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Above the Fold

The Moral Component to Transparency

Jan 9, 2011• 1

By PAUL LEVY

Many of you have asked if I intend to continue this blog, now that I am stepping down as CEO of BIDMC. Yes. (I’ll have to change the name. How about “The blog formerly known as . . . ” or just a simple “Not Running a Hospital”?)

Please expect a combination of commentary on current events and issues. But also please expect an occasional lesson or two from my experience of the last nine years, all offered in the hope of being helpful to others in the field. I apologize in advance if some portions seem self-aggrandizing or self-praiseworthy. I don’t mean them that way, but sometimes, to be historically accurate, I’ll have to include a few good things about myself!

Here we go. Act 2.

In a comment on a post below, author Charles Kenney asks:

Isn’t there a compelling — perhaps even overriding — moral component to transparency?

The answer, of course, is yes. Doctors and others pledge to do no harm. How can you be sure you are living by that oath if you are unwilling to acknowledge how well you are actually doing the job? As scientists, how can you test to see if you are making improvements in evidence-based care if you cannot validate the “prior” against which you are testing a new hypothesis? At the most personal, ethical level, how can you be sure you are doing the best for people who have entrusted their lives to you if you are not willing to be open on these matters?

Clueless in Utah?

Jan 9, 2011• 16

By ROGER COLLIER

The trials and tribulations of Utah’s much-touted Health Exchange continued in December, with the announcement that yet another chief executive had quit, along with the admission that very few eligible employer groups had signed up for the exchange.

The Utah exchange differs from that of Massachusetts in that it currently focuses on coverage for small employers offering defined contribution plans, a policy that was hoped to demonstrate the effectiveness of such plans. However, so far enrollment has been far too low to test the merits of this approach.

The Salt Lake Tribune reported in late December that a new executive director had been appointed to head the exchange, which is administratively located in the Governor’s Office, making the third director in just over six months.

The Tribune went on to compare the expectations of State officials, who had anticipated enrolling 3,000 small employers with an estimated total of 40,000 employees, with the current reality. As of late December, with coverage scheduled to start on January 1, 2011, just 43 of the State’s estimated 50,000 small businesses had signed up and been determined eligible.

Back in September, when the Utah exchange started to accept coverage applications, Utah’s Governor Gary Herbert was quoted as saying: “[the exchange] is quickly becoming a model for the rest of the nation when it comes to health care reform.”

Hopefully not.

Roger Collier was formerly CEO of a national health care consulting firm. His experience includes the design and implementation of innovative health care programs for HMOs, health insurers, and state and federal agencies. He is editor of Health Care REFORM UPDATE.

The Study Question

Jan 8, 2011• 1

By MARYA ZILBERBERG

Let's start at the beginning. Why do we do research and write papers? No, not just to get famous, tenured or funded. The fundamental task of science is to answer questions. The big questions of all time get broken down into infinitesimally small chunks that can be answered with experimental or observational scientific methods. These answers integrated together provide the model for life as we understand it.

Clearly, the question is the most important part of the equation, and this is why in my semester-long graduate epidemiology course on the evaluative sciences we spend fully the first four to five weeks talking about how to develop a valid and answerable question. The cornerstone of this validity is its importance. Hence, the first question that we pose is: Is the study question important?

This is a bit of a loaded question, though. Important to whom? How is "important" defined? This is somewhat subjective, yet needs to be scrutinized nevertheless. In the context of an individual patient, the question may become: Is the study question important to me? So, importance is dependent on perspective. Nevertheless, there are questions upon whose importance we can all agree. For example, the importance of the question of whether our current fast-food life style promotes obesity and diabetes is hard to dispute.

That Which We Call a Rose

Jan 8, 2011• 6

By MARGALIT GUR-ARIE

What’s in a name? Sometimes nothing much.

Sometimes a shift in paradigm. The Medical Record in its current format was created over a century ago by Dr. Henry Stanley Plummer at the Mayo Clinic. When in the course of human events the Medical Record began migrating from paper folders to computer files, the Institute Of Medicine naturally named the new invention Computer-based Patient Record System (CPRS)

The Medical Records Institute chose the term Electronic Patient Record (EPR). Somewhere along the line the “patient” got dropped from the concept and the software used to compose and store medical records became known as Electronic Medical Record and the name EMR stuck.

