Speranza Avram from the UC Berkeley School of Public Health Center for Health Leadership writes to say that they’re hosting a two-day conference on April 15-16 called 21st Century Tools for Health Leaders: Using New Media and Health Communication Technologies. New media tools including social media, blogs, digital storytelling, video, virtual communities, Twitter, mobile phones and more, are being effectively used to facilitate the management of health organizations, support health education and disease management, inform health research and promote health advocacy. We invite health leaders, practitioners, educators and students to join us. Early bird registration ends March 12! Click here for more information about the conference and to register on-line. Or watch the video.
Rating or Narrating, that is the question.
By
This April 6–7, the Health 2.0 Europe conference will feature the many ways in which Web 2.0 tools are providing innovative solutions to, amongst others, our fundamental need for self-expression, known more recently as “user-generated content”.
Several panels will refer to these issues, but we will focus in this post on the Hospital and Payers’ panel. Payers want to ensure that their patients are being oriented to good care. Hospitals want to know that they are being considered “justly”. The Health 2.0 panel will include demonstrations by Guide Santé (France) and Patient Opinion (UK), both web 2.0 sites created by physicians concerned by patient satisfaction with hospitals and clinics. Payers like the UK NHS and Big-Direkt from Germany will participate in the conversation and Big-Direkt will also demo their new online tools.
Rating sites in health are high profile in France, especially amongst those who are rated and some early entrants have bit the dust for methodological reasons. Rating sites, however are not all identical and they are certainly not alone in capturing the patient experience. They live alongside online story telling or narrative tools, deployed in a variety of ways on sites that will be featured in Paris from a dozen countries.
How did all of this come about?
A quick review of the world of hospital ratings will remind us that consumers and professionals have long been seeking comparative guides to the quality of hospitals. Twenty years ago, US News and World Report launched its “best hospitals” special issue, and so the concept of comparative hospital ratings for consumers was born. Such “best of” lists quickly became popular, despite the lack of consensus on the choice of quality indicators. In France, so many of the major national dailies and weeklies provide “best of” lists that new ones come out throughout the year and create a certain level of confusion since the institutions listed are never quite the same.
In the US, the HealthGrades Annual Hospital Quality and Clinical Excellence study examines patient outcomes at all 5,000 nonfederal hospitals in the United States, based on 40 million hospitalization records obtained from the Centers for Medicare and Medicaid Services. In the most recent HealthGrades study released on Jan 26 2010, “hospitals rated in the top 5% in the nation by HealthGrades have a 29% lower risk-adjusted mortality rate and are improving their clinical quality at a faster pace than other hospitals.”
With the arrival of Web 2.0 technologies, the first generation of hospital comparison tools took the form of rating sites; consumers would express their opinions essentially through response to multiple choice questions regarding their degree of satisfaction. At the same time other tools made it possible to pursue the narrative approach via the posting of the “patient story.”
According to Wikipedia, Narrative Medicine is actually “a practice of medicine, with narrative competence and marked with an understanding of the highly complex narrative situations among doctors, patients, colleagues, and the public.” Narrative Medicine aims not only the validate the experience of the patient, but also to encourage creativity and self-reflection in the physician. Patient narrative of course, does not necessarily imply the contribution of anyone other than the patient!
Dr Paul Hodgkin, the founder of Patient Opinion is an NHS physician who still practices part-time. He wanted to give patients a place to express their personal stories and to enable the story to reach the managers of the establishment concerned by the story. According to Dr Hodgkin,
“We now understand that the experience of being a patient, far from being peripheral to health care, is actually central to understanding the effectiveness and efficiency of services, and how they can be improved. Because the author is unconstrained by pre-set questions, they may tell their story in ways that suit them, and address whatever they see as important. Sometimes a single story will motivate staff and managers to take immediate action to put something right. And it is often the case that the patient themselves, through their experience, sees clearly how a problem could be avoided or put right. We can now make a contribution – small or large – towards co-creating, with professionals and other patients, better care, better services, and perhaps even better professionals and better policy. And as we do this, we will see the health care system itself slowly shift to becoming more transparent, more responsive.”
