The Health Care Blog – Page 551 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Defense Probably Goes Commercial, Not Necessarily Proprietary

Jun 13, 2013• 5

By Edmund Billings, MD

Secretary of Defense Chuck Hagel’s long-awaited (in health IT circles, anyway) decision on the Department of Defense’s core health IT system has been made. The VA’s VistA system is out as the preferred DoD. Unless it’s not.

I’ll explain.

In his May 21 memo, Hagel directed the DoD to initiate a competitive process for a commercially available electronic health record (EHR) solution. Understandably, the secretary has to create a level playing field, a competitive process, so he can tell Congress with certainty that due diligence was done. Hate it a lot or hate it a little, this is the nature of our political process.

Already, many are spinning Hagel’s decision as a huge win for proprietary solutions; popular blogger Mr. HIStalk has already established Epic as the frontrunner in the upcoming DoD derby.

But before we simply anoint Judy Faulkner the queen of American health IT, I want, as the Brits say, to throw a spanner in the works.

Commercial ≠ Proprietary

A careful review of the Hagel memo and other recent statements from his top lieutenants reveal a more progressive vision and clear requirements for an open architecture and service model.

From the Hagel memo:

I am convinced that a competitive process is the optimal way to ensure we select the best value solution for DoD … A competitive process will allow DoD to consider commercial alternatives that may offer reduced cost, reduced schedule and technical risk, and access to increased current capability and future growth in capability by leveraging ongoing advances in the commercial marketplace … Also, based on DoD’s market research, a VistA-based solution will likely be part of one or more competitive offerings that DoD receives.

To sum up, the secretary has directed the DoD to go commercial instead of developing and maintaining their own VistA-based solution, but commercialized VistA-based solutions will be included in the competitive process.

Guahao: VC Fantasy. Online Appointment Registration System for China’s 700 Million Internet Users

Jun 13, 2013• 3

By Bradley Hoath

The promising platform is called Guahao (挂号网) and it claims to be China’s largest online appointment registration system. With a national network of nearly 4,000 hospitals, 600 being Level-3 hospitals, and over 300,000 specialists, it is hard to dispute it’s size.* Guahao began development in Shanghai 2010 in collaboration with the Chinese Health Education Network, Fudan Hospital and Healthcare Management Co., and the Chinese Hospital Association, and later expanded nationally. Guahao attempts to alleviate the bitterness patients endure during a typical hospital visit.

*It should be known that there are actually several online appointment registration systems in China; However, most are small, regionally splintered and have questionable legitimacy. Guahao is by far the largest and most well supported system in China.

China historically has not had a call-ahead appointment scheduling system. Patients throughout China have long lamented the country’s hospital queuing system, or the lack thereof. Patients arrive at the hospital, literally take a number, and wait for their turn – sometimes for over 24 hours. It is not uncommon to see throngs of patients and their family members outside of the hospital, camping out in makeshift beds to see a physician. A lack of appointment system puts pressure on the hospital’s health workers. Patient scheduling provides predictability of patient flow and allows for more efficient allocation of healthcare resources. Not to mention it makes for a much more patient-centered approach to healthcare delivery.

When Is It Appropriate to Ignore an Advance Directive? Is It Ever Appropriate to Ignore a Patient?

Jun 12, 2013• 27

By Eric Widera, MD

An 85-year-old woman with moderate Alzheimer’s disease who enjoys walking in her nursing home’s garden with her walker has fallen and broken her hip. An advance directive signed by the patient states a preference for “Comfort Measures Only,” and specifically states that she does not want to be transferred to the hospital. The physician believes that surgery would provide long-term pain relief and the chance to maintain some mobility.

What do you do? How do you reconcile her previously expressed hypothetical wishes in an Advance Directive with what is now a rather unanticipated scenario?

In a paper published recently in JAMA Internal Medicine, Alex Smith, Bernard Lo, and Rebecca Sudore developed a 5-question framework to help physicians and surrogates through the decision making process in time like this. The framework proposes 5 key-questions to untangle these conflicts:

Is the clinical situation an emergency?
In view of the patient’s values and goals, how likely will the benefits of the intervention outweigh the burdens?

Could Halbig et al v. Sebelius Sink Obamacare?

Jun 11, 2013• 29

By Dan Diamond

Innovare may be Latin for innovate, but the values at Innovare Health Advocates are traditional: An “Old School” commitment to delivering “Healthcare the Way it Ought to Be.”

The Missouri-based health practice is run by Dr. Charles Willey, a staunch tea party conservative who’s been mentored by former Sen. Jim Talent, one of his patients. “I’ve personally, for a long time, been interested in politics,” he told a radio show in 2010, noting that he’d been leading efforts “to get doctors excited about resisting Obamacare.”