As EMR software evolved and started exhibiting rudimentary information exchange abilities and some semblance of “intelligence”, it was felt that a name change was in order. To differentiate the newer and smarter software from the original EMR, the term Electronic Health Record (EHR) was introduced and is now enthusiastically supported by the Federal Government. The term EHR is used in acts of Congress, rule makings from CMS and ONC and Presidential speeches. Since EMR has been around for quite some time, most industry veterans, as well as most doctors, are a bit confused about the new terminology.

Wicked Good

Jan 8, 2011• 5

By ED PULLEN, MD

I grew up in Maine and wicked is an adverb or adjective meaning “very” or “especially” that can be attached to almost any verb or adjective. Wicked good is by far the most prevalent use though, and so I thought I’d take a minute on what I hope you think is a wicked good health blog to talk about what I think is wicked good medical care.

Let’s talk about what would qualify a specific care as wicked good.

First it would need to have excellent evidence that it is beneficial. In this regard effective treatment of hypertension could qualify as wicked good, but pushing for a HemoglobinA1C or less than 6.5% rather than less than 7% in a diabetic wouldn’t as the evidence for significantly better outcomes is unconvincing. Second it would have to be something that is realistic to do for most or at least many patients.

For example here effective treatment of CHF with an ACE inhibitor or an ARB and a beta blocker would qualify, whereas counseling patients to lose weight by better diet and exercise wouldn’t as it is just something that seldom is successful. The third and most challenging criterion is that it needs to be applicable to a large number of patients. The more patients for whom a medical intervention can be used, the more likely it is to be wicked good medicine. Here is a list of Dr. Pullen’s wicked good medical interventions:

Sam’s Club as a locus for (The) Prevention (Plan)?

Jan 7, 2011• 1

By Matthew Holt

There’s lots going on in the world of online tools for health improvement and prevention. Yesterday I saw a new demo of the latest version of Keas (can’t tell you much but think Zynga!). Just this Fall we had a whole host of wellness tools including Limeade which is working with REI and other employers. Another of our buds in the world of Health 2.0 is Fred Goldstein, who runs The Prevention Plan. Like the others, Fred’s mostly been going after employers as his main client base. But is there room for a consumer-direct online wellness plan?

Fred obviously thinks so and today is announcing that a major retailer, Sam’s Club (the warehouse store owned by the beast of Bentonville) will be selling The Prevention Plan at $99 to its members. Sam’s Club has had a couple of false starts in health care before (remember them trying to sell eClinicalWorks to doctors?) but it’s likely that they think that their members (many of whom are small businesses) might be interested in buying wellness as a consumer product. By the way, Whole Foods CEO John Mackey also said at a conference in October that they’re getting into that business too.

So we’ll see. But maybe this is the way that (at least some of) middle America gets into the world of wellness.

And if you want to get a freebie intro, tomorrow (Saturday) Sam’s Club will be offering free health screenings.

How the Republican Assault on Health Care Could Backfire On Them

Jan 7, 2011• 6

By ROBERT REICH

When it comes to health care, Republicans should be careful what they wish for.

Their upcoming vote to repeal the health-care law will be largely symbolic — they don’t have the votes to override President Obama’s certain veto. The real thing happens later, when they try to strip the Department of Health and Human Services of money needed to implement the law’s requirement that all Americans buy health insurance. This could easily precipitate a showdown with the White House—and a government shutdown later this year.

On its face it’s a smart strategy for the GOP. The individual mandate is the lynchpin of the heath-care law because it spreads the risks. Without the participation of younger or healthier people, private insurers won’t be able to take on older or sicker customers with pre-existing medical conditions, or maintain coverage indefinitely for people who become seriously ill. The result would be to unravel the health-care law, which presumably is what many Republicans seek.

