So I spent part of yesterday at the HIT meeting west in San Francisco.  The most amusing session has Molly Coye  pretending that she’s the governor, and apart from the wisecracks about steroids and occasionally forgetting that she’s supposed to be pretending to be a Republican, there is some serious discussion of how information exchange between systems in California might work. This is the creation of the RHIO (regional health information network) to get to that mythical state of  inter-operability.

The CMA rep (Jack Lewin) believes that his members–all those poor solo surgeons struggling by on $200K plus a year–can’t afford EMRs or any inter-operability and shouldn’t be given an unfunded mandate to get on it.  In fact he thinks that if a RHIO made health plans better off due to the elimination of duplicate testing, then they should be taxed $25 per head to pay for all this.  I don’t think that Arnie Milstein (Med Director of PBGH) representing the employers. They are not too interested in paying any more than "their fair share". On the other hand Bob Margolis (CEO Health partners, the second biggest group in California with 1,000 docs) thinks that the state and Federal government should just piggy back off the private efforts.  In other words let Health Partners connect to Kaiser and hope everyone else can hang on. No reason for those two to slant it to their advantage, is there?

Well at least they are all talking about business models and there does seem to be some agreement that there is money to be saved, at least if anyone’s information was available when they showed up in the Emergency room. So that may be a place to start, as it appears to be in Indianapolis, but while (as Jeff Rose says) at the end of the day people want to do a good job, waiting for that to happen may take a long long time if no one’s funding the inter-operability. In fact in Santa Barbara there are, after all that time and money from the CHCF, only 50 odd doctors are on the system.

David Lansky (Foundation for Accountability) on behalf of consumers pointed out that the industry is getting $10,000 a year from each consumer and yet it hasn’t got enough money, wants more….and the industry is having the meeting about moving the consumer’s data around without telling the consumer about it! (The only funny line so far!). He wants consumers to get a seat at the table, and wants the product to serve the public more than the industry.  Plus he wants privacy and auditability, and for the info gathered to used for report cards, quality and who to go to–in other words accountability! And he warns that if industry does this without the consumer, then the consumer will torpedo it later (shades of the backlash against managed care).

So how to move things ahead? Jeff Flick from CMS likes demos, like the small and hard to find (unless you know how to spell it) DOQ-IT program. He also likes putting up data for consumers — Medicare has done it for nursing homes and home health. Their comparative data is changing behavior and being accessed by consumers, but at the moment they don’t have the data for the rest of the system, especially doctors.  In the end though he thinks that a successful RHIO will allow access to that data —  another good reason for providers to resist it.

Jeff Fickenhaser (ex WebMD now CSC) says that to get RHIOs to work you need a) organization — all sides at the table inc payers and providers, b) leadership, c) clear sense of where the money will come in and where the value is created, and d) the data has has to be transparent.

It all sounds very like a CHIN meeting in the mid-1990s  I hope it has a better outcome, but I still see no reason why it will. There doesn’t seem to be any common ground and there doesn’t seem to be any money or business reason to do it. And that’s not my idea, it’s what David Brailer himself said at the last HIT conference out here.

BONUS : Great quote from Arnie Milstein"My aim is to change the direction of begging"

(That is begging from medical directors and quality people having to beg physicians to get involved to the other way around because the market is going to punish them if they don’t)

I’ll be at the HIT West conference later today hopefully with a little live blogging if things go well.  But meanwhile two articles over the weekend persuaded me that plus ca change plus c’est la meme chose in the wacky world of American health care.

15 years ago I wrote a thesis on the spread of laproscopic cholestectomy (gall bladder removal), which replaced both the conventional surgical method and a sound wave machines called a lithotripter to blast the gallstone. Lithotripsy didn’t actually work in that the gallstones tended to reform later.  Lap choles did work, and were self-evidently better than laparoptomy (surgical dissection and removal).  But in the case of a new surgical technique or procedure, there is no clinical trial required before it hits the market. Lap chole was popularized by a Tennessee surgeon called Eddie Jo Rickett.  In his heyday in the late 1980s, he was teaching other surgeons how to do it 50 week for a couple of grand a time.  He made so much money that (if I recall rightly) he quit surgery and became a country and western singer. Of course everyone had converted over to lap choles without any big clinical trial, just as lots of hospitals had bought million dollar lithotripters who’s main use a couple of years later was as a doorstop. Meanwhile the quick spread of lap choles also produced some real horror stories.

