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Tag: Margalit Gur-Arie

Horses, Camels & Signals

By MARGALIT GUR-ARIE

On June 8, the HIT Policy Committee at ONC has approved the Workgroup recommendations for Meaningful Use Stage 2. Before diving into the details, it is worth noting that the time crunch for moving from Stage 1 to Stage 2, for those seeking incentives in 2011, was proposed to be resolved by postponing Stage 2 for these early adopters for one year. As I noted before, if you are able to attest and obtain incentives in 2011, go ahead and do that. You will be rewarded by having the opportunity to stay at Stage 1 for 3 consecutive years. The final Stage 2 ruling is not expected to occur until June 2012 and judging by previous experience with Stage 1, the recommendations approved today will be significantly relaxed by the CMS process of proposed rulemaking and public comments. So although analyzing (rejoicing or bemoaning) the various measures on this long list is a bit premature, it may be helpful to look at the general principles embedded in this new stage of Meaningful Use.

Horses

Many of the Meaningful Use more pedestrian measures have remained unchanged, have increased in intensity, or have been moved from menu to core (more on this later). These measures include such items as recording patient demographics, maintaining medications, allergies and problem lists, recording of vitals, running reports, electronic prescribing, incorporating structured lab results, medications reconciliation, using formularies, enabling clinical decision support, reporting to state and federal agencies and ensuring privacy and security of medical records.

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Meaningful Use — A Pinch of 3 and a Dash of 4

By Margalit Gur-Arie

While most folks are busy trying to keep up with Meaningful Use Stage 1, and Meaningful Use Stage 2 only recently emerged from the customary rulemaking process, those who plan for distant futures are providing us a glimpse of what is being considered for Meaningful Use Stage 3 and here and there a hint at the possibility of a never before mentioned Stage 4 and beyond. Since Stage 2 is still somewhat theoretical, there is little value to enumerating the proposed measures of Stage 3, which is not due to take effect until 2016, but it may prove instructive to take a general look at the overall direction that seems to be favored by policy makers for future design and use of EHR technologies. To that end, several new proposed measures seem most enlightening.

The New US Census Bureau

Stage 1 of Meaningful Use added language, race and ethnicity to the customary demographic information collected from patients, such as name, address, date of birth, gender, etc. Stage 2 proposes to add language, race and ethnicity to clinical summaries provided to patients or sent to other providers of care. So the patient header of a Stage 2 clinical summary might look something like this:

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Single-Payer is the American Way

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By MARGALIT GUR-ARIE

As is customary for every administration in recent history, the Trump administration chose to impale itself on the national spear known as health care in America. The consequences so far are precisely as I expected, but one intriguing phenomenon is surprisingly beginning to emerge. People are starting to talk about single-payer. People who are not avowed socialists, people who benefit handsomely from the health care status quo seem to feel a need to address this four hundred pound gorilla, sitting patiently in a corner of our health care situation room. Why?

The all too public spectacle of a Republican party at war with itself over repealing and replacing Obamacare is teaching us one certain thing. There are no good solutions to health care within the acceptable realm of incremental, compromise driven, modern American solutions to everything, solutions that have been crippling the country and its people since the mid-seventies, which is when America lost its mojo. To fix health care, we have to go back to times when America was truly great, times when the wealthy Roosevelts of New York lived in the White House, times when graduating from Harvard or Yale were not cookie cutter prerequisites to becoming President, times when the President of the United States conducted meetings while sitting on the toilet with the door open and nobody cared. Rings a bell?

Single-payer health care is one such bold solution. Listening to the back and forth banter on social media, one may be tempted to disagree. We don’t have enough money for single-payer. Both Vermont and California tried and quit because of astronomic costs. Hundreds of thousands of people working for insurance companies will become unemployed. Hospitals will close. Entire towns will be wiped out. Doctors will become lazy inefficient government employees and you’ll have to wait months before seeing a doctor. And of course, there will be formal and informal death panels. Did I miss anything? I’m pretty sure I did, so let’s enumerate.

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Hacking Doctors

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By MARGALIT GUR-ARIE

flying cadeuciiFor decades and decades we have been counting the number of doctors in America. For decades and decades we have been coming up short compared to other developed nations, and some less developed ones as well. A poorly educated person may be tempted to suggest that we should “make” more doctors. After all, there is hardly a shortage of young people willing and able to undergo the rigors of a medical education. But luckily we are not poorly educated, so we devised much smarter solutions.

