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QUALITY/CONSUMER/TECH: Health — On Demand by Pat Salber

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Pat Salber writes The Doctor Weighs In, and she has some pretty interesting thoughts about this consumer health schtick. I cross-posted here but go check out her blog too!

The Internet has changed the way we do so many of life’s routine activities. We shop on-line for clothes, food, birthday presents (thank heavens–no more going to the post office), insurance, dates, and new friends. The list of things we can do and get on the net just goes on and on. PEERtrainer (www.peertrainer.com) has joined many other websites as a convenient, fun way to meet people with common interests and goals. It offers peer support and accountability with 24/7 convenience, and if desired, anonymity. And the Internet is changing the face of health care as well. I belong to Kaiser Permanente, an integrated health care system that makes it easy to make appointments on-line as well as to refill and have my medications mailed to me. I can get my lab results via a secure website and I can communicate with my physician via email.

But I never thought I would be able to get health and wellness services on the web. This weekend, I was at a medical conference and learned about an amazing new website: www.keepyoursight.com. A young ophthalmologist, Sean Ianchulev, described how his company, Peristat Group, has developed a way to screen for glaucoma on-line. Now, I guess I am a little out of date. My first thought was, "How are they going to deliver that little puff of air to my eye via the web?" Of course, that is not the only way to screen for glaucoma anymore. Rather, machines that test your peripheral vision have replaced the air puffs in many health care settings. This type of testing is called perimetry. The Peristat Group has figured out how to mimic what on-site perimetry machines do — on-line. That means, anyone can get screened for glaucoma in the privacy of their home anytime they want. It’s a bit complicated and takes some practice, but the site takes you through some simple instructions and then allows you to practice until you get the hang of it. Dr. Ianchulev tells me they built algorithms into the on-line test that help them weed out tests that are not performed properly. He also tells me they are developing an on-line test for macular degeneration, one of the leading causes of blindness in the US. Imagine, as this technology gets better and better and the test-taking gets easier and easier, glaucoma testing, testing for macular degeneration, and who knows what else, will be available to people “On Demand.”

As we move into an age where consumers are being asked to shoulder more and more of the financial burden of health care, I suspect we will see even more innovation in the delivery of services. The FDA recently turned down the request to have statins, very effective cholesterol-lowering drugs, available over-the-counter (OTC). Opponents of OTC statins worried that consumers would not recognize the rare, but serious side effects of these relatively safe medications. However, such dangerous drugs as aspirin and acetaminophen (e.g., Tylenol) have been available OTC for decades. I can’t tell you how many people I treated for overdoses of these benign drugs during the years I practiced emergency medicine. I think the argument of having to protect the public is one that will not hold up in the long run. Combine the use of home testing electronic devices with great interactive web-based programs, OTC availability of cholesterol-lowering drugs and blood pressure-lowering drugs, and on demand lab testing (available in many states) and you now have a way to get treatment of these common conditions to millions of people who are now untreated or undertreated…and for a fraction of the cost.

I think innovations in health care delivery, such as these, are very exciting, but also threatening to the same folks who have been promoting "Consumer Directed Health Plans" as the way to save the disintegrating American health care "system." But, hey, if I have to pay for it out of my pocket, I am going to get what I want, how I want it and when I want it. If I can get it for free on the net in the middle of the night, I say, bring it on. “Health On Demand,” — now this will usher in the age of real consumer directed health care.

HOSPITALS/TECH: Is the kiddie porn hysteria going too far?

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You would expect Children’s Hospital in San Diego to be very, very nervous about anything to do with porn. After all, this is the place where apparently a nurse and a tech roamed free taking pornographic pictures of children, molesting them, and spreading the pictures on kiddie porn sites.

Wayne Albert Bleyle, 54, who was arrested March 8, has pleaded not guilty to molesting five patients. He also pleaded not guilty to distributing pornographic pictures of patients on the Internet. Christopher Alan Irvin, 32, a nurse who was arrested April 15, has pleaded not guilty to charges of molesting a 4-year-old girl and distributing child pornography.

And speaking from experience I know about second-hand, people do very, very foolish things on their work computers. But it seems that the latest news from San Diego Children’s may be a little over the top. So far three doctors have been suspended because one of them, while logged on to the hospital’s system from home, visited a porn site

Hanscom said using the access code to look at pornography would violate hospital policy whether the images were of adults or children. The access appears to have been on a home computer. Improper use of the code was discovered as a result of more vigorous auditing adopted after the arrests of the two hospital employees.

