Category: Uncategorized

Catalyzing the app store for EHRs

Jun 4, 2009• 13

By STEVE DOWNS and JOHN LUMPKIN, SVP, Health Care Group, RWJ Foundation

Dr. Lumpkin serves as director of the Robert Wood Johnson Foundation’s Health Group, where he is responsible for planning and program management. Prior to joining RWJ, Dr. Lumpkin led the Illinois Department of Public Health for 12 years. As assistant vice president, Downs plays a leading role on the Foundation’s Pioneer Portfolio team. During his tenure at the Foundation he has created, developed, or overseen the Foundation’s investments in such key initiatives as Project HealthDesign, InformationLinks, the Health e-Technologies Initiative, the Public Health Informatics Institute, Connecting for Health, and Common Ground. His writings may be found at Pioneering Ideas, where this post first appeared.

Recently, Steve posted about the idea, floated by Ken Mandl and Zak Kohane, that EHRs (or health IT more broadly) could move to a model of competitive, substitutable applications running off a platform that would provide secure medical record storage. In other words, the iPhone app model, but, for example, you could have an e-prescribing app that runs over an EHR instead of the Yelp restaurant review app on your iPhone. We’re thinking about the provider side of the market here, as Google Health and Microsoft HealthVault are already doing this on the consumer side.Continue reading…

PHRs, The Model T, Meaningful Use and the Patient-Centric HIT Revolution

Jun 3, 2009• 7

By BOB COFFIELD

There is a growing discussion on the health consumer-centric (patient-centric) meaning of “meaningful use” of EHRs and health information technology. Jane Sarasohn-Kahn summarizes this discussion in her recent post, “Meaningful USe – or, whose health is it, anyway?” at Health Populi where she reflects on Ted Eytan’s post, “Is it Meaningful If Patients Can’t Use It?”

Since Ted’s post other health care thought leaders have offered their comments. A list of these individuals can be found in Jane’s post. As Jane mentions, this topic was central to much of the discussion that occurred during the first two days of the testimony before the National Committee on Vital and Health Statistics (NCVHS) on the Future of Personal Health Records held on May 20 and 21. The discussion will continue at the NCVHS hearing on June 9 when there will be a panel focused on “Consumer Advocates and Attitudes” that will include Susannah Fox, Dave deBronkart, Deven McGraw, JD and Robert Gellman, JD.

Jane mentions in her post our testimony before the Subcommittee on Privacy, Confidentiality and Security of the National Committee on Vital and Health Statistics (NCVHS) on the future of PHRs. Our panel, including me, Jane and Daniel Weitzner, the W3C Technology and Society Policy Director, opened the hearings on PHRs. Our role as the opening panel was to try to set the stage for the context of the discussion on the future of PHRs and consumer facing health care information technology.

As the opening speaker at the hearing I decided to stay away from immediately diving into the legal issues and instead give the committee a landscape view of where I think we are in the history of health information. My goal was to provide a historic framework for PHR development by drawing some historic parallels to the history of the development of our transportation system. By analogy I compared today’s PHRs to the Model T era of the automobile area and taking a page from Dave deBronkart told the committee my personal family e-health information story. Below is a complete copy of my written testimony submitted to the committee.

As the discussion continues on “meaningful use” the role that PHRs play is important. Focusing on health care consumers and their practical use of PHR tools is vital to the future of our health care system. As I said in my testimony there will be game changers but we need to see the potential of today’s Model T PHRs and build toward the Prius Hybrid PHRs of the future.
Prepared Statement for Subcommittee on Privacy, Confidentiality, and Security National Committee on Vital and Health Statistics (NCVHS)

Discussion on the Future of Personal Health Records

Good morning. I want to thank the Co-Chairs, Subcommittee and Committee Staff for the opportunity to participate in today’s discussion on the current state of the personal health record (PHR) and the future use of this and other health care technology tools by the health care industry and the health care consumer.

My name is Bob Coffield. I am a health care attorney from Charleston, West Virginia, with the law firm of Flaherty, Sensabaugh & Bonasso, PLLC. I have a broad-based health care practice, providing legal and business services to a variety of health care clients. A large portion of my practice focuses around health information issues, regulatory compliance, privacy, security, and health technology. Over the past five years, I have become involved in the social media movement, and that involvement has changed the way I live, work, collaborate and communicate. My involvement and interest in the social media movement and its impact on our lives has led me to focus a portion of my practice on legal concepts and issues generated by the use of social media tools and technologies in health care, law and other industries.

Introduction: Today’s PHR is the Model T

As the opening speaker, I want to set the stage for today’s discussion on the questions raised by the committee. As the committee examines the issues, I recommend that you look toward a longer horizon of 20 to 50 years. In this age of information and accelerating technology, it is often easier to predict what may happen in 50 years than what will happen next year. As information technology advances and new technologies are developed, it has become more difficult to conduct short-term strategic planning in the three to five-year range. Over the past 10 years of the maturing information era, we have seen incredible advances and significant disruption in all business, including health care.

At its center, the information age is characterized by the ability to create and transfer information and knowledge freely and to have instant access to knowledge that would have been impossible, difficult or too expensive to find in the past. Jane Sarasohn-Kahn and others today will provide the Committee with an understanding of the current health care consumer marketplace and the major motivators driving health care consumer empowerment in the information age, and also will provide a perspective on the current state of consumer engagement in health care. It is my belief that this changing era is having a profound impact on today’s health care industry. The strategies, systems, approaches and governing rules used today and by past generations may not be successful in today’s and tomorrow’s changing information era.

