Category: Uncategorized

Swamp Creature

Nov 5, 2010• 10

By JEFF GOLDSMITH

Many people forget that before Washington DC was our nation’s capital, it was a pestilential swamp, whose few hardy residents regularly succumbed to tropical diseases like malaria. It was virtually uninhabitable in the summer (some say it still is), and like Houston and New Orleans, really began to boom only after the advent of affordable air conditioning. It is also a political swamp, infested with lobbyists and special interests, and Washington “lifers” – commentators, political operatives, consultants, intellectuals and bureaucrats who outlive increasingly fragile Presidential administrations. The electorate despises Washington, and sends waves of “outsiders” (e.g. ordinary Americans) to drain the swamp.

Though President Obama signed it into law in March, the new Affordable Care Act of 2010 is a swamp creature. Written by an exhausted Congress, half beast, half plant, the ACA is a seething, octopus-like tangle of well meaning but opaque government projects intended to expand health coverage and fix the health system’s numerous problems. Far more than “insurance reform”, it sprawls over and touches virtually every corner of our $2.5 trillion health system, bringing change, uncertainty and a ton of taxpayer dollars. It also has sunk its taproots deep into the national treasury and extends its feeding tentacles to an obese and hungry industry that already claims 17% of the national wealth.

A new wave of Republicans are about to hit town, fired up by their stunning mid-term election victory and control over the House of Representatives. One of their campaign pledges is to kill the swamp creature. They will shortly charge off into the swamp to try and kill it, like the British army tried to kill Francis Marion. In doing so, they expose themselves to a whole bunch of hidden hazards, including the beast itself. Handled thoughtlessly, the Republican campaign against health reform could damage the party’s prospects in 2012, even if the economy continues to sputter.

From Progressive to Zombie Legislation after Midterms?

Nov 4, 2010• 4

By RICHARD REECE, MD

This is a guess as to what the midterms, a political setback for supporters of the Affordable Care Act (ACA), might mean for health reform. Exit polls indicate 58% of voters opposed the ACA, and cracks are beginning to show among progressives that implementation of the reform law will be difficult and fraught with political obstacles. During the campaign, Democrats fled from endorsing the health reform law, most of those supporting it lost, and Republicans will soon be holding hearings seeking to expunge or changes many of its provisions.

These cracks are beginning to show in the New England Journal of Medicine, long an echo chamber among supporters of Obamacare. Almost to the person, contributors to the “Perspective” section of the New England Journal of Medicinehave hued to the Obama health reform line, namely that the Affordable Care Act is a step in the right direction, that all will be well if only we follow its provisions to the letter, and that its implementation is inevitable and is needed to correct deficiencies in our health system.

In the October 28 NEJM issue, Henry Aaron, PhD, of the liberal Brookings Institute in Washington, D.C. sounds the alarm and breaks out of the chamber by saying, in effect, “Hey! Maybe this thing we call ACA isn’t going to work after all.”

He breaks ranks with conventional progressive wisdom by opening admitting the ACA may fail “The Midterm Elections– High Stakes for Health Policy.”

Patient Engagement on the Med-Surg Floor

Nov 4, 2010• 1

By JESSIE GRUMAN, PhD

Three times a day, as though responding to some signal audible only to the generously medicated, we rise from our beds to join the slow procession around the perimeter of the unit. Like slumped, disheveled royalty, each of us blearily leads our retinue of anxious loved ones who push our IV poles, bear sweaters to ward off the harsh air conditioning and hover to prevent stumbles. Some make eye contact. Few talk. Each of us is absorbed in our suffering and our longing to return to our bed.

I find this experience strangely moving.

Despite the nausea, dizziness and enough mind-altering drugs to fell a horse, so many of us fight our way to consciousness, creakily right ourselves and step out of our rooms to join the others. At that moment we are able to say “I’ll do the one thing they say might help me get better,” taking one painstaking step after the next – the height of our ambition meets the limits of our abilities – to resume the life we left behind when we entered the hospital.

This is one glimpse of what it means to be engaged in our health care.

Jessie Gruman, PhD, is the founder and president of the Washington, DC -based Center for Advancing Health. She is the author of Aftershock: What to Do When You or Someone you Love is Diagnosed with a Devastating Diagnosis. She blogs regularly on thePrepared Patient Forum.

The EMR Cage Match Results

Nov 4, 2010

By JONATHAN BUSH

It turns out, there was no cage at the experimental debate earlier in October between me and Girish Kumar Navani of eClinicalWorks. And Girish was wearing a shirt…and no mask.

These, plus other anticlimaxes, sent our PR guy John Hallock into a deep, week-long depression.

