Category: Uncategorized

From Pain to Poverty

Feb 24, 2010• 48

By STEVE SANDERS, MD

“What am I going to do now Doc?” asked Mike, a down on his luck, 29 year–old recently unemployed truck driver, as he handed me his hospital bill.

Mike was seen at our local emergency department on a Friday evening with complaints of indigestion. Earlier that day he and his wife Susan celebrated their second anniversary by splitting a store bought pepperoni pizza. Mike had just lost his job and his wife, already working two jobs, managed to keep them afloat. When Mike later complained of indigestion, Susan became alarmed. She had just read about the symptoms of heart disease in the local paper. Mike wanted to get some antacids but Susan demanded he go to the hospital. Mike stated he initially protested, but when it came to his health he looked to his wife for advice.

He said he wanted her to drive him to the hospital and told me his wife wouldn’t hear of it. “We’re going to call 911, she told him. “You could die on the way to the hospital.” Now, Mike admitted, that made him scared and he quickly agreed. Fifteen minutes later he was on a gurney rolling through the double doors of the emergency department.

Physical assessment by the emergency resident physician came quickly followed by an EKG, chest x-ray, CT scan of the chest (“they said I might have had a blood clot”), and lab, specifically including cardiac enzymes. Mike said his only complaint was it took over five hours before he heard any news.Continue reading…

Health 2.0: Beneath the Hype, There’s Cause for Real Hope

Feb 24, 2010• 3

By MICHAEL MILLENSON

Health 2.0 is a trend accompanied by both buzz and buzzwords. That worries some advocates for the poor, under-served and just plain old and sick. Will those groups be left behind in the latest information revolution?

The potential positives of the Web-as-health-care platform for interactive health care services could be seen in two full days of presentations and discussions at a recent meeting in San Francisco, called the Health 2.0 Conference. Still, a certain Silicon Valley sensibility remained: widgets for weight control were much more likely to target the calorie count of cappuccinos than corn dogs.

Yet the real question is not whether Health 2.0 arrives clothed in hype; of course it does. The capitalistic ritual of “new and improved” is similar for software and soapsuds. The important issue is whether the substance of Health 2.0 can help deliver health care services significantly more efficiently and effectively while reducing disparities. Look beneath the hype and you can see it’s already starting to do so.Continue reading…

Is Geography Your Health Destiny?

Feb 24, 2010• 8

By RISA LAVIZZO-MOUREY, MD Risa

Dr. Lavizzo-Mourney is the President and CEO of the Robert Wood Johnson Foundation. Before joining Robert Wood Johnson she taught at the University of Pennsylvania, where she was the Sylvan Eisman Professor of medicine and health care systems and director of Penn’s Institute on Aging. In Washington, D.C., she was deputy administrator of what is now the Agency for Health Care Research and Quality.

Thanks to a new set of reports, we now know that where you live matters to your health. People who call Prince George’s County Maryland home are twice as likely to die prematurely from disease as their neighbors just across the line in Montgomery County. The data cut both ways. People who live in the healthiest counties, such as Montgomery or Howard County Maryland have a two-to-three times better chance of living longer than people who live in less healthy counties such as Prince Georges or Baltimore.

These important new facts aren’t just for the Washington area, because the same disparities are happening across the country. This story unfolds in 50 state reports – The County Health Rankings (www.countyhealthrankings.org) – that the Robert Wood Johnson Foundation just released with the University of Wisconsin Population Health Institute.

The Look

Feb 22, 2010• 4

By ROB LAMBERTS

“He gave me the look,” the patient said to my nurse as he walked out of the exam room.

My nurse laughed and said, “I had a feeling you’d get it today.”

What were they talking about? ”What look? I didn’t know I had a look!” I asked my nurse.

The patient tipped his chin down and looked at me over his glasses. My nurse laughed, pointing at the patient, “That one! Exactly! You give that look to me too!”

I was mystified. I don’t like lecturing people or acting like their parent. Patients do no harm to me when they gain weight, don’t take their medications, or eat a lot of Little Debbies. My job is not to get them to do everything I say, it is to give them enough information and motivation to do it for themself. I am the coach; they are the ones who have to go out on the field and play. I may be disappointed when they mess up, but it’s not my job to patronize them and wag my finger.

