Otherwise known as Blackford Middleton wants to take your money!

The NY Times reports on the latest reports to Brailer about how to create inter-operability in the brave new world of health records. I’m somewhat hopeful but I’m not holding my breath.Partners in Boston lead by ex-Stanford and Medicalogic geek Blackford Middleton) has an updated version of its report that I featured in THCB late last year which basically says that if you implement a full EMR, you should end up spending less money because you’ll do things right the first time, and prescribe cheaper drugs. Another Stanford Prof, Lauren Baker poo-poohs some of the Harvard group’s assumptions about whether there are real savings.

Meanwhile, the Center for Information Technology Leadership (a think-tank a

I can’t really comment yet because this is all coming out in Health Affairs tomorrow and though the NY Times is on their "see it early" list, THCB is not. But Lauren understands well that the health care system can take illusory savings and spend them many times over. And Blackford knows that his work is designed to be provocative, in that most of the savings are for drugs not dispensed that the average clinician isn’t paying for now and therefore won’t accrue any savings from when they stop prescribing them.

More on all this tomorrow, when hopefully I’ve had a chance to look at the articles. (I’ll be on a plane so don’t expect an early update).

Meanwhile all this depends on the typical American physician deciding to go for the EMR prize. And everyone’s favorite medical blogger, Sydney at Medpundit, has decided to do just that. I really hope that she keeps writing about it, because its her experience (and that of docs like her rather than that of the Permanente or Partners’ docs) that will determine the speed of this transformation.

There’s a relatively new site for patients called iHealthBuzz. It’s in the mix with the social networking sites that I keep the odd tabs on, and looks to try to take the disease specific list-servs up a level, although obviously its got a long way to go before it takes over from WebMD or YahooHealth. Is there a need for yet another health discussion venue? Judge for yourself but here’s founder Ellen’s take:

Our goal is to provide an anonymous (email address optional),friendly, useful, free, and trusted environment for those who are in search of health advice, support, and discussion. We are also nonprofit so we don’t try to sell anything at all. As we are a grassroots site that really has started out as a hobby for many of us who are interested in using the Internet to promote health. We created this site to help people. We want to make iHealthBuzz message boards better also. Any ideas will also help. We are here to provide a useful service.

Our goal: To build a busy virtual "cafe" or meeting place where people are connecting around health issues. We want them to share stories and help each other. We hope to create a buzz about health on the internet. Hence i-health-buzz as the name.

There’s a relatively new site for patients called iHealthBuzz. It’s in the mix with the social networking sites that I keep the odd tabs on, and looks to try to take the disease specific list-servs up a level, although obviously its got a long way to go before it takes over from WebMD or YahooHealth. Is there a need for yet another health discussion venue? Judge for yourself but here’s founder Ellen’s take:

Our goal is to provide an anonymous (email address optional),friendly, useful, free, and trusted environment for those who are in search of health advice, support, and discussion. We are also nonprofit so we don’t try to sell anything at all. As we are a grassroots site that really has started out as a hobby for many of us who are interested in using the Internet to promote health. We created this site to help people. We want to make iHealthBuzz message boards better also. Any ideas will also help. We are here to provide a useful service.

Our goal: To build a busy virtual "cafe" or meeting place where people are connecting around health issues. We want them to share stories and help each other. We hope to create a buzz about health on the internet. Hence i-health-buzz as the name.

I must go on record as not getting the iPod. Why you would want to lock into a proprietary format when there are a gazillion (free) MP3s and MP3 players out there–and pay over the odds for the privilege–is beyond me. But then again all the music I like was made by people who are now dead and the last DVD I bought was of a concert that happened in 1986 (which I went to!). So I guess I’m not Apple’s target market.

However in an article that reminds me of the piece I did on torrents last week, apparently another non-target market of Apple’s is using the iPod. Yup. radiologists are moving their digital films from place to place, using the iPod as an expensive portable hard drive. Yet more instances of unusual technology crossovers in healthcare.

UPDATE: Graham Walker reminds me that it’s just Apple’s iTunes that’s proprietary (and where you have to pay money for the music): The ipod plays mp3s, as well as Apple’s proprietary format–all the other music players also support MP3, as well as another proprietary format (Real, Windows Media, etc.) It’s got great usability, works with both Macs and PCs, and you can carry your entire library of music on it.

