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Above the Fold

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.

Making Sense of the Debate Over Patient Access to Medical Information

Feb 14, 2012• 3

By John Lumpkin, MD

“When it comes to health care, information is power.”

This comment from U.S. Department of Health & Human Services Secretary Kathleen Sebelius has sparked a heated debate among doctors and patient advocates about the merits and drawbacks of giving patients easy access to their lab results, doctors’ notes and other personal medical information. A deliberation in this month’s issue of SGIM Forum, the newsletter of the Society of General Internal Medicine (SGIM), is emblematic of how doctors’ and patients’ views on transparency vary.

Internist Douglas P. Olson, MD says it’s too early to offer patients electronic access to their lab results or medical records and that without systemic changes it could actually undermine the patient-doctor relationship lists among his concerns the potential to confuse or worry patients; a lack of evidence showing the positive effect on healthcare safety and quality; and the increased demands on doctors’ time to respond to patient questions.

These concerns are valid and shared by many other doctors. In a recent survey by OpenNotes―a project supported by the Robert Wood Johnson Foundation’s Pioneer Portfolio that enables doctors to share their visit notes with patients online―doctors were asked about their expectations and attitudes toward sharing electronic medical notes. The survey was conducted before doctors engaged with OpenNotes. Responses revealed doctors were worried about the impact on workflow and weren’t convinced that it would make a difference to patients’ health.

Price Variation and Confidentiality in the Market for Medical Devices

Feb 14, 2012• 2

By Emma Dolan

The Government Accountability Office (GAO) recently released a report that cites “substantial variation” in the prices paid for implantable medical devices in the Medicare program, and a lack of robust data needed to properly compare the prices paid for these devices across surveyed hospitals. A key driver of both of these findings is the existence of confidentiality clauses in medical device purchasing contracts that prohibit hospitals from sharing prices with third parties, including physicians, the health plans that pay for these devices, and patients.

It was with a sense of déjà-vu that I read this report; in 2010, UC Berkeley professor James Robinson and I published a series of briefs looking at variation in implantable device prices in California hospitals as part of a joint Value-Based Purchasing of Medical Devices project between the Berkeley Center for Health Technology and the Integrated Healthcare Association (IHA). This project included data collection on device costs, total surgical costs, complications, and length of stay for seven orthopedic and cardiac procedures in 45 California hospitals.

The data, as well as a series of IHA-sponsored roundtable conversations with stakeholders, found the same thing that the GAO report finds: a lack of transparency in device prices, sometimes driven by clauses that prohibit hospitals from disclosing the prices paid for devices, a lack of alignment between hospitals and the physicians practicing within their facilities, and very substantial variation in both the prices paid for devices and the total costs of the procedures used to implant these devices. For example, the average cost hospitals paid for knee implants ranged from $3,408 to $10,830, and the average paid for implantable cardioverter-defibrillators ranged from $19,578 to $35,916. There was also a substantial amount of within-hospital variation in device prices.

Privacy in the Age of Big Data

Feb 13, 2012• 5

By Omer Tene & Jules Polonetsky

We live in an age of “big data.” Data has become the raw material of production, a new source of immense economic and social value. Advances in data mining and analytics and the massive increase in computing power and data storage capacity have expanded, by orders of magnitude, the scope of information available to businesses, government, and individuals.[1] In addition, the increasing number of people, devices, and sensors that are now connected by digital networks has revolutionized the ability to generate, communicate, share, and access data.[2] Data create enormous value for the global economy, driving innovation, productivity, efficiency, and growth. At the same time, the “data deluge” presents privacy concerns that could stir a regulatory backlash, dampening the data economy and stifling innovation.[3] In order to craft a balance between beneficial uses of data and the protection of individual privacy, policymakers must address some of the most fundamental concepts of privacy law, including the definition of “personally identifiable information,” the role of consent, and the principles of purpose limitation and data minimization.

Big Data: Big Benefits

The uses of big data can be transformative, and the possible uses of the data can be difficult to anticipate at the time of initial collection. For example, the discovery of Vioxx’s adverse effects, which led to its withdrawal from the market, was made possible by the analysis of clinical and cost data collected by Kaiser Permanente, a California-based managed-care consortium. Had Kaiser Permanente not connected these clinical and cost data, researchers might not have been able to attribute 27,000 cardiac arrest deaths occurring between 1999 and 2003 to use of Vioxx.[4] Another oft-cited example is Google Flu Trends, a service that predicts and locates outbreaks of the flu by making use of information—aggregate search queries—not originally collected with this innovative application in mind.[5] Of course, early detection of disease, when followed by rapid response, can reduce the impact of both seasonal and pandemic influenza.

Minders of the Gap

Feb 12, 2012• 12

By Richard Hoey

When British Prime Minister David Cameron defended his reforms of the National Health Service against a series of aggressive attacks from critics this week, he fell back on a familiar argument – that his reforms would hand control from bureaucrats to clinicians. But the reforms don’t, in fact, hand power to clinicians generally – they hand responsibility for commissioning in the NHS largely to general practitioners (GPs), our answer to US family practitioners. I think it’s worth spending a bit of time explaining quite why, because as other bloggers have written on this site, US policy experts often find it surprising that in the UK such a high status is afforded to family medicine.

