The Health Care Blog – Page 756 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

EMR and the Falling Patient

Jan 20, 2011• 8

By STEVE SANDERS, DO

Is Mom at risk of falling?

Electronic medical records (EMR) efficiently capture physician’s keystrokes—yes or no—to this question and tuck it along side other data about our so–called medical lives.The physician’s judgment has to take into account many factors: is the patient elderly and ‘frail,’ do they have an orthopedic or neurological problem causing them to lose their balance, can they get up from a chair without having to use their arms to push-off, importantly do they live alone. Most of the answers to these questions come quickly through discussions with the patient or their family, or by simply observation. Nine times out of ten physicians can predict that a patient will fall before it happens.

Now, the EMR owns this critical piece of information. But the next most obvious question, as many of you can guess, seems clear: now what?

Ideally by clicking yes, a sequence of events occurs; (a) Home health receives an electronic message requesting a patient safety visit. Specially trained home health nurses look for loose rugs that may slip out from under the patient, extension cords waiting to snag an unsuspecting foot, toilets without support for getting up and down, or the need for an electronic alert system bringing help quickly (b) An alert goes to the patient’s pharmacy requesting a drug–drug interaction report, detailing which drugs interfere with each other causing precarious side effects. Alerts also goes to the primary physician highlighting which of the patient’s medication tend to cause problems in the elderly (c) Schedules an appointment with physical therapy for balance and strengthening exercises (d) Arranges for a visual examination and hearing test, after checking on previous tests. These steps become placed into motion within a nanosecond after clicking ‘yes.’

The Proposed Stage 2 and 3 Meaningful Use Recommendations

Jan 20, 2011• 2

By JOHN HALAMKA, MD

On January 12, the Health Information Technology Policy Committee published its proposed Stage 2 and 3 Meaningful Use recommendations for public comment.

Robin Raiford from Allscripts created a Quick Guide to the recommendations, making it easy to compare Stage 1, 2 and 3 in a single PDF.

Here’s my analysis of the proposed Stage 2 and 3 criteria.

1. CPOE – Stage 1 requires more than 30% of unique patients with at least one medication in their medication list have at least one medication order entered using CPOE Stage 2 expands this to 60% of patients for at least one medication, lab or radiology order. Stage 3 expands this further to 80%. CPOE orders do not need to be transmitted electronically to pharmacies/labs/radiology departments. This is a very reasonable rate of CPOE adoption. The hardest part of implementing CPOE is getting started, which happens in Stage 1. Adding different types of transactions (without requiring electronic transmission to back end service providers) is more about workflow and behavioral change than technology change.

2. Drug-drug/drug-allergy interaction checks – Stage 1 requires that interaction technology be enabled. Stage 2 adds that it will be used for high yield alerts, with metrics for use to be defined. The idea is that many drug databases contain too many false positive interaction rules, so adoption is slowed by alert fatigue. If only high yield alerts are required (here’s what we’ve done at BIDMC ), clinicians are more likely to trust drug interaction decision support. Stage 3 adds drug/age checking (such as geriatric and pediatric decision support), drug dose checking, chemotherapy dosing, drug/lab checking, and drug/condition checking. These are all reasonable goals, but automating chemotherapy protocols is quite challenging. BIDMC built an Oncology Management System and added a full time research nurse to ensure all chemotherapy protocols are updated and accurate. It may be asking too much to require chemotherapy dosing decision support nationwide by 2015.

Not Colon Cancer

Jan 19, 2011• 22

By DAVIS LIU, MD

My mother’s oncologist ordered the blood test, carcinoembryonic antigen (CEA), to check for the recurrence of colon cancer. The good news was that there was no evidence of recurrence. The bad news was that she didn’t have colon cancer.

She had breast cancer.

Though she was feeling better, the chemotherapy and radiation had taken its toll. For the past couple of months, she had experienced constant nausea and vomiting. During and after treatment, her hands and feet felt like they were on fire. Many times she wanted to give up and quit. Yet she persevered and felt emotionally stronger after the ordeal. She started to feel like herself again. Life began to have some normalcy. Until an insurance bill appeared asking for hundreds of dollars.

Apparently over the past year, her oncologist had routinely ordered the CEA test multiple times as part of her cancer follow-up. When she called to contest the charge, the insurer told her to talk to her doctor. She didn’t know this test was unnecessary until the bill. And until she called me, her son, a primary care doctor.

She asked her oncologist about the repeated blood tests. He simply shrugged. No apologies. No explanation. No acknowledgment of the error. Didn’t he get the lab results of the CEA? Shouldn’t he have been aware that the test was not relevant for her care?

Job Post: THCB Editorial

Jan 19, 2011

THCB is looking for talented interns to assist with editorial, research and web production tasks as our web site undergoes a major expansion. Perfect for a grad or med student with an interest in journalism, public policy, and/or the business of health care.

Centrists Back Health Care Reform

Jan 19, 2011• 11

By MERRILL GOOZNER

The tone on Capitol Hill during Tuesday’s debate was more civil, the partisan rhetoric less harsh than previous exchanges on the House floor. But there’s little doubt that the Republican-led House will vote later today to repeal President Obama’s signature health care reform law.

That largely symbolic vote – there’s almost no likelihood the Democratic Senate will follow, nor would the president sign the bill – signals the start of a two-year campaign by newly empowered Republicans in the House to undermine the new law. Proponents of “repeal and replace” will next turn to eliminating the most unpopular elements of the law—including the individual mandate – and to cutting off funding for implementation.

