Tag: Information Therapy

The Info-Button Standard: Bringing Meaningful Use to the Patient

Regardless of the U.S. administration’s “meaningful use” requirements, if health information technology (HIT) is to become meaningful for patients, it must include the prescription of information and tools to help each patient better manage his or her own care.

Ask patients what they want from HIT systems, and they will tell you three things:

– “Tell me my diagnosis, what will happen, and what I can do myself to better manage the problem.”

– “Tell me my medical tests results and what they mean to me.”

– “Tell me my treatment options, and help me participate in the treatment decisions.”

The soon-to-be-finalized HL7 International Context-Aware Information Retrieval standard (nicknamed the HL7 “Infobutton” standard) makes it far easier for providers of electronic health records (EHRs) and personal health records (PHRs) to deliver just what the patient wants. And that is what will put the meaning into meaningful.

Using the HL7 Infobutton Standard for Information Prescriptions

The HL7 Infobutton standard has been widely adopted since 2007. It facilitates the delivery of a set of standardized information about the patient, the provider, and the activity of a specific care encounter or moment in care. An Infobutton manager (or equivalent) accessed by an EHR application can then pull from that set the information it needs for any relevant use case. In most cases the Infobutton has been used to bring up decision support information for the clinician.

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MedEncentive’s Five Year Report

As many involved in the worlds of Health 2.0 and Information Therapy know, some of the most interesting experiments in the world of patient-physician engagement have been happening in the somewhat unlikely environs of small town Oklahoma. There the City of Duncan has put its employees (and their providers) into a system that incents (but doesn’t mandate) physicians to practice according to accepted guidelines, and incents (but doesn’t mandate) patients to read information prescribed by their physicians about their treatments (and tests them about it). The system then asks each party to rate the other.

It sounds simple and frankly, compared to much in health care, it is. The system is supplied by MedEncentive, an Oklahoma City firm led by the charming and engaging Jeff Greene. While I remain fascinated by MedEncentive’s program (and FD MedEncentive has sponsored the Health 2.0 Conference in the past), it’s perhaps grown a little more slowly than Jeff and other fans might have liked—given the scope of the problem.

But the results have been impressive in reducing costs (mostly by reducing hospitalizations) and increasing patient involvement. Yesterday MedEncentive released a five year retrospective. The key finding?:

City of Duncan costs for the most recent year was 8.6% less than five years ago prior to implementing the Program, which is 34.9% less than the projected costs. The resultant four year savings equates to an 8:1 return on investment. (emphasis added)

Jeff abandoned a lucrative business in physician practice management to have a go at this intractable problem. Five years on he deserves plaudits for what he and his team have achieved, and hopefully we’ll see much more innovation like this mushrooming in the future.

Given the relatively lightweight nature of the intervention, I’m amazed that many much larger payers/employers haven’t given it a try. After all, whatever else they’re doing doesn’t seem to be exactly working too well!

Innovation and Absence of Evidence vs. Evidence of Absence


Jon Gabel from the National Opinion Research Center has an excellent op-ed piece in today’s New York Times. The basic argument is summarized in his conclusion:

“The Congressional Budget Office’s integrity is beyond questioning. But the record shows that it has substantially overestimated the cost of health care reform three times out of three. As Congress now works on its greatest push for reform in generations, the budget office needs to revise the methods it uses to make predictions about costs.”

Far from being an arcane methodological debate, CBO’s approach has profound consequences for health care reform and for the long-term health and economic conditions of the country. As Gabel puts it:

“The budget office’s cautious methods may have unintended consequences in the current health care reform effort. By underestimating the savings that can come from improved Medicare payment procedures and other cost-control initiatives, the budget office leads Congress to think that politically unpopular cost-cutting initiatives will have, at best, only modest effects. This, in turn, forces Congress to believe it can pay for reform only by raising taxes, which then makes reform legislation more difficult to pass.”

The reason that CBO has underestimated savings from past reforms of Medicare is that it makes the assumption that — without convincing empirical evidence of an initiative’s cost impact — it basically “scores” it as delivering zero savings. No doubt that CBO is consistent and conservative, but that doesn’t necessarily produce the most accurate budgetary forecast.

Perhaps more so than any other area in the federal budget, there are an enormous number of unknowns in health care. CBO has historically built its model on the premise that absence of evidence equates with evidence of absence.

But there is a major distinction. “Evidence of absence” means that we have an empirical reason to believe that there is no effect of an intervention (in this case on cost). In that case, it makes sense to score zero savings.

In contrast, “absence of evidence” simply means that we do not have sufficient evidence that an intervention produces any effect.  The problem is that, by definition, any true “innovation” (defined by Merriam-Webster as “the introduction of something new”) has no evidence. Which is to say: CBO has effectively ruled out scoring savings for true innovation.

Perhaps some would argue that’s an overstatement in that we certainly commonly use the term innovation to describe something that has been around long enough to be tested. Yes and no. There’s no doubt that new and innovation are relative terms, but there are still important reasons why that approach for CBO remains flawed.

First, evaluation takes time. To design a study, appropriately manage it, collect and analyze data, submit to peer review, and publish often takes many years.

