Category: Uncategorized

Victims of Health Care Reform

Jan 31, 2011• 43

By JOHN GOODMAN, PhD

Who will be hurt the most by the health reform legislation Congress passed last year?

Answer: The most vulnerable segments of society: the poor, the elderly and the disabled. That’s right. Virtually everyone in Congress who is left-of-center voted for a law that will significantly decrease access to care for the people they claim to care most about.

Why isn’t anyone writing about this?

Answer: Because almost all the people who write about health care know almost nothing about economics.

Basically, there are two ways to reform health care. One way is top down. The other is bottom up. The latter is based on the economic way of thinking. The former rejects that way of thinking. The latter gets the economic incentives right for all the individual actors, leaving the social result largely unpredictable. The former starts with a social goal and tries to impose it from above, leaving individuals with perverse incentives to undermine it. The latter depends for its success on people acting in their self-interest. The former depends for its success on preventing people from acting in their self-interest.

I think I can probably count on the fingers of two hands the number of people in health policy who accept the economic way of thinking. All the rest — 99.9% of the total, including a lot of people with “Ph.D., economist” after their names — reject it in spades.

The Safety of HIT-Assisted Care

Jan 31, 2011• 1

By JOHN HALAMKA, MD

I was recently asked by an Institute of Medicine committee to comment about the impact of healthcare information technologies (HIT) on patient safety and how to maximize the safety of HIT-assisted care.

“HIT-assisted care” means health care and services that incorporate and take advantage of health information technologies and health information exchange for the purpose of improving the processes and outcomes of health care services. HIT-assisted care includes care supported by and involving: EHRs, clinical decision support, computerized provider order entry, health information exchange, patient engagement technologies, and other health information technology used in clinical care.

There are two separate questions:
1. What technologies, properly used, improve safety?
2. Given that automation can introduce new types of errors, what can be done to ensure that HIT itself is safe?

To explore these topics, let’s take a look at Health Information Exchange (HIE). What HIE technologies improve safety and how can we ensure the technologies are safe to use?

A Medical Student’s Dilemma

Jan 31, 2011• 9

By LIBERTAD FLORES

I remember joking with Dad about how he’d outlive us all. He had gone vegetarian 10 years before I was born, never smoked, took vitamins, and asked for a designated driver after his annual Heineken at the neighbor’s Christmas shin-dig. He flossed, wore a seat belt, and looked forward to annual physicals. If I tried leaving our Michigan house in the winter with more than 3 inches of skin exposed, he would follow me to the door yelling “It’s no fun being sick!” We were always working class, but both my parents had union jobs with solid benefits and therefore we were covered by two health plans. Despite our attempts at persuasion, he refused to drop his coverage–the Rolls Royce of health plans, as we dubbed it–in favor of my mother’s plan. “I don’t want to worry about bills” he said, and only dug his heels in after retiring.

Nevertheless, on his 64th birthday my father had an endoscopy, after which the physician looked stricken. Later I saw images of the adenocarcinoma that spread like a hand around the top of his stomach and into his liver. He was supposed to have 3 months without treatment, but things were looking up after a few rounds of chemotherapy. He was tolerating the treatment well, and the spots on his liver shrank. Thank God he stuck to his guns about the insurance, I thought. It was one less thing to worry about.

Electronic Medical Records Attack Hospitals

Jan 31, 2011• 22

By MICHAEL KIRSCH, MD

Readers know of my criticisms of the electronic medical record (EMR) juggernaut that is oozing over the medical landscape. Ultimately, this technology will make medical care better and easier to practice. All systems will be integrated, so that a physician will have instant access to his patients’ medical data from other physicians’ offices, emergency rooms and hospitals. In addition, data input in the physician’s office will use reliable voice activated technology, so that some antiquated physician behaviors, such as eye contact, can still occur. Clearly, EMR is in transition. I place it on the 40 yard line, a long way from a touch down or field goal position.

A colleague related a distressing meeting he had at the community hospital he works at. This hospital, like nearly every hospital in Cleveland, is owned by one of the two towering medical behemoths. I’m not a businessman, but I have learned that when something owns you, it’s generally better for the owner than the ownee. This meeting was about the hospital’s upcoming EMR policy. Sometimes, these hospital meetings are ostensibly to seek physician input, but the true purpose is to inform the medical staff about decisions that have already been made. In the coming months, this hospital will adopt a computerized ordering system for all patients. In theory, this would be a welcome advance. It would create a digital and permanent record of all physician orders that could be accessed by all medical personnel involved in the patients’ care. It would solve the perennial problem of inscrutable physician handwriting, including mine.

The Price of Marginal Thinking in Healthcare Policy

Jan 31, 2011• 5

By MARYA ZILBERBERG, MD

I find it fascinating how our brains have this propensity to latch on to what is at the margins at the expense of seeing the bulk of what sits in the center. This peripheral only vision is in part responsible for our obscene healthcare expenditures and underwhelming results.

I have blogged ad nauseam about the drivers of early mortality in the US. In one post I reproduced a pie chart from the Rand Corporation, wherein they show explicitly that a mere 10% of all premature deaths in the US can be attributed to being unable to access medical care. The other 90% is split nearly evenly between behavioral, social-environmental and genetic factors, of which 60%, the non-genetic drivers, can be modified. Yet instead of investing the bulk of our resources in this big bucket of behavioral-environmental-social modification, we put 97% of all healthcare dollars towards medical interventions. This investment can at best produce marginal improvements in premature deaths, since the biggest causes of the effect in question are being all but ignored.

