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What’s In a Word?

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By MARK FRISSE

The Health Information Exchange (“HIE”) at HIMSS11 appears noticeably different than the “HIE” of HIMSS past. HIE will be ubiquitous. It is not just a topic for a Sunday session any more. Of the 26 sessions that listed HIE as a topic, only eight were specific to the topic. The dedicated Sunday session seemed informative but predictable. Speakers provided perspectives from the federal government, states, and stakeholders. The session also included a Town Hall Meeting, a treatment of consumer engagement, and  – my favorite topic  – financial sustainability.

Scratch beneath the surface of most topics, and one may find a bit of HIE. It is central to many strategies including Meaningful Use, e-Referrals, workflow management, regional performance improvement, wired BEACON communities, quality measurement, public health, and it will play a growing role as providers and health plans form new relationships.

Each of the more than 20 sessions that place great emphasis on HIE presents an informative perspective very distinct from all of the others. Each presentation is a small chapter in a book describing the far-larger elephant of health care transformation. Confusion is to be expected; the “exchange” in the term “HIE” has many different meanings.

To some, HIE is a “thing”  – a regional organization providing exchange services or a state-level organization either providing similar services or fostering exchange through other means – this a bit like a “stock exchange.” To others, HIE is the act of communicating information from one point to another in hope of providing additional value to the point of decision-making or care. (This is more akin to an auto parts swap meet.) To Clayton Christensen, Jason Hwang, and others, exchange is an economic model for commerce – this model  – the facilitated user network – is more like Napster.

As a HIMSS attendee or an interested observer, it is important to keep these various models in mind when walking among the vendor exhibits or attending the scientific sessions. It is important to remember that the Electronic Health Record (EHR) is not simply a “computerized record” as much as it is a communications device operating within a vast and increasingly seamless network of commercial and clinical affairs. With or without health care reform, inevitable and consequential reimbursement changes will be taking place.Continue reading…

Two Kidneys and 100,000 Lives

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By PAUL LEVY

This story about a kidney transplant mix-up in California is bound to get lots of coverage. It is these extraordinary cases that get public attention. I am sure it will lead to a whole new set of national rules designed to keep such a thing from happening.

Of course, such rules already exist, and it was likely a lapse in them that led to this result.

Nonetheless, we will “bolt on” a new set of requirements that, in themselves, will likely create the possibility for yet a new form of error to occur.

This kind of coverage and response is a spin-off from the “rule of rescue” that dominates decisions about medical treatment. We find the one-off, extreme case and devote excessive energy to solving it. In the meantime, we let go untreated the fact that tens of thousands of people are killed and maimed in hospitals every year.

Those numbers are constantly disputed by the profession. To this day, many doctors do not believe the Institute of Medicine’s studies that documented the number of unnecessary deaths per year.

And you never hear anyone talking about this 2010 report by the Office of the Inspector General, which concluded:

An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths, which projects to 15,000 patients in a single month.

As the IOM notes, “Between the health care we have and the care we could have lies not just a gap, but a chasm.”

There is an underlying belief on the part of policy makers and public and private payers that the focus on quality is best addressed through payment reform. Let me state as clearly as I possibly can: That is wrong. It is a classic example of the old expression: “When you have a hammer, everything looks like a nail.” Changes in payment rate structures, penalties for “never events,” and the like can cause some changes to occur. Their main political advantage is that they give the impression of action, and their major financial advantage is a shift in risk from government and private payers to health care providers.Continue reading…

HIMSS11 Update from the Chairman

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By C. MARTIN HARRIS, MD

As the Chairman of the board of HIMSS, the Health Information Management Systems Society, which is the largest information technology organization in the world, I’ve been very busy at our annual conference in Orlando, Fla.

As I move through this enormous venue, talking to as many of our 30,000 attending members as possible, I can’t help but think about how much work we all have to do in the coming years.

As healthcare and IT professionals, we are privileged to live at a moment in history when the work we do, the product of our shared passion, the professional discipline to which we devote so much of ourselves, is taking its place as the central catalyst of a transformation in healthcare that is in many ways, unprecedented.

Whereas previous breakthroughs in medical technology, such as the invention of the X-ray or the discovery of antibiotics, have obviously been profound, and powerful; I can think of none that ever impacted the entire medical practice model.