The next really disruptive technology is already here, but most people don’t know about it. Torrents were mentioned at a health care IT conference I went to last June and no one there other than the geek presenting knew what they were. This article in Wired called The BitTorrent Effect explains. They’re essentially a way of sharing huge files relatively quickly between lots of people. Everyone downloading a file is also uploading parts of it. So the more people (or computers) sharing the file the faster you can download it. I’ve become an avid user of torrents to download soccer matches. It takes about 2-4 hours to download a game (around about a gig). I don’t know if there’s copyright on the games, but as they’re not being broadcast where I live, to me it’s the equivalent of someone else lending me a video tape of the game straight after it’s been shown. Hollywood is rightfully terrified that this will be a version of Napster, with people putting movies up on the web, others downloading them and DVD sales plummeting. But the Wired article suggests that there’s a much greater change going on, with the ability for virtually anyone to start developing their own content, and then to use the web for distribution.

I haven’t really figured out a health care angle on this yet other than moving very large files around asynchronously is probably of interest to radiologists. But like blogging software, and the web itself, this is another example of a fast-moving technology changing the way things are done and the way information is distributed. So continue to pay attention, and email me if you want to know how to access those soccer games!

Unfortunately this stock picker wasn’t paying much attention, but there were some signs that this would happen. Last week a Prudential analyst thought that Guidant was the top pick in medical devices, while the NY Times had a story late last week that Guidant had no clear succession plan. (Hint, hint–if no internal successor, perhaps an external one would impose itself!) And now comes today’s news that J&J is going to buy Guidant (or at least is in talks to buy it). The price mentioned in the article is $24 billion, or about $3 billion more than Guidant’ closing stock price of $68. So if it goes through as is we can expect a price of about $75, or exactly where the Prudential analyst forecast. Perhaps we should pay them more attention in the future.

Where does that leave the device business? Guidant is big in bare-metal stents and has a new drug eluting stent coming out in 2007. It is better know for its defribillators in which its a strong second to Medtronic. J&J is strong in stents but needs to get stronger to combat Boston Scientific, and the defribillator business helps it broaden its dependence on some pharma products that will be coming under competition (like is anit-anemia drug Procit).

J&J has always managed to keep its diversified portfolio of companies more or less happily under one corporate organization. mMost other big pharma have basically relied on their dominant therapeutic areas and have treated their other units like the poor relations. For instance SKB’s role in consumer products was never as successful or as central as J&Js, while Pfizer and BMS have in recent memory sold medical devices business because they weren’t core to their business. Guidant itself was a spin-off from Eli Lilly about a decade ago.

Being a diversified health care conglomerate is challenging because some product lines make so much more money than others. Dealing with Procrit, stents, diabetes test strips and Splenda (not to mention baby powder) under one corporate roof certainly requires different management skills than big pharma usually exhibits, and it lowers the overall margins in the boom times. But when times are tough, it’s clear though that J&J’s diversification strategy has its advantages, given that it’s the only pharma stock to have actually gone up this year–up 20% compared to Pfizer for example which is down 20%. From that perspective Guidant looks to be a good, if somewhat pricey, addition to the J&J steamroller.

If you want a slightly more thoughtful commentary than I provided live blogging the HIT conference, whip over to this column by Dan Weintraub on Technology and Health. Although he doesn’t come out and say it directly, Dan notes that the dis-integration of the system is the major barrier to inter-operability. And of course the VA and Kaiser are the models that he cites as doing the best work here — which means that no real Americans are going to enjoy the benefits (OK, OK, that doesn’t mean that veterans and KP members aren’t real Americans but in terms of the health care system they are weird exceptions!).

As we go into this most uniquely American holiday, here’s a story or two about the place the pilgrims were thankful to get away from. Of course my British friends tell me that Thanksgiving is really on July 4th for them.

First up is CapGemini’s John Quinn (a Brit) writing about why the national health infrastructure initiatives in the UK and the USA are very different. He correctly points out that the UK is some 3-4 years ahead in its process, and that it is basing its infrastructure on a largely government run health system. He also points out that the financial commitment from the government there is huge — adjusted for population it’s the equivalent of $140bn over 10 years here. Adjusted for proportion of GDP spent on health care per head, the UK’s number is closer to the equivalent of $400bn over 10 years. Here, despite all the rhetoric the funding for Brailer’s office was just cut in yesterday’s spending bill, and he’ll be living on handouts for the next little while. Of course private sector players here are spending real money, and even $40bn a year is less than 3% of total health spending. So it’s almost certain that we’ll spend more than that number on IT here.

