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TECH: More on Tech from Ix

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Holly Miller runs Cleveland Clinic’s MyChart. Cleveland Clinic has rolled out Epic EMR to its main campus, all its primary care clinics and about 25% of its affiliated specialists. Also rolling it out to community physicians who admit to its affiliated hospitals.

MyChart is a complex combination of a view a) into the Epic system, plus b) to their own editorial information plus c) into WebMD content (to which they supply content). The information has been empowering to patients. They can see the visit note, which includes a patient instruction function. The patient can get information about all kinds of stuff based on their own test results, connected to those results, including what the test is, what it means, and what the normal range is (plus whatever note the doctor wants to add). She has one patient who read up on diabetes in conjunction with a physicians visit, realized that she was on the verge of becoming morbidly obese, and read up on how to stop it. 70% of messages sent out are opened in the first week.

They are now starting to have information from diabetics input straight into the system, with immediate feedback on results, including surveys, information, etc, and what to do if the measure is way out of line (It also has histories, etc,etc). They’ve been running the study for a while. Only about 25% are looking at the information links they’re sent, but more are looking at lab results.

They’re pretty serious about this, and have a person who’s job it is to monitor web behavior both in terms of customer service (following up on appt requests within a certain time) and trying to figure out how to move and improve patient online behavior. Keep watching this space….with PAMF, Kaiser and Group Health of Puget Sound, these guys are leaders in the provider-based PHR world.

POLICY: The Uncertain Future of Public Retiree Health Coverage

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Brian Klepper has been warning about this for a while. Public agencies have much better benefits for their employees than their private equivalents. And they don’t account for those future costs. There is a FASB106 moment coming up—it was FASB106 that inspired private corporations to push managed care in the 1990s by forcing them to put their future health care liabilities on their balance sheets. Same thing is about to happen to government agencies, hence the new CHCF focus on The Uncertain Future of Public Retiree Health Coverage.

“These accounting changes will illuminate the significant and growing impact of retiree coverage on many public agency budgets,” said Marian Mulkey, M.P.P., M.P.H., senior program officer at the California HealthCare Foundation. “Difficult decisions about spending priorities will follow.”“By confronting this issue head-on and weighing options, elected officials, administrators, unions, and other decision-makers can begin to identify remedies to this complex problem,” said Dr. Smith.

In other words the brown stuff is about to fly through the air to hit the whirly thing. 

QUALITY: DM on Medicare Health Support, and a nice award

Next up at the Ix conference, Medicare Health Support got three cheerleaders telling us that they’re doing very, very well (Sandy Foote ex CMS, George Bennet from Health Dialog, Michael Montijo from American Healthways. There;s lots and lots of details about how to do this, and there are lots of problems to be overcome. But it works. I wont go into the details as I’ve written plenty about it a while back. And my sense is that the lack of DM is so apparent in the wider health system that basically any intervention which concentrates on educating and informing people about their health works.

I want to know whether it will work when we look to crank down beyond the 5% savings that Medicare Health Support committed to making today. Usually the rule is that Medicare overpays the private sector for what it does. But perhaps we’ll never find out.

Meanwhile, Ted Eytan, who’s the MD who runs Group Health Cooperative in Seattle’s Informatics group just won the first annual award for really making a big difference in information therapy (not sure what the award really is called but that’s what it’s about). No question that GHC is a leader, and kudos to Ted for making it so! (Ted is also the sponsor of a secret blog which will appeal to you process types)

POLICY/HOSPITALS: UNC relents from going after the house

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Jerry Ansley has had a pretty tough time, catching encephalitis, going to the hospital alot, and losing his life savings because whatever level of health insurance he had wasn’t enough. The good news is that after lots of pressure Univ of North Carolina Medical Center has relented on its legal claim to go after his house—all he had left. Nice, eh.

This is the kind of horror story that we’re going to see lots and lots more of in the coming years—especially next year when Jonathan Cohn is going to become a big media star after his sifting through the appalling underbelly of the insurance market, or the lack of it, appears in print.