If people can’t get a doctor appointment, it must be the doctor’s fault. Hence, we put our foot down and mandated that doctors see people the same day they want to be seen, or shortly thereafter. It sounds great and it worked perfectly for the Veterans Administration (VA), so it should scale terrifically to everybody else.Taking a page from the highly respected Samuel Hahnemann, we decreed that physically “seeing” an actual doctor is not only completely unnecessary, but it may very well be detrimental to the healing process. A doctor effect is created by simply having an MD somewhere in the building, and as technology continues to improve, a virtual doctor presence should do the trick. Some have argued that Mr. Hahnemann’s homeopathic fantasy is no better than a placebo, but we have plenty of research showing that placebos are indeed effective.Continue reading…

Healthcare’s Perpetual War

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By MARGALIT GUR-ARIE

Screen Shot 2015-09-28 at 1.49.03 PM

There are three visions of peace in the seemingly never ending, but really rather brief, Israeli-Palestinian perpetual crisis. One peace features two independent countries living in collaborative harmony on a piece of land approximately the size of New Jersey. Another peace yearns for a messianic Jewish state stretching from the blue Mediterranean shores to the Jordan River, and possibly beyond. The third and final peace is expected to materialize after the Zionist entity has been permanently erased from the face of this earth, or at least from the face of that New Jersey size holy piece of land.  Each definition is amenable to slight compromises in form, but not at all in substance.

There are three visions for the future of medicine in the seemingly insurmountable, but really rather minor, perpetual health care crisis in America. One future of medicine sees physicians unencumbered by useless administrative tasks, wielding sleek and useful technology tools, offering the best medical care to all patients who need and want attention. Another future is yearning for the revival of chickens and charity as bona fide methods of payment for whatever medical care the free market wishes to bestow on the less fortunate. The third and final future is one devoid of most middling and often faulty doctors, where the health of the nation is enforced by constant computerized surveillance with fully automated preemptive interventions.  Each definition is amenable to slight compromises in form, but not at all in substance.Continue reading…

Set My People Free

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By Margalit Gur-Arie

Somewhere between the 20th century Bank ATM and the 25th century Tricorder, lays the EMR that we should have today.

Somewhere between the government-designed Meaningful Use EMR and the Holographic doctor in Star Trek, there should be a long stretch of disposable trial-and-error cycles of technology, changing and morphing from good to better to magical. For this to happen, we must release the EMR from its balls and chains. We must release the EMR from its life sentence in the salt mines of reimbursement, and understand that EMRs cannot, and will not, and should not, be held responsible for fixing the financial and physical health of the entire nation. In other words, lighten up folks …

A patient’s medical record contains all sorts of things, most of which diminish in importance as time goes by. Roughly speaking, a medical record contains quantifiable data (numbers), Boolean data (positive/negative), images (sometimes), and lots of plain, and not so plain, English (in the US).

The proliferation of prose and medical abbreviations in the medical record has been attacked a very long time ago by the World Health Organization (WHO), which gave us the International Classification of Disease (fondly known as ICD), attaching a code to each disease. With roots in the 19th century and with explicit rationale of facilitating international statistical research and public health, the codification of disease introduced the concept that caring for an individual patient should also be viewed as a global learning experience for humanity at large. Medicine was always a personal service, but medicine was also a science, and as long as those growing the science were not far removed from those delivering the service, both could symbiotically coexist.

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2011 EHR Adoption Rates

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By MARGALIT GUR-ARIE

On Wednesday the Centers for Disease Control and Prevention (CDC) released the results of its yearly survey on Electronic Health Records (EHR) adoption for office-based physicians. No surprises. Generally speaking, the majority of physicians in ambulatory practice are now using an EHR, and over half of surveyed doctors say that they intend to seek Meaningful Use incentives. The report is also presenting results broken down by state, so you can learn what folks are doing in your immediate vicinity. The more instructive exercise is to compare last year’s survey results [Fig. 1] to this year’s estimated EHR adoption numbers [Fig. 2].

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Who Should Pay for EHRs?

