Interesting blurb on consumer use of health plan web sites from Manhattan Research. Matt Quinn writes:

I haven’t read the whole study, but I feel that it significantly overstates the case: 21.9 million Americans using health plan web sites for anything isn’t critical mass… and significant hurdles (specifically in the area of of organizing and providing access to information) still exist with the vast majority of plan web sites to make them useful for what most consumers want (the ability to make decisions on cost, among other things).

I feel that the principal difference between plan websites today and a couple of years ago is the amount of stuff that they provide for their members. There is a lot more of it on most sites. The jury is still out as to whether the stuff that they are providing is accomplishing any of the goals of e-health: making consumers loyal to their plans, achieving administrative efficiencies by reducing call center volume, making patients healthier, or attracting new employer customers through competitive differentiation (an employer chooses a plan based on its e-health offering vs. strictly on price). Although it’s a managed care organization and not a plan, per se, but Group Health Cooperative is doing many of the above and is actively differentiating with its e-health offering.

Maybe things have radically changed in the couple of months since I was knee deep in this stuff, but I don’t think so.

There have been many miracles from biotech but there have also been some rash promises made that haven’t panned out. One of these is featured in this Boston Globe story about Biopure.  Biopure is a company that has been trying to approve and market a substitute blood product. Given the problems with infections in the blood supply and the interest from the military in transportable blood with a long room temperature shelf life,  Biopure’s prospects looked good.   Back in 2001 I heard a stock analyst, who’s name–luckily for him–I’ve forgotten, pitching the stock at a pharma conference. The price was around $25 a share, and when the FDA approved its product Hemopure it was sure to go into the stratosphere.  But the approval never came, and the Street.com ran a series of articles (correctly) forecasting that the approval never would come and the company would run out of cash. Sadly for me, I’d listened to the analyst and bought in before I read the Bears’ version of events.   I keep the few hundred now almost worthless shares in my portfolio to remind me that a) analysts are there to sell stock trades and not tell you reality, and b) that it’s better to take a small loss than a big one! While my minor financial woes are good for a giggle at this distance, Biopure’s story is a salutary reminder that medical miracles are risky and demanding, and that the world of the genome and biotech which promise so much are not certain to deliver in every instance.

THCB, in many posts on the subject of drug-eluting stents, has picked up on the occassional quality issues plauging both J&J’s Cypher stent and Boston Scientific’s Taxus stent in the past few months. But I must admit I didn’t expect Friday’s news of basically a virtually total recall by Boston Scientific of all its DES and some bare metal stents. (Of course if I had expected it, I’d have gone short and pocketed the $3 a share profit!).   Don’t expect drug eluting stents to exactly fall out of style. This is a production quality issue, carediologists remain sold on the value of the stents, and so are patients, even if the widespread use of DES are contributing to the financial detriment of hospitals and, eventually, Medicare and the taxpayer.

A while back THCB reported that there were some murmurs about problems with Boston Scientific’s Taxus stent. That followed earlier manufacturing problems with J&J’s Cypher stent. Now Boston Scientific has recalled about 200 stents with manufacturing defects.

This is probably a very minor hiccup in what has been a stellarly successful product launch. The Drug Eluting Stent (DES), which is on the way to being a $5bn market, has grown very fast to replace the bare-metal stent as a treatment of choice. This transition has helped over shadow research that showed that bare-metal stents (and the TCPA that accompanies them) were not as effective as by-pass surgery. Of course there are as yet no long term studies of the impact of re-stenosis from the new DES–but cardiologists and their suppliers have carried the day, and the drug-eluting stent (which incidentally is beginning to really negatively impact hospitals’ bottom lines) is the latest and greatest thing to hit interventional cardiology in ages. That’s a typical evolution of medical technology–put into mass use before it’s proved cost-effective compared to other treatment largely on implied promise. That’s the way health care works, and three decades of technology assessment work hasn’t changed it, and isn’t likely to soon. And minor manufacturing quality issues, if handled properly, won’t make any difference to that process.

A quickie for July 6th. I have been moving house (and office), had limited access to DSL and THCB has suffered a bit. Sorry, but the move is almost done (You must all come and visit!). My backlog is huge and there’s tons of interesting stuff coming!

Robert Mittman wrote about fuel cells last year and Forbes followed up last week. Hopefully PDA Fuel Cells That Keep Going And Going… will mean that we won’t be searching around for that socket in the departure lounge in a hopeless attempt to keep that phone or laptop going all flight.

I’m on the road this week so things might be a little backed up here at THCB. So please excuse the unusual publishing schedule, but as always you get what you pay for!

