Random Acts Of Reality :: Grand Rounds

This is the forecast that’ll be sent out today for FierceHealthcare for 2006, not my only forecast for the year but the only one I’m committing to posterity thus far.  You could of course always look at what I said would happen in 2005! I’m not sure that too much has changed, but I was right to say that Chelsea would win the English Premier league, and that forecast is easily repeated!

  Here are the top 5 trends to watch in 2006, along with some wild cards.

 1) NHIN, RHIOs, and all that.

For those of you keeping score of activity in the National Health Information Infrastructure (with its plethora of accompanying acronyms): pilot projects have now been funded, early standards have been announced, and Brailer’s office has announced that it will attempt to properly count what the adoption levels of EMR, CPOE et al actually are. But this is the year that the discussions behind the 100-odd RHIOs will bear fruit or like the CHIN movement will they die on the vine?

Can we develop data exchange standards so that records and information can be exchanged? Almost certainly? Can we create a messaging infrastructure that allows open standards so that system A can communicate with system B to find patient Y’s data? Maybe, and with email and TCP/IP we at least know what that infrastructure might look like. Can we develop a business case for health care organizations to share data with each other? That remains most uncertain.

The concept of open and secure data exchange bears great promise for health care. If the NHIN is to be successful there must be some real "wins" from the emerging RHIOs and the time for that is this year.

2) How Medicare Part D, and health care plays out in an election year.

It will escape no one’s attention that 2006 is an election year,. Many hopeful Democrats are looking at the lousy 2005 "enjoyed" by the Bush Administration and have decided that 2006 is shaping up to be the reverse of 1994 all over again. While it’s hard to imagine the news for Republicans staying as bad as it’s been, there are at least three areas where health care will play into politics this year. The most obvious is the roll-out of Medicare Part D’s drug coverage, about which there has been much controversy. It may go well, but angry seniors are always a political force, and as they are faced with the prospect of signing up by May or seeing premiums increase, the pressure will increase.

The early news also suggests that employees who are "empowered" into high-deductible health plans are not that happy. And the number being moved into these plans will increase fast in 2006. Meanwhile, employers (led by GM) are getting increasingly vocal about looking for government help to solve the cost crisis. Finally middle-class insecurity about health insurance is also a potent political force.

It’s hard to say how much these factors will influence this coming election, but poll after poll shows Democrats doing better on health care issues. Health care organizations may wake up in early November to find that health policy is no longer more of the same. So they must start planning for that possibility

3) New technologies changing health care processes

FierceHealthcare will be continuing to track the evolution of new technologies as they are adopted by health care organizations. Here are a few that while not adopted much yet in America’s hospitals and clinics will see a great deal more prominence in 2006. 

> Tracking technologies. A mix of active RFID, Wi-Fi, UWB and infra-red technologies are for the first time enabling cost-effective tracking of people and equipment in hospitals. More hospitals will adopt these technologies in the coming year, and they’ll find that it will not only help them save money on equipment losses, but will also change their fundamental work processes.

> ePrescribing has now been connected to pharmacies and formulary information by the Surescripts and RxHub networks. They are also available as standalone applications that a physician can adopt without needing to buy a full EMR. And Medicare is pushing ePrescribing as part of its Part D initiative. Expect to see more physicians coming on board in the next year.

> Remote monitoring has been gaining force for a while, notably in the ICU, with remote monitoring of patients by physicians down the block or across the world becoming popular. As the leader in this field, VISICU, prepares to go public, expect this trend to grow and spread to less intensive settings.

> Health plan PHR and CRM. To say that health plans are not known for their excellence in customer service is putting it mildly. However 2005 saw some of the first steps by major insurers to integrate what they know about patients’ clinical information with their administrative activity. Using technology from WebMD on an ASP basis, Empire BCBS has led the way here putting its members’ patient records online. It looks like the rest of the Wellpoint organization (which bought Empire last year) will adopt the technology this year. That will force competitors like United to follow suit.