A part of today’s process should be to consider what the long-term goals are for health information technology, including the PHR, and how it can be used to drive consumer-focused and controlled health care in the information age. Along with this discussion, we have a responsibility to talk about why involvement of the consumer matters and what impact it will have on improving care, reducing costs and creating efficiencies in the health care system.

As we discuss health information technology and PHRs today, we have a responsibility to stay focused on this question: “What will improve the quality of care for you and me, as consumers of health care?” This single question needs to remain at the center of today’s discussion and the continuing debate on consumer health information technology. As the health care industry becomes more and more specialized, complex and technologically advanced, we often lose sight of the purpose of the health care system. That purpose is human care and compassion. You and I, as health care consumers, must remain at the center. My hope is that the future of our health care system will use technology, including PHRs, to improve the human experience and interaction between the professional caregiver and health care consumer.

The questions I often struggle with and hope to hear discussion on today are: How will PHRs drive consumer empowerment, and how will this consumer empowerment lead to improving care? We can all sit around and discuss the best ways to build PHRs, but the questions remain whether or not the health care consumer will be attracted to use PHRs and whether providers will be willing to incorporate PHRs into the treatment and care process.

As I said at the opening of my remarks, I want to set the stage for the discussion and testimony today by sharing a story and painting a historical perspective. As I looked over the agenda of those speaking today, I was struck by the level of experience and diverse backgrounds that each of us brings to the discussion. However, because of the level of specialization represented in this gathering, there is the risk of remaining deep in the weeds, dealing with details, and failing to step back and take a wider view of the landscape. The story and analogy I want to share with you is my attempt to take you on a tour of that broader view.

I am a believer in the adage that history repeats itself. What we are trying to do today is to provide you with a perspective and prediction of the role that the PHR will (should) play in the health information technology infrastructure over the next 10 years. So a historical sketch of where we have been and where we are is valuable to the discussion of where we may go.

I want to start the story with a quote from the 1800s, by inventor Oliver Evans, as he spoke about the future of the transportation system in the United States.

“The time will come when people will travel in stages moved by steam engines from one city to another, almost as fast as birds can fly, 15 or 20 miles an hour . . .

A carriage will start from Washington in the morning, the passengers will breakfast at Baltimore, dine at Philadelphia and supper in New York the same day . . . .

The 1800’s saw the dawn of the railroad system in the United States, as a result of the development of the steam engine. These developments led to the widespread use of trains as a mode of transportation for a growing population that, until that time, had been relatively immobile. The growth of the railroad system started at the local level, grew to regional connections and ultimately led to a national network of railroad tracks from east to west and from north to south. Prior to this time, personal travel required one to travel on foot, by horse or by carriage.

My ancestors, who grew up in the hills of northern West Virginia, came to West Virginia (then Virginia) in the late 1700’s. As we say in West Virginia, “they lived out on the ridge.” A number of generations went by, and there was little mobility of my family. They lived out their lives on those same ridges for well over 150 years. They raised their families and farmed. They lived a relatively isolated and stationary life. Traveling beyond a few miles was difficult, impractical and largely unnecessary, at least from their perspective of the world.

However, by 1900, the landscape had changed, and the Industrial Revolution was having a profound impact on the world. My great-grandfather and grandmother had two sons who were teens in the 1890s. In the 1890s, my great-uncle went to college, came back and taught school for a few years and then went on to law school. Likewise, my grandfather went to college, came home like his brother to teach school for a few years, and then continued on to medical school in Cincinnati, Ohio – at that time a long distance from the northern part of West Virginia. He came back and practiced medicine in Wetzel County, West Virginia, from 1911 until his death in 1936. He saw home patients initially by horseback, and then in 1915, he traveled to Pittsburgh, Pennsylvania by train to pick up a brand new Ford Model T, which replaced his horse in his rural medical practice.

As the rail system in the United States matured, it grew into a more complex mass transportation system. Individuals who, prior to that time, had used their own modes of transportation, whether on foot, by horse or carriage, started to rely upon the system for transportation. They became passengers who didn’t own the train or the rails. As the railroad system developed, we saw issues related to standards, such as the gauge of tracks. Local, state and federal government become involved in furthering the growth and expansion of the railroad system by providing financial support, political influence and regulatory assistance to the growing railroad industry.

At that stage in history, no one in the powerful railroad industry would have predicted the disruptive influence by a young, different type of engineer – Henry Ford. With the advent of the automobile and the mass production of the Model T in 1908, our transportation system in the United States was forever changed. Over the next 20 years, the adoption of automobile travel was unprecedented. This revolution led to a demand for better roadways and improvement of the largely privately built turnpike roads. The Federal Highway Act of 1921 authorized the Bureau of Public Roads to provide public funding to help state highway agencies construct paved systems of highways, and this led to the Federal-Aid Highway Act of 1956, which authorized the creation of the Interstate Highway System.

By analogy, we can compare the development of the transportation system to the development of today’s health information system and draw many comparisons and parallels. The health information system, up through the 1950’s and 1960’s, was paper-based, centrally located and uncomplicated. The medical record system for my grandfather’s practice – to the extent that it was used – was simple. Likewise, the medical record system and documentation used by my father and uncle during their medical careers, roughly 1940-2000, was relatively non-complex. During this time, there was little specialization: Physicians were generalists in everything. In large part, physicians from this era cared for their patients from birth to death and, in the case of my grandfather, father, and uncle, cared for multiple generations of families. Providers during that time had a relatively comprehensive picture of the medical history of each individual, as well as that individual’s immediate and collateral family members. Prior to specialization in health care, we had a health system focused on the individual patient, and health information was centered on that individual and the individual’s family.