Today I wanted to point you at Manhattan Research’s Mark Bard’s article in HealthCare Informatics on the Economics of ePrescribing. Manhattan’s numbers from their physician tracking study are actually showing some stagnation in the numbers using ePrescribing tools. This jibes with a rumor I heard about the Mass Blue Cross and Tufts rollout of ePrescribing using Zix Corp’s Pocketscript. Apparently getting any physician who wasn’t already one of the hundred or so in the pilot program to use it has proved very hard, and instead of the 3,000 targeted for use late last year fewer than 200 are using it so far. However, Bard remains confident:

But he also points out how the economic incentives to use ePrescribing aren’t lining up::

In other words, if the savings is at the pharmacy and the drug company benefits from more utilization, why should the providers pay for the technology? The answer is that so far they haven’t.

A recent spate of studies is out on health care IT spending. iHealthbeat had an article about Forrester Research’s report on health care IT spending, which they think will be $61 billion in 2004. Their estimate is that 3.7% of health care revenues are spent on IT, while for hospitals it’s 5.5% of revenues. Interestingly Forrester says that the rate of increase for hospital spending on IT is less than 2% a year, which sounds dubious to me, but maybe the big increases were earlier in the decade.

This all somewhat contradicts an earlier June 8 iHealthbeat story which bundled together several different studies, including those from Datamonitor and the (newly bought by HIMSS) Dorenfest organization. All these studies showed that the rate of growth in the health care IT market was pretty strong:

The most recent survey from analyst firm Datamonitor found that 66% of U.S. health care providers plan to increase their IT budgets by more than 10% by 2006. In addition, analyst firm Gartner predicted that IT spending would grow to $47.9 billion in 2006, up from $34.1 billion in 2001. Research firm Sheldon I. Dorenfest & Associates predicted that the growth in health care IT spending would outpace that of other industries, growing from $23.6 billion in 2003 to $30.5 billion in 2006.

While all of these totals somewhat disagree and are all measuring somewhat different things, my rule of thumb was that the total health care IT vendor market back in the late 1990s was around $20 billion (or 2% of the total $1 trillion spent). $65 billion out of $1.6 billion is only 4% of all spending (still way less than the oft-quoted 10% spent in other information intensive industries like financial services) but it’s not a small number.

How true that number is can be debated. Last week at Healthtech one CIO told the group that his system was spending 3.8% of revenues on IT, a number he claimed was much higher than average, and no one argued with him. Some others indicated that they didn’t much trust the traditional surveys (and didn’t participate in them).

However, the number is clearly bigger than it was 5 years ago and as the denominator (i.e. overall health spending) is much bigger too, the total spent on IT is increasing. However, the question is what will be done with the money? In the UK, IT spending was relatively low in advance of the recent infusion of roughly $20 billion over 10 years for the new IT contracts. But even that money is less than 3% of all health care spending, and yet the UK has already got almost all of its primary care practices computerized before the big bang approach that’s now being taken to link the whole nation together. In the US, we haven’t got anywhere close to that level of daily clinical computerization use, and apparently we’ve been spending way more than the Brits (2-3% of 14% of a bigger GDP per head, as compared to 1-2% of 7% of a much smaller GDP per head).

Hopefully good old American know-how allied to the emerging demands of government and payers will get us there. The CIOs at the Healthtech meeting believed that they had to act in the next 5 years to survive in their markets. It may be that fear which finally pushes us towards the real use of computing in the clinical setting. But of course predicting the imminence of EMRs has been the graveyard of many a futurist, and may still be.

Following a Matt Quinn story in THCB last month, Mark Spohr, MD, has written to me about the AAFP and its grant from CMS to further the use of EMRs in family practice. This topic is a little obscure but it’s worth me attempting to relay the story and see if there’s any meat here. Much of the credit here goes to Jacob at DocNotes who’s been much involved. As some might find this all a little dry, I’ll try to confuse it with a popular movie trilogy.

Long, long ago, in a galaxy far far away, a feisty EMR company called Oceania (which was a client of mine in the mid-1990s) developed a really cool template based EMR, which a friendly giant promised to use. But the giant, known as Kai-Sir, went over to the Dark Side and turned its Death Star rays on poor Oceania in favor of a more Epic adventure.

But while Oceania’s life ebbed away, its force continued to be felt faintly in far corners of the galaxy. A few years later the EMR that was Oceania’s was seized on by the noble AAFP as the basis for its open source initiative which attempted to free the poor doctors of that galaxy from dependence on expensive proprietary EMRs. Rebel fighters cheered at the thought of the open source force being with them.

