Category: Uncategorized

Cousin Jimmy Syndrome

Nov 17, 2010• 2

By JOHN HALAMKA, MD

I have great respect for my colleagues in the IT industry. It’s a challenging profession that requires a mixture of technical knowledge, people skills, and the emotional stability to deal with customer dissatisfaction when technology fails.

However, there’s a downside to being an IT professional. No matter how much expertise you have or what your reputation may be, many customers will not be able to distinguish between a polished industry expert and a self-promoting IT groupie.

I call this the “Cousin Jimmy Syndrome”.

Here’s how it happens. You join a meeting to discuss a major IT project. You talk about issues such as security, disaster recovery, change management, training, and support.

Then someone says, “Oh yeah, we’ve got ‘Cousin Jimmy’ doing that.” Or Bob who lives in his parents’ basement. Or Carol who knows how to use Excel and serves as the go to technology guru.

Unfortunately, when Jimmy, Bob, or Carol have an opinion, their colleagues trust them over you, since professional IT organizations may appear less nimble, less focused, and less accommodating than dedicated local experts.

Health 2.0 Fall Conference Videos

Nov 17, 2010

By Bianca Grogan

The annual Health 2.0 Fall Conference was held October 7-8 in San Francisco and opened with this presentation from founders Matthew Holt and Indu Subaiya. More videos with keynote speakers, panels and product demonstrations may be found at Health 2.0 TV.

Antibiotic Resistant Bacteria in Hospitals: A Time for Action

Nov 17, 2010• 20

By ARJUN SRINIVASAN. MD and RAMANAN LAXMINARAYAN, PhD

Every few years there are reports of antibiotic resistant microbes that prompt a series of predictions about “the end of antibiotics.” It happened in the 90s with multi-drug resistant tuberculosis and then again earlier this decade with methicillin-resistant Staphylococcus aureus or MRSA. It’s happening again with carbapenem-resistant Enterobacteriaceae or CRE. Predictably, over time these bacteria have become resistant to more and more antibiotics. Almost just as predictably, they could be treated by a category of powerful antibiotics known as carbapenems – until now.

Today, 35 states have reported cases of CRE infection to the Centers for Disease Control and Prevention in Atlanta. And they are dangerous. In a recent study of almost 100 cases, more than a third of the patients died from the infection. The concern over these bacteria is compounded by the fact that there are no new antibiotics to treat them coming anytime soon. Most experts agree that even in the most optimistic scenario it will likely be about 10 years before effective new drugs are developed. A variety of efforts are being debated to speed the development of new antibiotics, but these discussions often overlook one critically important issue. One of the reasons our current antibiotics are losing their effectiveness is because we don’t use them properly. Studies have shown, repeatedly, that up to 50% of antibiotic prescriptions are either unnecessary or inappropriate – a statistic that is disappointingly consistent across both in-patient hospitals and out-patient clinics. Not only does this overuse reduce the effectiveness of our current antibiotics, it threatens the utility of any new antibiotics that come along in the future.

S.M.A.R.T. Objectives: An Essential Step in Strategy Formulation

Nov 17, 2010• 3

By MATT MODLESKI

We are often asked to weigh in on organizational strategy when the proverbial “house is on fire” and a client’s business is experiencing challenges. Our first question to the CEO and his/her staff once we begin our consulting journey is simply, “what is your objective?” Many times there is uncomfortable silence, or clients offer admirable and ambitious objectives that are not quantifiable. Things like “we want to be the high quality provider” or “we want to delight our customers.” In one instance a CFO told us “I’ll worry about the financial objective later, I want to talk strategy!”

Aspirational and inspirational rhetoric is valuable in many contexts. Leadership arouses energy and enthusiasm with aspirational declarations from the podium. And Mission and Vision statements are appropriately fraught with statements that reflect aspirations and commitments to what we want our organization to “do and be.” That’s fine. What’s not fine is when we confuse these things with business performance objectives.

Needless to say, with no clear objective, there can be no clear strategy. When there is no clear S.M.A.R.T. objective, an organization has difficulty deciding how to align activities and resources in ways that will result in achievement of that objective. For example, “to be the Quality Provider” is much less clear than saying “by December 31, 2011, we will be in the top 15% of VHA Hospitals in Employee Satisfaction Scores.”