By the 1970’s, we saw the development of the first electronic health record – the problem-oriented medical record (POMR), predecessor of today’s current Electronic Health Records (EHR) and Electronic Medical Records (EMR). At this same time, we saw the expansion of medical litigation, which has played a significant role in the health information system over the past 30 years.

Prior to 2000, little had been written or heard about PHRs. Back in 2001, in a report called Strategy for Building a National Health Information Infrastructure, the National Committee on Vital and Health Statistics mentions PHRs and the growing consumer use of Internet-based health information services. This was important because it was the first time that a national health body acknowledged or officially recognized PHRs. In 2005, the American Health Information Management Association (AHIMA) formed a work group to examine the role of PHRs in relation to EHRs, and the pace and interest in PHRs has continued to increase since that time.

Over the last year, interest and activity in the development and use of PHRs has accelerated. This new-found interest has now culminated in the first law directly regulating PHRs and PHR vendors, under the Health Information Technology for Economic and Clinical Health Act (HITECH), which is a part of the American Recovery and Reinvestment Act of 2009, signed into law on February 17, 2009.

How is the history of our transportation system analogous to our health information system? On a basic level, both provide transportation – one transported humans, and the other, human information. Both started as uncomplicated systems that were not interconnected. I imagine you are already formulating other parallel points between these two systems.

To begin today’s discussion on PHRs, we need to examine where PHRs fit in this historical perspective and timeline. What is the equivalent of the PHR in the history of our transportation system? Today’s PHR is the equivalent of the Ford Model T. The PHR will be the vehicle to individually transport health information in the future, introduce the involvement of consumers in their own health information and wellness and inspire a time of innovation and creativeness over the next five to 10 years. If the age of the PHR takes off, it will bring about a wholesale change in the way that health information technology is structured and will radically disrupt traditional health care industry models.

There are various other analogies to be drawn between the two historical perspectives. For example, do the trains and the rail system represent the traditional health care providers and payors in the industry who are maintaining data in silos and segregated systems? Can we draw comparisons between the powerful railroad industry versus the nascent auto industry and the current health care and insurance industry and the emerging Health 2.0 technology movement? Are the disagreements that occurred in the railroad industry over the gauge of railroad tracks analogous to the debate occurring over the need and process to develop standards for health information technology? Can we draw parallels between our country’s development of a national network of railroads through local, state, and federal initiatives to those ongoing efforts by state health information exchanges (HIEs), regional health information organizations (RHIOs) and the national health informational network (NHIN)? Will there be similarities between the freedom that consumers felt the first time they bought an automobile and drove it down the road and the feeling of empowerment experienced when a health care consumer adopts and uses a PHR? In the coming years, will the connecting of EHR and EMR systems and the development of the NHIN be relegated to being used to transfer bulk health data, not unlike the role that the railroad system plays today?

As we look toward the future of PHRs, we have to understand that we are now looking at the Model T stage of PHRs: Call it PHR 1.0. The PHRs of the past 10 years and, in large part, the PHRs of today, are still relatively rudimentary and impractical, not unlike the first automobiles. I suspect my grandfather’s experience of traveling to Pittsburgh by train, having never owned a car before, to pick up his new Ford Model T and drive it back into the hills of West Virginia, was not unlike Dave deBronkart’s experience when he set up his Google Health account and imported his own health information from his providers. Prior to their experiences, neither knew how to drive the vehicle, but they learned in the parking lot. Once they both bought into the product, they didn’t have any good roads to drive on, and when the vehicle broke down they had to fix it themselves. However, through their efforts the world began to change, and their lives were and will be forever changed.

Over the next five to 10 years, and probably longer, we may see PHRs become the multi-colored, sleek-designed, more powerful automobiles, analogous to the golden era of the automobile industry from 1940 to 1950. Continuously over that time period, new personal options will be developed as add-ons to the PHR. As PHR adoption grows, we will have to develop larger, longer and more robust highway systems to allow for the transfer of health data by and between PHRs. Likewise, new standards will come into existence, not unlike those adopted by industry or those created by government. Safety features also will be developed continuously to protect and secure the health information maintained, stored and transferred through PHRs. Think of these as the modern-day innovation, adoption and enforcement of traffic signals, the use of seat belts and requirement for guard rails.

As we look toward the future, we also have to be aware that there will be game changers that we can’t envision at this time. Although PHRs might now be the industry solution to change the way we aggregate and store health information, new technology may be invented that disrupts this strategy and approach. For example, consider the impact that air travel had on the automobile industry. We must remain open to change in this new information era – change will be the norm and not the exception.

Using PHRs to Transform the Health Care Industry

The efforts by large technology companies and other Health 2.0 technology companies could transform the health care industry by triggering advancements in health information technology and laying the groundwork for overall health care delivery and payment reform. Although it is too early to say whether the PHR, in fact, will be the catalyst for health care reform, the Committee, government and the larger health care industry and community need to understand and explore PHRs and their role and consider how the consumer-focused PHR revolution will impact the health industry.