> Clinical/Med-tech integration? Most diagnostic and imaging devices are now putting out digital signals, and more and more hospitals have clinical data repositories that can handle those files. The obvious center of activity is in the PACS world, but this overall trend is one that has seen GE, Siemens, Philips and other imaging powerhouses make moves into hospital information systems. The two sides of the technology "house" — the bio-medical and the IT shop are getting closer — and managing that merger is a challenge for hospitals as well as vendors

4 ) The evolution of consumer-directed health plans (CDHP)

There’s been much fuss about the HSA, with by some estimates over 1 million accounts opened this year. But the majority of those have been opened by people who already had high-deducible plans. But as companies like UnitedHealth Group, Aetna and Cigna push these consumer-directed plans to their mainstream employer clients, they are going to face two challenges. The first will be to educate Americans about how to evaluate the health care services they are asking for and receiving. The second will be to deal with the care for those sick people who have blown through the deductible, who account for the vast majority of health care costs. 

Early indications are that plans will try to combine CDHPs with old style managed care techniques of restricting access to specialists and differential pricing based on network tiers. It will be interesting to see how far this goes, and more particularly what the reaction from providers and patients will be a decade after the "backlash against managed care".

5) Pay-for-Performance, and how Medicare pays for care

Pay for performance (P4P) is the latest panacea that’s supposed to overcome the cost problem, improve quality and remove practice variation. Medicare has leapt on this, following the examples of pilots in California and Massachusetts. It’s already rewarding hospitals (albeit only a tiny amount) for reporting quality information. This year we’ll see with a full year of reporting the impact that has had on hospital quality. A similar program for nursing homes had good success so far.

Of course the big issue behind all this is how physicians and hospitals will demonstrate quality, and how they will be paid extra for doing so….or paid less for failing to do so. While Medicare is taking a softly, softly approach so far, there’s at least one bill in Congress demanding the introduction of pay-for-performance for the whole of Medicare Part B. However, there are also some early indications that P4P may not be having as big effect on physician behavior as its backers would like.

Considering we’re talking about how health care gets paid for in America, this is definitely one to watch.

WildCards:

Some WildCards that are unlikely but would have a big impact:

> A serious bird-flu epidemic breaks out and spreads world-wide> Significant numbers of physicians stop taking Medicare after a fee cut> Bankruptcy of major for-profit hospital system> Malicious virus infects significant number of medical devices causing patient deaths due to inaccurate readings> FDA regulates health information software> Outbreak of hospital-centered bacterial infection like MSRA becomes major factor in North America> Uninsurance and cost concerns put single payer in center of political discussion and Democrats adopt it for 2008. (Remember Harris Wofford?)

It’s time for my end of year 2005 letter….even if it’s already 2006. I send it out to my friends and contacts and it’s up over at my personal blog and it’s mostly about charities and causes that I support. Self-indulgent, but take a look if you like.

Welcome to Grand Rounds on THCB, the weekly round-up of all
that is good and great in medical and health care blogging. This is a
special edition as it’s the last of 2005 and so I’ve asked my fellow
bloggers for their best posts of 2005. For some of them, like any great
soccer player whose best goal is their last, their best post is their
most recent. But for many we’ve gone back into the archives. There’s
some great stuff, and some great series of posts too. So let me act
like the consultant I am and put it into sections, and act like the
blogger that I also am, and give you some not so unbiased commentary.
Oh, and it’s pretty long with some nearly 60 posts mentioned. But you
weren’t doing anything else this week, were you?  So settle in and
enjoy.

This was the year that the medical and health care blogosphere
exploded. I now track some 25 “healthcare” blogs and over 40 “medical”
blogs in my Bloglines,
and there are many, many more. But of course I’m going to start with
the ones I like the most. You’ll note that some of mine feature
somewhere in here too, but then again what’s the season of goodwill if
at least a little isn’t self-directed!