And that is exactly what the technology-driven transformation of healthcare is poised to deliver.Continue reading…

HIMSS11 Live: Meaningful Use

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By NEIL VERSEL

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

By PETER KRUGER

‘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…

Getting DIRECTLy to the Point

By RICH ELMORE and ARIEN MALEC

A patient’s health records are no longer confined to a doctor’s office, shelved inside a dusty file cabinet. With the advent of the Nationwide Health Information Network, a framework of standards, services and policies that allow health practitioners to securely exchange health data, medical records digitized to be easily shared between doctor’s offices, hospitals, benefit providers, government agencies and other health organizations, all across America.

This health information exchange is dramatically enhanced by the Direct Project. Launched in March 2010, the Direct Project was created to enable a simple, direct, secure and scalable way for participants to send authenticated, encrypted health information to known, trusted recipients over the Internet in support of Stage 1 Meaningful Use requirements. The Direct Project has more than 200 participants from over 60 different organizations. These participants include EHR and PHR vendors, medical organizations, systems integrators, integrated delivery networks, federal organizations, state and regional health information organizations, organizations that provide health information exchange capabilities, and health information technology vendors.

On February 1, the Department of Health and Human Services and the White House announced the first live, production uses of Direct for sending medical records securely among providers. Additionally, EHR and PHR vendors announced support for Direct, allowing many types of system-to-system messaging including sending health information to a patient’s PHR or sending a referral to a consulting physician.  These developments are an accelerator to achieving directed health messaging much faster than before predicted, using the Internet!

This month, at the Healthcare Information and Management Systems Society 2011 Conference (HIMSS 11) in Orlando, Fla., eight Direct Project pilots will be demonstrated and discussed. These projects include a collaboration with the Department of Veterans Affairs and a regional health information exchange network known as CareSpark; a demonstration that will explain how the Direct Project technical standards and services are being used to securely transport immunization data in Minnesota; and a project that shows how Albany Medical Center is able to send a closed-loop referral from primary care provider to specialist and back.

These and additional projects are included below with a brief description of the work.

Continue reading…

Computers in 2020

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By RICHARD REECE, MD

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…

What Venture Capital Can Learn from Emerging Markets

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By VIJAY GOVINDARAJAN and JUSTIN CHAKMA

Venture capitalists are increasingly interested in emerging markets, and in working with local funds based in those markets (despite the fact that reverse innovation in venture capital seems counterintuitive). The reason for the interest in in part because the industry has suffered from poor returns on investment over the last decade; indeed, some sectors, including biotechnology, report negative aggregate returns. China and India, in particular, offer attractive liquidity and investment opportunities VCs haven’t seen for a while.

The interesting part of this shift is that VCs are taking a more holistic or “systems” approach to investing than they typically do in developed markets. Traditionally, VCs evaluate each investment as a discrete entity; the firms in their portfolio rarely interact with one another. In contrast, emerging-market VCs such as Nadathur Holdings (established in 2000 by N.S. Raghavan, one of Infosys’ co-founders) create intentional links between firms. Nadathur’s portfolio includes firms operating in drug discovery research, companion diagnostics, pharmaceutical analytics, reimbursement claims processing, patient relationship management, and specialty healthcare delivery for running clinical trials — and they all work together. In effect, the VCs at Nadathur Holdings serve as the executive team for a miniature healthcare innovation ecosystem.

Why do VCs in emerging markets take a systems approach? Because of three significant challenges innovators face in emerging markets:

  1. Innovation ecosystems are not well-developed. The supporting industries that an early-stage tech start-up needs simply don’t exist locally. VCs encourage upstream and downstream, often service-based, investments. These can be exited at lower multiples, with the trade-off of higher success rates for the R&D-intensive high-multiple investments.
  2. Technology-intensive firms are expected to generate revenues before they make an exit; local investors are reluctant to put money into start-ups centered on intellectual property. Portfolio firms upstream or downstream can help establish commercial proof, generate retained earnings and make it easier to get additional customers.
  3. Few local financial intermediaries (including VCs) exist. A portfolio that contains an entire ecosystem helps to decrease risk by allowing inferior business models to be refined or killed faster.Continue reading…

New Cures! Faster! Faster!

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By DEREK LOWE, PHD

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

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By JOHN GOODMAN

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…

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