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Above the Fold

Datapalooza Report on Data Economics and a Call for Reciprocity

Jun 5, 2013• 4

By Adrian Gropper, MD

Uwe Reinhardt said it perfectly in a Tuesday plenary but I can only paraphrase his point: “health information is a public good that brings more wealth the more people use it.” Or, as Doc Searls puts it: personal data is worth more the more it is used. Datapalooza is certainly the largest meeting of the year focused on health data, and our Health and Human Services data liberation army was in full regalia. My assessment is: so far, so good but, as always, each data liberation maneuver also reveals the next fortified position just ahead. This post will highlight reciprocity as a new challenge to the data economy.

The economic value of health data is immense. Without our data it’s simply impossible to independently measure quality, get independent second opinions or control family health expenses. The US is wasting $750 Billion per year on health care which boils down to $3,000 per year that each man, woman and child is flushing down the drain.

Data liberation is a battle in the cloud and on the ground. In the cloud, we have waves of data releases from massive federal data arsenals. These are the essential roadmap or graph to guide our health policy decisions. I will say no more about this because I expect Fred Trotter (who is doing an amazing job of leading in this space) will cover the anonymous and statistical aspects of the data economy. Data in the cloud provides the basis for clinical decision support.
Continue reading…

Electronic Health Records. Are We There Yet? What’s Taking So Long?

Jun 5, 2013• 20

By Michael Painter, MD

I am a family physician, but one who doesn’t currently practice and importantly, one who isn’t slogging day after day through health care transformation. I do not want to be presumptuous here because the doctors and other health professionals who are doing this hard work are the heroes. They are caring for patients while at the same time facing tremendous pressure to transform their life’s work. That includes overwhelming pressure to adopt and use new information technology.

This level of change is hard, difficult and confusing—with both forward progress and slips backward. Nevertheless, doctors take heart because you are making progress. It may be slow at times, but it’s substantial—and it’s impressive. Thank you.

The Annals of Internal Medicine today published a study (I was one of the authors) finding that more than 40 percent of U.S. physicians have adopted at least a basic electronic health record (EHR), highlighting continued progress in the rate of national physician adoption of EHRs. The study, also found that a much smaller number, about 9.8 percent of physicians, are ready for meaningful use of this new technology.

Some might say, “Wake up, folks!” Look at those small meaningful use numbers. Change course, now. After all of this time and tax-payer expense, less than 10 percent of doctors are actually ready to use these important tools meaningfully. What’s up with that?

To me, though, this study is good news. All who care about health care transformation should be heartened by the progress—but also impressed by the enormous challenge that our health professionals have undertaken.

An Anesthesiologist Thinks Out Loud

Jun 5, 2013• 14

By Shirie Leng, MD

Anyone who has read my work knows that articles like the one written in the New York Times on Sunday by Elisabeth Rosenthal will immediately get a response out of me. If you haven’t read it, here’s the link.

Where do I start with this??? I’m going to let Ms. Rosenthal tell you about how many unnecessary colonoscopies we do. I’ll let her tell you how much more it costs here than anywhere else. I will address the anesthesia bit. Let me tell you a little story. When I was a baby anesthesiologist my hospital sent anesthesiologists “downstairs” to do anesthesia for GI procedures maybe once a week for a few hours.

This was in 2004 or so. Now we send three board certified anesthesiologists to various GI units every day all day. We do maybe 25 cases a day on average. Now, some of this is due to the aggressive expansion of the advanced GI procedures unit as well as the addition of an outside private group that was recently folded into the greater hospital system. It’s also because we’re there. It’s no accident that as soon as we committed troops to the GI battle all of a sudden everybody needed anesthesia.

The NYT article uses Dierdre Yapalater as an example, a healthy 60-something. Putting aside the ridiculous cost for the overall procedure, she was billed $2,400 for anesthesia. But she didn’t need anesthesia. There is absolutely no reason for her to have an anesthesiologist involved for that case. None.

Anesthesia care used to be limited to very sick patients, not because they are harder to sedate (they’re actually often easier) but to monitor them closely because of their tenuous physiologic status. Now everybody is getting it. Why did she get anesthesia, why did the anesthesiologist give it, why does insurance pay for it?

A SEC for Health Care?

Jun 4, 2013• 9

By Peter Pronovost, MD

If you have ever tried to choose a physician or hospital based on publicly available performance measures, you may have felt overwhelmed and confused by what you found online. The Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Joint Commission, the Leapfrog Group, and the National Committee for Quality Assurance, as well as most states and for-profit companies such as Healthgrades and U.S. News and World Report, all offer various measures, ratings, rankings and report cards. Hospitals are even generating their own measures and posting their performance on their websites, typically without validation of their methodology or data.

