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Paving the Regulatory Road

Feb 17, 2012• 1

By Deven McGraw

The poor quality and high cost of health care in the U.S. is well documented. The widespread adoption of electronic medical records—for purposes of improving quality and reducing costs—is key to reversing these trends.[1] But federal privacy regulations do not set clear and consistent rules for access to health information to improve health care quality. Consequently, the regulations serve as a disincentive to robust analysis of information in medical records and may interfere with efforts to accelerate quality improvements. This essay further explains this disincentive and suggests a potential regulatory path forward.

The U.S. has dedicated approximately 47 billion dollars to improve individual and population health through the use of electronic medical records by health care providers and patients.[2] Much of the funding for this initiative, enacted by Congress as part of the Health Information Technology for Economic and Clinical Health Act of 2009, will be used to reimburse physicians and hospitals for the costs of purchasing and implementing electronic medical record systems. The legislation also includes funding to establish infrastructure to enable health care providers to share a patient’s personal health information for treatment and care coordination purposes and for reporting to public health authorities.

Federal policymakers also intend for electronic medical records to be actively used as tools of health system reform. The legislation directs the U.S. Department of Health and Human Services to develop a “nationwide health information technology infrastructure” that improves health care quality, reduces medical errors and disparities, and reduces health care costs from inappropriate or duplicative care.[3]The 2011-2015 Federal Health Information Technology Strategic Plan identifies improving population health, reduction of health care costs, and “achiev[ing] rapid learning” as key goals of federal health information technology initiatives.[4]

Does ICD-10 Delay Create an Easy Opportunity for Coding Improvement?

Feb 16, 2012• 4

By Al Lewis

Implementation of ICD-10s has been delayed “indefinitely.” Rather than opine on whether that’s a good thing or a bad thing, I will note that it creates an opportunity for a simple but powerful improvement in the value of the coding.

Caveat: I am not a coding expert (I don’t even play one on TV) so there might be something wrong with this idea. The specific reason for the post is to find out whether there is some reason this can’t be done, given the value of doing it. (I am so unfamiliar with coding that it is possible this is already being done and I’m the last guy to find out about it, in which case perhaps John and Matthew would be kind enough to remove it.)

Quite simply, how about adding an optional “R” for “rule-out” after the codes? For instance, today if a patient gets tested for diabetes and it turns out that he HAS diabetes, he gets coded “250” in the ICD-9s. Whereas if it turns out the patient does NOT have diabetes, he still gets coded “250.” My proposal would code that (in ICD-9s) 250R.

By contrast, giving two opposite diagnoses the same code creates a cascading set of problems, in outcomes measurement, risk scoring, registries, disease management, reimbursement, and predictive modeling, problems that will be exacerbated as risk shifts down to the provider level and payors move to outcomes-based reimbursement.

The Creative Destruction of the News Business and Other Weird Stories

Feb 16, 2012• 8

By Dave Chase

Health system CEOs would be well advised to study what newspaper industry leaders did (or perhaps more appropriately, didn’t do) when faced with a dramatic industry change. Turn back the clock 15 years and the following dynamics were present:

Newspaper leaders knew full well that dramatic change was underway and even made some tactical investments. However they didn’t fundamentally rethink their model.
Newspapers were comfortable as monopoly or oligopoly businesses allowing for plodding decisions. Their IT infrastructure mirrored the plodding pace with expensive and rigid technology architectures.
Newspaper companies bought up other newspaper chains and took on huge debt.
Owning printing presses was a de facto barrier to entry allowing newspapers unfettered dominance.
Depending on one’s perspective, it was the best of times or the worst of times to be a leader of local media enterprise.

Before they knew it, owning massive capital assets and the accompanying crushing debt became unsustainable. The capital barrier to entry transformed into a boat anchor while nimble competition dismissed as ankle-biters created a death-by-a-thousand-paper-cuts dynamic. Competitively, newspaper companies worried only about other media companies or even Microsoft, but their undoing was driven by a combination of craigslist, monster.com, cars.com, eBay, and countless other marketing substitutes for their advertisers. In addition, there were easier ways to get news than newspapers. Generally, the newspaper’s digital groups were either marginalized or unbearably shackled so that the encumbered digital leaders left to join more aggressive competitors. The enabling technology to reinvent local media didn’t come from legacy IT vendors who’d long sold to newspaper companies, but from “no name” technologies such as WordPress, Drupal and the like.