But it’s what Quinn doesn’t point out that may be even more crucial, as it relates to what we’ll be spending that money on. In his talk last week Brailer noted that the US has two challenges. First getting physicians to use the EMR, and then getting all those EMR’s to talk to each other. The Brits are focusing on the second part of that, the inter-operability piece. By the late 1990s they’d basically already done the EMR piece, albeit in a rudimentary way and mostly outpatient only. The average GP practice in any small British town vastly out-does the EMR-use anywhere in the US, apart from a few notable exceptions. So the Brits are starting from a position of strength in EMR uptake (at some 80% penetration), while the US needs to catch up. And of course the inter-operabilty piece is an imposing (or impossible) challenge here, where there are no incentives for the competitors in a marketplace to cooperate, and no government mandate telling them to, even (as Kaiser’s Robert Pearl pointed out) if it would be good for the health of the community and nation.

Meanwhile I’m sure my British surgeon father wishes this had happened to him; the BBC reports that a hospital in Winchester, Hampshire (which is incidentally where I went to high school) overpaid its doctors by 290,000 GBP and wants its money back

UPDATE: Matt Quinn notes that interoperability could be done, and that there is a private sector model for it–well sort of:

While it’s a vast oversimplification from the cultural adoption standpoint, the technology to implement and interconnect clinical systems across the nation is not too different from the technology that connects all of Wal-Mart’s point of sale and logistics management systems across the country such that anyone in a Wal-Mart store has nearly real time access to critical alerts and supply information and the HQ in Bentonville can monitor and research the whole network.

Of course, a key difference is that Wal-Mart centrally funded such a system and it appears that the federal government will not.  It’s not as if — given the choice — each Wal-Mart store would have funded, implemented and connected it’s own system without central funding.

Oh yeah, and Wal-Mart employees cooperate a lot more than physicians do (i.e. can’t refuse to use the system).

Molly Coye

Molly is the CEO of HealthTech a research organization that looks at this introduction of new medical technologies, mostly from a provider point of view. She was asked how IT is changing health care in California. The answer is not much yet. She’s also going with the line that you can reduce inadvertent services and improve quality (showed the VA numbers that Health Hero Network improved costs). The VA is rolling it out nationwide because they are stuck with those sick vets for life. Of course in California remote monitoring is not reimbursed, so no one does it.

The tech is there but the social and policy infrastructure is not.

Actually several states are getting further along. Wyoming, Florida and Delaware are getting along, but adopting it in California is tough.

IOM (of which Molly was a big part) called in 2000 for a paperless system in 10 years. Not going to happen, but 10 years from now it might be possible. And all the indicators in a very unscientific survey she did asking about patient electronic connections with providers and plans are very low. She wants a state agenda to accomplish that goal. Also numbers aren’t much better in administrative care and clinical indicators.

Molly thinks we need private and public sector state leadership to get this done. But she calls for 80% of health data to be available online in California within 5 years. She says "We need the leaders to step forward". The Feds will help with the standards, including with the interoperability" but we need to do it ourselves in California.

I think that we should put this on the ballot–it worked with Stem cells! In answer to my question Molly doubts that we can get people riled up about chronic care management technology (and from her time in state government she doesn’t like initiatives!)

No cats for Friday blogging, but people blogging instead, as I went to the ballpark witha camera today. Here are some of the people I’ve been watching and chatting with.

Carolyn Clancy, Head of AHQR

Shorter Clancy: AHQR is bought into the concept of DSM adn using IT for it, but that there’s a disaggregated messed up medical system. but there are beacons of hope where cardiac care, etc has been improved

Sam Ho, Pacificare

Shorter Sam Ho, Pacificare CMO. Need to focus on particular patients based on predictive relative risk. Use case management and incentives wth physician groups to improve DM enrollment. It works and saves money, and Pacificare is integrating a huge range of IT functions across the board to get it down via their portal.

Arnie Milstein, MD and Sharkmeister

Shorter Arnie Milstein: The cost of care is going up too fast and that low wage earners are seeing it at 35% of total wages. That’s the shark (chart not online — imagine the difference between 2 lines with teeth!) who’s jaws can’t be shut. Crossing the Chasm is an engineer’s report about supporting the people who have to get more efficient than the advanced technology coming down the road will cost. He thinks that we can take out 25% on costs and increase efficiency by 40%.