The value and validity of these measures varies greatly, though their accuracy is rarely publically reported. Even when methodologies are transparent, clinicians, insurers, government agencies and others frequently disagree on whether a measure accurately indicates the quality of care. Some companies’ methods are proprietary and, unlike many other publicly available measures, have not been reviewed by the National Quality Forum, a public-private organization that endorses quality measures.

Depending where you look, you often get a different story about the quality of care at a given institution. For example, none of the 17 hospitals listed in U.S. News and World Report’s “Best Hospitals Honor Roll” were identified by the Joint Commission as top performers in its 2010 list of institutions that received a composite score of at least 95 percent on key process measures. In a recent policy paper, Robert Berenson, a fellow at the Urban Institute, Harlan Krumholz, of the Robert Wood Johnson Foundation, and I called for dramatic change in measurement. (Thanks to The Health Care Blog for highlighting this analysis recently.)

We made several recommendations, including focusing more on measuring outcomes such as mortality and infections rather than processes (e.g. whether patients received the recommended treatment) or structures of care (e.g. whether ICUs are staffed around the clock with critical care specialists). We urged that measures be at the organization level rather than clinician level, to reflect the fact that safety and quality are as much products of care delivery systems as of individual clinicians. We propose investments in the “basic science” of measurement so that we better understand how to design good measures. You can read these and other recommendations in the analysis.

The Doctor is Viral

Jun 4, 2013• 5

By Rob Lamberts, MD

A post I wrote nearly three years ago has recently gone viral, bringing tens of thousands of readers and a huge number of comments. It’s a letter I wrote to my patients who do something that all but guarantees a bad relationship with many (if not most) physicians: they don’t get better. There are basically two responses I get to this post: either readers are grateful to have a doctor admit to our flawed humanity, or they are furious that I would suggest that patients, the ones with the disease, should see physicians as needy and flawed humans and therefore watch how they act around them. If you haven’t done so, read the comments to this post and hear the deep frustration and anger brought out by a letter that sympathizes with their pain and (apologetically) tries to help.

Amidst the dichotomy of reactions, both of which I understand, is the obvious question: why has a relationship that exists for the purpose of healing and helping become one of frustration and anger? The corollary to this question is perhaps more important: what can be done to heal this broken relationship? A reader of my last post (about viewing patients from a different perspective) asked me point blank: ”Dr. Rob, for the 99.999% of us who do not have a primary care doctor who is thinking as progressively as you, what advice can you give so that we can get our doctors to be treating us in the manner in which you are treating your own patients?”

I must admit, I get a bit uncomfortable with this, as it sounds like I am putting myself above my colleagues morally. Ironically, it is my deep understanding of my own huge flaws, coupled with an upbringing that scorned conformity, that rips me away from the survival self-centeredness most docs eventually adopt. Putting myself on any moral high ground only invites a very public (and deserved) fall back to the low ground I usually inhabit. No, I’m also not putting myself down out of false-modesty; I’ve made peace with my flaws, embracing them for what they are: a lens with which I can understand my fellow human scum-bags. Of course, as my best friend (and best man) used to remind me: “remember, I am doctor scum bag to you.”

Now, I don’t lay the whole problem at the feet of the fallen nature of mankind. I believe that our system of “health care” doesn’t just fail to counter the flaws of our nature, it actively promotes bad relationships. It does this by:

Reducing patients to “problems.” The payment system requires we use “problem codes” to classify patients and justify visits. The problem-oriented approach is not just a byproduct of the payment system, though, it is at the very core of medical education. Despite a 100% ultimate failure rate, we are still taught that death and disease are the opponents we need to outsmart or out-procedure. Perhaps its analogous to the public infatuation with the tawdry and grotesque (the more gruesome the murder, the more news shows cover it), but we physicians love “interesting cases.” But nobody ever wants to be an “interesting case.” Ask any of the people who commented on the blog post. Boring is better.

Health Datapalooza Day One: How Will We Grow Data for Improving Health?

Jun 3, 2013• 4

By Andy Oram

An unfathomably complex entity such as a health system grows over time like a city. Right now, communications and data usage in the US healthcare system is a bit like a medieval town, with new streets and squares popping up in unpredictable places and no clear paths between them. Growth in health information has accelerated tremendously over the past few years with the popularity of big data generally, and we are still erecting structures wherever seems convenient, without building codes.