So I was vexed when I learned about “the look.” I’m honestly not sure how much of it is just a product of a guilty conscience on the parts of my nurse and the patient, but there is usually at least a grain of truth in this kind of revelation. I do know that I mysteriously intimidate new employees at our office. The longer-standing ones think this is funny – realizing the softie I really am.

I’m also not sure if it is so bad that they don’t want me to look at them over my glasses. I have had patients (and probably employees) assume my silence on an issue was a tacit approval. ”He never told me I shouldn’t smoke,” ”He never said I needed to lose weight.” I’ve had people use my lack of lecturing as an excuse to continue behavior they already know is bad for them.

I also never told them it was bad to hit themselves in the head with a hammer. I hope that omission isn’t resulting in head trauma.

I saw another patient recently, who said to me before I could sit, “I am sure you noticed I gained 6 pounds. Christmas and Valentine’s Day were bad for me.” I hadn’t had the chance to check the chart, but returned a remark about how there is a clear correlation between eating too much and gaining weight. I could tell he had a guilty conscience, so I didn’t say anything more.

As I wrapped up the visit he asked me, “Aren’t you going to say something about the six pounds I gained?”

I smiled, realizing that he was expecting “the look” from me. I told him that it was not good to gain weight and then looked at him over my glasses.

We’ll see how much power it has.

ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

CCD Standard Gaining Traction, CCR Fading

Feb 22, 2010• 10

By JOHN MOORE

In a number of interviews with leading HIE vendors, it is becoming clear that the clinical standard, Continuity of Care Document (CCD) will be the dominant standard in the future. The leading competing standard, Continuity of Care Record (CCR) appears to be fading with one vendor stating that virtually no client is asking for CCR today. This HIE vendor did state that one client did ask for CCR, but only to enable data transfer to Google Health.

CCR was created by ASTM with major involvement by AAFP wih the objective to create a standard that would be far easier to deploy and use by smaller physician practices. At the time of CCR formation, the dominant standard was HL7’s CDA, a beast of a standard that was structured to serve large hospitals and based on some fairly old technology and architectural constructs. With competing CDA and CCR standards in the market, there was a need for some rationalization which led to the development of CCD, a standard that combined some of the best features of CCR and CDA.

Today, CCD is seen as a more flexible standard that is not nearly as prescriptive as CCR. This allows IT staff to structure and customize their internal HIT architecture and features therein for their users and not be confind to a strict architectural definition such as that found in CCR. (Note: such strict definitions are not always a bad thing as they can greatly simplify deployment and use, but such simplicity comes at a price, flexibility.)

Unfortunately for Google Health, who has built its system on top of a modified version of CCR, this trend likely lead to increasingly difficulty in convincing healthcare providers to provide patient health records in a CCR format. Google would be wise to immediately begin the work necessary to bring CCD documents into their system as the writing on the wall is getting clearer by the day. CCR is a standard that will fade away.

John Moore is an IT Analyst at Chilmark Research, where this post was first published.

Chilmark Needs to Chill Out on CCR/CCD Findings

Feb 22, 2010• 16

By VINCE KURATIS

John Moore of Chilmark Research and I agree on things 90+ percent of the time. He even thanked me personally for our collegial relationship in a Thanksgiving Day essay on his blog.

However…I can’t help but comment on John’s misleading story “CCD Standard Gaining Traction, CCR Fading” on THCB. He writes: “In a number of interviews with leading HIE [Health Information Exchange] vendors, it is becoming clear that the clinical standard, Continuity of Care Document (CCD) will be the dominant standard in the future. The leading competing standard, Continuity of Care Record (CCR) appears to be fading with one vendor stating that virtually no client is asking for CCR today.”Continue reading…

Health on the Net Foundation goes Web 2.0

Feb 22, 2010• 5

By Denise Silber

The subject of the quality of healthcare information on the Internet is rich and recurring. The main question we hear regularly is whether or not Internet users are finding quality health information. But it’s not the only one. There is also: how governments can/should protect citizens? And more recently, do Web 2.0 tools give users more power or make them more exposed to poor quality information?

This article focuses on Health on the Net. Established in 1995 in Geneva Switzerland, HON is the longest running, most widespread code of conduct dedicated to health and the Internet. HON will release its next Web 2.0 tool during the Health 2.0 Europe Conference, Paris April 6-7, 2010

HON plays a special role in France. In October 2007, after a lengthy review process, the French High Health Authority (Haute Autorité de Santé) accredited HON as its partner for the certification of health sites in France, in view of its simplicity, widespread presence, and accessibility for webmasters free of charge. 859 French sites are currently certified by HON, one of the largest numbers for a single country, except for the U.S.