But of course the Empire always Strikes Back, and last November as Jacob blogged direct from Republic’s council meeting the AAFP changed gears and went with an "open standards" approach cutting a deal with nine bounty hunting proprietary EMR vendors, for which it lined up discounts. So is Java The Family Doc actually helping to kill off the open source force, or are there simply not enough rebel doctors to help resist the pull of the Empire? In any event, a suspicious organization declaring itself to be at the Center of the M&Mpire gave some tribute to Java the Family Doc.

Now in June 2004 Matt in THCB and others reported that Center for M&Mpire said the grant was supporting open source. As Mark Spohr wrote to me.

The AAFP grant reported in your June 3 blog has been widely reported as a grant to report open source software (including in the Federal Register). However, it appears that the AAFP has changed the project and will be supporting a proprietary software system.

According to a communication from William Saunders, Deputy Director, Office of Research, Development, and Information at the Center for M&Mpire:"CMS’ grant provides some funds to support an evaluation of AAFP’s effort to develop and pilot test a low-cost, standards-based electronic health record that could be used by smaller family medical practices. Originally, AAFP intended the project to develop open source software, however, they were unable to achieve the support they had anticipated from information technology companies and from other physician specialty societies, and found it advisable to focus on testing open standards software instead."

I find it very odd that a grantee is able to change the purpose of a grant after it has been approved. This is not a minor change, it is a fundamental change in the activity from supporting open source to supporting proprietary software. The fact that the proprietary software will be testing data standards is irrelevant.

I’ve been trying to pin down CMS on this and they don’t seem to think it’s a problem for AAFP to change the terms of the grant after the fact. I think an audit should be done.

The AAFP is presenting it’s current activities as a way for a few brave rebel family docs to experiment with various EMR systems, and fight the forces of proprietariness. But as Mark believes, has the dark side of the force over come them and upon accepting the Evil Empire’s aid, have they become Darth Vaader? With possibly much more tribute on offer from the forces of the emperor is there hope that the Millenium Falcon will turn back to help destroy the Death Star so that the brave rebels may regroup for another try? And do the citizens of the Galaxy care?

If you’re interested in this subject, comments to me please, and I promise that I won’t do any pre-quels in the same style, even if George Lucas couldn’t resist the same temptation!

More musings from the Healthtech meeting. Given that this is a somewhat private meeting, and I’m an invited guest, I’m not going to name names, but suffice it to say that the health systems here include many of the largest (predominantly non-profit) regional hospital systems in the US.

So from my non-scientific surveillance, where are they and what are the challenges they are facing? In general the last few years have been about automating their laboratory, pharmacy and PACS (radiology) systems. At least in some hospitals, this has led to reducing costs in testing , and getting results back much faster (in 6 minutes in one case). This of course promotes quicker decisions which filters into lower ALOS and increases ROI. The rest of the effort in the last few years has been about creating the wired and wireless infrastructure that’s needed to support the next stage of their plans–in fact wireless is a major focus.

The new challenge is CPOE and bedside medication records. Now they are starting at varying rates to move to clinical documentation at the bedside and also at the nurses station. CPOE (i.e. getting the physician ordering, particularly medication ordering, in the loop) is the major push many of the systems are working on now. This somewhat tracks with various studies showing that CPOE use is pretty low (of course it’s existed at some hospitals such as Brigham & Womens and Intermountain for several years).

Some of these systems are creating big time process improvements (so long as the medical team is bought into the decision process). But by no means do the medical staff appear to be so compliant in all cases–in one case there was no improvement in several basic process measures. So putting the system in is only part of the battle, and the medical culture still seems to be the biggest hurdle.

One big system (which has introduced a lot of new technologies) is very rigorous about incubating a test-lab learning environment before any new technology is moved into different facilities. This is part of an extremely detailed planning process, which needs exceedingly high levels of buy-in from clinical and operational staff, and rigorous assessment at all levels of every roll out. In other words there’s no organic growth of IT use, its all carefully designed. Nor are new or innovative, but untried, technologies allowed into the system. Instead the IT group makes sure that any devices or applications they introduce does not distract them from their total focus with keeping the network up for Five Nines reliability (99.999% up time). So their priority is keeping the mission critical network up. Their system hasn’t gone done unscheduled in 2 years. Some time ago Paul Saffo at IFTF said that eventually computer downtime (like phone downtime) would start killing people. Plenty of these hospital CIOs seem to believe it. So as IT becomes more integral to other parts of the hospital (ie. lab/pharmacy first, nursing next, then physicians) many hospital systems are looking for incredibly (and justifiably) high levels of network/application uptime and reliability.