A couple of other striking examples of this marginal magical thinking have surfaced in a few recent stories covered with gusto in the press. One of the bigger ones is the obesity epidemic (oh, yes, you bet it was intended), and its causes. This New York Times piece with its magnetic headline “Central Heating May Be Making Us Fat” entertains the possibility that because of the more liberal use of heat in our homes we are no longer engaging our brown fat, which is a furnace for burning calories. And this is all well and good and fascinating, in a rounding out sort of a way.

Some EHR Vendors Losing Out as Market Evolves

Jan 30, 2011• 13

By DON FORNES

Electronic health record (EHR) software vendors aren’t churning out profits like you might expect. You’d think that the Federal subsidies for EHR implementation would create a rising tide that lifted all boats in the EHR software industry. In reality, some vendors are about to capsize.

Based on data points I’ve observed in the market over the past few months, I think some vendors are facing a cash flow crunch. They’re thrilled to have the wind at their backs for once, but the pace is proving hard to maintain as market evolution has accelerated under the unnatural effect of government subsidies.

Here’s the problem.

EHR Vendors Are Spending Money Like Crazy

Most software markets evolve over a twenty or thirty-year period. Consider the enterprise resource planning (ERP) market: the first ERP vendors were founded in the early 1970s, but rapid growth and innovation continued until about the year 2000. The EHR market, however, will mature in the next five years. This is because healthcare providers are buying EHR systems sooner than they otherwise would, to make the most of massive federal subsidies and avoid penalties. Consequently, EHR vendors are in a mad rush to gain market share.

Those that win will own a massive customer base paying recurring support fees. Those that lose will become irrelevant from a market share standpoint and will be ingested into a larger vendor (if they’re lucky; some will just go broke). As a result, EHR vendors are increasing their R&D budgets to develop new features and meet meaningful use criteria. Their marketing colleagues are spending heavily on demand generation and brand building. These vendors have no choice but to win today’s market share battle.Continue reading…

Defining a Maturity Model for HIEs

Jan 30, 2011• 1

By JOHN MOORE

Before entering the convoluted healthcare IT sector, I had worked in the manufacturing sector both as an IT analyst and in corporate strategy for Europe’s second largest enterprise software company. In those many years I learn quite a bit about not only how to effectively deploy large enterprise software systems (SAP, PeopleSoft, i2, PTC, SSA, Dassault Systemes, etc.) but how to create models that would guide clients in a methodical manner in IT adoption. A common model used was the five stage Maturity Model, which was originally developed at Carnegie Mellon University.

The beauty of the maturity model is its simplicity and focus on process change. This proved very effective in educating all stakeholders within a manufacturing company, from the C-suite on down, as to how they needed to think about their internal processes, the technology they were preparing to deploy and the final end-point that they should strive towards. But one should not look at maturity models as completely static for the technology does change overtime and subsequently what is possible.

Crowdsourcing the Future: Health 2.0 and HIPAA

Jan 27, 2011• 6

By DEVEN McGRAW

The Health 2.0 movement has seen incredible growth recently, with new tools and services continuously being released. Of course, Health 2.0 developers face a number of challenges when it comes to getting providers and patients to adopt new tools, including integrating into a health system that is still mostly paper-based. Another serious obstacle facing developers is how to interpret and, where appropriate, comply with the HIPAA privacy and security regulations.

Questions abound when it comes to Health 2.0 and HIPAA, and it’s vital we get them answered, both for the sake of protecting users’ privacy and to ensure people are able to experience the full benefits of innovative Health 2.0 tools. We can’t afford to see the public’s trust in new health information technology put at risk, nor can we afford to have innovation stifled.

To help solve this problem, the Center for Democracy & Technology (CDT) has launched a crowdsourcing project to determine the most vexing Health 2.0/HIPAA questions.

This is where you come in:

Whether you are a healthcare provider, a Health 2.0 developer or an e-patient, we hope you’ll visit our website to submit your questions on Health 2.0 and HIPAA.

Once CDT has received your questions, we’ll use them to urge the Office of Civil Rights, which enforces HIPAA, to provide clarification. We’ll accept questions until Feb. 11, 2011, so please weigh in soon, and ask others to do the same.

Deven McGraw is Director of the Health Privacy Project at the Center for Democracy & Technology.

Commerce Clause Challenges to Health Care Reform

Jan 27, 2011• 28

By MARK HALL, JD

The following article, forthcoming in U. Penn. L. Rev., pinpoints the strongest arguments for and against federal power under the Commerce Clause to mandate the purchase of health insurance: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1747189

Among the key points I make in defense of this federal law are:

1. The “commerce” in question is simply health insurance, and not the non-purchase of insurance as challengers have framed it. Because “regulate” clearly allows both prohibitions and mandates of behavior, mandating purchase is lexically just as valid an application of the clause as is prohibiting purchase or mandating the sale of insurance.

2. Although existing precedent might allow a line to be drawn between economic activity and inactivity, there is no reason in principle or theory why such a line should be drawn in order to preserve state sovereignty. Purchase mandates, after all, are as rare under state law as under federal law.