“He could have gone for the jugular! Why didn’t he go for the jugular?!?”

This was all he said for days.

The truth is that it’s hard to get too snippy with a guy who has built such an awesome company—WITHOUT VENTURE CAPITAL! It’s just an incredible accomplishment. That, combined with his incredible intuition around software design, made him a guy I really wanted to hear from…rather than jump on.

Also though, I heard Girish start to say words that for most plain ol’ software company leaders are “un-sayable.” He said he wanted to host for his clients. He said he wanted to maintain their data for them. As a private company, I think Girish is in the best place to go the rest of the way. Why not insist that all ECW clients get on a shared instance? Why not start to take on some of the functions that cause so much frustration (34% of new athenaClinicals clients are actually frustrated software-based EMR clients!) These acts would destroy ECWs profits for a few years but they would emerge a genuine candidate for national HIT backbone, along with athenahealth.

We need that…a lot more than we need more versions of software.

Jonathan Bush co-founded athenahealth, a leading provider of internet-based business services to physicians since 1997. Prior to joining athenahealth, he served as an EMT for the City of New Orleans, was trained as a medic in the U.S. Army, and worked as a management consultant with Booz Allen & Hamilton. He obtained a Bachelor of Arts in the College of Social Studies from Wesleyan University and an M.B.A. from Harvard Business School.

The Electronic Medical Home

Nov 4, 2010• 4

By JOHN HALAMKA, MD

In previous blog posts, I’ve mentioned an idea deserves its own dedicated post.

Over the weekend, I keynoted the eClinicalWorks National User’s Conference in Florida. One of the attendees emailed me the following question:

“I have a number of questions regarding certain types of patient-level data that might cause us problems in the future of HIE. No one, to date, has been able to answer these and I thought I might ask you.

The first, and easiest, is how we we going to handle the following situation:

1) I am seen in Boston as a child and my mother says that I am allergic to Penicillin (or pick your drug of choice). The nurse-practitioner asks a few questions of my mother, who isn’t terribly forthcoming with information but insists that I am allergic. While he/she has reservations, they record it as an allergy in their eclinicalworks EMR. It goes to the Massachusetts HIE.

The Republican Landslide and the Affordable Care Act

Nov 3, 2010• 39

By GLENN LAFFEL, MD

After their resounding triumph in yesterday’s midterm elections, House Republicans will likely act on their promise to repeal the Affordable Care Act, the health reform bill President Obama signed into law last March.

Their efforts could be blocked by the Democratically controlled Senate or, if necessary, by a veto from the Big O himself. But the Boehners might still get the final say, since they have the power to halt appropriations funding for large swaths of the law.

These realities have health-industry groups, some of whom vigorously supported Democratic efforts to pass the law, cozying-up to the GOP like a Snuggie on a cold winter night.

Private insurers want Congress to nix that $70 billion tax that will be levied against them beginning in 2014. They’d also like lawmakers to permit them to widen the rating bands which cap the amount of money they can charge older enrollees.

Insurers and providers want Congress to add a tort reform rider to the law, preferably one that protects physicians against malpractice lawsuits if they adhere to best practice guidelines. Drug companies want to kill the proposed Independent Payment Advisory Board, whose job it is supposed to be to control the rate of growth in Medicare spending. The Board’s recommendations would, after all, likely include reduced federal spending on prescription drugs which is very bad for their business.

Yet these same groups are worried sick that Republicans might go too far in their zeal to repeal the deal. The baby in the bathwater for these trade groups is the individual mandate: a provision in the law that requires most Americans to carry health insurance.

Laying on of the Hands

Nov 3, 2010• 8

By HERBERT MATHEWSON, MD

It appears that except for physical therapists, masseuses, and priests no one lays on the hands anymore. Certainly contemporarily trained physicians do not.

Recently I went to my local ER because a 2-day old pain in my back “due to a strained muscle” from a gym work-out was now, at 11:00 PM, causing me to be quite short of breath and unable to lie down. The ER reception desk was empty and, as the sign instructed, we picked up the phone and announced our presence. An ER nurse came out, signed me in, registering me as a new patient, escorted me back to a cubicle, recorded my vital signs, took a short history, listened to my chest (“A few crackles there in your back”), started an IV, ordered an EKG and a chest x-ray, and drew a whole bunch of bloods, one tube of which revealed that I was probably having pulmonary emboli (clots to my lungs). The CT scan confirmed the diagnosis of “multiple bilateral pulmonary emboli”.

