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Tag: David Kibbe

Bringing Patients into the Health IT Conversation About “Meaningful Use”

The Obama health team at HHS and ONC are gradually establishing the rules that will determine how approximately $34 billion in ARRA/HITECH funds are spent on health IT over the next several years. But there is a “missing link” in these deliberations that, so far, has not been addressed by Congress or the Administration: how the patient’s voice can be “meaningfully used” in health IT. After all, we, the taxpayers, will pay for all this hardware, software, and associated training. There are many more consumers of health care than doctors or health care professionals. Shouldn’t we have a say in what matters – in what is meaningful – to us?

It may have been an oversight, but patients and consumers have been left very much on HITECH’s sidelines. The attention and the money is squarely aimed at the health care providers – doctors, clinics, and hospitals. The Act’s intention is to create “interoperable” electronic health records that, in the future, will be more accessible to them: doctors, clinics, and hospitals.  This is a policy that is tied unnecessarily to an outdated vision. It is provider-centered, paternalistic and top-down. But it could be re-imagined to take advantage of the new ways millions of consumers, patients, and care giving families are using information and communications technologies to solve problems, form online communities, and share information and knowledge.

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An Open Letter to the New National Coordinator for Health IT: Part 3 — Certification As The Elephant in Health IT’s Living Room

6a00d8341c909d53ef01157012476e970b-pi In the first and second parts of this series we talked about how and why there is no universal definition for the term “EHR.” Instead there is a legitimate, growing debate about the features and functions that “EHR technologies” should offer physicians seeking to qualify for HITECH incentive payments. We explored the layers of network technology, suggesting that federal regulators should “separate the data from the applications.”

We also argued that there is much to learn from development platforms, recently and in the distant past, that have used standards to open the aperture of innovation. The best of these standards have reflected the experience of what works rather than specifying how to make it work. Defining the standards for data, devices, and network technologies too restrictively could choke off innovation, rendering HITECH’s offerings whose expense and complexity are a barrier to, rather than an incentive for, adoption by physicians. Incoming National Coordinator for HIT David Blumenthal, MD seems to have been considering just this concern when he recently wrote:“… [M]any certified EHRs are neither user-friendly nor designed to meet HITECH’s ambitious goal of improving quality and efficiency in the health care system. Tightening the certification process is a critical early challenge for ONCHIT.”

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The Parable of the Wicked EMR

Preface by e-Patient Dave: This is a story of bad data gone wild, wrong info that spreads. It starts with a story from the 1600s, which applies all too aptly to our EMR situation today, in which there are inadequate controls on data quality, and errors that leak can be impossible to contain.

It was a scandal. In 1631 two London printers published an edition of the bible that omitted “not” from the seventh commandment. [It should have said “Thou shalt not commit adultery,” but it didn’t.] The public outrage over what was dubbed the “Wicked Bible” was loud and immediate. King Charles I heard about it, and was incensed. This simple mistake by print compositors landed their employers in the Star Chamber before the infamous Bishop Laud, where they were tried, found guilty, and fined 300 pounds. They also had their print licenses withdrawn; the fine was directed to be used to for a new set of print typefonts and to oversee new quality control practices to prevent such a mistake from ever again occurring in the future.

The episode of the Wicked Bible has historical importance because it demonstrated how the new print technology allowed printers to create “standardized” errors, something impossible in the scribal era when all books were the product of hand copyists. Textual drift – the result of small copyist’s errors in single books, which were then repeated in the next copy, and so on – was no longer possible, replaced by the textual fixity of print type. If printing presses could greatly lower the costs of producing books, and make them available to whole new classes of people to read, they were also capable of mass producing errors!

Enter e-Patient Dave. As we all know by now, Dave asked to have his hospital’s electronic medical record system upload his health data to his Google Health account, only to find that the diagnoses transferred were claims data that were largely unintelligible and meaningless to Dave, and some of the problems listed were downright inaccurate or false.