To be certified, web sites commit to the respect of 8 principles that primarily concern transparency. HON certification status is indicated on the site by presence of the HON seal. HON uses online tools to monitor the certified sites and also performs a systematic annual review of each one. The HONcode is used by over 6,800 certified websites, covering 118 countries and has been translated into 26 languages.

In addition to the HONcode, HON has developed various search and other tools.

Healthcare: Right or Responsibility?

Feb 20, 2010• 47

By STEPHEN C. SCHIMPFF, MD

During the presidential debates, Tom Brokow asked, “Is healthcare a right, a privilege or a responsibility?”The candidates did not answer the question, but now would be a good time for Congress and the Obama Administration to balance the rights being offered as part of reform with corresponding responsibilities.

We are the only developed country that does not assure all of its citizens basic medical care insurance access – shame on us. We spend more per capita for medical care than any other developed country yet our outcomes are not the best – shame on us. We mostly use price controls to try to slow rapidly escalating costs. They not only don’t work but leave patients with less than adequate care and huge bureaucratic frustrations – not logical. All too many individuals find that they are denied coverage because of a preexisting condition when they move from one job to another or find themselves unemployed – unacceptable. As a population we have all too many adverse behaviors such obesity, lack of exercise and smoking that are leading to expensive, lifelong chronic illnesses like diabetes and heart failure – killing ourselves. And primary care physicians find that they do not have time to offer good preventive care nor care coordination to those with chronic illnesses because insurance does not pay for these essential activities, thereby resulting in more visits to specialists, more expensive prescriptions when life style changes could have been effective, more procedures and tests – all of which lead to higher total costs of care.

Wellpoint: just incompetent?

Feb 20, 2010• 84

By MATTHEW HOLT

I’m viewing the latest rumblings in the US health care debate from the confines of a clear but cold Britain, where the big news is that the country is joining the PIGS in entering economic meltdown—or at least being a lot more broke than it thought it was. (PIGS are Portugal, Greece, Ireland & Spain, not farm animals). And yet it appears that health reform is making if not a comeback then at least vigorous palpitations. The reason for this seems to be the strength that the Anthem Blue Cross/Wellpoint premium rises have imbued into the Administration.

Those of you reading THCB over the years will know that I think the individual insurance market is doomed to fail and should be replaced. It has its apologists; for example Cato’s Michael Cannon here criticizes Paul Krugman who explained last Friday why the individual market goes into a death spiral. Michael claims that Mark Pauly’s research shows that the individual market works. What Pauly’s work (and I despair at having to read it again, so this is from memory) tends to show is that insurers are incompetent at charging sick people to the full extent that they cost them, but do charge them roughly three times what they charge healthy people. Pauly also said in Health Affairs that the individual market works pretty well for 80% of the people in it, but he seems to think that screwing the remaining 20% is OK. Coming from a tenured Ivy league professor who’s probably never had to buy health insurance in his life, that was pretty rich. But apparently Wellpoint’s latest performance shows that it’s not OK for much of the other 80% either—hence their dropping out, leading to Krugman’s death spiral.Continue reading…

McAllen, TX As Outlier? Why Not Houston?

Feb 19, 2010• 27

By MERRILL GOOZNER

Or Lubbock? Or Oklahoma City? Or New Orleans? Or any of a dozen major and minor metro areas throughout the South? According to the Medicare Payments Advisory Commission, all of them have significantly higher usage rates and costs per Medicare enrollee than McAllen, which was high-cost locale ground zero for Atul Gawande’s famous New Yorker article, “The Cost Conundrum,” which has become, to use the New York Times‘ formulation, “must reading in the White House.”

Gawande grounded his analysis on per-patient Medicare claims data compiled annually by researchers at Dartmouth Medical School. “The explosive trend in medical costs seems to have occurred here in an especially intense form,” Gawande wrote after the Dartmouth Atlas of Health showed McAllen as the highest spending region in the country outside Miami, where Medicare fraud is an especially virulent problem. Not so, MedPAC said. Adjust for prices and McAllen’s outlier status compared to the rest of Texas and large parts of the South all but disappears.Continue reading…