A decade further on not much has changed.  Today’s trendiest surgery is bariatric bypass (or stomach shrinking).  You might think this is pretty rare but there were over 150,000 done last year in the US including weather man Al Roker. However, just like lap choles and anything else that’s spreading fast, there’s not really any good trial data that shows it’s an effective treatment in the real world.  This fascinating and long article in the St Louis Post-Dispatch shows that like lap-chole and laser eye surgery, bariatric surgery has become a cash cow for some hospitals, and a stampede of surgeons learning the technique has massively increased its use.  Of course the backlash is starting and patients including former proponents of the surgery are starting to come forward with a litany of complaints, and many professionals and facilities are either getting out of the business or are starting to offer repairs on the shoddy work that’s being done. The article starts with this grim story:

She dropped from 302 pounds to 126 after her gastric bypass surgery in 2001. Since then, she’s become a strong advocate for other patients,
providing encouragement and advice to hundreds who have had weight-loss
operations. She arranges visits to the hospital rooms of people just
undergoing the surgery. From her home in Cincinnati, she runs a support
group called "Midwest Losers." Her work was honored with an award last
October at a national surgery trade show. But she’s paid a price to be thin: Five surgeries in four years for
related problems, including two hernias and three small bowel
obstructions. She was just diagnosed with a crippling vitamin
deficiency.She’s 41 now. She wonders how much more her body can take. "I’m second-guessing everything right now," Pierce said recently. "Is this what I have to look forward to the rest of my life?"

The point is of course that these surgeries spread in an uncontrolled fashion.  While there’s been plenty of criticism of the FDA, there just is no equivalent body demanding a clinical trial of surgical procedures, and any government agency that even dares to suggest such a thing needs to be wary of the fate of the AHCPR which fell foul of some Texas back surgeons in the mid 1990s and damn nearly was killed off by the surgeons’ friends in the newly Republican Congress.

The only time that surgery tends to get a clinical trial is if Medicare does one (which is rare) or if it involves a medical device regulated by the FDA. That’s just happened in the case of the drug eluting stents (DES).  A new study shows that the DES (Taxus from Boston Scientific and Cypher from J&J’s Cordis unit) both are much more effective than bare metal stents. (Incidentally both stents worked equally well and a new one from Medtronic coming on the market next year did just as well too. In any other industry you might expect a price war, but here don’t hold your breath)!
So at least there’s some good news that the trial proves these things are helpful.  But let’s consider two things.

1)  Virtually anyone who needed a stent was already getting a DES. Even despite the manufacturing problems both major stents have had and an entire recall of the Taxus stent last year, their use has been growing like crazy and they are the dominant treatment of choice for early stage heart blockages.  All this happened well before any clinical trial results came out. So what was the point of the trial? I guess it was like phase IV post market surveillance in the drug world.  But if the results had been bad, would it really have stopped Taxus and Cypher in their tracks? I doubt it.  Why? See reason number two.

2) Because the trial is comparing DES to a treatment that is known to be pretty useless.  The Bare Metal Stents have a high degree of re-occlusion. In other words the arteries they are placed in clog up again anyway. In late 2003 a Stanford study showed that that stents were less cost-effective than traditional by-passes. So the real challenge for the DES is to prove that over time they are more cost-effective than CABGs.  Do you expect to see that clinical trial any time soon? Nope, neither do I.

So 15 years on from the lap chole and lithotripsy story, we still don’t have anything like the clinical controls over new types of surgery that the FDA imposes over drugs.  And you may have noticed that some grumpy people have been complaining that the clinical trial and surveillance system for drugs is too lax!

I am wrestling with a much longer piece on the EMR than I was hoping it would be, but silly me I’ve got myself mired in CHINs, ePrescribing and RHIO.  And given that I’m going to see Duran Duran tonight I will doubtless be further into "Rio" before I’m done, and hopefully she’ll still be dancing in the sand…

So meanwhile go look at these pieces.  In the first Healthcare Informatics features Nine Tech Trends that it thinks are hot in health care. I’m not certain that the list is quite correct, but it’s well worth a scan and I do like this one quote from a hospital CIO in New Jersey:

"I really think we’re just beginning to see digitization," Sharrott
says. "I think if we’re talking 10 or 20 years out, the amount of
integrated digitization is going to be amazing."

Meanwhile the ever wonderful Jane Sarasohn Kahn has her wrap up from HIMSS over at iHealthbeat. She pretty much confronts the inter-operability issue head on. 