A convergence of factors could cause a comprehensive shift in the way health information is stored and used. Innovations in health information management technology are altering the way that patients, health care providers and payers maintain, use, control, and disclose health information. Through such technology, the current, decentralized system of records maintained by multiple providers and entities at multiple locations – often with conflicting and duplicative information – is being transformed into a centralized record maintenance system that may rely on personal health information networks (PHIN), where the PHR serves as the central repository for health information shared through a system of developing regional or national health information exchanges. Vince Kuraitis of the e-CareManagement Blog calls this change a “transformation from Industrial Age medicine to Information Age health care.”[1]

This transformation in the way information is maintained, stored, and exchanged empowers the health care consumer by offering a new level of control and responsibility over his or her care. It will directly impact the patient-provider relationship.

The traditional model for maintaining medical records, in which the provider of care stores, maintains, and updates the record, is based upon the need to provide continuity of care. The medical record reflects the plan of care, documents the care provided, and records communications among providers. Also, the medical record assists in protecting the legal rights and interests of both consumers and providers.

In the 21st century, our health care system simultaneously has become more fragmented and specialized, on one hand, and more coordinated and wellness-focused, on the other. Health care consumers have become mobile and now seek the services from a variety of providers engaging in numerous specialties. These same consumers change providers on a regular basis and take advantage of new models of care, like urgent care services, to complement traditional primary care services. The increasingly mobile population has caused breakdowns in continuity of care. As individuals move from city to city and state to state, they leave behind a trail of partial medical records – some on paper, some electronic – with various providers, insurers, and others.

The increasing popularity of EMRs, EHRs, RHIOs, and HIEs signals a need to address the increasing complexity of maintaining and sharing these different types and silos of health information. The PHR may be the disruptive technology that provides a simple alternative to ongoing efforts to create an interconnected network of interoperable health information systems with detailed querying functions, capable of making accessible in one place the health information and continuity of care record for individual consumers. In contrast, PHRs would travel with health care consumers and provide a central location for information regarding the consumers’ individualized needs.

Ownership of Health Information

The shift to a consumer-controlled PHR from a provider-based and controlled medical record raises traditional property law issues. As health information becomes increasingly networked and technology permits health information to be transferred more easily, the lines demarcating ownership of health information become further blurred.

Health information is often viewed under the traditional notion of property as a “bundle of rights,” including the right to use, dispose, and exclude others from using. This legal application of historic property law may not be well-suited to the information age, in which patient information is shared through a variety of formats, copied, duplicated, merged, and combined with other patient records into large scale databases of highly valuable information.

Who owns health information? The physician? The insurer? The health care consumer? Under the traditional theory, providers own the medical records they maintain, subject to the consumer’s rights of access in the information contained in the record.[2] This tradition stems from the era of paper records, where physical control meant control and ownership. Provider ownership of the record is not absolute, however; HIPAA and most state laws provide consumers with some right to access and receive a copy of the record. Health care consumers have received other rights out of the bundle of property rights, including the right to request corrections to their medical information and the assurance that such records are maintained confidentially.

The PHR model, where all records are centrally located and maintained by the consumer, flips and realigns the current provider-based ownership model of managing health information. Instead of provider-based control, where the provider furnishes access to and/or copies of the record and is required to seek patient authorization to release medical information, the PHR model puts the health care consumer in control of his or her medical and health information.

[1] Vince Kuraitis, E-CareManagement Blog, Birth Announcement: the Personal Health Information Network, March 8, 2008, http://e-caremanagement.com/birth-announcement-the-personal-health-information-network-phin/.

[2] Alcantara, Oscar L. and Waller, Adelle, Ownership of Health Information in the Information Age, originally published in Journal of the AHIMA, March 30, 1998; http://www.goldbergkohn.com/news-publications-57.html.

Bob Coffield is a health care lawyer who writes the Health Care Law Blog, where this post first appeared.

Should We Open the VA to All Comers?

Jun 3, 2009• 34

By MERRILL GOOZNER

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect and The Washington Post. Until March of 2009, Merrill directed the Integrity in Science project at the Center for Science in the Public Interest. His first book, “The $800 Million Dollar Pill – The Truth Behind the Cost of New Drugs ” (University of California Press, 2004) won acclaim from critics for its treatment of the issues facing the health care system and the pharmaceutical industry in particular. You can read more pieces by Merrill at Gooznews.com,where this post first appeared.

Public plan proponents point to Medicare and its low administrative costs as their primary argument for why a similarly-structured public insurance product, offered through a Massachusetts-style insurance exchange (the connector), would dramatically lower health care costs. Not so, says blogger and health plan consultant Joe Paduda, who offered a persuasive rebuttal on the Campaign for America’s Future website last week. Joe made the following points:

1) Medicare has no underwriting or sales expenses or marketing costs. No commissions, either. This saves a lot of admin dollars. This differential would disappear in a health connector-type system, with the playing field leveled by dramatically reducing commercial healthplans’ marketing costs and elimination of their underwriting expense.

2) Medicare has one-time enrollment and dis-enrollment, and greatly simplified eligibility processes. This cuts their costs, but would not continue under a connector model.

His solution? Make the public plan an extension of the Veterans Administration, which he points out has lower costs, higher quality, higher patient satisfaction and lower utilization rates than virtually every other public or private insurance plan.