In some cities, as growth reaches the breaking point, commissioners step in. Neighborhoods are razed, conduits are laid in the ground for electricity and plumbing, and magnificent new palaces take the place of the old slums. But our health infomation system lacks its Baron Haussmann. The only force that could seize that role–the Office ofthe National Coordinator–has been slow to impose order, even as it funds the creation of open standards. Today, however, we celebrate growth and imagine a future of ordered data.

The health data forum that started today (Health Datapalooza IV) celebrated all the achievements across government and industry in creating, using, and sharing health data.

Useful data, but not always usable

I came here asking two essential questions of people I met: “What data sources do you find most useful now?” and “What data is missing that you wish you had?” The answer to first can be found at a wonderful Health Data All-Stars site maintained by the Health Data Consortium,which is running the palooza.

The choices on this site include a lot of data from the Department of Health and Human Services, also available on their ground-breaking HealthData.gov site, but also a number of data sets from other places. The advantage of the All-Stars site is that it features just a few (fifty) sites that got high marks from a survey conducted among a wide range of data users, including government agencies, research facilities, and health care advocates. Continue reading…

Health Care Like It’s 1972?

Jun 3, 2013• 8

By Bruce Chernof, MD

Growing older with health care and support needs is a “people” issue; not a partisan one.

As the entitlement debate rages on and the health care system evolves, the bottom line remains that there needs to be more affordable and accessible options for all people who need long-term care. This is the kind of care that we are all likely to need at some point in our lives as we age; it will range in scope from everyday assistance such as getting groceries, to more comprehensive help in the form of assisted living or nursing home care. Those few who are fortunate enough not to face these kinds of needs personally are likely to need to care for a loved one at some point in their lives, such as a parent, grandparent, or spouse. As a country, we seem blind to these realities, even as the short window that we have to make a meaningful difference for the emerging older population is closing rapidly.

The fact is that roughly 70 percent of Americans over the age of 65 will need some form of long-term care, on average for three years. Yet most people, when asked, think they will never need this kind of care.

To make matters even worse, many individuals mistakenly believe that Medicare will pay for long-term services and supports even (it does not). The result is a public that is woefully underprepared and ill-equipped to prepare for what are probably inevitable health needs.

This gap in knowledge and awareness has contributed to our current “non-system” of financing long-term care, in which people are left to fend for themselves to pay for services or spend down to near poverty levels to qualify for Medicaid; for only then is public help available. This is neither a sustainable nor a dignified policy. We need to develop a better model that will ensure that all Americans can age with dignity, choice, and independence. But what would that look like?

As a physician, I believe we have perfected the health care delivery model for 1972 that focuses on acute care, and is not necessarily designed to meet the needs of individuals living for an extended period of time with multiple chronic conditions. What we need today and into the future is an updated toolbox for financing long-term care that serves the needs of a 2013 population. In 1965, the average life expectancy was 69 years old. If an older person experienced a major health event—a heart attack or stroke, for example—they might have recovered, but they probably did not live much longer beyond that event. Today, with advances in medicine and technology and the increased number of intensive care units and critical care units, people are living longer than ever before, but with functional impairments and multiple chronic conditions. The delivery model we have today is not designed to meet these growing care needs, and the financial strains on individuals and families are significant.

Unintended Financial Consequences

Jun 3, 2013• 12

By Edmund Billings, MD

A question: What is the opposite of health IT return on investment?

The answer: Unintended financial consequences, or UFCs, for short.

The scenario: A sophisticated medical center health system begins to roll out an expensive proprietary EHR and shortly thereafter sustains an operating loss, leaving no choice but to put the implementation on hold. The operating loss is attributed to “unintended financial consequences” directly related to buying a very expensive EHR system.

This is exactly the situation at MaineHealth, who selected Epic. As recently reported, a little while ago Maine Medical Center President and CEO Richard Peterson sent a memo to all employees saying the hospital …

… has suffered an operating loss of $13.4 million in the first half of its fiscal year. The rollout of MaineHealth’s estimated $160 million electronic health record system, which has resulted in charge capture issues that are being fixed, was among several reasons Maine Med’s CEO cited for the shortfall.

“Through March (six months of our fiscal year), Maine Medical Center experienced a negative financial position that it has not witnessed in recent memory,” Richard Peterson, president and CEO of the medical center, wrote in the memo to employees.