Wicked EMR! How is it possible that that such mistakes could be made? Not exactly the Word of God, but most people trust that their health information is accurately recorded inside the EHR technology of the hospitals where they are cared for and treated.
Plus, since insurance billing records are transferred to the MIB, an insurance industry database that insurers use to check patients for pre-existing conditions, errors in billing records can have serious effects, as the Consumer Reports blog reported last August. A truly wicked consequence of a propagated error.

Hundreds of blog posts later and two articles in the Boston Globe, here are my takeaways from the Parable of the Wicked EMR:

  • Hospitals must recognize that more and more of its customers will want their medical records in electronic format, and help filter and organize these data, rather than just “dump” them to the patient’s chosen PHR, in this case Google Health.
  • Dave’s healthcare providers need to help keep the data and information available in terms that patients can understand, along with coded data, and be aware that reconciliation at discharge in CCR or CCD format will be valuable to them. This will help them check for errors (free quality control!) and empower them to be increasingly responsible for their medical information.
  • And the PHR companies need to continue to help bridge the gaps that exist between health data in EHRs and IT systems, some of which is largely incomprehensible, and organized sets of information available in patient-understood terminology on the Web.
  • Finally, as Dave is proving every day, the patients/consumers have to take some responsibility for feedback and additional commentary until we all get this right.

The good news in all of this is that so many people actually care about e-Patient Dave’s experience getting better. It’s lit up the blogosphere because it’s important. This isn’t about blame – it’s about improvement to the point that patients get accurate and up-to-date summary health information about themselves at every point in the health care system.
A few questions that we might want to answer before this is all over:

  • How can it be that a doctor’s list of problems/diagnoses and those that the hospital uses are not the same? Is this an error, or is there upcoding and possibly abuse of the system going on?
  • If Dave’s doctors had acted on the data sent from the hospital to Google that was incorrect, and Dave was harmed in some way, would he have a legal cause for action against the hospital? Against Google?
  • If these billing data are inaccurate, wildly so in some cases, then why are we using them for analytics and quality research? For disease management?
  • If Dave’s billing data in the hospital EHR/EMR system is actually data from someone else, ie. another patient, then is Dave prohibited from seeing his own chart due to HIPAA privacy rules?
  • Isn’t it time for there to be a patient right to summary health data that is digital, up-to-date, and accurate?

We don’t have access to the same recourse King Charles had; we’re not likely to arrest and fine those who mismanaged the “sacred” data. But if you ask me, we ought to have the same sense of indignation, and the same commitment to hunt down and eradicate the Wicked EMR.

This posting was originally published on e-patient.net and is republished on THCB with permission of the author.

An Open Letter to the New National Coordinator for Health IT – Untying HITECH’s Gordian Knot: Part 1

KibbeB&WjpgCongratulations to David Blumenthal on being named National Coordinator for Health Information  Technology (ONCHIT). Dr. Blumenthal will be the person most responsible for the rules and distribution of the American Recovery and Reinvestment Act’s (ARRA) nearly $20 billion allocation, referred to as HITECH, designated to support physician and hospital adoption of health information technologies that can improve care.

The job is fraught with difficulties, which Dr. Blumenthal has readily acknowledged. His recent New England Journal of Medicine (NEJM) Perspective, “Stimulating the Adoption of Health Information Technology,” is a concise, clear and honest appraisal of two of these challenges, namely how to interpret and act upon the key terms used in the legislation, “meaningful use” and “certified EHR technology.” Dr. Blumenthal gets to the heart of the matter by identifying the tasks on which the National Coordinator’s success will most depend, and which will foster the greatest controversy.

The country needs Dr. Blumenthal to succeed. The issues are complex and, with huge ideological and financial stakes involved, politically charged.