At the same time, the mandate is the least popular aspect of the law. According to a December 9-12 ABC/Washington Post survey, 60% of the public opposes the individual mandate. While they want help with their health-care bills, and over 60% want to prevent insurers from dropping coverage when customers become seriously ill, most Americans simply don’t like the idea of government requiring them to buy something. It not only offends libertarian sensibilities, but it also worries some moderates and liberals who fear private insurers will charge too much because of insufficient competition in the industry.

Health Problem Quantified

Jan 7, 2011• 11

By JOHN GOODMAN, PhD

We now know how many people have the problem most often cited as the reason for last years’ health overhaul legislation. Answer: 8,000

No, that’s not a misprint. Out of 310 million Americans, only 8,000 people have the problem given as the principal reason for spending almost $1 trillion, creating more than 150 regulatory agencies and causing perhaps 150 million or more people to change the coverage they now have.

Alert readers will remember the White House summer of 2009 invitation to all Americans to send in their horror stories describing health insurance industry abuses. Although the complaints were many, the vast majority were about pre-existing condition limitations. Then, on the eve of the ObamaCare vote, every member of Congress who appeared on television to defend the legislation was able to cite by name an individual or family in his or her state or Congressional district with a heart wrenching story.

Gone was any interest in “universal coverage” or “insuring the uninsured” or “helping poor people get health care.” The case for change was focused almost exclusively on protecting the middle class from miserly insurance companies.

The Needle In the Haystack

Jan 6, 2011• 2

By J. LEONARD LICHTENFELD, MD

Well, it didn’t take long to get into the New Year, did it?

There I was this earlier this week, starting my New Year right by getting exercise on my elliptical when I heard the announcement that Johnson & Johnson was partnering with researchers at Massachusetts General Hospital’s cancer center and other major cancer centers to evaluate the potential of a new technology which can isolate single cancer cells circulating in the blood of patients with known cancers.

The news in itself is an impressive step forward in this type of research. Being able to isolate a single cancer cell in a sample of blood is in a sense one of the holy grails of cancer research. Scientists have been working diligently on developing these techniques for a number of years, and to now have a technology that may in fact move that dream closer to a clinical reality where it actually improves the treatment of patients with cancer is exciting.

However, there is always a caution that comes along with these types of announcements.

First, and perhaps the most obvious, is the fact that this is an announcement of a research deal. Nothing more, nothing less. It is not a new breakthrough. It is not something that has been proven effective in improving cancer detection and treatment. Not that it is anything less than stunning to develop and demonstrate that this technology works-but as with all research it is a giant step to go successfully from the laboratory phase of development to the clinical phase of making a real difference in patients’ lives.

A Healthcare Information Services Provider Business Model

Jan 5, 2011• 8

By JOHN HALAMKA, MD

I’ve written previously about Healthcare Information Exchange Sustainability and the need for Healthcare Information Services Providers (HISPs) to serve as gateways connecting individual EHRs.

How should HISPs be funded and how can we encourage HISP vendors to connect every little guy in the country?

We’ve started to think about this in Massachusetts.

There are numerous vendors promising HISP services – Medicity (Aenta), Axolotl (Ingenix), Surescripts, Verizon, and Covisint.

An HIE needs to include at least one common approach to data transport, a routing directory, and a certificate management process that creates a trust fabric. Existing HISP vendors have heterogeneous approaches to each of these functions. In the future, the Direct Project may provide a single approach, but for now HISP vendors will need to be motivated to adhere to State HIE requirements.

An idea that has been embraced by some State HIEs, such as New Hampshire, is to pay HISP vendors a modest fee (under 100K) to support State requirements. This “connectivity” incentive results in interoperable HISPs, creating a statewide network of networks.

Once a standardized HISP approach is supported by multiple vendors, then individual practices need to be connected. Some practices will be aggregated into hubs by EHR software vendors as has been done in cities such as North Adams (Massachusetts), projects such as the New York City PCIP project, and physicians organizations such as the Beth Israel Deaconess Physicians Organization. However, it’s not likely to be cost effective for a vendor to connect every isolated practice to a HISP for the $50/month the practice is willing to pay.