Now the key issue we don’t know is what type of porn site—and there is a huge legal as well as ethical difference between the secret chat-rooms where paedophiles trade pictures, and the Playboy online type sites. And of course whoever was logged into the hospital’s Internet access was dumb, dumb, dumb not to log out and go off to their own local ISP before looking for smut online. But let’s get real. A huge proportion of Americans look at porn online, and doctors are no different.

Assuming that this is a case of legal behavior at home, that was inappropriately sourced through the wrong ISP, you have to think that handing this over to the “Internet Crimes Against Children Task Force, which includes local and federal agencies” and suspending three physicians and putting it in the newspaper, may be an over-reaction.

Did the hospital management not think to first have a quiet word with the physicians concerned to find out a) which one of the three was the guilty party and then b) have their IT staff and lawyers investigate what they saw, and discover whether their behavior was illegal or just stupid. And if was only the latter, then take some administrative action against them before ruining careers and getting law enforcement involved. Which if it was the former would clearly happen anyway.

Meanwhile, a reminder to all of you out there, make sure that you keep a private Internet connection, email server, et al away from your employer.

TECH/CONSUMERS: It’s care delivery that matters most

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Here’s my FH editorial today….

This week two very different healthcare conferences rolled through San Francisco. One was about Consumer-Directed Health Care and was a cross between a capitalist land-grab and a political pep rally for HSA-backers and Canada-bashers. There are clearly interesting ideas from many start-ups as to how to better serve consumers , and plenty of new initiatives from bankers wanting to get at the new accounts being set up within health care. Google’s announcement of its new “Co-op” service that includes a “Health” component, and Intuit’s deal with Ingenix show that big time consumer companies are viewing this movement seriously.

Later in the week the National Patient Safety Conference saw clinicians discussing the issues of medial errors, nursing and clinical efficiency, and how to use technology to turn around provider performance. That is clearly a much bigger and even more intractable problem than making health care more consumer friendly. It’s also a movement that has been going on for more than twenty years, and we are really only seeing marginal improvements. Health care has many problems, but clearly the care delivery coal-face is where most health care money is spent, and where we have the most to change.

TECH: CDHCC Conf. Report Esther Dyson on start ups

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I’ll be dipping in and out of the CDHCC conference. Yesterday I popped in to remind Esther Dyson that we’d met 10 years ago, but now just know each other via email. (She emailed me during someone else’s talk to tell me to pay attention to it!) Esther didn’t really have a prepared talk—she’d been spending her time going weightless like one of those astronauts in training. She basically said that start-ups had to be realistic and very focused.

I asked her what VCs should be investing in. She suggested management of the chronically ill, such as compliance reminders, and products for women and family aimed at pregnant women and those with newborns.

Given that she’s spending a lot of time holding conferences on personal health records, Esther was asked about her vision for them….but more interesting was who was going to win. She said health plans were not trusted. We need something like banking system. She thinks that employers might be the driver of this. They’re well positioned to be the key. In the end its the consumer who has access, they’ll assign permission to providers and insurers to access that record. Each patient will have broad records, that will cut out lots of inefficiency, and pay up quicker. Then add data for researchers which will improve health care, even without changes in legislation.

Other interesting mentions; she’s getting involved in the open genome project. Genetic information is being put online. Esther will be one of the first to put her genes online. Esther realizes that this is a big political mess. (Perhaps we need an ICANN for health care). She said that we need to be clearer about how we ration things. But she didn’t really follow up on that.

Other talks—CEO of Healthline, the reborn Yourdoctor.com, and Intermap systems spent a while telling us how his search engine was better than everyone else’s. He might have noted that his site is only #7 when you do a Google search on the name, so perhaps the bug guys are scared of him! This is a third time restart for this technology and it’s pretty interesting, so maybe this will work out now. $42m in so far, though!

Ryan Phelan, ex Direct Medical Knowledge (which was basically PlaneTree online) had $5m investment in that and sold it to WebMD for $65m about 25 minutes later….instead of lying around on the beach drinking Krug (well maybe after a few years of that), she’s now started DNA Direct, which is aiming to be a consumer friendly hub for genetic testing. I thought that the presentation was succinct and that she may well have a real long term business model.

Today I’ll be dipping in some more. Pity Reggie is on before I get out of bed!

