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Matthew Holt interviews Allscripts CEO Glen Tullman at HIMSS12. Tullman recaps what happened this year at his company and explains how Allscripts can help small companies innovate.
Above the Fold
Will Doctors or Patients Bend the Cost Curve?
The American Board of Internal Medicine (ABIM) and nine other professional medical societies announced that doctors should perform 45 tests and procedures less often than currently done because there is no good medical evidence that they add any value. Specifically, a xray or other imaging for low back pain in an otherwise healthy individual or an EKG as part of a routine physical, just add a lot of unnecessary cost to the health care system as a whole and don’t provide doctors or patients any meaningful information that would be helpful in improving health or arriving at the right diagnosis and treatment.
The ABIM partnered with Consumer Reports to create a new campaign called Choosing Wisely and are joined also by collaborators like employers (the National Business Group on Health, the Pacific Business Group on Health), hospital safety (the Leapfrog Group), and labor unions (SEIU). The mission is simply to have doctors and patients deliver and receive care that is medically necessary, based on evidence, avoids harm, and minimizes duplication.
The real question is – will it work? Will doctors follow what their professional societies recommend?
Though Choosing Wisely is a laudable attempt to make medical care better quality, the truth is doctors won’t likely follow these guidelines from their medical societies. If it was that easy, we would not have this problem! Even today, it is still a challenge for the medical profession to have all doctors wash their hands correctly every patient every time, get immunized routinely against influenza, or even not to prescribe antibiotics for coughs, colds, and bronchitis due to viruses! What is more disturbing is that doing these basic interventions did not impact a doctor’s income. Some on the list of Choosing Wisely, however, will.
Why the Fragility of Health Outcomes Research May Be a Good Outcome for Health
Durably improving health is really, really hard.
I’ve discussed this in the context of drug discovery, which must contend with the ever-more-apparent reality that biology is incredibly complex, and science remarkably fragile. I’ve discussed this in the context of patient behavior, focusing on the need to address what Sarah Cairns-Smith and I have termed the “behavior gap.”
Here, I’d like to focus on a third challenge: measuring and improving the quality of patient care.
I’ve previously highlighted the challenges faced by Peter Pronovost of Johns Hopkins in getting physicians to adhere to basic checklists, or to regularly do something as simple and as useful as washing hands, topics that have been discussed extensively and in a compelling fashion by Atul Gawande and others.
Several recent reports further highlight just how difficult it can be not only to improve quality but also to measure it.
Consider the recent JAMA article (abstract only) by Lindenauer et al. analyzing why the mortality rate of pneumonia seems to have dropped so dramatically from 2003-2009. Originally, this had been attributed to a combination of quality initiatives (including a focus on processes of care) and clinical advances. The new research, however, suggests a much more prosaic explanation: a change in the way hospitals assign diagnostic codes to patients; thus, while rates for hospitalization due to a primary diagnosis of pneumonia decreased by 27%, the rates for hospitalization for sepsis with a secondary diagnosis of pneumonia increased by 178%, as Sarrazin and Rosenthal highlight in an accompanying editorial (public access not available).
Health Care Law Supporters Ought to Be Sentenced to Serve as Governors
During the debate two years ago over the health care law—which I called an historic mistake because it expanded a health care delivery system we already knew was too expensive, instead of taking steps to reduce its cost two years ago—I suggested to our colleagues on the other side of the aisle who were supporting it that, if they voted for it, they ought to be sentenced to go home and run for governor and see whether they could implement it over an eight-year period.
Governors have long wrestled with the rising costs of Medicaid, paid for partly by the states according to rules set in Washington, and the question of how to deal with public education, especially higher education. Some 30 years ago, when I was a young governor, I was still struggling with the fact that at the end of the budget process, we had money either to put into higher education or into Medicaid – but the rules from Washington said it had to go to Medicaid.
I remember going to see President Reagan and asking: ‘Why don’t we just swap it, Mr. President? Let the federal government take all of Medicaid. Let the states take elementary and secondary education.’ That didn’t happen, and gradually, the increasing Washington-directed costs have distorted state budgets so much that now 24 percent of the state budgets go to the Medicaid program.
Because of the health care law, we are going to add 25.9 million more Americans to Medicaid, according to the Medicaid Chief Actuary.
Our former governor, Governor Bredesen, a Democratic governor, estimated that between 2014 and 2019 the expansion of Medicaid would add $1.1 billion in new costs to the state of Tennessee.
Jack Cochran, The Permanente Federation
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The Permanente Federation is the national organization for Kaiser Permanente’s doctors. In this interview taken at HIMSS12, Executive Director of the Federation Jack Cochran gives an overview of transitions physicians are undergoing in the workplace. He also debunks what he says is the biggest myth about patient to doctor emails.
The Magic of Doing One Thing at a Time
I’ve previously written about multitasking and work induced attention deficit disorder.
I’ve also written about the burden of having two workdays every 24 hours – one for meetings and one for email
Yesterday, I was sent a post from the Harvard Business Review that summarizes these issues very well.
It highlights the problem and a series of solutions.
Nearly half of employees report the overwhelming stress and burden of their current jobs, not based on the hours they work, but the volume of multitasking – too many simultaneous inputs in too little time. They’ve lost the sense of a beginning, middle, and an end to their day, their tasks and their projects. There is no work/life boundary.
