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Category: Health Tech

Health Affairs is all about IT

Most of the Health care geek squad is in DC as I write, at a press conference conducted by Health Affairs which has an entire issue out today about IT in health care. Here’s the table of contents. And for those of you who don’t have a subscription, well here are four articles for free including those from David Brailer and John Halamka.

As you might guess KP’s HealthConnect is featured prominently with academic articles about the impact of its installation on physicians & the system (office visits down 25%) and patients (they love it).

There’s lots and lots more, including an article that makes stars of nerdy docs Jay Parkinson, Danny Sands and Ted Eytan—if “star” is the right word for this rarefied environment. (Oh, and somehow Bob Coffield got in there too!) My early tweetings on that one (which is the only one I’ve read so far) were captured and blogged by e-Patient Dave. Converting tweets into a blog post and making it make sense may be the new art form. Be warned that despite the words “Facebook & Twitter” in the title, this is about using Health 2.0 tools for patient to physician communication not about the social networking side of Health 2.0. Still I guess there’s room for another article in the next Health Affairs about that.

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Google Health sharing–simple but potentially important

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Today late afternoon PST Google flipped the switch on an important change/add to Google Health.

Recently they’ve been adding more and more little features, such as printing & graphing, and in the last month getting CVS retail pharmacies on the network (to join Walgreens), and sucking up device data. But this new one may be the most interesting, as Google Health has added the ability for users to invite others to see their records.

Anyone who’s used Google Docs (and that includes all of us working at Health 2.0) immediately gets addicted to sharing those spreadsheets and text documents with a wider team. It’s so easy, you just invite them to it, and then one day you wake up and you’re sharing hundreds of documents with everyone you work with and cannot imagine how you did it before.

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Frances Dare explains HITECH, really well

Frances Dare from Cisco is a buddy of mine who has more and more been their student of what's going on in Washington. Given that we just saw the biggest piece of health care IT legislation ever pass, I thought I'd check in with her. Frances, has really done her homework about exactly what's in that $19.2 billion pot and more (yes there's more than that) and how it's going to be spent.

This is a long(ish) and detailed interview, but if you care about IT in health care, I highly suggest you listen!

Reform? Marginal, I fear…

Matthew HoltToday’s news is that there is now a double header running health care with the addition of the 
(notably all-female) team of Sebelius & DeParle joining Orzsag, Zeke Emmanuel and a host of others with influence on the health care policy tiller. We await a CMS leader, and probably multiple other appointments quickly down through the ranks.

However, I remain convinced that not much is going to happen, and that even if Obama’s “plan” gets enacted, it’s a limited reform that is not the big bang we need to do the job.

Thankfully rather than me having to explain why, Bob Laszewski (who makes me feel like an inadequate noobie every time I read his stuff) details the problems over at Health Affairs blog. The Bob L summary?

  1. Obama’s team has not aggressively gone after the hard cost problems as part of Medicare & Medicaid, preferring to trifle around the edges with modest cuts 
  2. For the (these days relatively modest!) $120 billion a year the reforms are going to cost it’s only looking to the health care system to pony up around half of it—the rest (c. $65bn a year) will come from the taxpayer.
  3. The details of the plan are being left to the Congress which means that it’ll be watered down.

As I said in the looooong comment thread on Maggie Mahar’s piece on THCB yesterday—BTW Maggie’s comment on her own piece may be the longest comment I have ever seen on any blog!—there’s no reason that the rest of the economy should contribute more to the health care system. As John McCain might say (albeit with disapproval), we need to redistribute the wealth within the system.

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Musings on Integrating Care at the IOM

Matthew HoltSo I’m in
DC figuring out how the East coast medical policy elite tries to change the world. While the rest of DC is buzzing about Obama’s speech and budget, The Institute of Medicine is having a conference on Integrative Medicine. But most people think it should be called integrative health. 

What is integrative health, you ask? Good question.