The Unfortunate Side Effect of Death

Feb 16, 2012

By Andrew Schutzbank

Peggy was in her early 70s and suffered from a terrible lung disease known as pulmonary hypertension. Her case was so bad that she had a pump infusing a medicine under her skin 24 hours a day to keep the blood supply to her lungs open. Once started, this medicine, treprostinil, was known to improve life in those with pulmonary hypertension. Unfortunately, like all continuous infusion medicines of this type, it has the unfortunate side effect of sudden death if stopped for more than 4 hours. Starting it was a difficult choice for Peggy and her expert team of physicians, but her disease had progressed to a point where it was the right decision. As you can imagine, this drug was mighty expensive. We would only find out how expensive later.

On the day that I met Peggy, she was being admitted to the Intensive Care Unit (ICU) not for her pulmonary hypertension, but because she had a bleed in her stomach, which caused her to swallow blood/stomach contents into her already damaged lungs. Once stabilized, our first challenge was to ensure that she continued on the treprostinil. It took a little magic from pharmacy and the drug’s manufacturer, but we were able to get everything together and Peggy was no worse for the wear.

A few days later Peggy was improving, breathing tube out and awake and back to herself. Due to the special nursing needs with treprostinil, Peggy was required to be in the Cardiac Care Unit (CCU), a special type of (ICU), despite her progress. Even though Peggy managed this medicine at home by herself, hospital policy prevented her from transitioning out of the ICU to the general medical floor, at a fraction of the cost. Conceding that point, the decision was made to try and transition Peggy directly to Rehab. But her progress was stalled for one simple reason: treprostinil.
Continue reading…

Should Your Doctor Talk with You About the Cost of Your Pills?

Feb 15, 2012• 9

By Peter Ubel, MD

I first realized something was amiss when I picked up my prescriptions and the pharmacist explained that she could not fill the anti-malarial medications as prescribed: “Your medication plan only pays for 30 days of pills, and your prescription was for five pills.” The pharmacist continued: “Your PBM [that’s an acronym for pharmacy benefits management company, the type of company that coordinates many peoples’ medication coverage] only fills this medication for 30 days at a time. And 5 pills would last 35 days.”

Expert logician that I am, I countered with some math of my own: “Well four pills, taken weekly, only lasts 28 days. If they really want to give me 30 days of coverage, they need to give me a fifth pill.” I thought it was insane to pay a whole extra co-pay to get my fifth and last pill, a co-pay I’d have to pay for my two sons too since all three of us were traveling together.

But the pharmacist was unpersuaded: “Sorry, four pills is it. You’ll need another prescription for the last pill.”

Irked, I handed over my credit card and hastily signed the bill, too bothered by the conversation to look closely at the bottom line.

When I got home and told my wife Paula about the saga of the fifth pill, she calmly looked at the bill and asked me: “If you were so concerned about a $10 co-pay, why didn’t you notice that the antibiotic you were given cost almost $200?”

Huh?

Oops! ICD-10 To Be Delayed Indefinitely. Never Mind!

Feb 15, 2012• 13

By ROBERT LASZEWSKI

After years of telling us they are serious this time and everyone in the health care system had better be ready on time to implement the new disease coding system, CMS said today the whole project is going to be delayed indefinitely.

The new ICD-10 system requires payers and providers to convert from the old system of 13,000 codes to the new system of 68,000 codes.

All payers and providers were supposed to be ready by October 1, 2013. The acting CMS Administrator said, “There is a concern that folks cannot get their work done around meaningful use [of information technology], ICD-10 implementation, and be ready for [insurance] exchanges. So we decided to listen and be responsive.”

Apparently, a new timeline will be developed through a “rule making process.”

Fine, but that has not been the message for months now and lots of people have spent lots of money for apparently no good reason.

The concerns that particularly physicians would not be ready on time have not been minor. CMS conducted a survey between January and March of 2011 that clearly showed there were big problems ahead. But in the year since that survey, they continued to tell stakeholders to keep going ahead full speed, spending big money to be ready.

But in the last few weeks, the American Medical Association has been sounding the alarm–their people wouldn’t be ready.

Sounds like the lowest common denominator in the health care system wins out.

Here are the results from a survey CMS conducted from January to March of 2011 by type of industry participant. AHIP is the insurance industry trade association, HBMA and AAPC are associations of industry coding and billing providers, ACP is the American College of Physicians and the AMA is the American Medical Association. The survey also measured readiness for the Version 5100 standards for electronic health transactions that were effective in January 2012, but for which enforcement has been delayed until March 31, 2012.

CareZone –1999 PHR Redux?