As a case in point, I’m writing now while doing email and listening to a Harvard School of Public Health eHealth symposium. Am I being more productive or just doing a greater quantity of work with less quality?
The author of the post points to evidence that multi-tasking increases the time to finish a task by 25%. He also notes that our energy reserves are depleted by a constant state of post traumatic stress induced by our continuous connectivity.
He suggests three strategies:
1. Rather than multi-task, reduce meeting times to 45 minutes, leaving 15 minutes for email catchup and transition.
Everyone Should Learn the Entrepreneurial Method
When I was a teenager, the older women in my family taught me to cook. I learned it was traditional not to add salt when cooking lentils, because it would slow down the cooking. For some reason, perhaps the sheer pleasure of being difficult, I insisted on taking two identical pots and cooking identical quantities of lentils, one with salt and one without. That caused quite a bit of a stir, and not only because I proved that the salted lentils cooked just as fast. On the one hand, my mother, grandmother, and aunts sensed more difficulties were to come. On the other, they knew they’d participated in something different and important: a scientific experiment.
The women in my family were courageous, smart, and resourceful. They knew many things: useful wonderful things. For the most part, their knowledge was received knowledge, knowledge they’d been given, not figured out on their own. This is a common situation. The idea that anybody can be taught to figure things out, that there is a logic to discovery and invention, would have struck our ancestors as radical and strange. Until quite recently — until science education became institutionalized and widespread — the creation of new knowledge depended on either genius or luck.
Pay for the “A”
Medicine is simple and straightforward; except when it’s complex and nuanced.
Medical diagnosis is a simple matter of taking a history, performing an examination, and reviewing the results of ancillary testing; except when it’s a complicated case of eliciting subtle nuances from the patient in both the interview and the exam, and interpreting multiple pieces of conflicting data.
Medical treatment is a straightforward affair of providing appropriate treatment; except when there are multiple treatment options with unclear risks and benefits, technically challenging surgical or other procedures to perform, not to mention fully informing the patient and family about all of those treatment options, risks, and benefits, plus eliciting and answering all their questions.
Nothing to it.
Notice, though, that the key ingredient here is DIAGNOSIS. Performing a flawless appendectomy won’t do a thing for an ovarian cyst, nor will a PPI prescription do much for an acute coronary syndrome. Performance measures that look at treatment without addressing diagnosis are somewhere between misguided and ludicrous.
Why does American medicine have this so bass-ackwards? Follow the money. Thanks to the specialty-heavy RUC, the commission that sets fees for various procedures, doing something — anything — is paid far more handsomely than thinking (even thinking about what to do).
Romney’s Second Shot at Healthcare Reform
Americans believe in second chances. The oral arguments before the Supreme Court last week were a rare opportunity to dispassionately re-examine the divisive healthcare debate of two years ago. What happens if, after the smoke clears, we get a second chance at healthcare reform?
We’ve long known that healthcare will be a central theme in the 2012 presidential contest. The High Court’s deliberations and June decision only reinforce that reality for President Obama and Governor Romney.
Unlike with the Patient Protection and Affordable Care Act (PPACA), the constitutionality of Governor Romney’s Massachusetts law has never been seriously questioned. States, not the federal government, have police powers, allowing them to require purchases (car insurance, taxes and licensure) and to pass wide-ranging public health laws and public safety laws. The Bay State law enjoys broad popular support.
In contrast, the case before the Supreme Court was brought by the majority of states. Regardless of what the Court decides, the PPACA will continue to polarize the country.
President Obama may cite Romney’s Massachusetts reform as inspiring his efforts, but there are profound differences in the size, reach and financing of the two laws. Elected just six months after the law’s passage, Romney’s successor, Democratic Governor Deval Patrick, has obscured some of those differences by taking a big government approach to implementation.
Where Romney sought an open marketplace for individuals to purchase benefit plans ranging from catastrophic to generous, Patrick has drastically limited choices and mandated minimum coverage levels beyond private-market norms.
The Supreme Court on Moral Hazard
I have had to take some time off for the funeral of someone very near to me, so I have not had a chance to comment on the Supreme Court hearings. Nor do I have much time to do so now. But I would like to comment on Justice Alito’s line of questioning about burial insurance. His questioning was in response to one argument used to justify the purchase mandate, namely that sick individuals will receive medical care at someone else’s expense and therefore there is an economic justification for mandating the purchase of health insurance in order to prevent free riding. Alito noted that individuals who did not provide for their own burials will still be buried at taxpayer expense. This is another form of free riding. If the Supreme Court were to uphold mandatory purchase of health insurance, could Congress not also mandate purchase of burial insurance?
Solicitor General Donald Verrilli seemed surprised by Alito’s questions and did not provide a good answer. Yet these questions strike at the heart of the case and at deeper economic issues. There is a direct analogy between the market for burials and the market for healthcare. Just as some patients free ride off of the generosity of others, some deceased do the same thing. By extension, any time that a good is provided at a price below cost, whether by the government, a charity, or any other organization for that matter, we can expect a certain degree of moral hazard behavior. Some individuals who ought to purchase the good themselves will instead free ride on the generosity of others.