Then I saw my first doctor. While standing at the bottom of the bed juggling a clipboard that was barely controlling various colored sheets of paper, she took a short history, listened to my chest (“A few crackles there in your right posterior chest”), told me that the CT scan was positive, and that the admitting hospitalist would come to see me soon. The nurse explained that the ER doc was busy with a very sick patient being transferred into town.

The admitting hospitalist was a true gentleman. He even sounded like a gentleman with his clipped British accent and Eastern Indian last name. He took a longer history, listened to my heart and lungs (“A few crackles on the right side there”) and outlined what was to happen next; a stay in hospital for three days at least, immediate anticoagulation, and tomorrow an ultrasound of the legs and an echocardiogram looking for a source of the clots. He explained things very clearly, was reassuring, and answered my questions succinctly and thoroughly. I felt that I was in good hands, …but I was a little uneasy that no one had done a complete, or even a semi-complete, physical exam.

What has happened to all that we were taught in second year Physical Diagnosis?

Can we get physicians to use modular apps?

Nov 3, 2010• 4

By MATTHEW HOLT

Health 2.0 is best known for (and started with) consumers using online tools, search, communities and other services. But over the last year or two we’ve seen more and more SaaS-based and modular tools developed aimed at physicians and their offices. At the same time of course the Feds have promised (but not quite started yet) to lay out up to $36 billion to put EMRs into doctors’ offices.

The problem is that most physicians practice as independent small businesses, and almost all the progress in mainstream EMR adoption has been in larger enterprises–particularly the VA using Vista and many larger provider systems (e.g. Kaiser) using Epic and a few other larger client-server based systems. But smaller businesses outside of health care are using a whole range of SaaS-based services to run their operations. For example, at Health 2.0 we use Highrise for customer tracking, Google Docs for records, Gmail for sharing information, Skype for communication, Surveymonkey for attendee surveys, Mailchimp for marketing emails, and several others.

Can physician offices use a parallel set of modular applications to run their various business and clinical processes? I believe that they can and will. But the problem is how to get the message out? So I was pretty interested to find that Sanofi Aventis is trying to reach physicians about these issues via a site called iPractice. They asked (and commissioned) me to write something about the topic. So I’ve described seven modular Health 2.0 tools for physicians. You can read my article here

Dismantling the Cottage Industry

Nov 2, 2010• 33

By MARGALIT GUR-ARIE

Last week I went to see a doctor about an EHR. Dr. Greene (not his real name) is a typical solo primary care physician in a typical small town in the typical middle of nowhere. Four hours from the closest airport and miles and miles of winding roads, cow pastures and corn fields away from medical centers of excellence. Dr. Greene is in his late fifties and has been practicing medicine for over thirty years in the same location. He works six days per week and missed “two and a half” days of work since he hung his shingle up and never missed a Rotary Club luncheon. Dr. Greene is planning on practicing for ten more years and now, he wants to go electronic.

Dr. Greene’s practice is located in a small and spotless one-story building with large windows and an open floor plan. We sat down at a white laminate round table in the kitchen during his lunch break. His wife of many years is his office manager and the only other employee is a nurse who doubles as front office receptionist. His shortest appointment is for 30 minutes and new patients, who are scheduled for 1 hour, come at the end of the day just in case it takes longer than planned. His notes, written on special gold colored paper in nicely rounded cursive font, are concise and neatly organized by visit date. Like most doctors who use paper charts, he doesn’t code his visits. He checks diagnoses and procedures on a sparse super-bill devoid of any numbers. His wife and office manager takes it from there and all his claims go out electronically every day.

Contemplating Safety While Lying Down

Nov 2, 2010• 3

By JESSIE GRUMAN, PhD

I write about what it takes for us — whether we are sick or well — to find and make good use of health care today.

At the end of September I was hospitalized for surgery to remove a tumor in my stomach. Below is one in a series of five observations about my experiences since then.

“You have to get out of this hospital – it’s a dangerous place,” each of my physician friends exclaimed when they came to visit me during my recent stay after surgery for stomach cancer.

Jeez! I know! Prior to my operation, I was more preoccupied by the possibility of medical errors than of the operation itself or the pain it might cause. What if they take out my kidney instead of my stomach? Or leave a sponge in there? Or over-hydrate me so I drown? What if one of my many overnight vitals-taking-shot-givers infects me with MRSA?

The human imagination has wondrous capacities, especially when fueled by true stories of harm people have experienced due to medical errors. I read closely the IOM report To Err is Human: Building a Safer Health System ; I am horrified by the medical errors experienced by Sue Sheridan and impressed by her leadership of Consumers Advancing Patient Safety and Diane Pinakiewicz’s at the National Patient Safety Foundation to raise awareness about the dangers patients face due to carelessness and lack of system-level controls.