Finally, Brailer is very concerned that adoption will be done in silos,
creating more IT fragmentation and an even greater barrier to
interoperability. This is a very real possibility because in the United
States we’ve made an art out of building a fragmented health system
based on outmoded regulations, unchecked competition and other
externalities. The great value for Americans and the national economy
in achieving interoperable health information networks will be what
Brailer calls "the ubiquitous sharing of patient information."

The
leap of faith here is that nationally interoperable health information
networks will be developed as regional programs adopt sharing through
open standards and convergent business practices and policies. As
Brailer characterized, interoperability will occur "not from the top
down, but inside-out."

Developing interoperable health
information systems will require the collaboration of the broad range
of stakeholders in communities to give up their proprietary data
concerns and ante up cash and a collective spirit.

Those of us who spend too much time whining about why this or that health plan can’t get their IT and customer service together now have a chance to do something about it. Highmark, one of the nation’s biggest and richest Blues plans is looking for a VP of Healthcare Informatics, and via one of their vendors asked me to publicize their search.

Here are some minimal details –the catch of course is that you have to move to Pittsburgh (cue abusive letters about snobby Californians…). You can email me if you want the full description and I can send you on — (and no I’m not getting a cut!).

By the way the first job for the new VP of Informatics should be to fix the careers part of the Highmark web site which is totally fouled up when viewed in Firefox and not a whole lot more helpful (but at least is functional) when viewed with Explorer.

I’ve always noticed that the first day of HIMSS is the biggest each year for press releases in health care IT. But this year I thought that I’d actually go and cull all of them. So here is all those that appeared before 12 noon EST on Monday. There are quite a few (over 75), and it indicates that, vaporware or not, something is going on in this industry.

Take a moment to peruse the list–obviously I don’t expect you to read them all, but you’ll get a sense of what the IT sector of the health care industry is considering news.  And that includes wireless, EMR and patient records, security issues, and medication safety systems.

Itemfield Charts Growth in Healthcare Application Integration with Recent Wins

Siemens Health IT Innovations Drive Workflow-Enabled Transformation in Healthcare

NEC Solutions America Delivers TouchPass Secure Single Sign-On to Atlantic Health System

MedSeek Launches Professional Services Division to Optimize E-Health Initiatives at Hospitals & Health Systems Nationwide

CodeRyte Expands Computer-Assisted Coding Solutions to New Specialty Areas

Two Healthcare Industry Leaders Select CodeRyte Medical Coding Technology

iAnywhere Database Helps Healthcare Partners Revolutionize Point-of-Care Solutions

Anywhere MD INC. (OTC: ANWM) Has Successfully Secured Its Proprietary Desktop and Handheld Computer Programs Against Software Piracy and Duplication

Axolotl Consultants Lead HIM Departments Into the Information Age

Mercy Health Partners Targets Medication Safety Imperative with McKesson Clinical IT and Automation Solutions

Nation’s Leading Hospitalist Network Provides Epocrates Essentials Mobile Clinical Reference Suite to its Physicians

MedKey to Use SanDisk SD/USB Combo Card in New MedChip Product Line
GE Healthcare Unveils Vision of Digital, Wireless and Paperless Healthcare

MedcomSoft to unveil MCDR – its revolutionary clinical data repository for communities

Digital Angel Corporation Ships Electronic Products to USDA in Connection With Study of Chronic Wasting Disease

ScanSoft Dragon NaturallySpeaking Becomes De-Facto Standard Speech Recognition Solution for Healthcare Industry

ProPath Deploys Sybase Technology to Streamline Laboratory Operations

Sybase Tapped for Clinical Information Systems in Two Top Montreal Health Centres

MCS Health Inc. Announces Its Physician Drug Solution Now Available on Blackberry Wireless Handhelds(TM)

Misys Healthcare Systems Connects Physicians Remotely with Misys CPR’s First Web Browser Release

Lawson Signs Multi-Suite Software and Services Contract with Michigan Cancer Center

Regional Healthcare Provider Completes Lawson Multi-Suite Upgrade

GlobalSCAPE’s Healthcare Security Solution Enhances and Protects Electronic Data Exchange Processes

OptiFlex(TM) Supply Chain Software Added to Omnicell Color Touch Supply Cabinets

Mercy Health Partners Targets Medication Safety Imperative with McKesson Clinical IT and Automation Solutions

McKesson’s CarePoint-RN(TM) Gives Nurses Unparalleled Point-of-Care Solution

Omnicell Rolls Out New vSuite(TM) Service Program at HIMSS,

Eclipsys Unveils its ‘Vision of Health’ by Demonstrating the Connected Enterprise at HIMSS 2005