And don’t mistake that putting this all in is anything other than damn hard work. The words Six Sigma and Process Improvement were heard alot. All in all they are probably not having as much fun as we technology futurists have looking at all the new toys. But in terms of creating the environment for process-driven hospital-based care, at least some of the leading systems in America are making progress.

Yesterday I was at Healthtech’s conference on The Digital Delivery System. Healthtech is a non-profit research consulting group which conducts research on information and medical technologies, and how their emergence and use will impact hospital systems. Healthtech is led by health care superstar Molly Coye, who’s been in both the public and private sector, and is one of the authors of the recent IOM reports on patient safety and quality. The meeting attendees are IT folk from large hospitals systems that care about how they’re going to use technology to change their clinical processes, while not being shot by their medical and financial staff in the process.

The key issue being discussed at the conference is how do you get standardized clinical procedures used uniformly across a system. IT clearly helps and is a driver, but non-IT solutions work too. The keynote speech was by Brent James, from Intermountain Healthcare (IHC) in Utah, who have long been EMR pioneers. Most of the rest of this is my take on James’ speech. Of course apologies are mine if I misconstrued information, but there was much good stuff in it. James introduced his talk with three quick stories.

a) a color coded discharge tool for severity assessment at Primary Childrens hospital was developed by the residents and was taken up by the management. During a viral outbreak that happens every so often in Utah, they had been so swamped that they had to close the OR for 18 days. When the next outbreak hit, using the discharge tool they were able to reduce ALOS by one day and the OR was only shut for 1 day.

b) Traditionally a general internist plus 2 assistants can manage 600 patients on Coumadin/Warfarin. With a virtual lab seeing the results of patient measurements taken across the Intermountain system, one 50% time Nurse Practitioner plus one assistant can now monitor and look after 1400 patients.

c) James’ dad enters info on an IHC website that monitors his CHF, and monitors his care every day. If any of his measures go downhill, a nurse calls and schedules follow up. He is doing well and is healthier than he’s been for a long time.

James introduced the story of how well medical care has done in improving life and health. Then James got into the nitty gritty of how poorly we’ve done to move that scientific marvel over the context of all care provided to a population. He displayed some grimly amusing charts that showed that Beta blockers were used on discharge for acute MI patients 48% of the time by major teaching hospitals (and only in the 30% range for community hospitals). And this had direct results on mortality 2 years later–mortality was higher in the community hospitals. But more to the point, as he said: "We get it right 50-55% of the time and we achieve miracles. What would happen if we got it right 70% of the time?".

Medicine is much more complex now than it used to be. Back in the 19th century there were 6 active medications; by 1970 60-100 medications. Now as a general internist you should know 600 drugs.

So can you make this complexity better? Traditionally medical practice says you can’t– the mistakes and missing the best care protocols are just the price you pay for complexity. But IHC showed that with a simple check sheet on discharge that the nurse fills out, IHC got beta blocker use from 56% up to the high 90%s! So it is possible to do better than the 55% appropriate care that RAND showed we currently expect! In the IHC system this saved 331 lives per year for CHF and reduced hospitalization rate by 551 admissions. Brent believes that closing that gap represents the future of medicine. But he didn’t want to talk about who gets the money!

Another area IHC has used IT is in avoiding ADEs (medication errors). "Voluntary" incidence reporting reveals less than 1% of actual ADEs. At IHC ADEs went from 15 per year in the 1980s (detected by incidence reporting) to 580 in 1991 (when they started counting using an IT system) but came down to 280 by 1999. At IHC they found that 66% of these ADEs were preventable–hence the reduction. And all this saves money, on average $2,400 per ADE. James thinks their error rate is still too high. But nonetheless he says if you are sick, you should come to IHC in Utah because you are going to have significantly lower chance of getting a complication!

Diabetes care is another area of concentration. (IHC is in top decile for HbA1c control in HEDIS/NCQA). Every quarter their docs get a report card on diabetic care, and IHC gives them a notification of any patient off the protocol–before the patient comes in. This can also work off the EMR, and any time a diabetic comes in a new chart front is printed out with a whole worksheet so that the patient is checked in their visit for all that’s needed according to the protocols. This measurement system is backed up with a home glucometer and an interactive website for the patient. IHC has seen care rates again improve to make them better than the top decile.

Overall the IHC experience, which has been well known within the medical quality and EBM circles needs to still get more publicity. As another speaker said later in the day, no other industry would get away with this level of safety violations. But perhaps if consumers really knew not only that appropriate care was provided just 55% of the time, but there is a real live American example of a place getting it right more than 90% of the time, the reaction would force the system into much faster change.

More on my sense of where the IT folk are on creating the infrastructure for that change tomorrow.