastructure mirrored the plodding pace with expensive and rigid technology architectures.
Newspaper companies bought up other newspaper chains and took on huge debt.
Owning printing presses was a de facto barrier to entry allowing newspapers unfettered dominance.
Depending on one’s perspective, it was the best of times or the worst of times to be a leader of local media enterprise.

Before they knew it, owning massive capital assets and the accompanying crushing debt became unsustainable. The capital barrier to entry transformed into a boat anchor while nimble competition dismissed as ankle-biters created a death-by-a-thousand-paper-cuts dynamic. Competitively, newspaper companies worried only about other media companies or even Microsoft, but their undoing was driven by a combination of craigslist, monster.com, cars.com, eBay, and countless other marketing substitutes for their advertisers. In addition, there were easier ways to get news than newspapers. Generally, the newspaper’s digital groups were either marginalized or unbearably shackled so that the encumbered digital leaders left to join more aggressive competitors. The enabling technology to reinvent local media didn’t come from legacy IT vendors who’d long sold to newspaper companies, but from “no name” technologies such as WordPress, Drupal and the like.

Should Your Doctor Talk with You About the Cost of Your Pills?

Feb 15, 2012• 9

By Peter Ubel, MD

I first realized something was amiss when I picked up my prescriptions and the pharmacist explained that she could not fill the anti-malarial medications as prescribed: “Your medication plan only pays for 30 days of pills, and your prescription was for five pills.” The pharmacist continued: “Your PBM [that’s an acronym for pharmacy benefits management company, the type of company that coordinates many peoples’ medication coverage] only fills this medication for 30 days at a time. And 5 pills would last 35 days.”

Expert logician that I am, I countered with some math of my own: “Well four pills, taken weekly, only lasts 28 days. If they really want to give me 30 days of coverage, they need to give me a fifth pill.” I thought it was insane to pay a whole extra co-pay to get my fifth and last pill, a co-pay I’d have to pay for my two sons too since all three of us were traveling together.

But the pharmacist was unpersuaded: “Sorry, four pills is it. You’ll need another prescription for the last pill.”

Irked, I handed over my credit card and hastily signed the bill, too bothered by the conversation to look closely at the bottom line.

When I got home and told my wife Paula about the saga of the fifth pill, she calmly looked at the bill and asked me: “If you were so concerned about a $10 co-pay, why didn’t you notice that the antibiotic you were given cost almost $200?”

Huh?

Medicine’s Tech Future: the View from the Valley

Feb 14, 2012• 4

By David Shaywitz

A few quick impressions from last week’s FutureMed extravaganza put on by Singularity University at the Museum of Computer History, a stone’s throw from Google’s Mountain View headquarters.

The event featured an exhibition session where emerging digital health companies (with some others) demo’d their initial products, followed by a plenary session introduced by FutureMed Executive Director (and former MGH medicine colleague) Daniel Kraft, and featuring presentations to the packed house by several leading innovators – including one of the developers of IBM’s Watson, which is pivoting from Jeopardy to clinical medicine.

Given the high density of reporters there – to say nothing of innovators, would-be innovators, VCs, and assorted poseurs (categories not mutually exclusive) – I expect there should be lucid coverage available elsewhere on the web.

Instead, I want to capture the three sequential reactions I had, which strike me as somewhat analogous to Haeckel’s Law (ontogeny recapitulates phylogeny), as each response seems to reflect a distinct stage of professional development.

The inevitable initial, and most visceral reaction to this sort of event, is that technology is wicked cool, and will deliver us all; I think this two minute introductory video captures the vibe more effectively than any description I could offer. I’m also certain any student of semiotics would find it especially rewarding.

Accordingly, even much of the informal discussion at the event seemed to revolve around Big Questions, lofty ideas, and the Next Big Thing. New technologies and approaches – artificial organs from stem cells! Computers that can read your mind! Bottom-up innovation! Exponentials! – were discussed expectantly, the key question being not if, but when. The remarkable progress many in the tech crowd had seen in other disciplines suggested that technology advances in health would be similarly achievable, and just as inevitable.

The Perfect EHR

Feb 14, 2012• 2

By John Halamka, MD

I support over 3000 clinicians in heterogeneous sites of care – solo practitioners, small offices, multi-specialty facilities, community hospitals, academic medical centers, and large group practices.

In every location there is some level of dissatisfaction with their EHR. Complaints about usability, speed of documentation, training, performance, and personalization limitations are typical. Most interesting is that users believe the grass will be greener by selecting another EHR.

I’ve heard from GE users who want Allscripts, eClinicalworks users who want Epic, Allscripts users who want AthenaHealth, and NextGen users who want eClinicalWorks.

The bottom line from every product I’ve used and everyone I’ve spoken with is that there is no current “perfect” EHR. We’re still very early in the EHR maturity lifecycle.

What is the perfect EHR? I’ve written about my best thinking, which has been incorporated into the BIDMC home built record, webOMR. (and has dissatisfied users too)

However, after listening to many “grass is greener” stories, I believe that what a provider perceives as a better EHR often represents trade offs in functionality. One EHR may have better prescribing functionality while another has better letters, another is more integrated and another has better support. The “best” EHRs, according to providers, varies by what is most important to that individual provider/practice, which may not be consistent with enterprise goals or the needs of an Accountable Care Organization.

Making Sense of the Debate Over Patient Access to Medical Information

Feb 14, 2012• 3

By John Lumpkin, MD

“When it comes to health care, information is power.”