TECH: Oops! Hospital loses 5,000 X-rays in hard-drive crash

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Ore. hospital loses 5,000 X-rays in hard-drive crash. Apparently 4 out of 5 hard drives failed, and the back-up wasn’t backed up. Still that’s nothing—I lost a whole year of downloaded soccer videos when I knocked over my external hard drive. And I still was too cheap to buy a back-up to the back-up.

Of course some of you might think that the radiology images are slightly more important than say Chelsea’s game with West Brom….

TECH: Just in case you thought RHIOs had a business model..

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…they don’t, at least so says an HHS funded study by Avalere Health

While some states have progressed, the Avalere report highlights challenges in achieving national goals. None of the highlighted HIE projects — even those with deep political and physician support — have established a sustainable business or financial model. Some states are also struggling to gather providers and other commercial organizations’ agreement on technology standards and win over their long-term support.

At IFTF we (Jane Sarasohn Kahn and I) wrote a report on CHINs in 1994 which basically said we didn’t think they’d be much more than a sideshow—and it turned out we were over-optimistic!  Not that much has changed. Some things have, but there are few incentives to promote inter-operability. Don’t believe me, Brailer said as much when I saw him talk two years ago.

The incentives that prevent interoperability can be (and ought to be) changed—if we want to use that Medicare carrot/stick. But that would mean Congress taking on a litany of providers, payers and vendors…

POLICY/PHARMA/TECH/PHYSICIANS: The Industry Veteran thinks Uwe and McLellan are missing the point

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It’s been a while since we heard from The Industry Veteran, but the dialogue between Mark McClellan and Uwe Reinhardt I reported on at WHCC last week did raise his hackles. I love Uwe’s analysis and think McLellan is very sensible (though suffering from obvious political restraints). But the Veteran didn’t exactly see it that way. Here’s his sense of what ‘s wrong with health care and how to fix it.

The dialogue you reported between Mark McClellan and Uwe Reinhardt was hugely disappointing as both appeared more intent on glad-handing each other than identifying culprits in the health care system. I offer the following as a useful rule of thumb for THCB readers: whenever someone says more IT represents a principal solution to a better health care system, the red light should flash on one’s shit detector.As uncle Marcus Aurelius advised, let’s return to first principles. Assuming THCB wishes to address the big issues and not turn into a blog for techie nerds, the problems of health care cost, quality and access in the U.S. result from some basic factors. The first of these is that there are too many middle men extracting too much profit (or, in Marshallian terms, too much economic rent) from the system. Among these, third-party payers are both pernicious and dispensable. Most analysts euphemistically classify payers and the efforts of other sectors to deal with them as “administrative costs.” It seems I’ve been seeing these administrative costs pegged at 25-30% of the health care bill for the past twenty years. Since Bush’s millenarian-oil junta has been running the country, I would guess that figure to be substantially higher because payments to providers have been tapering while premiums keep escalating. Given that the administrative costs for Medicare are approximately 2%, it appears self-evident that the current system, based on employers and insurance companies, should appeal only to Reagan-Bush types who consider the proper role of government to be one of handmaiden to business.Within the provider segment, specialist physicians are another extortionist bunch. There is simply no defensible reason for every mother’s doctor-son to expect an annual income between a quarter-million dollars and $650,000. Do I hear in the background, diminuendo, the arachnid voices of techie wonks crying for tactical proposals in lieu of venting and ideology? Sink your incisors into these. (1) Use relative value reimbursement scales to promote a systematic de-skilling. (2) Increase the labor supply in the medical specialties with U.S. citizens who graduate from foreign medical schools. (3) Feminize the medical profession by elevating nurse practitioners and using staff-model and other arrangements that permit 9-to-5 shift work.Manufacturers, particularly in pharmaceuticals, are due their reproach as parasitic middle men. The European countries routinely use reference pricing to help keep them in line and health care’s Iron Triangle of cost-access-quality does not appear worse there than here. In fact the WHO rates U.S. health care as thirty-something in world while France receives the number one spot.Now you’re probably correct, Matthew, in pointing out that the public opinion polls on health care have to show a larger percentage of people expressing a vehement discontent with the system over a sustained period before substantive change can occur. To foster that attitude, I humbly advise interested parties to hammer away at the big issues instead of creating diversions and wasting time with minor tributaries such as IT. I believe there is sufficient greed to expose, enough contradictions to raise and tragedies to highlight, all of which can help prepare the public mood. The drama that can affect public attention, however, seldom resides in the IT department

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