As the narrative approach develops in popularity, does this mean that the end is in sight for rating sites? Not really. There are several well-known rating sites in the US and many sites including a rating feature. In France, while firmly in the “rating category” although still including commentary, Guide Santé is the only such site to have experienced significant development to date. Drs Del Bano and Bach of Marseilles, the founders, are former directors of a clinic and public health specialists. Their past experience has helped them from falling into the many pitfalls of rating methodology and policy.
Drs Del Bano and Bach’s goal was to launch a successful hospital comparison web site, based on a mix of user-generated content and government data. They cite three problems that explain the attraction of le Guide Santé.
“The French national health system evaluation data on hospitals is not accessible to consumers. It does not allow the comparison of establishments on a same criterion. Up until the launch of Le Guide Santé, there was no French survey site where patients could anonymously report on hospital quality. We offer both the right to rate the establishment and to comment on it.”
Le Guide Santé is launching its V2 in the near future and has become the exclusive supplier of benchmarking information for one of France’s key digital and paper properties, “Le Figaro”.
Oh yes, and when asked the question, both sites Patient Opinion and Guide Santé report having published nearly all stories and comments that have been submitted.
We hope you’ll join us for the conversation at Health 2.0 Europe.
Denise Silber of, Basil Strategies is Health 2.0’s European partner. Basil Strategies is based in Paris, where the Health 2.0 Europe Conference will be held on April 6–7.
EHR & The Art, Science and Business of Medicine
“The practice of medicine is an art, not a trade; a calling, not a business…”
– William Osler
Dr. Osler was a great physician and a great man. However, in America today medicine may be a calling and may be partly art, but it is also increasingly part science and, for many physicians in private practice, it must also be part business.
This article will attempt to examine the role of Healthcare Information Technology (HIT), and Electronic Medical Records (EMR or EHR) in particular, in the art, science and business of medicine as practiced today, whether by choice or due to political and economic circumstances in 21st century America.Continue reading…
Massachusetts’ Problem and Maryland’s Solution
While health care reformers argue about what it would take to “break the curve” of health care inflation, the state of Maryland has done it, at least when it comes to hospital spending.
In 1977, Maryland decided that, rather than leaving prices to the vagaries of a marketplace where insurers and hospitals negotiate behind closed doors, it would delegate the task of setting reimbursement rates for acute-care hospitals to an independent agency, the Maryland Health Services Cost Review Commission.
When setting rates, the Commission takes into account differences in labor markets and how much a hospital pays in wages; the amount of charity care the hospital does; and whether it treats a large number of severely ill patients. For example, the Commission sets the price of an overnight stay at St. Joseph Medical Center in suburban Towson at $984, while letting Johns Hopkins, in Baltimore Maryland, charge $1,555. For a basic chest X-ray, St. Joseph’s asks $81 and Hopkins’ is allowd to charge $155. The differences reflect Hopkins’s higher costs as a teaching hospital and the fact that it cares for generally sicker patients.Continue reading…
President Obama on Bipartisanship
By MERRILL GOOZNER
As in, he spent a large part of his briefing in the White House press room talking about the fate of the health care reform bill. Here’s what he had to say about the summit with Republican and Democratic leaders, that’s still two weeks away:
Bipartisanship depends on a willingness among both Democrats and Republicans to put aside matters of party for the good of the country. I won’t hesitate to embrace a good idea from my friends in the minority party, but I also won’t hesitate to condemn what I consider to be obstinacy that’s rooted not in substantive disagreements but in political expedience.
To read the rest of President Obama’s thought on the current state of the health care reform debate, see the transcript, here.
Why Is the Boston Globe Picking On Charlie Baker Again?
When Charlie Baker began his run for Governor of Massachusetts, the Boston Globe critiqued his record and found it wanting (State aided Baker’s business triumph), a piece that struck me as weakly argued and unfair (Why is the Globe picking on Charlie Baker?). To the Globe’s credit, they published an excerpt of my post in their VoxOp column.