TECH: Physicians and patients at the IX conference

I’m getting a little late start this morning, and sat through a few talks without taking decent notes. Suffice it to say that Al Mulley talked about reconciling patient and physician expectations which funnily enough are not always the same. Geisinger’s Buzz Stewart is re-engineering the patient visit using structured patient history questionnaires. Ashley Peterson has a 5 years old child with severe developmental disabilities, and is very very active in her clinic in essentially managing the teams of clinicians, therapists et al that help care for her daughter. She’s really helping them redesign how they communicate with patients. She has a life most of us would just not be able to handle and she’s really pushing the barriers. Amazing, harrowing and inspiring.

Next is a session about tools being used for Ix. First up was Janet Wright, a cardiologist from Chico in a paper-based office. She’s trying to do the right thing but her job is close to impossible (similar to the Dr. Mom on THCB lately), and she’s not sure how to handle the year of the “switch” if she puts in an EMR. Then Kate Christensen from Kaiser tells up about KP.org, the patient view into the medical record. Pretty soon they’re adding things like pictures and device-entered data to all the other things that patients can already communicate (questionnaires, instant history). And she thinks that physicians will be engaged. Jeff Levin-Schertz from Partners (Mass General/Brigham) who is in charge of getting their community centered docs on board with EMR and Ix, and by the quotes he showed they’re a crotchety bunch. They offer their home grown Mass Gen system and the GE Centricity system (the old Medicalogic) to their docs, most of what their docs have they can also swivel the screen and show the patients. They do have a patient portal but at the moment it has limited functionality—but they are able to push letters, test results and other information to patients that way. There are some good results from rolling out this EMR and some keen early enthusiastic physicians. But as he says “getting physicians on board with this stuff is not easy.” Anyone who thinks it is, should read the lots and lots of comments to the “Can Doctors Ever Learn To Love The EMR” post from last December.

TECH: Brief cuts from mini presentations

The conference has a series of  little demo sessions which look at new tools for Ix

Medseek. Spend the last ten years building web portals and content management systems for hospitals. Their 4 audiences are patients, consumers, employees and providers/physicians.

Their aim is for personalized, targeted in time and documented. What they have put into the eVisit is delivery of written documentation but done through the web. Henry Ford has implemented the MyHealth personal health site relevant to their site. They have inbox for messages, different transactions and different personalization. All this is within Medseek’s tech world (which lies ontop of their home grown EMR) or adjacent to it.

For the eVisit they first present them with a billing set-up and then a profile creation site (very similar)—then patient is matched to a record number in the HFHS EMR. Then they select their physicians—may have been instructed to do this by their physician, and might be able to tell their usual complaint or introduce a new one. Then they go through a clinical questionnaire of 15–25 minutes (like an instant medical history). Then that is all signed off one and sent to the physician. Typically at HF the doc is in the EMR when they get this and they can see the patients questionnaire. They review it as a clinical note (like a SOAP note).

Then the doc can respond within the work flow. They can either send a (secure) email back to the patient (and keep a thread of the message). The physician can end the visit with a diagnosis and a treatment, which involves entering billing and ICD9 codes. The system can add information content (e.g. Healthwise) to the doctor. That is then all documented as part of the encounter in the EMR.

At the moment HF is not really integrating this with the EMR fully (in terms of giving a health history) but this can be done.

Do already do appt requests, Rx refills. Use a CRM system to manage and mine that, and find that the most profitable patients are their online patients. Around 75,000 appt requests. generated $20m from appointment requests.

For these visits instead wanted to not do unstructured text messages (as a doc). Want instead to get the structured history (which is a version of Primetime’s).

Are not charging if they are a HAP plan member (that’s the captive plan of HFHS) but it’s going to be $20 for others.

As an extension of this HF is doing a study. 50K patients already on the portal and now releasing it for 3 clinics (out of 24) Goal is to have 12 using eVisits, 12 are a control. In a 3 year study want to look at outcomes, work days lost, etc. So we’ll let you know in 3 years.

Enhanced Medical Decisions. Has a new product called DoubleCheckMD

Most drug errors are between drugs that should be taken together, but don’t work for those patients. So they’ve built an online system that can match drugs and symptoms and figures out all the various permutations. Essentially a drug-drug-symptom interaction checker system….that can take consumer data (including OTC weird foods, herbals, grapefruit juice)

Also now are adding more than symptoms—e.g are now reading what lab tests that you should have. Here are the symptoms that you should be looking for.