Personal favorites: Medbloggers

My two favorite medbloggers are Bob Centor at DB’s MedRants and Syd Smith at Medpundit. Bob had a great series on the key to being a good doctor, not understanding the disease but “Understanding the patient”. He put it at the top of his Top 10 for the year, but they’re all worth a read. Sydney at Medpundit
is someone I’ve had running battles with over the years, but she is
still the doyen of MedBloggers (although she says she’s slowing down).
And when she’s not driving me mad ranting about Canada or Holland,
she’s either brutally honest about the process of putting an EMR into a solo physician’s office, as described in her three part series, or she’s a breath of common sense in a world filled with hype—such as her take on Herceptin being the cure for cancer. Hardly.

Personal Favorites: Health IT Guys

But I’m a business and tech guy so I like a couple of bloggers who
live in that world. And they each bring attention to screamingly
important issues that tech people are not paying enough attention to in
these days of national infrastructure revolutions. Shahid Shah, The HealthCare IT Guy gives you the skinny on — when we are building these health care information systems — why data models matter.
Complex, but trouble if it’s not understood (and it’s not). The other
huge issue is whether the EMR/CPOE is usable by physicians. Mr HISTalk, the leading cult health care blogger you may never have heard of, tells you what’s behind a famous recent CPOE study where it looks like things went very wrong. There was lots and lots of discussion on a post written by Kelly Clark on THCB about whether physicians can learn to love the EMR. Of course if you want the real (and cynical) low down on RHIOs, Mr HISTalk has that too in his RHIO guide for CIOs (scroll
down in the post). If you want more on health care IT, Shahid has set
up an aggregator of virtually every health care IT blog at the HITSphere.

Policy wonks: Too many favorites to count

Health care is in essence about politics, but the mainstream
political bloggers not only hardly mention it but betray staggering
ignorance when they do. Meanwhile, the academics in Ivory Towers tend
not to sully themselves explaining the problems in the health care
insurance system to the masses (although Paul Krugman has been making a
half-decent effort). Filling this hole is a group of valiant bloggers,
divided between the old farts wise heads, and the young punks. Much of my writing on THCB mostly lives here, although I moonlight policy stuff at Spot-on.

Elisa at HealthyConcerns (despite being sponsored by an
insurance broker) is a (in health care terms) young punk learning about
health care and getting upset about medical underwriting that stops ordinary people getting health insurance. And she’s not alone, and by no means should she be. In fact we should all be much more outraged about uninsurance. Of course over at political blog Spot-on I explain why health care will be the domestic political issue of the next couple of decades.
Back in the torpor of 2005, consumer health, CDHPs, HSAs et al are the
new propaganda slogans of the health care “free-marketeers”. Tom
Hilliard at Signal Health is not impressed by the Cato Institute’s approach
promoting it and ended up with interesting comments from his targets at
Cato and their quasi-fellow traveler Wharton professor Mark Pauly, who
stepped down briefly from his ivory tower to speak to the masses. Still
in the new consumer health mode, Joe Paduda at Managed Care Matters was suspicious of AOL founder Steve Case’s Revolution Health when it was announced, and didn’t really see that it had much going for it after Case chucked the first $250m into the ring.

Pay for Performance is going to be one of the screaming big deals
for the future of healthcare no matter what system we end up with. At Health Voices Hippocrates (Dmitriy Kruglyak) has a three part series
on the concept and complexities of P4P, suggesting that the American
College of Physicians has a reasonable approach. Henry Sturn at InsureBlog thinks that P4P might work, or at least that tipping doctors is no more dumb than tipping waiters.

Talking of series, Ezra Klein had perhaps the best of the year from a health policy perspective, explaining in concise terms what goes on in the health systems of Japan, Germany, Canada, France and the UK.
Really good stuff from a young punk who is helping drag health care
into the mainstream policy debate. Fellow punkette Kate Steadmanhas been displaying great promise (and hopefully having a good recuperation from her own recent surgery), and her piece on the society lady in the Midwest who couldn’t understand  why her uninsured housekeeper couldn’t get access to a doctor is a classic. Don’t miss the comments which show some of the pure frustration and pain of the uninsured.