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An Open Letter to the New National Coordinator for Health IT: Part 2 – Opening the Aperture of Innovation

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One of the important decisions before Dr. Blumenthal and his colleagues at ONC and HHS is whether the national health information network will be one of closed appliances that bundle together proprietary hardware, software, and networking technology, or one of open data exchange and management platforms in which the component parts required to do medical computing can be assembled from different sources. If the former direction is chosen, power and control will be concentrated in the hands of a very few companies.  If the latter, we could see an unprecedented burst of disruptive innovation as new products and services are developed to
create the next generation of e-health services in this country.

Separating the data from the devices and applications, and maintaining a certain degree of independence of both from the networks used for transmission, is far more than a technical quibble. It can determine the economics of technology in stunning ways.

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A Self-Fulfilling Prophecy: The Continuity of Care Record Gains Ground As A Standard

Brian KlepperWe live in a time of such great progress in so many arenas that, too often and without a second thought, we take significant advances for granted. But, now and then, we should catalog the steps forward, and then look backward to appreciate how these steps were made possible. They sprung from grand conceptions of possibilities and, then, the persistent focused toil that is required to bring ideas to useful fruition.

We could see this in a relatively quiet announcement this week at HIMSS 09. Microsoft unveiled its Amalga Unified Intelligence System (UIS) 2009, the next generation release of the enterprise data aggregation platform that enables hospitals to unlock patient data stored in a wide range of systems and make it easily accessible to every authorized member of the team inside and beyond the hospital – including the patient – to help them drive real-time improvements in the quality, safety and efficiency of care delivery.”

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A Research Agenda for Participatory Medicine and the Connected Medical Home

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Recently, in a blog post published December 22, 2008 in The Health Care Blog entitled  "The Connected Medical Home,” we described the synergy between the efforts of proponents of Participatory Medicine and the Medical Home.  Our main purpose was to suggest that both providers and patients are longing for a synthesis that takes the best features of Health 2.0 as consumer-generated health care, and combines these with a primary care medical home model offering personal relationships with health professionals who understand the power of the Web and are willing to use the Internet to improve patient care. 



Since our earlier writing, which received mostly positive commentary, a new President has been elected and Washington is on fire with talk of health reform and economic stimulus. Health IT and the medical home are primed to take center stage in the evolution of health reform, most observers would agree.  However, there are still many details to be worked out.  It is not entirely clear what constitutes the best uses of health IT inside the medical home model, nor how to hold these uses accountable for improved care and lower cost of care, let alone how to connect these with consumer-based technologies and bring both to market at a reasonable price, certainly a prime consideration during a recession and if we expect efficient widespread use. 



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Is the Healthcare Economy Rightsizing?

Brian KlepperMore than at any time in recent memory, powerful forces are buffeting
the health care sector. We are in

the midst of profound upheaval,
driven by
market and policy responses to the industry's long-term 
excesses
.
We can already see evidence that the dysfunction of our traditional
health system is accelerating. It also seems clear that the center
cannot hold indefinitely.


Dog Eat Dog

It is useful to remember that the health care industry's
different stakeholders are adversaries. While they clearly share a
common understanding that a wholesale meltdown is possible, there is
little real motivation for collaboration and no unity. Independent of
role, the industry as a whole has been focused on, and extremely
effective at, securing dollars from purchasers: government, employers
and individuals. But each silo within the industry has been separately
focused on growing its own slice of the health care pie. In every
niche, there are courteous conceits –
access, appropriateness, efficiency and value – reserved
for the good manners of public relations. But these are meaningful in
practice only if they do not conflict with the professional's or the
firm's economic performance.

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Five Recommendations for an ONC Head Who Understands Health IT Innovation

Now that the legislative language of the HITECH Act — the $20 billion health IT allocation within the economic stimulus package — has been set, it’s time to identify a National Coordinator (NC) for Health IT who can capably lead that office. As many now realize, the language of the Bill can be ambiguous, requiring wise regulatory interpretation and execution to ensure that the money is spent well and that desired outcomes are achieved. Among other tasks, the NC will influence appointments to the new Health Information Technology (HIT) Policy and Standards Committees, refine the Electronic Health Record (EHR) technology certification process, and oversee how information exchange grants and provider incentive payments will be handled.