Health Reform Won’t Fix the Real Problem: Unemployment

Nov 16, 2010• 6

By GEORGE PILLARI

While the effects of persistently high unemployment have surfaced in the shape of reduced consumer spending, shrunken tax rolls and a host of social problems, there is yet another harsh reality lurking in the shadows. Hospitals, already in precarious financial positions, are seeing their most profitable source of revenue fade away. Should the situation continue, even darker days for hospitals will surely be in store.

More than 150 million people in the U.S. rely on employer-sponsored health insurance to pay for the bulk of their medical costs. One of the more credible criticisms of health reform is the potential backlash against the employer pay-or-play provisions in the legislation, which could throw millions of today’s insured off their employer plans and into the streets with the chronically uninsured. Even if this did not occur, or at least not to a market-moving degree, it would be small recompense, literally, for hospitals relative to the boogeyman that no political party can legislate or filibuster in or out of existence at will: unemployment. Hospitals in our country rely on the privately insured and better-paying patients for approximately 35 percent of net revenue. Given the already compressed profit margins in the hospital industry, any deterioration in the supply of its best customers could seriously threaten the financial solvency and operational viability of many hospitals across the country. Health reform will not prevent this from happening. Reform targets the un- and under-insured and provides only a base level of coverage (Medicaid), coverage that traditionally add nothing to hospital margins and in many cases erode them.

HUB’s List

Nov 16, 2010• 2

By HERBERT MATHEWSON, MD

1). CELL PHONES DON’T CAUSE CANCER–

Despite ample scientific evidence to the contrary much buzz continues about cell phone usage causing brain cancer. Why is that ? A recent review in Scientific American magazine points out how hard it is to prove a negative. I am reminded about the story of the English farmer spreading purple dust over his fields last year. When asked why he did that he replied “To keep the lions away”. The questioner pointed out that there had been no lions in England for at least four centuries. “Works pretty well doesn’t it,” was the proud rejoinder.

A $24 million study (2) of 12,000 regular cell phone users, half of whom already had brain cancer, found no correlation between cell phone use and the two most common brain tumors. A recent article in Skeptic magazine stated that the non-correlation was because, as my oldest son the engineer often says to me, “It’s just physics.” X-rays and gamma rays can cause cancer because their radiation energy can disrupt chemical bonds inside cells, about 480 kilojoules per mole (it’s just a physics energy term). A cell phone generates radiation of less than 0.001 kilojoules per mole. Whatever kilojoules per mole are, it is clear that cell phones don’t generate very much of them; no where near enough to disrupt chemical bonds. The article’s author notes that probably the only way to hurt someone’s brain with a cell phone is to throw it at his/her head. I would add that since HPV (a virus) is associated with cervical cancer and is more apt to be present in sexually active women, I guess you could cause cancer with a cell phone by sexting!

Hospital Discharge Without a Net

Nov 16, 2010• 1

By JESSIE GRUMAN, PhD

By the time I reached the sixth day of my hospitalization for stomach cancer surgery, I was antsy to go home and I quizzed each nurse and physician who came into my room about what must happen for me to be liberated the following day. Their responses were consistent: my surgeon would visit in the morning and write orders for my release. Then I would have a comprehensive discussion with my nurse about my discharge plan, after which I could leave.

I was pretty curious about getting that discharge plan. The Patient Protection and Affordable Care Act raised the stakes for hospitals to reduce high readmission rates and new data on those rates are available. The rates and approaches to reduce them through improved discharge planning are the subject of news reports, journal articles and conferences. And I, a patient in a modern, quality-conscious hospital, was going to experience this process myself!

Here’s a rough transcript of my discharge discussion:

Nurse: Good news! The orders came through! You can go home.

Me: (in the corner untangling wires from my cell phone and iPod chargers) Wonderful. What do I need to know?

Nurse: Here are a couple prescriptions for pain medication. Don’t drive if you take it. Call your surgeon if you have a temperature or are worried about anything. Go see your doctor in two weeks. Do you want a flu shot? I can give you one before you leave. If you need a wheel chair to take you to the door, I’ll call for one. If not, you can go home. Take care of yourself. You are going to do great!

That was it: 8:45 a.m. and I could leave.

EHRs in Surgical Practices

Nov 16, 2010

By JOHN HALAMKA, MD

I was recently asked to offer advice about implementing EHRs in surgical practices. Here are the lessons learned from our Massachusetts EHR rollout experts.