GPs in the UK often earn more than their specialist colleagues, and they do so because they have a much more central and wide-ranging role in the British NHS than family practitioners do in the American healthcare system. GPs are in traditional terms, the gatekeepers, and in updated terms, the navigators for the NHS. Patients can’t simply book themselves in to see a hospital doctor – the great majority of first contacts with the health system are with the GP practice. GPs are highly trained, following their medical degrees with two foundation years and then three years of specific GP training (with pressure to extend that to four or even five years).

Although they’re generalists, the profession is regarded as a specialism – and its expertise is measured partly by its ability to manage as many patients as possible in primary care, without the need for referral to hospital. GP care has proved highly cost-effective, both by controlling the numbers of patients who access expensive hospital treatment, and by directing patients to the most appropriate part of the NHS when they do need specialist attention. And in an NHS facing unprecedented cost pressures, that’s given them an enormous amount of power, and is about to gain them a whole load more.

Startups: The Other Health Technology Revolution

Feb 11, 2012• 7

By Ricky Choi, MD

These days my physician colleagues and I are up to our necks in a health technology revolution. To be honest, its not as captivating as Pinterest or socially-engaging as a Google Huddle but to be sure your life will depend on it. The revolution ushered in by electronic health record (EHR) is less about the technology than the widespread impact it will have on patient care. Rather than digging through stacks of paper charts, your doctor will have ready access to all of your health history on a digital device. And not just your health history, soon I will be able to combine it with the history of other patients in my practice: the digitized data will allow me to track the childhood obesity rate in my clinic and trend it over time with just a click (or tap). But look out, there are glimmers of another emerging health tech revolution.

I recently attended the Health Innovation Summit organized by Rock Health, a seed accelerator for health startups based in San Francisco. Coming from the bureaucratic and comparatively stagnant world of health care systems, this event made me feel like I could dream again. Speakers provided pearls of wisdom for an engaging design. Panels offered strategic advice to attract VC and Angel funding. Most exciting was the chance to hear from entrepreneurs, each of whom offered their own incremental solution to improve health.

Take something like Cardiio, which measures heart rate in a few seconds by scanning your face. Imagine how future related technologies could replace monitoring wires and tubes thereby improving comfort during a hospitalization and reducing hospital acquired infections.

No Free Lunch. No Free Contraception.

Feb 11, 2012• 22

By ROBERT LASZEWSKI

The otherworldy Obama Administration solution to the contraception firestorm might work politically but it makes no sense in the real world.

The President, hoping to quell a growing political firestorm, today announced a new policy that no longer requires religiously affiliated organizations to provide employees with contraception coverage in health-insurance plans.

Under the new policy, insurance companies will be required to offer free contraception for their employees and dependents. The administration’s idea is to shift the onus for the coverage from the employer to the insurer. Catholic leaders, and lots of other people, had objected to the requirement, which exempted churches but not hospitals, charities and universities with religious affiliations.

So, let’s just play a game here. The religious organization just pretends that it has nothing to do with it but the insurance company pays for it anyway. Hey, the insurance companies are rich.

Of course there is a cost. Today, contraception is almost universally covered in health insurance policies. The argument that forcing insurers to pay for it, without deductibles and copays, saves money because it avoids pregnancy costs is just plain silly.

The Audacity of Dupe

Feb 10, 2012• 25

By David Dranove

Let me get this straight. Catholic institutions won’t have to pay for contraception coverage in their health insurance? Instead, their health insurers will provide it for free? Did I hear that right?

The President seems to have found the long elusive free lunch. If he has, hand him his Nobel Prize in Economics now; no economist will ever top that. (That would make him just the fifth person to win two Nobel Prizes. Such greatness inspires.) I am afraid that the Nobel Prize committee will have more work to do, as the free lunch will remain as scarce as the unicorn. Just bear in mind that health insurers charge different prices for all of their clients. How is anyone to know whether they are providing contraception to some Catholic institution for free? Will we have a federal agency auditing whether an insurer’s 6.743 percent price increase should have been 6.682 percent? And is this new rule even Constitutional? Since when can the government force private businesses to give away their products? I guess a government that believes it can mandate that consumers purchase contraception coverage regardless of the price also believes that it can mandate insurers set the price for contraception coverage to zero.

And suppose insurers really do provide contraception for free to Catholic institutions, but not for any others. This gives the Catholic institutions a competitive advantage in labor markets. Mr. President, may I suggest that as long as you are giving away stuff to employees at Catholic institutions, why not force Apple to give away iPads to Northwestern University employees? (Most of them voted for you and surely deserve it!) Apparently all it takes is an executive order. What did Mel Brooks say about this? Oh yeah, “It’s good to be the king.”