Medicare Modernization Act and its Part D (drug coverage)’s
introduction passes for what counts as health “policy” in these days of
ignoring the problem. Another great series at Healthy Policy from Kate Steadman, was this whole series on what’s so screwed up about Part D. (Hint—virtually all of it). Joe Paduda explains why private plans like Medicare Part D so much–they’re playing at the casino with the bank’s taxpayers money (note the comment from the true believer!). The best explanation of how to use CMS’ very user-unfriendly calculator to
figure out your Part D process comes from medical student Graham
Walker—so much for the great works of government, even though since
2001 it’s now run by CEOs instead of those incompetent bureaucrats. Of
course if you really want to understand the problems behind Medicare
and the angst it causes political liberals, you could do worse that
read what I wrote on THCB about separating the Medicare discussion between its individual and corporate welfare sides.

And if you really want the long term picture of the tension between
social and individualistic health care in the political world, well,
this old chestnut from January 2005 in THCB might amuse you. It’s called Health Care = Communism + Frappuccinos.

Physician and clinician blogs about medicine

When most people think of medical blogs, it’s usually about the
experiences of clinical professionals dealing with patients and others
who get in their way. In this blogging round-up, that world lives here,
and it’s proof that medicine is a lot more complex than we lay people
and consultants tend to make it out to be.

That complexity shows up as often as not in the emergency department. DrTony hangs out in ED’s and is troubled by suicides at what’s supposed to be the happiest time of year. Gruntdoc lives there too and is devastated by a sudden head injury and life long brain damage to a teenager. On the other hand he was aggrieved that the WSJ got it wrong on how emergency doctors should treat strokes. Doc Shazam is writing fiction about how one might end up in the ED. Kim, an emergency RN  has some amusements over what happens in patient–clinician “communication” at Emergiblog.

Meanwhile outside the ED Graham Walker at Over My Med Body knows that both patients and doctors can be the difficult ones.  Medscape’s The Differential has some blogging students and residents, whom we all know are overworked. Pin-Chieh Chiang has a cartoon which describes how they get by on no sleep! And while Kristen Heinan finds pediatrics therapeutic, Iranian med blogger Ali Tabatabaey instead uses medicine to observe a Culture of War

And if you want to see some of the gory pictures that make me glad
I’m not a doctor like my old man, head to Jon Mikel Iñarritu’s post on open fractures classification and its clinical manifestations at Unbounded Medicine. Lots of fracture images with the emphasis on the word “open”. Meanwhile, troops in Iraq are picking up a yucky sounding skin infection called leishmaniasis from sand-fly bites, although Mike Pechar at Informed Participant tells us that 12 million people each year in the developing world get it. On a better known note, Paul Cheney at The Cancer Blog tells of the announcement from (the now late) Peter Jennings that he had cancer and that chemo was a bear. Barbados Butterfly gives us a harrowing tale of a patient bleeding out.

Even deeper in the science of medicine psychoanalyst blogger ShrinkWrapped is lost in the brain looking for the development of the self. To round out the topic of physician blogs, there’s an entire self selected Top 10 of the year at the Internal Medicine Doctor, the Mad House Madman, who writes the Chronicles of a Medical Madhouse.

Finally, the RedStateMoron explains why he’s in high risk obstetrics. It’s a personal and moving story.

Drugs, developed and marketed.

The pharma business is a very important part of health care. We’ll start with my favorite in the space, Derek Lowe at In The Pipeline.
Derek usually lives in the R part of the R &D world, but he has
lots to say about the industry’s tribulations from the inside. For
instance, he thinks that the NEJM may be covering its legal ass with its repudiation of the Vioxx VIGOR study, while he considers a reader’s suggestion that Pfizer’s new clinical trial for Celebrex is a four year insurance program against more suits.

And more in your brain on drugs: Dr Crippen at NHS Blog Doctor in the UK thinks that we are over-medicating children,
and that it’s mostly the fault of drug companies who, now done with the
medicalization of overactive kids, are interested in doing the same to
his wife’s….inadequate intimate bodily functions, as diagnosed by her
hairdresser. (We blush at THCB about those topics, unless they concern horny school-teachers).