Second, the level of evidence that CBO typically requires takes A LOT of time.

Third, innovation often comes from combining different initiatives and strategies that create a combined effect greater than the sum of their parts. Information therapy, patient decision aids, comparative effectiveness research, and other delivery system reforms may have a powerful impact when thoughtfully and appropriately combined together.

Fourth, the pace of innovation and the greatest innovative impacts can be dramatically robust. There is no way, in its current model, for CBO to capture those things that will have the most important effects on the federal health budget.

Like Jon Gabel, I don’t question the CBO’s integrity or analytical capacity, but I do believe that its methodological approach requires amendment. As I have written before, we — as health services researchers (and I admit to being one myself) — need to maintain our analytical rigor while being as creative in our research methods as the innovators are at innovating.

We should not shy away from the empirical idiosyncrasies that innovative care delivery initiatives create. Rather, we should rise to the challenge by employing a broader set of research and analytical skills to tackle these compelling research questions about new innovations. Indeed, the new care delivery strategies create opportunities for health services researchers to develop their own innovative research techniques.

I hope that health services researchers out there are up to that challenge.

If we aren’t, we will continue to create perverse public policy incentives.

Joshua Seidman is the president of of the Center for Information Therapy that aims to provide the timely prescription and availability of evidence-based health information to meet individuals’ specific needs and support sound decision making.  He frequently blogs for THCB and the Center for Information Therapy Blog, where this post first appeared.

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IDEO and Ix Innovation Design

Ionescu_Arna_217pxNext week Matthew will be in a workshop with the folks from design firm IDEO and our friends from the Ix Center. In preparation we’re posting this article from IDEO’s Arna Ionescu who was at the recent joint Health 2.0 Meets Ix Conference on a panel moderated by the Center for Information Therapy’s President Josh Seidman. And if that wasn’t all incestuous enough, this post was originally on Josh’s blog over at Ix.

Thank you to those of you who participated in our interactive webinar last Tuesday. During the webinar we used IDEO’s design approach to tackle the challenge of providing effective Information Therapy (Ix) to a fictional character named Vernon, who has minimal resources and was  recently diagnosed with high blood pressure.

To inspire solutions for this challenge, members of the IxAction
Alliance submitted images of unexpected learning moments in their daily
lives. These images spanned from public service billboards to Snapple
caps and restaurant placemats. In advance of the webinar, the IDEO team
synthesized the images into brainstorm questions.

The webinar attendees voted and selected the brainstorm question,
“How Might We leverage curiosity to prompt Vernon to engage with Ix?”
Following IDEO’s brainstorm rules attendees submitted ideas using the webinar software.

More than 30 ideas were generated in the ten minute brainstorm, and
a second vote allowed the attendees to select which idea to pursue
further. Attendees selected the “High Blood Pressure Club.” We
discussed “$10, 10 minute prototypes” – an approach that allows us to
try out fast and cheap experiments to gain insight before costly design
and implementation efforts.

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A Declaration of Health Independence

DonkemperWhen in the course of human events, it becomes necessary for individuals to dissolve their professional  bands of medical dependency and to assume among their obligations the primary responsibility for their own health to which the Laws of Nature and of Nature’s God entitle them, a decent respect to the opinions of humankind require that they should declare the causes which impel them to seek Health Independence.

We hold these truths to be self-evident, that all people are created equal, that they are endowed by their Creator with certain inalienable Rights, that among these are the freedom to direct ones own Life, to provide for ones own Health and to die with dignity—that to assist in providing such rights when otherwise unattainable, health professions are instituted among people, deriving their roles solely from the consent of the people they serve—

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Creative thinking about the CER agenda

Picture 13This week the Institute of Medicine (IOM) released its list of the top 100 topics that should be addressed in  comparative effectiveness research (CER) now — thanks to $1.1 billion in the American Recovery & Reinvestment Act
— that the federal government actually has the resources to do
substantial CER. IOM has prioritized the list by creating four
quartiles, noting that the first quartile is the highest priority
group, etc.

In order for the federal government to make good use of the huge pot of CER money, there are at least five things that they need to do to ensure its value and actually change care delivery.
I’m all for trying to find out whether me-too drugs add any significant
value. However, the greatest opportunities for implementing delivery
system change that improves care effectiveness and efficiency relate to
innovations in how care is organized and delivered, and how insights
are communicated to the broad range of health care actors — most
notably consumers.

That’s why I was heartened by the IOM’s top 100 list — though
certainly I’d move a few up a quartile or two. The list has many
projects that fit my priorities, including a strong emphasis on CER to
reduce health disparities.

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Decoding “The Social Life of Health Information”

The Pew Internet/California HealthCare Foundation report, The Social Life of Health Information, is packed with new findings from a survey of 2,253 adults, including 502 cell-phone interviews, conducted in either English or Spanish.

We spent a bundle of money on making this a random sample of the U.S. population, but guess who got a call on his cell phone?  None other than e-patient Dave!  He had never talked with me about the survey questions or reviewed a draft, so I decided to keep his interview in the mix, but he surprised the heck out of the interviewer when he finished the sponsor identification for her at the end.Continue reading…