But Willey’s doing more than just resisting the health law these days — he’s become an active player in Halbig et al v. Sebelius, a lawsuit that threatens a key element in the Affordable Care Act: Whether the tax subsidies slated to help many Americans purchase coverage through many insurance exchanges are even legal under the ACA’s language.

(Innovare Health is one of the small businesses that has joined the suit.)

And the stakes are higher than most people realize, according to Michael Greve, a law professor at George Mason University.

“If the statute means what it says, Obamacare’s machinery simply doesn’t apply in half the country,” Greve contends.

“This is for all the marbles.”

Law’s Language a Sticking Point

Conservative scholars say it’s obvious in the text of the Affordable Care Act, right as rain. (Italics added by columnist.)
Continue reading…

The Wellness Game: The Employer As the New Parent

Jun 11, 2013• 52

By Vik Khanna

Eat your vegetables. Turn off the TV. Go outside and play. Go to bed on time. These four imperatives were once amongst the core messages delivered to children by their parents and neighbors, a setting of behavioral parameters that people intuitively expected would help to produce healthy, well-balanced kids. We’re not so good at this anymore. Like so many other behaviors that animate the phrase “personal responsibility”, in the face of economic and demographic tumult we have decided to pass the buck on them in our homes, neighborhoods, schools, and churches. We now want employers to handle them, and health-contingent wellness is the final step in the ascendancy of the employer as the new parent.

Employers find themselves teaching employees how to read and write effectively, do math, be polite, how to eat in the presence of others, and even how to sleep better. Why not throw at their feet the notion that employers should coerce workers into intrusive and dubious health-contingent workplace wellness strategies that are easy as pie for the healthiest, but far more difficult for the less fortunate who are, ostensibly, the ones who need the most help? This is not why most people start businesses (unless, of course, you’re a wellness vendor). It certainly is not why people devote themselves to work, which is supposed to be for securing (hopefully) individual and familial prosperity and experiencing the unique contribution to personal dignity that comes from purposeful endeavors.

US employers are not responsible for the chronic disease crisis; truth be told, their sufferance of the costs of many wellness-sensitive events is limited because the majority of the medical catastrophes that health-contingent wellness programs promise to prevent (such as heart attacks, strokes, and many cancers) happen predominantly in older people who have mostly left the work force. Employers have been caught up in the maelstrom of demographic, industrial, and technological changes just like the rest of us. Yet, not only do we actively seek their participation in fishing expeditions such as health-contingent workplace wellness programs, some of them jump in with both feet. This should help to remind you that your CEO might just be the one who graduated at the bottom of his class.

The IRS Scandal: Implications for HIPAA and the Affordable Care Act

Jun 11, 2013• 5

By Dr. Wes

As my head reels at the implications of the IRS scandal mushrooming in Washington, the IRS’s recently disclosed ability to access e-mails without warrant, the intricacy of the NSA PRISM wiretap techniques that includes their ability to acquire tech firms’ digital data, and even the Justice Department’s ability to secretly acquire telephone toll records from the Associated Press, I wonder (as a doctor) what all this means for the privacy protections afforded by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in our new era of mandated electronic medical records. Are such privacy protections credible at all?

It doesn’t seem so.

Now it seems everyone’s health data is just as vulnerable to federal review as their Google search data. This is not a small issue. We have already seen that discovering “leaks” of personal health information has produced some very handsome rewards for the feds, so it is not beyond reason to think that HIPAA might also be a funding tool for our government health care administration disguised as a beneficent effort to protect the health care data of our populace.

But even more concerning is the role the IRS scandal has for America’s health care system. After all, the Affordable Care Act is ultimately funded by the IRS by administering some 47 tax provisions. These include the right to levy a penalty against businesses and individuals who don’t provide or acquire insurance and determining how to distribute annual subsidies to 18 million people who make less than $45,000 a year and thus qualify for subsidies in buying health coverage. In addition, the agency will collect taxes on medical devices and a surtax on people making more than $200,000 a year, as well as conducting compliance audits of tax-exempt hospitals.

Will “Too Big to Fail” Come to Health Care?

Jun 11, 2013• 9

By Robert S. Galvin, MD

Purchasers of health care, long-time supporters of organized systems of care, are watching with growing alarm as horizontal and vertical mergers between providers accelerate. Buyers with experience in other sectors understand that consolidation can improve efficiency, quality, and the generation of capital, especially where there is excess capacity and abundant waste. They are equally aware, however, that ‘over’-consolidation can lead to pricing power, the absence of competition, and the crowding out of disruptive innovations.

Catalyst for Payment Reform(CPR), a non-profit working on behalf of large employers and public health care purchasers to improve the quality and affordability of health care through payment innovation, convened a National Summit on Provider Market Power on June 11^thin Washington D.C.

There, the nation’s leading experts discussed and debated how to maintain enough competition among health care providers to stimulate improvements in the delivery and affordability of care.

