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TECHNOLOGY: The UK’s EMR project is not apples to apples, with UPDATE

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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).

PHARMA/POLICY/QUALITY: A deluge, sorry

I said a while back that I wouldn’t do just tell you to go read other stuff, but there’s a deluge that you just must pay attention to–all out in the last 24 hours.

1) Kaiser Family Foundation is out with a confirming study that those seniors at the bottom with high drug spending will be better off from the drug-benefit in the MMA, but that many more in the middle will not be.

2) Arnie Milstein shows why he believes that the "shark" of rising health care costs will be contained by the efficiencies brought to the system by the "engineers".

3) The continued aftershocks of the Vioxx hearings continue very very loudly. JAMA is out with a whole raft of articles mostly suggesting that major FDA reform is needed, and that drug company studies have routinely withheld data from the public and by inference JAMA and its fellow journals. While a lawyer for Bayer fires back very aggressively, Astra-Zeneca CEO McKillop seems to be breaking with PhRMA orthodoxy and admitting that there’s a real problem–possibly in an attempt to save Crestor before it falls victim to the Vioxx syndrome.

Given that my work putting together the FierceHealthcare newsletter (go sign up!) was, shall we say, made somewhat challenging by this plethora of activity, I suggest that you go take in some of these articles, and I’ll be back with more comment later in the day/week.

Thank God we get to take the end of the week off!

Meanwhile one of my true fans has nominated THCB for the worst medical blog over at Echojournal!

PHARMA: The Industry Veteran on drug patents and who pays for research

Last week the NY Times had an NY article about drug pricing that suggested a new approach for keeping innovation while controlling prices. In particular it suggested changes to the way the patent system works, and how the Federal government might change some of the ways it spends the $30bn the NIH spends on basic research and the $40bn it spends via various programs as a purchaser on drugs:

The government could compensate drug companies for their inventions as an incentive for them to keep innovating. How to determine how much an innovation is worth? One possibility would be for the government to selectively buy patents at a premium over the price a private bidder was willing to offer, and then put them into the public domain, Professor Kremer said. Aidan Hollis, an assistant professor of economics at the University of Calgary in Alberta, devised a different approach: the government would set up a fund to compensate drug companies based on how much their new drugs improve the quality of life and how often they were used. These alternatives would carry several benefits, economists say. In addition to making drugs available at lower prices, they would make it much less profitable for pharmaceutical companies to spend millions of dollars to develop drugs, like Nexium and Clarinex, that are protected by patents but offer little improvement over similar drugs already on the market.

The goal is not to spend less to develop new drugs, Professor Hollis said, but to get more therapeutic bang for the buck – by channeling investment to where it matters most – as well as to increase access to the resulting drugs. "This can be done within the same budget as we devote to pharmaceuticals now," he said.

The Industry Veteran is intruiged by this ray of innovative thought in the nation’s paper of record. He writes  for THCB that:

There are some cute ideas here, but in what is rare for a piece of mass media journalism, the author did a good job of pointing out the flaws in each one of the patent-altering proposals. My own ideas on this matter are somewhat similar to one of the proposals. Let the government fund and conduct all new drug research from pre-clinical up through Phase I clinical trials. At that point they would auction off the compounds, each carrying patent exclusivity to run from the auction date and extending a specified number of years. Since the Big Pharma companies are, essentially, late development managers and marketers, my scheme would just rationalize the process. The auctions would attract high bids because the compounds would carry patent exclusivity and not, therefore, become immediate generics. Of course, I don’t know how much this process would reduce drug costs. I suspect it wouldn’t be much at all. The main virtue of my plan is that it would allow clinical needs and scientific evaluation to drive research instead of profit potential. Then too, it might knock down the fiction that Big Pharma propagates about their high R&D costs for introducing every product. People familiar with the situation already know that their claim is BS, but I suppose the current fiction diverts the general public.

Isn’t it just like economists to advise fixing the basement when the roof is leaking? You want to reduce drug prices? Use price controls the way Europeans do. Afraid that will stifle innovation? Use tax policy to end the 50% tax credit and the expense deductions for me-too’s and for cock-raising, wrinkle-smoothing, lifestyle products. That way you give drug companies a simple message: innovate or die.

POLICY: A Blue state Republican talks about expanding healthcare access

One of the great ironies of American political life is that three of the biggest Blue states have Republican Governors. One of those governors (and of course it’s not Arnie or Pati-Pati-Aki) has developed a plan for universal health care, of sorts. OK so he’s been forced into it by the Democrats who run the rest of the state, and he doesn’t want to put any more money into it but Massachusetts’ own Mormon Mitt Romney is at least talking   about expanding healthcare to the uninsured.

His theory is that he can expand Medicaid (i.e. get the Feds to pay) to more of the uninsured, relax state mandates on insurers so that cheaper plans can be offered to the working poor, and expand the state’s community clinic program. Ideologically this isn’t a million miles away from what Bush sort of hinted at in the campaign. But this is a real announcement, and we haven’t heard Bush say anything nationally–and we won’t. So look to state experiments, and hope that the fate of Tenncare isn’t shared everywhere else they try to extend health coverage. And for the time being we can all go along with the fiction that no real subsidies are needed to get health insurance to the working poor.

TECHNOLOGY: Molly Coye’s call for action


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!)

TECHNOLGY/QUALITY: Carolyn Clancy says DSM works; Sam Ho agrees; Arnie Milstein says that we’ll cut costs just in time

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%.

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