Peterson’s memo outlines the specific UFCs that explain, in part, MaineHealth’s operating loss:

Declines in patient volume because of efforts to reduce re-admissions and infections
Problems associated with being unable to accurately charge for services provided due to the EHR roll out
An increase in free care and bad debt cases
Continued declining reimbursement from Medicare and MaineCare, the state’s Medicaid program

These challenges are common to just about any medical system in the country, making MaineHealth potentially a harbinger of things to come for those hospitals and health systems that pay multi-millions of dollars for a health IT system.

The Most Important Thing (code: e.280.11) I didn’t Learn in Med School (code: 780.92)

Jun 3, 2013• 10

By Jessica Jou

Mrs. B was washing dishes in the kitchen when she heard a thump where her twelve-month-old son was asleep. She ran to him and found her son had fallen from a chair (code: e884.2). He was crying (code: 780.92) and visibly shaken, but did not have overt signs of bleeding, bruising, or trauma. She picked him up and immediately brought him to the emergency room. There, he was triaged by the nurse (nursing report #1) and vitals were taken (nursing report #2). Shortly after the mother and son pair settled into the pediatric emergency room, he vomited once (code 787.03).

The emergency medicine residents came by an hour later to conduct a focused interview, and performed a comprehensive physical exam (code: 89.03). He took care to ask at least four elements of the history of present illness that included location, quality severity, duration, timing, context, or associated symptoms from the event. He performed a complete review of at least 10 organ systems and surveyed the patient’s social history (code: 99223). It was decided that the boy was to be observed in the ED for the next few hours for signs of brain injury or concussion.

No labs or imaging studies were ordered. The nurses were instructed to check for vital signs every hour (nursing reports #3,4,5,6). During the observation period, the boy was found to be active, interacting well with mom, hungry, without signs of lethargy or focal neurologic deficits. When the attending physician came by to evaluate and assess the patient, he agreed with the resident’s report and signed the discharge note. The mother was given discharge paperwork and instructions for returning to the hospital if she noticed any new, alarming symptoms.

This is what Kelly, an emergency department medical coder, gathers while reading an ED admission note. She turns to me and explains that the few lines of attending attestation are the only way the patient can get billed. Kelly types in “959.01” into her software because she memorized the diagnosis code for “head injury, unspecified.” She has been doing this for the last 18 years.

As I listened, she explained that a head injury in a twelve-month-old infant is automatically a level three, so long as the resident documents a review of ten systems, past medical history, and a physical exam. These levels indicate the complexity and severity of the patient’s disease/injury. “It’s all about the documentation,” she says. “If just 9 organ systems instead of 10 are documented, even a critically ill patient could be down-coded to a level 4.”

Why Texting Patients Works: The Health Belief Model

Jun 2, 2013• 7

By Rosa Arriaga

With the rise of cell phone usage, smart and otherwise, many health care providers, researchers and entrepreneurs alike have assumed that this ubiquitous technology can be used to improve health and wellbeing. Entrepreneurs have led the charge and so the common catch phrase “there’s an app for that” underscores the fact that nearly 17, 000 health related apps are available either for free or a small charge for Android or Apple users. Young people in the US are perhaps the best targets of our mhealth efforts because they are eager users of mobile technology. However two questions arise naturally: 1) does data show that these apps lead to improved outcomes? 2) is there a theory of how we might use cell phones to improve health outcomes?

In a series of studies, we found that simply responding to text messages over a 3-month period led to improved quality of life and pulmonary function in pediatric asthma patients. In both studies, the researchers randomly assigned 30 asthmatic children, 10 to 17 years old, into three groups – a control group that did not receive any SMS messages; a group that received text messages on alternate days and a group that received texts every day. The children that received messages everyday between two scheduled appointments had the improved psychological and physical outcomes. Thus, our data does indicate that cell phones can be used effectively to improve health outcomes.

Perhaps more compelling is that we may have evidence of a possible mechanism that can lead to improved outcomes. The Health Belief Model is a cognitive theory of behavior change that espouses the notion that a critical pillar of behavior modification is that the individual must make the connection between the severity of the symptoms and the disease itself. In the case of asthmatic patients, we found that many times they attributed their symptoms to other causes. For example, they would say that they couldn’t exercise in the afternoon because they had a heavy lunch or that they couldn’t sleep the night before because they had seen a movie that had made them anxious— rather than attributing these symptoms (inability to exercise or sleep) to their asthma. The Health Belief Model also places value on acquiring knowledge about the disease. Thus, we sent patients texts messages that either asked about symptoms they had experienced or about asthma myths. Thus, our studies also indicate that improving symptom awareness and knowledge about their disease led them to have better medication adherence which in turn led to improved health outcomes.