Participating experts stated that by as early as 2006, over 75% of U.S. metropolitan statistical areas (MSAs) had experienced enough hospital mergers to be considered ‘highly consolidated’ – a trend that continues. Economists agreed that the evidence demonstrates that highly-consolidated providers can raise prices considerably. Provider leaders offered their views on why consolidation is occurring, including to meet the demands for integration and efficiency, to counterbalance a highly-consolidated health insurance market, and to have enough income to invest in IT systems and other infrastructure necessary for population management.

How to Fail at the Next Health Care

Jun 11, 2013• 13

By Joe Flower

The Next Health Care calls for very different strategies and tool sets. Many systems are acting as if they read a manual on how to do it wrong. How many of these critical strategic and tactical mistakes is your system making?

So I was beta testing FutureSearch, this cool new Google add-on app I’m writing with a coder, and I found an article that I wrote in 2025. My first thought was, “Cool! It works!” My second thought was, “I’m still working at the age of 75?” It was only then that I focused on the title of the article: “Fail: The 16 Steps by Which Hospitals Failed in the Post-ACA Risk Environment — An Analysis.”

The article detailed a dispiriting history from 2013 to 2020. More important, it listed the 16 most common mistakes that hospitals and health systems made while trying to navigate the new risk environment of the Next Health Care.

I found this interesting because of course right at this moment much of the health care industry, in many different ways, is trying to move away from the traditional fee-for-service payment system, which has given the whole industry adverse incentives, leading to much higher costs, poorer quality and restricted access. The rubric of the day is “volume to value.” And I see many different institutions and systems across the country making exactly these mistakes already in 2013.

Step-by-Step Instructions

As you read this list, ask yourself in what way you and your institution might be making the wrong decisions, and ask yourself what they will look like looking back from 2025.

Stick with fee-for-service. Though they included various incentives and kickbacks, most accountable care organizations and ACO-like structures built in the 2012–2014 period were based on a payment system that remained stubbornly fee-for-service. Systems continued to make more money if they checked off more items on the list (and more complex items), rather than solving their customers’ problems as well and as efficiently as possible.

The Patient Explanatory Model

Jun 11, 2013• 7

By Namratha Kandula, MD

In The Birth of the Clinic, Foucault describes the “clinical gaze,” which is when the physician perceives the patient as a body experiencing symptoms, instead of as a person experiencing illness. Even in the era of the biopsyschosocial model, the physician’s perspective is largely through a biomedical lens where biology and behavior cause disease.

In contrast, what I hear from patients is that health and illness are not merely the end results of individual biology and behavior. What people believe and experience when they are ill is usually something far more complex, deeply interconnected with their daily lives. And research shows the way people think about health influences whether they are receptive to health information, willing to change health behaviors or take medications, and even whether or not their health improves. But how are physicians, who are able to spend less and less time with patients, supposed to expand their clinical gaze to include the patient’s health beliefs and perspectives?

Psychiatrist and anthropologist Arthur Kleinman’s theory of explanatory models (EMs) proposes that individuals and groups can have vastly different notions of health and disease. Kleinman proposed that instead of simply asking patients, “Where does it hurt,” the physicians should focus on eliciting the patient’s answers to “Why,” “When,” “How,” and “What Next.”

Kleinman suggests the following questions to learn how your patient sees his or her illness:

1. What do you think caused your problem?

2. Why do you think it started when it did?

3. What do you think your sickness does to you?

What Do Patients Really Think? A Report From the Third Annual Health Privacy Summit

Jun 11, 2013• 10

By Andy Oram

Health reform activists and privacy mavens have been at loggerheads for years. Those touting health reform complain that an oversensitivity to privacy risks would hold back progress in treatments. Running in parallel but in the opposite direction, the privacy side argues that current policies are endangering patients and that the current rush to electronic records and health information exchange can make things worse.

It’s time to get past these arguments and find a common ground on which to institute policies that benefit patients. Luckily, the moment is here where we can do so. The common concern these two camps have for giving patients power and control can drive technological and policy solutions.

Deborah Peel, a psychiatrist who founded Patient Privacy Rights, has been excoriated by data use advocates for ill-considered claims and statements in the past. But her engagement with technology experts has grown over the years, and given the appointment of a Chief Technology Officer, Adrian Gropper, who is a leading blogger on this site, PPR is making real contributions to the discussion of appropriate technologies.

PPR has also held three Health Privacy Summits in Washington, DC, at the Georgetown Law Center, just a few blocks from the Capitol building. Although Congressional aides haven’t found their way to these conferences as we hoped (I am on the conference’s planning committee), they do draw a wide range of state and federal administrators along with technologists, lawyers, academics, patient advocates, and health care industry analysts. The most recent summit, held on June 5 and 6, found some ways to move forward on the data sharing vs. privacy stand-off in such areas as patient repositories, consent, anonymization, and data segmentation. It also highlighted how difficult these tasks are.