The majority of the panelists are mainstream health care players like Bill Novelli (AARP), George Halvorson, (Kaiser Permanente), Ralph Snyderman, (Duke). They’re talking about integrating coordinated allopathic health care and information across an individual’s personal health plan. Snyderman, said we need to move from “find it, fix it” to a “personal health plan”. Halvorson said (surprise, surprise) that we need electronic health data on every patient, and to not just replicate the current silos of care in our new data strategy. Novelli went straight at the environmental factors—smoking, fast food et al. And to not ignore them.  Mehmet Oz (he of the Oprah show) said that

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Getting “the CCHIT question” wrong

Matthew Holt

There’s been a lot of blather from one commenter (who may or may not be a front for a group of  malcontents) on the WSJ Health Blog and lots of other blogs about CCHIT and whether it was doing business without a license in Chicago, and/or was a front organization for HIMSS or EHRA. All summarized on Neil Versel’s blog. Indeed I did get a call from one well known blogger telling me that HIMSS’ lawyers had asked for him to take those comments down—not too bright a piece of PR on HIMSS’ part IMHO.

MrHISTalk thankfully did what I certainly could not be bothered to and actually looked into the “CCHIT is not a licensed corporation” situation and figured out that it’s basically being run legitimately. I myself cracked the joke privately that if CCHIT/HIMSS/EHVRA/Leavitt et al had only managed to get $2m (or $7m for that matter) out of the Bush Administration, they needed to go to the Haliburton school of “how to stick it to the taxpayer properly.”

The other wisecrack I’ve heard is that  the way to determine the list of functions an EMR needs to have to get CCHIT certified was to copy the feature set of Allscripts TouchWorks. (Of course you can insert the name of any of the other big EMR vendors here too).

OK, so we’re kidding around here, but underneath this discussion are some serious points. And those serious points have got little to do with what has indeed been a pretty close relationship between the powers that be at HIMSS,EH(V)RA, CCHIT & HITSP.

In any case I assure you that the back room dealings and conflicts of interest are nothing compared to how the rest of the Federal government has colluded with industries it regulates for the last 8 years. The money given from ONC to CCHIT wouldn’t even be a rounding error on what’s been completely lost in Iraq in cash in suitcases. let alone what Blackwater, Halliburton et al have stolen, And there’s no evidence that the Feds didn’t get what they/we paid for from CCHIT, which is a certification process.

So if this is a non-story, what are the actual issues?

1) Part of the justification for a certification process is that there is a great deal of fear and trepidation among physicians who have heard the horror stories about EMR implementations, and are now being bribed (and later to be threatened) by the Federal government into installing EMRs. Given the plethora of vendors out there, and the fact that these providers are more or less Federal contractors who tend not to understand IT, it’s not unreasonable to suggest that the Federal government (or someone) gives authoritative guidance as to what’s a robust system that has the right features and functions. Remember that the nation’s biggest and richest integrated provider organization trashed not one, but two national investments in EMRs before getting it right at try three. Having recalled that it becomes reasonable to agree that most providers need some help. And of course there is some slight protection for the taxpayer if the providers who are about to get their $40K have to do more than just claim that they bought an EMR from Sonny on the corner.

2) Of course once you say that the Federal government will pay out only to those purchasing certified products you then run into two other problems. First, the certification process is going to get somewhat politicized. Despite all the yakking about “volunteers” on all these committees, what we’re talking about is the people with a deep interest in EMRs et al being those “volunteers” and of course they are mostly from the vendor side or users who know the vendors well. I don’t see a way around that unless we really want to develop a civil service that has expertise in health care IT and also is prepared to stay in the job for 30 years like they do in Japan. Second, by its very nature the certification process is likely to run behind the development of technology, which means that vendors building for the certification process are like teachers prepping students for tests, not creating innovations. Again that may not be a terrible thing, but it’s not how innovation works in most other industries. (John Moors at Chilmark has a rather blunter, bleaker assessment of how this might work out)

3) And of course, the reason that you don’t see Federal certification of, say, MP3 players or automobiles is that there’s a somewhat effective market there that means that innovation and user experience gets rewarded. Make a confusing MP3 player, you don’t move the needle much. Figure out how to make it easy and elegant and you’re called Steve Jobs and you sell a gazillion iPods a year. Health care doesn’t have such a market, or even rationally managed incentives from its Federal paymaster.