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Saving Health Care, Saving America

So far, Congress’ response to the health care crisis has been alarmingly disappointing in three ways. First, by willingly accepting enormous sums from health care special interests, our representatives have obligated themselves to their benefactors’ interests rather than to those of the American people. More than 3,330 health care lobbyists – six for every member of Congress – contributed more than one-quarter of a billion dollars in the first and second quarters of 2009. A nearly equal amount has been contributed on this issue from non-health care organizations. This exchange of money prompted a Public Citizen lobbyist to comment, “A person can reach no other conclusion than this is a quid pro quo [this for that] activity.”

Second, by carefully avoiding reforms of the practices that drive health care’s enormous cost growth, Congress pretends to make meaningful change where little is contemplated. For example, current proposals would not rebuild our failing primary care capabilities, which other developed nations depend upon to maintain healthy people at half the cost of our specialist-dominated approach. They fail to advance the easy availability and understandability of information about care quality and costs, so purchasers still cannot identify which professionals and organizations are high or low performers, essential to allowing health care to finally work as a market. They do little to simplify the onerous burden associated with the administration of billing and collections. The proposals continue to favor fee-for-service reimbursement, which rewards the delivery of more products and services, independent of their appropriateness, rather than rewarding results. Policy makers overlook the importance of bipartisan proposals like the Wyden-Bennett Healthy Americans Act that uses the tax system to incentivize consumers to make wiser insurance purchases. And they all but ignore our unpredictable medical malpractice system, which nearly all doctors and hospital executives tell us unjustly encourages them to practice defensively.

Most distressing, the processes affecting health care reflect all policy-making. By allowing special interests to shape critically important policies, Congress no longer is able to address any of our most important national problems in the common interest – e.g., energy, the environment, education, poverty, productivity.

Over the last four years, a growing percentage of individual and corporate purchasers has become unable to afford coverage, and enrollment in commercial health plans has eroded substantially. Fewer enrollees mean fewer premium dollars available to buy health care products and services. With diminished revenues, the industry is unilaterally advocating for universal coverage. This would provide robust new revenues. But they are opposing changes to the medical profiteering practices that result in excessive costs, and which often are the foundation of their current business models. And these two elements form the troublesome core of the current proposals.

Each proposal so far contemplates additional cost. But we shouldn’t have to spend more to fix health care. Within the industry’s professional community, most experts agree that as much as one-third of all health care spending is wasted, meaning that a portion of at least $800 billion a year could be recovered. There is no mystery about where the most blatant waste is throughout the system, or how to restructure health care business practices to significantly reduce that waste.

Make no mistake. A failure to immediately address the deep drivers of the crisis will force the nation to pay a high price and then revisit the same issues in the near future. It is critical to restructure health care now, without delay, but in ways that serve the interests of the nation, not a particular industry.

Congress ultimately must be accountable to the American people. The American people must prevail on Congress to revise the current proposals, build on the lessons gleaned throughout the industry over the last 25 years, and directly address the structural flaws in our current system. True, most health industry groups will resist these efforts over the short term, but the result would be a more stable and sustainable health system, health care economy and national economy, outcomes that would benefit America’s people, its businesses and even its health care sector.

Finally, the American people should demand that Congress revisit and revise the conflicted lobbying practices that have so corroded policymaking on virtually every important issue. Doing so would revitalize the American people’s confidence in Congress, and would re-empower it to create thoughtful, innovative solutions to our national problems.

Brian Klepper is a health care analyst and industry advisor. David C. Kibbe is a family physician and a technology consultant to the industry. Robert Laszewski is a former senior health insurance executive and a health policy analyst. Alain Enthoven is Professor of Management (Emeritus) at the Stanford University Graduate School of Business.

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