Good points. But what Paduda failed to note was that the VA also is a single-payer-type system that delivers health care directly, just like the British National Health Service. All its physicians are salaried; it owns its hospitals and clinics. The problem with using the VA as a model for the public plan is that those who would accuse its proponents of advocating for “government-run health care” would be right. How many of those proponents would be willing to stand up and say at that point: “Yes, that’s what we’re for.” Even Physicians for a National Health Plan over its more than three decades of advocacy for a single national health payer (“Medicare for all”) has never called for nationalizing the provision of care.

The Infrastructure Chronicles

Jun 3, 2009• 8

By PAUL LEVY

Paul Levy is the President and CEO of Beth Israel Deconess Medical
Center in Boston. He blogs about his
experiences at, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.

A recent Boston Globe story
by Stephanie Ebbert about squabbling between two state agencies
involved in the rehabilitation of a local bridge has prompted me to
start a new occasional series on this blog. People who don't know about
my lives before health care may not know that I am an infrastructure
junkie. For reasons my daughters consider very odd, I love roads,
bridges, sewage treatment plants, electricity cables, and the like. If
you are not interested in this topic, stop reading, but from time to
time, I'm going to relate stories to you about this field, but mainly
positive ones, where creative public officials and others have made the
fabric of urban life better for the public — in ways that never, ever
make the newspapers.

Here's the first. Back in 1999 or so, I was
Administrative Dean at Harvard Medical School. Connie Cepko, one of our
faculty members, called one day. Her complaint: Riding to work on her
bicycle every day, she noticed that the Longwood Avenue bridge over the
Muddy River and the MBTA tracks was full of dangerous potholes. What
could I do about this, she wondered.

Is Hospital Peer Review a Sham? Well, Mostly Yes

Jun 3, 2009• 16

By BOB WACHTER, MD

Dr. Sidney Wolfe, healthcare’s answer to Ralph Nader, spends most of his days unhappy with somebody. Pragmatic, see-both-sides types like me naturally recoil from Wolfe’s reflexive indictment of institutions ranging from the FDA to Medicare.

But Wolfe’s blistering condemnation of medical staff peer review contained in the new report, Hospitals Drop the Ball on Physician Oversight (co-written by Alan Levine, both of Public Citizen’s Health Research Group) is timely and, I believe, largely correct.

The report focuses on the National Practitioner Data Bank (NPDB), established in 1986 to collect data about problem physicians, mostly to help credentials committees make informed decisions about medical staff privileging. The legislation that established the NPDB requires hospitals to submit a report whenever a physician is suspended from a medical staff for over 30 days for unprofessional behavior or incompetence. Although the public cannot access NPDB reports on individual physicians, healthcare organizations (mostly hospitals) ping the database about 4 million times per year. When it was inaugurated, the best estimates (including those of the AMA) were that the NPDB would receive 5,000-10,000 physician reports each year.

Not so much. Since its launch two decades ago, NPDB reports have averaged 650/year, and nearly half of US hospitals (2845 of 5823) have never reported a single physician! The most extreme case is that of South Dakota, where three-quarters of the hospitals have never reported a single case to the NPDB. I’m sure South Dakota has some wonderful doctors, but the idea that the state’s 56 hospitals have never had a physician who needed to be suspended for incompetence, substance abuse, sexual harassment, or disruptive behavior since the Reagan presidency is a bit of a stretch, don’t you think?

Public Citizen chronicles several cases of egregious behavior by physicians who dodged NPDB reports – the cases either received no peer sanctions or were dealt with in ways designed to skirt the reporting requirements, such as – wink-wink – leaves-of-absence and 29-day suspensions. Most famously, a cardiologist and CT surgeon at Redding Medical Center in Northern California performed hundreds of unnecessary cardiac procedures but were not reported to the NPDB – largely because Redding’s medical staff and hospital were cowed by the physicians’ power and reluctant to kill two geese who laid many golden eggs. (Interestingly, the Joint Commission whiffed on this one too, a major reason why Congress removed its near monopoly on the hospital accreditation business last year.)

Levine and Wolfe recommend powerful medicine to fix the NPDB system, including much more vigorous legislative oversight, substantial fines to hospitals for failing to report, and linking NPDB reporting practices to accreditation standards and to Medicare’s Conditions of Participation.

A few years ago in our book Internal Bleeding, Kaveh Shojania and I described the limits of peer review; the Public Citizen report provides statistical confirmation of our observations. We wrote,

It is undeniable that hospitals do have a tendency to protect their own, sometimes at the expense of patients. Hospital “credentials committees,” which certify and periodically recertify individual doctors, are toothless tigers. Most committees rarely limit a provider’s privileges, even when there is stark evidence he presents a clear and present danger to patients. Instead, they assign a committee member to “have a chat” with the physician in question, perhaps gently suggesting he or she shouldn’t do a particular procedure anymore. They might even ask another physician, not on the committee but in a similar specialty, to “keep an eye on old Doug” and let them know if he continues to screw up, even if patients or other staff members don’t report it….

It is not that hospital credentials committees never take action. They do – removing a physician’s privileges at a hospital or recommending to the state board that a doctor’s license be suspended – when there is clear, repetitive evidence of gross negligence and incompetence. But when this happens – and it is really rare – it comes only after an orgy of soul-searching, handwringing, buck-passing, second-guessing and second chances that is painful, and sometimes embarrassing, to watch. In most cases, committee members just swallow hard and – unless the physician is under felony indictment or is so stewed that he can’t walk down a corridor without banging into both walls – the credentials are rubber-stamped.