Interesting product gives you back a list of symptoms from drugs, interactions, next steps and information.

Intended to be an early warning for the consumer (not a provider view) which then tells them to how to work with their physicians. Very early days and not on the web yet but well worth watching.

QUALITY/CONSUMERS: Wallace and some patient advocates

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Information Therapy center chair Paul Wallace is from Kaiser Permanente, who quite logically would be interested in Ix.

He notes that the medical care cost, and the costs of poor health to employers far exceed the medical cost. (Absenteeism. etc)

He also notes that no consumer is involved in designing consumer directed health care. How do we get “skin in the game” not to be a blunt tool like managed care? And he explains that the revenue that would pay for the care of the 20% has left the system. let’s not use blunt tools to solve complex problems. That means using co-pays to access selective care, but not for pharmacy, well baby care, etc. And are there incentives to use information therapy in those decisions?

He has a vision of putting the patient centered care integrating this around patients not their diseases.

Then it’s on to two patient advocates. Sue Sheridan (who gave a harrowing speech last year that’s well worth re-reviewing) and Jesse Gruman from the Center from Advancement of Health. Sue has got the CDC to engage consumers in telling mothers about the risk that jaundice can cause brain damage. So eventually this fall they are putting out information that are right for new mothers—not about the disease but “how can my baby get hurt and how can I do something about it. Sue thinks fear is a gift that will motivate. Jesse is not so sure, but know that we need to arouse the anxiety just enough to give them something productive to do. Last year Jesse told us about “blunters and monitors.” In other words some people want the second opinion, want to know everything, but others want the doctor to tell them what to do. But there is no neutral health information. So the people trying to engage patients in health information have a major challenge. But Sue thinks that we should create the demand for patients to be engaged because if they’re more involved they’ll have better outcomes.

Jesse thinks that using marketing methodologies that retail et al use to make people buy stuff they don’t really want/need (e.g. data mining connections) needs to be used to deliver information therapy and make people integrate it in their life. We also need to tell people what we expect them to do.

One of the most interesting questions is from a Canadian who is telling about how consumer health information in his hospital (McMaster, in Hamilton Ontario) is worked out in conjunction with marketing academics. In the US he says that this stuff seems to be part of the marketing department, and be kept as proprietary information.

QUALITY/POLICY: Information Therapy conference, the employer coalition view

So as I warned you, I’m at the Information Therapy conference in Park City, Utah.

Andrew Webber from National Business Coalition on Health. Tries to come at Information Therapy from the point of view of an employer—but an employer who was brought up as the son of a Minister living in Spanish Harlem.

Employers are figuring it out….he thinks they can improve quality while controlling costs, and do it by making the health care system more functional. Andrew thinks that employers really want a more productive healthier workforce. He thinks that there should be metrics for how Wall Street looks at individual companies on the health/productivity issue. So we need better stories to get employers to realize that they need to get on board with improving this.

But overall employers want to point at providers and call it their fault! (for a bunch of reasons). But he thinks that employers can do better and they’ve been a big part of the problem. Employers have created a toxic payment system, that pays for poor quality of care.

Andrew wants employers to take responsibility for it! Their vision is health purchasing reform via value-based purchasing community by community.

His 4 pillars (of wisdom) are

1. Performance measurements2. Transparency and reporting3. Payment reform (he wants population-based not a fragmented FFS-based payment)4. Informed consumer choice

But you all know that, so let me show you a photo I took in a slot canyon in Arizona yesterday (taken on my Treo no less!)

Photo_092406_010

Meanwhile, Andrew thinks that this is all wrapped up in the change of Federal incentives (and the recent directive) to do more transparency and get consumer purchasing on the national radar.

Personally I get very nervous when Information Therapy gets wrapped up in the ideology of consumer-directed health care. Somehow he manages to think that what HHS and Leavitt is up to and what RWJ is supporting are consistent with each other! But he does make the reasonable point that Ix needs to somehow connect with the wider movements. I just hope it gets done as a neutral issue without getting into a real war over the ideology. If Ix gets wrapped up in that it will be shot in the crossfire.

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