Saturday’s Globe carried a piece that was similar in tone (Baker finds campaign trove in health field) arguing that Baker is sucking big bucks out of the health care sector to fund his election campaign and implying that there is something wrong about it. After describing how some Democrats are giving to Baker (a Republican), the article says:
It’s one of many examples of how Baker, in his torrid fund-raising drive, has mined with extraordinary efficiency the health care industry he left last July to become a candidate.
A Boston Globe analysis of contributor reports shows that in seven months Baker’s campaign raised more than $122,000 in contributions tied directly to Harvard Pilgrim. This includes not only $43,000 in contributions from Harvard Pilgrim’s employees, directors, and affiliated companies, but also a broad array of vendors: its accountants, auditing firm, advertising agency, information technology providers, and consultants.
In total, Baker has raised at least $263,000 from employees of health-care providers, other insurers, and related businesses in the health-care sector. That’s about 10 percent of the $2.57 million he has raised overall.
A bit of perspective is warranted here. First, $263,000 is not a lot of money in the context of the governor’s campaign. Second, if anything Baker should be getting a lot more than 10 percent of funding from the health care industry. Health care is 16 percent of GDP and one of the leading industries in Massachusetts. Considering Baker is so closely tied to health care I would have guessed the percentage would be more
like 20 or 25 percent.
The Globe could just have easily gone the other way, using the same analysis to ask why the health care industry is not backing Baker.
DNADirect bought by Medco: Consumer genomic counselling goes mainstream?
Ryan Phelan started DNADirect to expand the power of genetic testing to everyone, using the Web. She’s been ploughing a tough furrow but been making some real progress in the last few years, including getting an investment from Lemhi Ventures and working with Humana to provide genetic testing to its members (and the utilization management going along with it), to go along with their initial DTC approach.
Late last week DNADirect was purchased by Medco. I spoke with Ryan and Robert Epstein, Chief Medical Officer of Medco to get just a taste of what this will mean for the future of DNA testing within Medco.
Here's the interview.
Gawande’s “Checklist Manifesto”
By BOB WACHTER, MD
Every now and then, I read and enjoy a book, but only later fully appreciate it as its lessons and insights slowly become apparent. Judging by the number of times I’ve said, “That reminds me of Gawande’s observations about ___” over the past month, The Checklist Manifesto is one such book.
In this short, deceptively simple volume, Atul (who I count as both friend and inspiration) discusses the history of “the lowly checklist,” the impact of checklists on various industries, how he came to understand the value of checklists to medical care, and what makes a useful checklist. Most of this content could have been written by a thoughtful healthcare journalist. But Atul put his interest in checklists to practical use, spearheading a WHO initiative to test a checklist-based “safe surgery” program in 8 diverse hospitals around the world, an effort that saved hundreds of lives. His description of this program forms the core of the book.
Which is as it should be, since these autobiographical elements highlight what is unique about Atul, and his book. Yes, he is a gifted journalist (of course, aided by a surgeon’s insider knowledge and access – as demonstrated by last year’s game changing article about healthcare in McAllen, Texas). But he is also a healthcare leader, whose clear aim is not only to explain attitudes and policy, but to change them. It would be as if Malcolm Gladwell had tried to create a Tipping Point himself, and written up the experience. The whole thing gets very “meta” very quickly, and in the hands of a lesser person, might even threaten to become a bit dicey. (Is he a medical George Plimpton – trying out checklists in the OR to provide fodder for his writing?) But there’s no such worry here: Atul’s passion for patients and humility are so obvious that one never questions his methods or motives.
EHR Redux
It’s time to revive the discussion of electronic health record software in light of the new federal regulations that define criteria for meaningful use and also set criteria for the EHR technologies that must be implemented by doctors and hospitals in order for them to become, and be paid for being, “meaningful users of certified EHR technology.”