Kaveh and I offered three reasons why medical staff self-policing is so wimpy. The first is the “fraternity of medicine” thing – no gang members like to “rat out their pals,” and in this regard, we’re no different from the Crips. The second is that credentials committee members are acutely aware of the amount of time and effort that it takes to become a practicing physician, which makes them reluctant to take away a doc’s livelihood.

A third reason, we wrote,

is simply that doctors aren’t very good organizational managers. Their people skills are usually confined to bedside chats and working with colleagues and support staff in task-oriented jobs; they aren’t particularly adept at managing conflicts and confrontations, so they avoid them. This is a pretty dumb reason to let an error-prone doctor continue to prowl the hospital wards, but because litigation… lurks behind any challenge to professional competence… many physicians are reluctant to go into that particular swamp unless the trail is awfully solid.

The fear of litigation is undoubtedly one of the major reasons why peer review doesn’t work. Although the statute establishing the NPBD provides immunity to physicians who perform good faith peer review, many hospitals and reviewers lack confidence in these protections. An American Hospital Association analysis of the NPDB concluded, “The specter of baseless, time-consuming and expensive litigation serves as a powerful disincentive to effective peer review.” If peer review is to be strengthened, these protections must be unambiguously robust.

Writing in his book Complications, Harvard surgeon and bestselling author Atul Gawande sees in the medical profession’s failure to perform aggressive peer review something understandable, even a tad noble. When it comes to disciplining a basically good but troubled doctor, “no one,” he says, “really has the heart for it.” Atul writes:

When a skilled, decent, ordinarily conscientious colleague, whom you’ve known and worked with for years, starts popping Percodans, or becomes preoccupied with personal problems, and neglects the proper care of patients, you want to help, not destroy the doctor’s career. There is no easy way to help, though. In private practice, there are no sabbaticals to offer, no leaves of absence, only disciplinary proceedings and public reports of misdeeds. As a consequence, when people try to help, they do it quietly, privately. Their intentions are good; the result usually isn’t.

There are still other reasons for the failure of peer review. When questions of clinical competency arise, there are often insufficient data to refute the inevitable arguments that “my patients are older and sicker.” When the issue is disruptive behavior, unless there has been documented scalpel throwing (by a surgeon with good aim), finding the bright line that separates the behavior of an aggressive, passionate, patient-advocate-of-a surgeon from the surgeon whose disruptive behavior creates a hostile work environment or places patients at risk can be elusive. Finally, peer review conducted by professional colleagues is fundamentally tricky – one the one hand, how could one’s practice be dispassionately reviewed by a golfing buddy? On the other, peer reviewers might well be competitors of the physician-in-question, with a financial stake in the outcome.

Is it any wonder that medical staffs kick this particular can down the road so often?

Layered on top of these traditional impediments is a new one: the paradigm shift introduced by the patient safety field. Remember, our patient safety mantra has been “no blame,” which is unlikely to be in the first verse of the Peer Review Fight Song. Haven’t we just finished convincing ourselves that most errors are due to dysfunctional systems and not bad apples? If that’s the case, who really needs peer review, anyway?

But this represents a fundamental misunderstanding of “no blame.” I struggled with this tension while writing Internal Bleeding, and went to The Source for guidance: Dr. Lucian Leape, the father of the patient safety movement. Lucian, I asked, how can we reconcile systems thinking with the necessity of standards and peer review? His answer was spot on:

There is no accountability. When we identify doctors who harm patients, we need to try to be compassionate and help them. But in the end, if they are a danger to patients, they shouldn’t be caring for them. A fundamental principle has to be the development and then the enforcement of procedures and standards. We can’t make real progress without them. When a doctor doesn’t follow them, something has to happen. Today, nothing does, and you have a vicious cycle in which people have no real incentive to follow the rules because they know there are no consequences if they don’t. So there are bad doctors and bad nurses, but the fact that we tolerate them is just another systems problem.

I’m proud to say that over the past five years, my hospital (UCSF Medical Center) has taken Leape’s challenge to heart, withdrawing clinical privileges (and filing accompanying NPDB reports) in several cases for behavior that, I’m quite confident, would have been tolerated a decade ago. This is progress. As Kissinger once said, “weakness is provocative.” As more hospitals take this tougher stance, I think we’ll see the boundaries of acceptable behavior shift everywhere. And patients will be safer for it.

A profession is group of individuals with special knowledge, who are granted privileges by society in deference to their expertise and in exchange for self-regulation. When thousands of hospitals can go 20 years without disciplining a single physician on their medical staff, our status as a profession is called into question.

In the end, peer review is about answering one deceptively simple question: Is it more important to protect problem physicians or vulnerable patients? If we can’t answer that question correctly, we should not be surprised when the Sid Wolfes of the world call us to task, nor when we find ourselves under an unpleasant media, legislative, and regulatory microscope. Professions don’t need that kind of outside scrutiny to do the right thing, but we just might.

Dr. Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”

Launch! Healogica–Clinical Trials Recrutiment service

Jun 2, 2009

By Matthew Holt

Healogica was one of the companies that presented at Launch! at the Health 2.0 Meets Ix conference in Boston in April. I felt that the quality of the Launch! companies as so strong that they all deserved to be featured to more than the 200 people in the room who saw it. So on the spur of the moment I offered all of them a spot on THCB to get them a little more visibility. And now there’s a flood of three minute videos headed our way.