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By MARGALIT GUR-ARIE

During the 2008 Presidential campaign, Candidate Obama promised an EHR for every American by 2014. The goal was to improve quality of care, reduce disparities and contain costs of health care. When the HITECH act became law in 2009, physicians found themselves under increased pressure to purchase an EHR. Many took action, went out and bought an EHR for their practice, and these are now well positioned to collect the financial incentives put forward by the HITECH act. Many more did not. EHRs are by and large a complex and expensive proposition and the HITECH incentives are not covering the average cost of purchasing and maintaining an EHR. In survey after survey, physicians consistently rank cost associated with EHRs as their top concern when considering transition from paper charts to electronic medical records. This is a bit disconcerting, since physicians have no problem buying other expensive tools and paying for human resources in their practices. How are EHRs any different?

There are three primary stakeholders in health care: those who receive care, those who provide care and those who manage the financial aspects of health care, and no, we are not getting into the quintessential argument of whether there should be only two primary stakeholders. There are several secondary stakeholders as well: those who manufacture medical goods, those who provide ancillary services and those engaged in medical research.

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Fulfilling the PROMISe

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By MARGALIT GUR-ARIE

A brand new EMR is being rolled out in a midsize hospital. The EMR is exclusively based on touchscreen technology, with devices strategically placed on the floor. It provides concurrent access to medical records for all team members (physicians, nurses, pharmacists, radiologists, dieticians, secretaries) wherever they may be. Patients are also accessing the EMR. They enter their own histories and describe symptoms in detail through the same touchscreen devices. This patient-centered EMR, built by a team of clinicians and technologists working together, is taking a huge step forward in Clinical Decision Support (CDS). Physicians are not only shown differential diagnoses based on what patients and other team members entered into the system, but are also presented with individualized care plans, possible side effects, dosage recommendations and drug-drug-interaction alerts, all referencing evidence available in medical literature. Longitudinal records, test results and narratives are available by problem and by patient, and the response time is never more than half a second between the thousands of screens available. The place is Vermont, and the year is 1970.

Half a century ago, when work on this EMR was taking place, Healthcare IT was on the cutting edge of technology. The Problem Oriented Medical Information System (PROMIS), the brainchild of Dr. Lawrence Weed, was pushing the envelope on every technology from hardware to operating systems, to network communications, database design and programming languages. By the time this government funded project was finally shut down, the PROMIS team dealt with such issues as mass storage, federated or single database, high availability, human interface design and networking between geographically dispersed locations. It will take several decades for the rest of the world to catch up with Dr. Weed’s, now defunct, innovation and produce something like IBM’s Watson software package, which is yet to be adapted and tested in health care. Somewhere, somehow, we took a wrong turn in Healthcare IT, and it wasn’t the much maligned billing influence, since PROMIS from day one, attempted to integrate billing in its software, with no ill effects.

 

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Coordinating Care Coordination

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By MARGALIT GUR-ARIE

Care coordination is one of the four pillars of Meaningful Use, one of the six NCQA Patient Centered Medical Home (PCMH) standards and one of the main goals of Accountable Care Organizations (ACO). Care coordination, particularly for patients with multiple chronic conditions, is expected to reduce unnecessary repetition of laboratory testing or imaging and the number of avoidable admissions. Other than reducing overall costs, care coordination is also supposed to improve quality of care. According to experts like Joe Flower, “Lack of care coordination is at the core of the mess healthcare is in”, and nobody in their right mind would argue that it is best that medical care remains disorganized and uncoordinated, if it is indeed so. It seems that our fee-for-service, fragmented and fractured (lots of f-words here) health care system is not conducive to care coordination. When patients float around in a sea of hospitals, physicians, nursing homes and other facilities, each care provider gets paid, and is responsible for the piecework performed at their independent entity and nobody is minding the handoff of patients to the next provider of care, and nobody is assembling a comprehensive picture of the entire care process, let alone orchestrating, or coordinating, the progression of patients between stages of care and the overall needs of patients in transit. What would it take then, to see that the bits and pieces of health care we now have, become a safe and affordable continuum of care?

CMS is taking the lead, as it should, in an all-out effort to encourage health care coordination through various carrot-stick initiatives, aligned to ultimately base payment for medical care on value to the patient, as measured on a population level, instead of fee-for-service and no accountability for outcomes. These initiatives fall into three general categories:

  1. Health Information Technology to assist with documentation, information exchange and measurements as required in any coordination effort.
  2. Incentives and penalties for providers based on measures thought to be influenced by care coordination (e.g. preventable hospitalizations, readmission rates, etc.)
  3. Financial and structural encouragement for vertical integration of the delivery system (e.g. ACOs, consolidation, employed physicians, etc.)Continue reading…