Now we’re getting a little silly, but pharma just seemed to inspite
it this year. Grand Rounds originator and ring-master (all hail!)
Nicholas Genes at Blogborygmi was having too much fun with those ridiculous clinical trial names, and  Ira Segal at Doc Around the Clock  was enjoying himself just a little with the concept that no-one seems to be paying for product placement in the ED. And the list of the year was the one with the real meaning of those pharma-medica(il)logical terms as explained by the cheerleaders at PharmaGossip. John Mack at the Pharma Marketing Blog can’t keep his thoughts away from those cheerleaders or ex-Mrs Rolling Stones selling impotence drugs
either. And there was plenty on the most bizarre pharma PR blunder of
the year — the financing of the “terrorists take over the Canadian drug
import market” novel, most notably described by Roy Poses at Health Care Renewal.

Problems in the provider world

Of course there are hospitals and there are clinicians and there are problems and half in that world too.

Stuart Henochowicz at MedViews is concerned that we spend too much on buildings and not enough on nursing basics, something that meshes with the “Pimp my Ride”
school of health care that Ian Morrison has been writing about
(although one column a month doesn’t make Ian a real blogger!). Tony
Chen at Hospital Impact thinks that perception is more important than we give it credit for being, and that things would be different if a big rodent from Los Angeles got involved in the hospital game. Tim Gee who usually writes about technology at Medical Connectivity Consulting keyed in on the problem of ensuring that only appropriate admissions end up in the ICU and CCU. AggravatedDocSurg and MSSPNexus Blog
are bickering about whether JCHAO, which is the main body which
inspects hospitals and is a tool of the industry/a regulatory body
attacking American health care(delete where applicable to your view), is The Borg or the Death Star.

Maybe technology will come to the rescue. Clinical Cases and Images Blog wants to build a Google for all medical knowledge, or rather wants to open all medical knowledge behind closed “doors” to Google. David Williams at The Health Business Blog wonders if the way to cut radiology costs isn’t to send all diagnostic reading overseas. Meanwhile The Difficult Patient thinks that physicians may be using interesting but not necessarily new decision tools at the point of care.

The two other big news stories this year were of course Katrina and the birds…

New Orleans/Katrina: Hsien-Hsien Lei at healthcare.wurk.net shows that it’ll be a long while
before the healthcare system in New Orleans is back in action. Enoch
Choi, a doc at Palo Alto Medical Foundation spent a lot of time down
there and his blow by blow account at MedMusings is well worth reading. Sart here and move on day by day.  Finally In her own words has a nurse telling about her experiences volunteering for the Red Cross in Baton Rouge.

Avian Flu: Tara Smith at Aetiology had the best history of pandemic influenza.

Late arrivals (added 12.30 PST Dec 28)

When cleaning out the junk mail, I found Bard Parker from A Chance to Cut is a Chance to Cure about whether the CT Scanner is a match for a duff appendix, Jim Hu from Blogs for Industry about skin conditions in the cartoon world, and Parallel Universes considering that drinking is bad for humans, while dancing boys are good for girls. Sorry that the first 1200 readers missed you guys, call Bill Gates and ask for a better Outlook filter with fewer false positives in 2006.

Parting Shots and gifts for reading this far….

Now just in case you over-did the holiday cheer and good food, you
may be thinking of a New Year diet. The nice people at the Discovery
Channel are having a National Health Challenge coming up starting on Dec 30. Go see their site for more details, but THCB
has three copies of this book on getting thin(ner) and healthier by the
perky looking Pamela Peeke to give away. Let me know if you want one
(and no I’m not getting a cut for advertising it…)

I will however get a menial cut if you want to get a THCB T-shirt or mug from my friend Shazza’s Vaniteez site.

Thanks for coming by. Hope you enjoyed this extended edition, and
I’m looking forward to what 2006 brings us in the medical and health
care blogosphere.

Next week Grand Rounds returns to its more usual weekly format at Random Acts of Reality.