SpectraLink Unveils New Wi-Fi Handset for Healthcare

Arrow International Announces Dividend Increase for Second Fiscal Quarter

Sentillion Selects CTG as Systems Integration Provider

Sentillion Showcases New Security Enhancements to Flagship Product Suite

Hospira and Bridge Medical Announce Agreement to Develop New Medication Management Solution for Use at the Patient Bedside

GetWellNetwork(TM) Introduces PatientLife:)System(TM) to Help Hospitals Achieve Vision of Patient-Centered Care

Xiotech Announces Expanded PACS Support for Healthcare

StorageTek, Partners Team to Provide Award-Winning Care for Health Industry Information

Picis Named Finalist for Microsoft Healthcare Users Group Annual Award

QCSI Introduces the NEXT Breakthrough… QNXT 3.0 at HIMSS 2005

IDX Expands Healthcare Performance Management Capabilities with New IDX(R) Flowcast(TM) Metrics Manager:

Dynamic Health Strategies Selects Intransa to Provide Low-Maintenance, Flexible Storage Infrastructure

Nortel, Verizon Deliver Healthcare Solutions to Leading Providers

Trusted Healthcare Information Solutions Alliance (THISA) Launches at Annual HIMSS Conference in Dallas

MEDecision Puts Payer-Based Patient Record in Doctors’ Hands

RxHub and Performance Partners Demonstrate an Immediate Impact in Reducing Medication Errors and Saving Costs

Demand for EHR Connectivity in Community Settings Drives Growth of Kryptiq Corp.

A4 Health Systems Unveils New Products at HIMSS

Kryptiq Introduces Disease Management Product Developed for Providers:

etrials Partners With The Cardiovascular Research Foundation

HIMSS Honors Healthlink Executives at Annual Conference

Swedish Medical Center in Seattle Selects Softricity’s Software Virtualization for Major IT Infrastructure Update

Intellitactics Demonstrates Industry Leadership with Intellitactics Security Manager Suite Featuring Foundation Services

InterSystems and Sapient Demo New Virtual Electronic Health Record at HIMSS 2005

Cardinal Health First to Integrate Medication Management Solutions for Hospitals

Boston Medical Center Chooses InterSystems’ Ensemble Universal Integration Platform

           Media Alert for StoredIQ

EMRConsultant.com Demonstrates Physician Matching Proprietary System at Booth 6561 During Healthcare Technology Show

PhDx Systems and Smith & Nephew Sign Agreement

Softmed Systems Announces Mobile Healthcare Documentation Solution

SoftMed Systems Continues to Earn Honors from KLAS Enterprises

Leading Healthcare Organizations Select WholeSecurity to Protect Endpoint Computers

Kodak Announces Aggressive Push Into Healthcare IT

Santa Barbara County Care Data Exchange and CareScience Announce Next Step in Roll-out of Care Data Exchange Solution

MobileAccess Introduces Enhanced Wi-Fi Solution Ideal for Healthcare Providers

Greenwich Hospital, a ‘Top 100 Most-Wired Hospital,’ Deploys American Power Conversion’s InfraStruXure(TM) On-Demand Data Center to Cool Blade Servers

St. Mary’s / Duluth Clinic Health System Selects MobileAccess for Wi-Fi Network

Symbol RFID Systems Will Support Law Enforcement to Reduce Drug Counterfeiting

Artificial Medical Intelligence Introduces EMscribe Dx For Automatic Scanning and Coding of Medical Documents

North Shore-LIJ Health System Partners with Cerner to Optimize its Laboratories

Fresenius Deploys Applix TM1 in Multiple Business Units

Media Alert for StoredIQ

QMed, Inc. Becomes the 1st Disease Management Firm to Successfully Complete Sarbanes-Oxley Audit

DST Technologies to Launch AWD Healthcare Process Management-TM- Platform at HIMSS Conference in Dallas

St. Croix Systems Names New CEO

CHRISTUS Health saves $12 million by standardizing 25,000 employees on Kronos

Metro Health Replaces SeeBeyond Software with InterSystems’ Ensemble Universal Integration Platform

CareGroup Goes Live with Web-based Electronic Health Record Built on InterSystems’ CACHE Post-relational Database

Novell Helps Healthcare Providers Organize, Secure Patient Information

Today is the first day of the annual HIMSS conference. I should be there, as it’s the main meeting and greeting place for all health care IT. In the past I’ve been there because my company (either a consulting firm or an IT vendor) paid my way. More recently if I’m not going in a paid capacity to work for a client, I’ve been going to conferences as a combined blogger and editor of Fiercehealthcare. Several conferences have let me in wearing that hat as a Press person. And if I’m not being paid to be there, and I’m reporting on the conference on my blog (as I did with this one on HIT in San Francisco) I don’t see why I can’t get a Press Credential.