First up is an innovative clinical trial recruitment service called Healogica. And yes it’s new (which is the point of Launch). Watch the short video below to get an idea and investigate further over at Healogica

The Kennedy Plan

Jun 2, 2009• 3

By ROGER COLLIER

Politico.com this past weekend included news of what it described as Senator Ted Kennedy’s
reemergence in the health care reform debate, with proposals “distinctly
to the left” of those of Senate Finance Committee Chairman Max Baucus.
It also included the staff
working paper being circulated among members of Kennedy’s
Senate Health, Education, Labor, and Pensions Committee, and which presumably
reflects Kennedy’s positions.

The Politico report and a parallel piece in the New York
Times both claimed significant policy differences
between Kennedy and Baucus, reflecting Kennedy’s liberalism and Baucus’
more moderate (or conservative, depending on one’s politics) views.
The New York Times focused on the public plan issue as a defining difference
between the two senators, and noted Baucus’ efforts to develop compromises
with Republicans as potentially moving a Senate Finance reform bill
further to the right. So, what’s the truth?

Comparison of Finance Committee comments
with those of the HELP Committee working paper does show differences,
but in most cases ones of nuance. The working paper is often vague
on details (What are “reasonable limits” for premium variations?
is there any real evidence of the effectiveness of “medical homes”?)
but it is also quite comprehensive in scope, including a major section
on long-term care, something that has been almost totally ignored in
the reform debate. Other than the long-term care issue, though, there
is little in the HELP paper that is truly at odds with the Finance Committee’s
own policy outline—the November 2008 White Paper.

Calendar: Health 2.0 NYC Chapter June 11, 2009 Meeting Announced

Jun 2, 2009

This post was submitted by Eugene Borukhovich, of the New York Healthcare Technology Organization – Health 2.0 New York Chapter

The last meetup had a great turnout and we are gearing up to have the 99%
"show-up rate" once again! Please make sure to RSVP and please make it
firm since we have limited seating. Space will be opened up to 55
members but it will be tight so please only breath when you need to 🙂
(Disclaimer: that was not a medical advice).

June Presenters:1. HealthWorldWeb, LLC – Dan Kogan, CEODan will present a private beta launch of our reincarnation MyHealthExperience.comMyHealthExperience helps healthcare consumers identify best resources and providers of healthcare by virtual word of mouth

2. Hello Health – Jay Parkinson, MD + MPHJay does not need any introductions as he is "The Doctor of the Future"Hello Health
is a revolutionary new experience with your neighborhood doctor. They
mix office and online visits to give you personal attention when and
how you want it.

Hostility Towards Scientists And Jenny McCarthy’s Latest Video

Jun 2, 2009• 18

By VAL JONES, MD

Val Jones, M.D., is the President and CEO of Better Health, LLC. Most recently she was the Senior Medical Director of Revolution Health, a consumer health portal with over 120 million page views per month in its network. Prior to her work with Revolution Health, Dr. Jones served as the founding editor of Clinical Nutrition & Obesity, a peer-reviewed e-section of the online Medscape medical journal. She currently blogs at Get Better Health, where this post first appeared.

I’ve been fairly quiet about Jenny McCarthy’s campaign against childhood vaccinations, partly because Dr. David Gorski has covered the issue so thoroughly already, and partly because of my “do not engage” policy relating to the deeply irrational (i.e. there’s no winning an argument with “crazy.”) But this week I was filled with a renewed sense of urgency regarding the anti-vaccinationist movement for two reasons: 1) I received a personal email from a woman who is being treated with hostility by her peers for her pro-science views on vaccines and 2) a friend forwarded me a video of Jenny McCarthy speaking directly to moms, instructing them to avoid vaccinating their kids or giving them milk or wheat because of their supposed marijuana-like addictive properties.

Anti-Vaccination Views Are A Status Symbol?

I was surprised to discover that some pro-science moms are being mocked by peers who are uninterested in evidence, choosing to believe any dubious source of health information that questions the “medical establishment.” This concerned mom writes:

I am the mother of two young children, and I live in the trenches of the anti-vax woo. In my circle of about 14 mothers, my anecdotal analysis is that the rate of complete vaccination hovers around 60%. The mothers in this group are all very well educated, middle-class or affluent, predominantly stay-home mothers. One problem is what they consider reliable sources of information. They rely on anecdotes and dismiss scientific evidence in part because they are very anti-medical establishment. The group is self-validating and many shared values (and myths) increase in intensity over time.

Many of the mothers practice “Natural Family Living” which has some appealing aspects, but also harbors elements of a cult. In this environment, anti-vaccination becomes a very powerful status symbol… I have lost friendships and been partially ousted from this circle because of my views.

This note struck a chord with me, since I experienced similar hostility in the past for voicing my concern about pseudoscience and misleading consumer health information. I was accused of being “paternalistic, narrow-minded, a dinosaur – part of a dying breed, a racist against complementary and alternative medicine, and a Bible school teacher, preaching evidence-based medicine,” insulted for my desire to be accurate about what was known and not known about treatment options, and my expertise, training, and academic credentials were called into question publicly on many occasions. I endured all of this primarily at the hands of someone who supposedly believed in “natural healing” and the “art of kindness” as an integral part of patient care.

I am troubled by the mounting antagonism towards those of us who’d like to use critical thinking and scientific reasoning to learn what we can about medicine and our health. I’m not sure what to do about it except to encourage one another to stand strong for science and reason – to expect all manner of attacks and insults, and to be firmly committed to the objective quest for truth. It shall set us free.