While most of the public commentary so far has been directed to the NPRM on meaningful use, the real news here relates to the de-construction of EHRs that is described in the interim final rule covering EHR standards and implementation specifications. Of course, the NPRM and IFR are by design tightly linked. But the NPRM on meaningful use is primarily a set of instructions for doctors and hospitals about how to participate in the incentive payment programs established statutorily under ARRA/HITECH. The rule on EHR technology certification criteria, on the other hand, is a playbook intended for vendors and developers who want to qualify their products to meet the expected demand by meaningful users in those programs.Continue reading…
How to Get Enough Votes in the Senate
When Hillary Clinton was running for President, she set forth a more modest agenda for health care reform than her competitor, Barack Obama. Maybe she understood better, based on her experience, how difficult it is to get a comprehensive bill through Congress in this field.
What is possible now that the President has lost the 60-vote majority in the Senate? I think the thing to remember is that he was having trouble even holding together the 60 votes he used to have. He had to agree to an assortment of give-aways — to Nebraska, to Louisiana, to the labor unions — to get the votes he needed. In part, that proved to be the undoing, as Massachusetts voters watched this sausage being made and sent a message through the election of Scott Brown that they didn’t like what they had been seeing.
Now, it may be that the Republicans will act to kill anything that might come along. I don’t think so. I think they are willing to be part of a bill, but it has to be a bill for which they can claim credit among their constituencies. What might it be?
Insurance reform: People, irrespective of party and political leanings, despise the practices of insurance companies that limit or take away coverage. The use of pre-existing conditions to deny coverage, lifetime limits of coverage, and rescission of policies are nasty and unfair. These practices remain as sources of insecurity among Americans, even those with insurance. There should be near-universal support to change them.
Tort reform: I think that most people feel that, while people should have a right to sue for medical malpractice, the process that exists today is inefficient and arbitrary for both plaintiffs and defendants. Any doctor will tell you that fear of such suits also leads to the practice of defensive medicine, driving up costs for all of society. Tort reform does not require limitations on payments. It could be accomplished with the establishment of specialized courts and procedures that would add greater certainty to outcomes and reduce the tensions and abuses associated with the system. This should not be a partisan issue.
Payment reform: Nobody likes the results of a system that systematically underpays primary care doctors and leads them to a life of 18-minute appointments and a role as triage doctors, a way station to referrals to higher paid specialists. If Congress were to order Medicare and state Medicaid plans to take the lead in establishing reimbursement rates for PCPs that reflected their value to families and patients, we would be on the way to a more rational system of care. Likewise, if physicians were paid for care delivered by telephone and electronically, millions of unnecessary and time-consuming office visits could be eliminated. If these steps were taken for Medicare and Medicaid, private insurers would follow.
Transparency: A national mandate for public disclosure of the rates paid by insurers to providers would help drive greater rationality in payment methodologies in the states. Disclosure of clinical outcomes in clinically important arenas would provide impetus to improvement in patient safety and quality. How can this be a partisan issue?
Now what about access? I fear that expansion of insurance coverage is the third rail in this debate. Why? Because it requires revenue to support the subsidies that would be required, and tax increases are really hard to achieve. The President made this issue more radioactive than necessary by proclaiming at the start that you could get access, choice, and lower costs all in one neatly wrapped package. Everybody in the field knew that you could not. This then resulted in sleight-of-hand revenue measures that became the undoing of the bill as Christmas tree ornaments were added to undo the effect on particular states or interest groups.
As I have stated here, a fair approach to generate the revenues for expanded access is to eliminate or reduce the pre-tax treatment of insurance premiums. Doing so would use the progressive income tax system in a way that would apply a larger percentage of these costs to more wealthy people. Could this approach gain a bi-partisan consensus? It could not gain support even among the Democratic majority, so I am guessing not. And the Republicans seem to express no interest at all in mandates for greater access. Maybe we have to accept as a reality the idea that expanded access is a casualty in this debate. I hope not, but I don’t yet see an answer to this that can get 50 votes, much less 60.