Feb 15, 2012• 5

By Matthew Holt

In 1999 PersonalMD & HealthCompass were some of the new personal health records (PHRs) where you could store health data and share it with others who needed to see it. They were basically vaults, they rarely even had data linked to a drug or condition database–just plain text, and they couldn’t get data out of larger systems. And they were not successful.

Later PHRs tried to overcome these problems by making it easier to import data from other systems (think geting your drug data from Walgreens) and linking to other reference databases (so that when you enter a drug name the right spelling comes up and it can tell you about interactions, etc.).

There was (and still is) the problem of how to get paper documents into the record. MyMedicalRecords.com allows you to fax in paper records to make PDFs, and has burned through some $30m in 5 years (and I was pretty cynical about them from the start). Of course even getting much of this right didn’t help many early PHRs like WellMed which went through some $40m before being sold to WebMD for $20m and iMetrikus (now Numera) which spent some $75m (est) of Chiron Founder William Rutter’s money before completely changing models.

CareZone is the product of ex-Sun CEO Jonathan Schwartz’s last two years since the fire-sale to Oracle. It was introduced to an adoring bunch of journalists yesterday including Techcrunch’s Eric Eldon, Robert Scoble, and Xconomy’s Wade Roush. All of them continue to confirm to me that they don’t much understand this market and they fawn over former techies who think that they’ve discovered health care nirvana. I really cannot see what the fuss is about. They’re all fascinated by the fact that this doesn’t link to Facebook and somehow keeping instructions to take Johnny to the doctor off the Twitter feed is a huge advance. But none of them see the really basic flaws in CareZone or seem to have any history of what’s happened in this market before.

Medicine’s Tech Future: the View from the Valley

Feb 14, 2012• 4

By David Shaywitz

A few quick impressions from last week’s FutureMed extravaganza put on by Singularity University at the Museum of Computer History, a stone’s throw from Google’s Mountain View headquarters.

The event featured an exhibition session where emerging digital health companies (with some others) demo’d their initial products, followed by a plenary session introduced by FutureMed Executive Director (and former MGH medicine colleague) Daniel Kraft, and featuring presentations to the packed house by several leading innovators – including one of the developers of IBM’s Watson, which is pivoting from Jeopardy to clinical medicine.

Given the high density of reporters there – to say nothing of innovators, would-be innovators, VCs, and assorted poseurs (categories not mutually exclusive) – I expect there should be lucid coverage available elsewhere on the web.

Instead, I want to capture the three sequential reactions I had, which strike me as somewhat analogous to Haeckel’s Law (ontogeny recapitulates phylogeny), as each response seems to reflect a distinct stage of professional development.

The inevitable initial, and most visceral reaction to this sort of event, is that technology is wicked cool, and will deliver us all; I think this two minute introductory video captures the vibe more effectively than any description I could offer. I’m also certain any student of semiotics would find it especially rewarding.

Accordingly, even much of the informal discussion at the event seemed to revolve around Big Questions, lofty ideas, and the Next Big Thing. New technologies and approaches – artificial organs from stem cells! Computers that can read your mind! Bottom-up innovation! Exponentials! – were discussed expectantly, the key question being not if, but when. The remarkable progress many in the tech crowd had seen in other disciplines suggested that technology advances in health would be similarly achievable, and just as inevitable.

The Perfect EHR

Feb 14, 2012• 2

By John Halamka, MD

I support over 3000 clinicians in heterogeneous sites of care – solo practitioners, small offices, multi-specialty facilities, community hospitals, academic medical centers, and large group practices.

In every location there is some level of dissatisfaction with their EHR. Complaints about usability, speed of documentation, training, performance, and personalization limitations are typical. Most interesting is that users believe the grass will be greener by selecting another EHR.

I’ve heard from GE users who want Allscripts, eClinicalworks users who want Epic, Allscripts users who want AthenaHealth, and NextGen users who want eClinicalWorks.

The bottom line from every product I’ve used and everyone I’ve spoken with is that there is no current “perfect” EHR. We’re still very early in the EHR maturity lifecycle.

What is the perfect EHR? I’ve written about my best thinking, which has been incorporated into the BIDMC home built record, webOMR. (and has dissatisfied users too)

However, after listening to many “grass is greener” stories, I believe that what a provider perceives as a better EHR often represents trade offs in functionality. One EHR may have better prescribing functionality while another has better letters, another is more integrated and another has better support. The “best” EHRs, according to providers, varies by what is most important to that individual provider/practice, which may not be consistent with enterprise goals or the needs of an Accountable Care Organization.