Jenny McCarthy – Inaccurate, Unhelpful And Dangerous Advice

Although I find Jenny McCarthy’s advice and opinions painful to watch, I committed myself to viewing her recent video at my friend’s request. In order to spare you similar discomfort, let me simply summarize what she said so you can get a high level overview of the sort of bizarre and misinformed claims she promotes (feel free to check out the video for yourself).

“Autism is not primarily a genetic disorder, but caused by vaccine-related toxins (including mercury, aluminum, ether, anti-freeze ,and human aborted fetal tissue) and pesticides.”

A recent study published in Nature links genetic alternations in DNA that codes for neuronal cell adhesion molecules to autism spectrum disorders.
A mercury-autism link has been fully debunked.
An aluminum-autism link has been disproven.
There is no ether, anti-freeze or human tissue in vaccines.
There is no conclusive evidence of a link between pesticides and autism.

“Kids get ‘stoned’ by wheat and dairy toxins. Giving them wheat or dairy proteins is like giving children marijuana.”

There is currently no evidence that any diet improves or worsens the symptoms of autism spectrum disorders. In fact, whole grains and dairy products are an important part of a healthy diet for most children.

“Food allergies are like Iran and Iraq. Glial cells (they’re like chef cell) provide food to the neuron kings. Glial cells can turn into Rambo to fight Iran and Iraq. If a child is allergic to everything, the Rambo cells stop feeding the neurons and the neurons starve. That causes the symptoms of autism.”

I don’t know what to say about this strange analogy – clearly no science-based information here.

“To treat autism, you need to give your child supplements to fight off the yeast in their bodies. I recommend Super Nathera, Culturelle, Cod Liver Oil, Caprylic Acid, CoQ10, Calcium, Vitamin C, Selenium, Zinc, Vitamin B12, B6, and Magnesium.”

There is no evidence of efficacy for any of these supplements in the treatment of autism.

“You need to consult with a DAN! Practitioner.”

DAN! Practitioners recommend chelation therapy for the treatment of autism. There is no evidence that chelation therapy has any benefit for children with autism, and in fact, can be fatal.

“Whatever you think becomes your reality. Imagine your child going to his/her prom and he’ll be cured.”

I think it’s pretty clear that Jenny McCarthy’s recommendations range from ineffective (imaginary healing) to harmful (malnutrition related to absent dairy and wheat in the diet, excessive levels of vitamins) to deadly (chelation therapy with DAN! Practitioners). Will mothers watching her new show on Oprah fall for her pseudoscience and poor advice?

I was pleased to see this open letter to Oprah from one concerned mom. Here’s an excerpt:

To me, it is clear that a significant number of people look up to you, and trust your advice and judgment. That is why it is such a huge mistake for you to endorse Jenny McCarthy with her own show on your network.
Surely you must realize that McCarthy is neither a medical professional nor a scientist. And yet she acts as a spokesperson for the anti-vaccination movement, a movement that directly impacts people’s health. Claims that vaccines are unsafe and cause autism have been refuted time after time, but their allure persists in part because of high-profile champions for ignorance like McCarthy. In fact, ten of the thirteen authors of the paper that sparked the modern anti-vaccination movement retracted the explosive conclusions they made due to insufficient evidence. Furthermore, it is now clear that the study’s main author, Andrew Wakefield, falsified data to support these shaky conclusions.

We have come close to eradicating life-threatening and crippling illnesses because of vaccines, but are now struggling to prevent outbreaks because of parents’ philosophical beliefs that vaccines are harmful. Realize this: when someone chooses not to vaccinate their child, they aren’t just putting their own child at risk, they are putting everyone else around them at risk. Diseases with vaccines should normally be of little concern even to unprotected individuals due to herd immunity – with the majority of the population immune, unprotected individuals are less likely to come into contact with the pathogen. Unfortunately, herd immunity disintegrates as fewer people are vaccinated, putting everyone who hasn’t yet been vaccinated at greater risk for infection. Now, the rates of infection by diseases for which we have safe and effective vaccines are climbing, thanks to anti-vaccination activists like Jenny McCarthy.

You reach millions of people everyday and your words and endorsements carry an incredible amount of weight. If you say to buy a certain book, people will buy it. If you do a segment on a certain charity, people will contribute. And if you say that what Jenny McCarthy is saying has merit, people will believe you…

Conclusion

A certain segment of society appears to be emotionally invested in medical beliefs that are not based on science, but rather anecdotes, conspiracy theories, and magical thinking. Those who recommend a more objective method of inquiry may be subject to ridicule and hostility by that segment. Nonetheless, it is important (for public health and safety purposes and the advancement of science) for critical thinking to be promoted and defended. While some celebrities, like Jenny McCarthy, are committed to misinforming the public about their children’s health – parents who recognize the deception are speaking out against it. Perhaps the best way to combat Jenny’s propaganda is to boycott Oprah. Refusing to support the promotion of dangerous pseudoscience may be our best defense.

Nothing Personal

Jun 2, 2009• 11

By CINDY THROOP

Center for Information Therapy disclaimer: This post was written by Cindy Throop and does not necessarily reflect the views and opinions of the Center for Information Therapy.

I agree that getting personal is not productive. But I guess that depends on what you are talking about. The health care system is broken, but it is not the fault of any single person or entity. Getting personal in this sense does not help move things forward.