But the administration won a powerful set of centrist allies on Tuesday as it scrambled to set in motion reforms that it believes will be popular with the American people once its key provisions go into effect. The new law, signed by Obama last March, is designed to provide about 32 million previously-uninsured Americans with coverage either through Medicaid or subsidized private insurance sold through state-based insurance exchanges. The total cost of the program of about $900 billion will be paid for by a combination of tax increases and slower growth in Medicare spending. The law also places consumer-friendly restrictions on insurance carriers, funds Medicare pilot models in alternative care delivery, and creates a government-run long-term care insurance program.

THCB Recommends …

Jan 19, 2011

Insurance Exchange Budgets: How Much is Needed?

Jan 19, 2011• 3

By ROGER COLLIER

It’s coming up to four months since the Department of Health and Human Services awarded more than $50 million in grants to states and US possessions for health insurance exchange planning and development, and the money is now starting to be spent. $50 million seems like a fair amount of cash, but it’s generally understood that this is just a down payment on the cost of exchanges. So how much might a state expect to spend?

Although neither complies exactly with the requirements of PPACA, the exchanges in Massachusetts and Utah provide some clues as to how much a state might have to spend in order to have a successful functioning exchange.

The Massachusetts Connector meets the PPACA requirements quite closely (not surprisingly given that PPACA drafters used it as a model), and has been operational for four years. It offers on-line enrollment to small groups and to both subsidized and unsubsidized individuals. There are now approximately 155,000 subsidized CommCare enrollees and close to 40,000 unsubsidized enrollees.

The Connector has been quite generously funded. An initial state appropriation provided $25 million in planning and development funds, while operations costs are funded through per-enrollee levies on participating health plans. Current levy rates are 4-4.5 percent (comparable to insurance broker renewal rates), giving the Connector an operations and ongoing enhancement budget of more than $40 million a year to pay for some 45 staff, consultants, and IT and other contractors.

Health Care Georgians Deserve

Jan 19, 2011• 1

By GAYATHRI SURESH KUMAR, MD

As a physician who works at Grady Memorial Hospital, I am regularly reminded of the implications of poor access to health care.

One of my regular patients had been suffering from diabetes and hypertension for five years. She was a single, dedicated mother who had been working long hours at a local grocery store to provide for her 15-year-old daughter. She understood that good health meant that she could perform better at work, and the earnings she received from her work would help her provide a stable home for her daughter. Therefore, she did whatever it took to keep herself healthy — monitored her diet, took her medicines diligently and visited the physician regularly.

Things changed one day when during one of her visits to my clinic she said, “Doc, I just lost my job. I don’t have insurance anymore. Medicaid denied me coverage even though they said it was OK for my daughter to have insurance. I can’t pay my co-pays to see you anymore. I may not see you next time.” I was horrified.

A mother who wanted nothing more than to be as healthy as possible for her child should be able to receive care. The health care system in our country that should be serving patients exactly like this one is preventing patients from receiving the care they need and deserve.

In many cases, access to health care coverage is not within the control of patients nor their physicians, resulting in significant consequences. That is, if they don’t obtain coverage, many of our patients will succumb to their (many preventable) illnesses if they don’t have access to their physicians or cannot pay for their medications. My patient’s future could be a testimony to this.

What further confounded me was that Medicaid denied my patient.

Minimum Essential Benefits

Jan 18, 2011• 5

By MICHAEL TURPIN

The Affordable Care Act is officially under construction. The framework for the minimum mandatory levels of benefits offered through state exchanges is now being researched and will soon be ready for prime time debate.

The Institute of Medicine, a non-partisan research group, has been retained by Health and Human Services to conduct public and private planning sessions to help shape final recommendations on what standard levels of benefits should be required as a “floor” for all health plans.

The queue of industry and special interest groups increases daily as stakeholders wade in to offer personal perspectives on why certain levels of benefits should be considered as “essential”. The stories will be heart wrenching as individuals plead for broader coverage terms and looser definitions of medical necessity to cover a range of therapies treating orphaned or difficult conditions that do not neatly fit into today’s definitions of coverage. The unfortunate fact also remains that the average consumer expects “essential coverage” to be synonymous with open access, comprehensive coverage, minimal out-of-pocket cost sharing and an affordable price tag. In effect, everyone wants a Cadillac when the nation can barely afford a Corolla.Continue reading…

HPHC Goes Its Way, Thoughtfully

Jan 18, 2011• 10

By PAUL LEVY

Lots of people are thinking about the form of payments between insurance companies and providers for health care services, but it is also important to think about how each such approach would be marketed as an insurance product to the population.

The payment model that gets the most attention is capitated, or global payments, combined with accountable care organizations. In this environment, an average annual budget is established for each person served by an integrated health care delivery system (ACO), and that budget is shared among the providers according to some mutually agreed upon arrangement.

But the insurance product that would accompany this kind of payment scheme is often left without much of a description. As I have talked with insurance executives, they often fail to explain how they would offer consumers a desirable choice for a product based on this payment plan. Instead the main focus seems to be on shifting risk from the insurer to the providers, reducing the amount of unnecessary expenses, and sharing the benefits of those changes between the insurance company and the providers. Over time, the theory goes, the cost curve is slowed and premiums go up less quickly. But, it remains unclear what the role is for consumer in this scheme.