So I don’t have the answer, but I do have the question. And it’s the same one being posed by the Dogs, in response to the Cats. Can we realistically expect CMS and the rest of the big payers to start rewarding providers for producing the correct outcomes. If we paid for outcomes, providers would change their organizational structure, and their processes, and the technology they use. The ones that worked would succeed and the others would go away. That’s how a market works. And that would create lots of interesting technological innovation of the type that is already happening in the consumer health arena in Health 2.0.

But (beware: run-on sentence coming up so take a deep breath) if we realistically can’t get to some massively enhanced version of pay for performance very soon, and instead are going to insist that providers use EMRs or something like them and the Feds will pay them for it, and we are happy to declare that that solution is as good as we’re going to get while we work on wider health system reform later, then I don’t think that we can complain about the CCHIT process too much. We have to accept that the Feds are going to put a stake in the ground somewhere as to what is an acceptable technology to reward. And those rewards are not going to be market or outcomes-based yet.

So the ultimate question, is what’s the time-scale for junking our stupid current health care incentives and finance system? And the answer is, not in the next 2–3 years.

Which means that if we’re paying directly for technology (which we are as the law is now passed), a certification process is a necessary evil to help providers and to make sure that the tax payer isn’t being defrauded (see we’re back to Iraq again!).

Of course, this doesn’t mean that the certifiers shouldn’t be made to appear to be (as we;; as actually be) completely above board and be watched like hawks to make sure that they’re not putting too many restrictions on smaller companies or discriminating against them. And maybe that kind of oversight demands that we see greater separation between the HIMSS/EHRA/CCHIT/HITSP/ AHIMA players, which would fit in with Obama’s “no lobbyists in the Administration” line.

But I can’t see that this is an issue for anyone to go to the barricades about. And in the end if CCHIT helps providers get better tools than they have now, it’s probably a net positive—even if it may prevent greater innovation happening faster.

Disruption breaking out over at Scott Shreeve’s place

Clayton Christensen's publisher is pressing me to read The Innovators Prescription and then interview him. Sadly I haven’t had the time to pay the book the attention it deserves. Messrs Kuraitis & Kibbe already did a review on THCB and probably said what I’d say, which was that like several other Harvard Business School profs, they got the problem right but the solution wrong. I’m on record from a couple of years back saying that Christensen’s guns are aimed in the wrong direction.

But to be fair my criticisms are pre-publication. Scott Shreeve has a great interview with Christensen’s co-author Jason Hwang (the late Jerome Grossman is also a co-author). and in this interview several of the incentive issues which concern those of us who understand how innovation gets stopped in health care, are addressed. Well worth reading.

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Divided we might get somewhere, but not yet

Matthew HoltThe NY Times describes the Republican-less lobbyist meetings with Democrats that are allegedly getting 
towards a consensus on an individual mandate as the way to universal health care. Funnily enough some of those same groups (e.g. The Business Roundtable & the NFIB) appear to be lessening their commitment to the worthily named “Divided we Fail” campaign.

And then on the second page of the NY Times article there’s this:

Many businesses, crushed by soaring health costs, say they now support changes in the health care system as a way to control their costs. But in its summary of the recent discussions, Mr. Kennedy’s office said, “There was little consensus on the employers’ role.”

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Connecting the dots–Uninsured people are poor!

A bunch of random articles all hit at once on Wednesday morning. And they win the John Madden award for stating the bleedingly obvious. This is kind of  a companion piece to my rant about Friday’s NY Times article on the health industry and its political allies and adversaries sitting down to come to consensus.

Inquiry featured a worthy study. It tried to suggest that high costs “crowd out” health insurance spending.

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