But that’s not good enough for HIMSS. They told me that they’d never had a blogger request before, and that as I wasn’t a full-time employee of a mainstream media publication, I couldn’t get a press pass. Well actually they said they would consider it and get back to me, but of course they never did. Apparently they wanted people who would be independent. I did point out that as a solo blogger not working for anyone at all I was a damn site more independent that a typical trade press journalist. But perhaps independence is not what they really want…

The amusing thing is that the people dealing with this were not HIMSS themselves, but their PR company. How having me write a pissy post like this rather than blogging live from the conference for 4 days improves the show’s PR is beyond me. But apparently that’s what they wanted.

While I spend far too much time on THCB arguing with Sydney Smith at Medpundit, her blog remains fascinating. At the moment she’s putting in a EMR into her small office practice. Now she’s not the first physician blogger to use an EMR — Enoch uses Epic at the Palo Alto Medical Foundation and Jacob is an early adopter. But those two are atypical nerds (sorry guys!). Given that she’s more or less typical of the majority of the physicians in the country, in that she’s a heavy Internet user in her personal life but hasn’t used a computer too much in her day to day practice workflow, Syd’s experiences are very important, and you should all follow them.

Thus far she’s finding that using the computer is making her slower than she was and that her staff are having some trouble adjusting to the new workflow patterns. This is a pretty typical experience from what I know about EMR installations at larger clinics. But in a larger clinic these dislocation costs don’t directly affect the physician’s income, whereas in a solo practice either the doctor has to work longer hours (and pay staff for staying longer) or see fewer patients. So they’re one huge reason why solo and small practice docs haven’t put in EMRs.

It will be very interesting to see Sydney’s results as the system she uses becomes more familiar to her and her staff, but there are already some positive results for some of her patients that I’d venture to suggest are improving the care they are receiving overall. And today there’s a study in JAMA which shows that information is likely to be missing from one primary care visit in seven, but that it’s much less likely to be missing if the clinic in question has a full EMR.

Syd is to be commended for both taking this leap and keeping us informed about it — warts and all.

Over at Medpundit Sydney Smith takes a hillarious rip at Bill Frist’s vision for the IT interconnected health care future. And she’s wrong in one of her takeaway points and right in another. She’s wrong that IT and interconnected EMRs won’t benefit patients. Although they probably won’t help too much in the case of the heart attack that the mythical diabetic in Frist’s example has, they certainly will have a great impact on making sure that diabetics and other chronically ill patients actually get the routine care and routine bullying that they require to stay healthier. The same EMRs, if we are to suspend disbelief and belief that they will be interoperable and shared, will inform all clinicians about all the drugs a patient’s on, so they don’t have to rely on the list the elderly patient wrote on their arm (or just guessed at!). Of course the benefit to patients may not be a benefit to doctors–especially ones in small practices who don’t really have the ability to change their work processes. But surely Sydney’s not preoccupied by those concerns?

On the other hand, Syd is probably quite right that the perfect information about the health status of the individual will allow insurance companies to cherry-pick the best risks and discriminate against the sick. Of course the real joke is that Syd has in the past railed against government medicine (i.e. anything to do with Kerry) and is a firm conservative Republican. Yet the only way out of the insurance conundrum is to put every patient in the same risk pool. And that is something that Sydney apparently wouldn’t like because it’s called mandatory universal health care.

Amazingly enough even the American public eventually couldn’t produce enough marks interested in generating a false positive using cash out of their own pocket to keep the body-scanning clinic business in operation. It was apparent from some consumer data IFTF had in 2003 that these centers were running out of new patients, and their chances for repeat business were slim. Americans in general don’t like paying out their own pocket for health care services which feel like ones their insurer should be covering, and this kind of high-end preventative service will have a limited appeal even amongst those for whom $1,000 means little financially, once people figure out that their doctor regards it as a pain rather than a good idea. What I found most interesting was the business destination of one of the doctors in at the start of the trend:

As for Dr. Giannulli, he has moved on to other things. He founded a company, CareTools Inc., which sells software for medical record keeping to doctors’ offices. That, he says, is the new frontier in medicine.

I assume he’s looking for a quick score there, too. Good luck, mate!