This comment from U.S. Department of Health & Human Services Secretary Kathleen Sebelius has sparked a heated debate among doctors and patient advocates about the merits and drawbacks of giving patients easy access to their lab results, doctors’ notes and other personal medical information. A deliberation in this month’s issue of SGIM Forum, the newsletter of the Society of General Internal Medicine (SGIM), is emblematic of how doctors’ and patients’ views on transparency vary.

Internist Douglas P. Olson, MD says it’s too early to offer patients electronic access to their lab results or medical records and that without systemic changes it could actually undermine the patient-doctor relationship lists among his concerns the potential to confuse or worry patients; a lack of evidence showing the positive effect on healthcare safety and quality; and the increased demands on doctors’ time to respond to patient questions.

These concerns are valid and shared by many other doctors. In a recent survey by OpenNotes―a project supported by the Robert Wood Johnson Foundation’s Pioneer Portfolio that enables doctors to share their visit notes with patients online―doctors were asked about their expectations and attitudes toward sharing electronic medical notes. The survey was conducted before doctors engaged with OpenNotes. Responses revealed doctors were worried about the impact on workflow and weren’t convinced that it would make a difference to patients’ health.

Price Variation and Confidentiality in the Market for Medical Devices

Feb 14, 2012• 2

By Emma Dolan

The Government Accountability Office (GAO) recently released a report that cites “substantial variation” in the prices paid for implantable medical devices in the Medicare program, and a lack of robust data needed to properly compare the prices paid for these devices across surveyed hospitals. A key driver of both of these findings is the existence of confidentiality clauses in medical device purchasing contracts that prohibit hospitals from sharing prices with third parties, including physicians, the health plans that pay for these devices, and patients.

It was with a sense of déjà-vu that I read this report; in 2010, UC Berkeley professor James Robinson and I published a series of briefs looking at variation in implantable device prices in California hospitals as part of a joint Value-Based Purchasing of Medical Devices project between the Berkeley Center for Health Technology and the Integrated Healthcare Association (IHA). This project included data collection on device costs, total surgical costs, complications, and length of stay for seven orthopedic and cardiac procedures in 45 California hospitals.

The data, as well as a series of IHA-sponsored roundtable conversations with stakeholders, found the same thing that the GAO report finds: a lack of transparency in device prices, sometimes driven by clauses that prohibit hospitals from disclosing the prices paid for devices, a lack of alignment between hospitals and the physicians practicing within their facilities, and very substantial variation in both the prices paid for devices and the total costs of the procedures used to implant these devices. For example, the average cost hospitals paid for knee implants ranged from $3,408 to $10,830, and the average paid for implantable cardioverter-defibrillators ranged from $19,578 to $35,916. There was also a substantial amount of within-hospital variation in device prices.

Privacy in the Age of Big Data

Feb 13, 2012• 5

By Omer Tene & Jules Polonetsky

We live in an age of “big data.” Data has become the raw material of production, a new source of immense economic and social value. Advances in data mining and analytics and the massive increase in computing power and data storage capacity have expanded, by orders of magnitude, the scope of information available to businesses, government, and individuals.[1] In addition, the increasing number of people, devices, and sensors that are now connected by digital networks has revolutionized the ability to generate, communicate, share, and access data.[2] Data create enormous value for the global economy, driving innovation, productivity, efficiency, and growth. At the same time, the “data deluge” presents privacy concerns that could stir a regulatory backlash, dampening the data economy and stifling innovation.[3] In order to craft a balance between beneficial uses of data and the protection of individual privacy, policymakers must address some of the most fundamental concepts of privacy law, including the definition of “personally identifiable information,” the role of consent, and the principles of purpose limitation and data minimization.

Big Data: Big Benefits

The uses of big data can be transformative, and the possible uses of the data can be difficult to anticipate at the time of initial collection. For example, the discovery of Vioxx’s adverse effects, which led to its withdrawal from the market, was made possible by the analysis of clinical and cost data collected by Kaiser Permanente, a California-based managed-care consortium. Had Kaiser Permanente not connected these clinical and cost data, researchers might not have been able to attribute 27,000 cardiac arrest deaths occurring between 1999 and 2003 to use of Vioxx.[4] Another oft-cited example is Google Flu Trends, a service that predicts and locates outbreaks of the flu by making use of information—aggregate search queries—not originally collected with this innovative application in mind.[5] Of course, early detection of disease, when followed by rapid response, can reduce the impact of both seasonal and pandemic influenza.

Startups: The Other Health Technology Revolution

Feb 11, 2012• 7

By Ricky Choi, MD

These days my physician colleagues and I are up to our necks in a health technology revolution. To be honest, its not as captivating as Pinterest or socially-engaging as a Google Huddle but to be sure your life will depend on it. The revolution ushered in by electronic health record (EHR) is less about the technology than the widespread impact it will have on patient care. Rather than digging through stacks of paper charts, your doctor will have ready access to all of your health history on a digital device. And not just your health history, soon I will be able to combine it with the history of other patients in my practice: the digitized data will allow me to track the childhood obesity rate in my clinic and trend it over time with just a click (or tap). But look out, there are glimmers of another emerging health tech revolution.

I recently attended the Health Innovation Summit organized by Rock Health, a seed accelerator for health startups based in San Francisco. Coming from the bureaucratic and comparatively stagnant world of health care systems, this event made me feel like I could dream again. Speakers provided pearls of wisdom for an engaging design. Panels offered strategic advice to attract VC and Angel funding. Most exciting was the chance to hear from entrepreneurs, each of whom offered their own incremental solution to improve health.

Take something like Cardiio, which measures heart rate in a few seconds by scanning your face. Imagine how future related technologies could replace monitoring wires and tubes thereby improving comfort during a hospitalization and reducing hospital acquired infections.