1) . Surgical practices are challenging in general because they frequently use dictation and the most obvious benefits of EHRs do not apply to them. They do not have substantial amounts of structured data to enter and they do not have a high fraction of recurring patients so a large fraction of records are “new” records. The highest benefit areas for them require interoperability, which takes time to accomplish. A significant fraction of the information they need for documentation comes from hospital operative notes, referrals/consults are the biggest element of workflow, and they rely on electronic lab and imaging test results.

2) . The most successful workflow change approach requires shifting more responsibility to mid-levels so that basic structured data entry (like vitals, history, etc) and billing related entry do not fall on surgeons who can be resistant to doing that type of documentation. Unfortunately shifting practice roles/responsibilities is not easy.

3) . Working with the practice to build structured procedure templates in advance of go-live and setting up voice-recognition to allow surgeons to continue to dictate are key workflow/adoption steps.

4). Some EHRs such as eClinicalWorks have templates for Operative Notes as well as SOAP notes, which are key to EHR adoption.

5). Interoperability should be implemented as quickly as possible: diagnostic results delivery (especially imaging results) and hospital document push (operative notes, discharge summaries) should be integrated into workflow during implementation.

The Road to Wellville: Pilots and Demos?

Nov 15, 2010• 15

By ROGER COLLIER

As might be expected of reform legislation, the Patient Protection and Affordable Care Act places a lot of emphasis on innovation. Reasonably enough, most of the potential changes—at least in Medicare—are to be preceded by pilot or demonstration projects designed to test their feasibility. In fact, according to one health care blogger with time on his hands, PPACA includes no less than 312 mentions of demonstrations and 80 mentions of pilots.

Just how important are all these pilots and demos? Harvard’s David Cutler, who served as a key advisor to the Obama administration in developing the reform strategy, clearly believes they are vital. Writing in the June Health Affairs, he stresses the need for rapid implementation of the pilots and demonstrations in order to help achieve eventual savings of “enormous amounts of money while simultaneously improving the quality of care.”

How realistic are Professor Cutler’s expectations?

CMS’ Medicare chronic care demonstrations provide some clues. With data showing that the costliest 25 percent of beneficiaries account for 85 percent of total Medicare spending and that 75 percent of the high-cost beneficiaries have one or more major chronic conditions, the demonstrations were expected to show big benefits from care coordination—the major theme of PPACA’s proposed demos.

The outcomes were decidedly discouraging, as noted by MedPac’s 2009 report to Congress:

“Results suggest that some of these programs may have modest effects on the quality of care and mixed impacts on Medicare costs, with most programs costing Medicare more than would have been spent had they not been implemented….In almost all cases, the cost to Medicare of the intervention exceeded the savings generated by reduced use of inpatient hospitalizations and other medical services.”

Unhealthy Skepticism

Nov 15, 2010• 5

By JOHN MOORE

There remains an unhealthy level of skepticism in the market as to whether or not consumers will use a personal health record (PHR). While a certain level of skepticism is healthy in any market, the level to which it is laid towards PHRs is unwarranted and likely more a function of ignorance then malicious intent. Following is a brief PHR case study that provides validity to the mantra that a patient who is provided access to their personal health information (PHI) via a PHR can become a more engaged patient in self-managing their health. What is particularly striking about this story is that it is does not take place in middle-class America, where many have targeted their PHR initiatives, but rather among the urban poor.

Last week, I met with Dr. Nunlee-Bland, Director of Howard University Hospital’s (HUH) Diabetes Treatment Center, who graciously provided the context and content for this remarkable story.

Empowering the Urban Poor to Self-Manage Their Diabetes:

In 2008, HUH received a grant from the Dept of Health, DC to launch a diabetes treatment program primarily targeting urban poor. As part of this grant, HUH launched a PHR initiative creating a patient portal using NoMoreClipboard (NMC), linking NMC to their clinical diabetes EHR, CliniPro from NuMedics. The PHR provides patients with access to their problem list, vitals (height, weight, blood pressure, BMI), medication lists, basic lab results, A1C results (can be charted for track and trend) and basic demographic information. While Dr. Nunlee-Bland stated that HUH has no reason not to provide patients with full access to all PHI, they have purposely kept the PHR simple and focused on the treatment of diabetes.