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Comment on the PCAST Report

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By MARGALIT GUR-ARIE

This comment is not in response to the specific questions posed by ONC, which seem to presume a certain validity of the PCAST report. This comment is respectfully raising several basic questions, which in my opinion, the PCAST reports either did not address or circumvented. With this in mind, you may choose to continue reading, or not.

I would like to start by clarifying that I am now, and always have been, a strong proponent and supporter of appropriate computerization of medical records, HIT in general and the resulting opportunities for expanded clinical research. For the purpose of full disclosure, I have no financial or any other, interests in any HIT vendor.

1. Where does clinical data reside today?

  • Providers – As we all know, there are massive amounts of paper based medical records residing within the walls of providers of all shapes and types. In addition to paper based records, there is a significant (and growing) amount of medical records maintained in electronic format by mostly large providers, but smaller ones as well. The vast majority of these records are created and stored in document format (scanned, dictated, typed, annotated, handwritten, transcribed, etc.). A small portion of this data is stored in structured format, mostly if not all, in relational databases. The most common discrete data elements are demographics, insurance details, diagnoses (ICD-9), procedures (CPT), vitals, and here and there lab results, immunizations, medications, some histories and relatively rarely, findings.

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A Necessary Compromise

By ROBERT LASZEWSKI Robert Laszewski

This week’s House health care repeal vote is little more than a political stunt–everyone knows the effort will die in the Senate.

But, when the day is done the only way for the Republicans to do anything with the new health law will be to work out a compromise—repeal before the 2012 elections is impossible and it isn’t very likely after the 2012 elections. Even if the Republicans sweep the White House and both houses of Congress in 2012, it is highly unlikely they will have the 60 Senate votes needed for a full repeal.

So, in the end, a compromise will be needed.

During the past week, more than one Democrat has indicated an interest in at least looking at compromise amendments to the health care bill—particularly on the individual mandate. But so far, Republicans are showing no signs of being interested in fixing what they say is a bill so bad it should only be repealed.

The House vote will take place against a backdrop of increasing debt and enormous fiscal challenge. In recent days, the national debt passed the $14 trillion mark—that is $45,300 for every person in the country!

Half of our national debt was added in just the last six years. The debt was “only” $7.6 trillion in January 2005 and $10.6 trillion the day President Obama was inaugurated just two years ago.

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Repeal is Irresponsible

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By LUCAS RESTREPO, MD Lucas Restrepo

“The primary ethical issue of modern medicine and public health is the outcome gap,” write Paul Farmer and Nicole Gastineau Campos in an essay published in 2004. Entrenched in “growing social inequalities,” this gap is immediately evident to every physician: poverty is inversely proportional to health. “The growing gap,” they elaborate, “constitutes the chief human rights challenge of the 21st century.” The proliferation of people who never experience abuse of their civil rights, but lack access to medical care, has damaging societal implications: “what does it mean when an African-American neonate does not have ready access to a neonatal intensive care unit?” The answer is that “[w]henever more effective technologies are introduced there will be, in the absence of an equity plan, a growing outcome gap.”

Around the country, this gap is exploding. Surviving an illness may sometimes depend on the good will of kids. I kid you not. Carlos Olivas, Jr., a 12 year-old  boy, in view that Arizona’s cuts to Medicare meant certain death to a man who he had never met named Francisco Felix, decided to help, raising money in the street. Carlos’ empathy toward Mr Felix―at least in part―originates from the thought of finding his father (who has cirrhosis) in a similar situation.

A sense of responsibility toward others, as exhibited by this young man, is the foundation of all societies. Carlos is an exemplary citizen, proof that the Social Contract is an intuitive concept. His behavior is strictly rational: today, I’m strong and can help the weak; tomorrow, when I’m not as strong, someone will help me.

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The Bookmarked Final Rules

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By JOHN HALAMKA, MDHalamka

Robin Raiford of Allscripts has completed the bookmarking of all the healthcare IT final rules:

CMS final rule – EHR incentive program (14 Megabytes)
ONC final rule – Standards Stage One (500K)
ONC final rule – Permanent Certification Program (500K)

Also, here’s the detail of the numerators and denominators of the meaningful use metrics with thresholds.

I’m sure these will help many people inside and outside of government.

Thanks Robin!

So, Are EHRs a Waste of Time and Money?

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By ROGER COLLIERPicture 12

The 2009 Health Information Technology for Economic and Clinical Health Act (HITECH) authorized incentive payments, potentially totaling some $27 billion over ten years, to clinicians and hospitals when they implement electronic health records in such a way as to achieve “meaningful use,” in terms of advances in health care processes and outcomes.

But, are EHRs really “meaningfully useful” or are they more likely to be costly and ineffective?

The latter seems to be one possible interpretation of a recent RAND study of EHR adoption in US hospitals.

The RAND study statistics are impressive: five study authors tallied 17 “quality measures” for three medical conditions against three possible levels of EHR capability (no EHR, basic EHR, advanced EHR) for more than two thousand hospitals for each of 2003 and 2007. They then related changes in quality over the four year timeframe against changes in EHR status (for example, from no EHR to an advanced EHR).

The reported results were disappointing to EHR proponents. Among the hospitals whose EHR capability remained unchanged over the four years, there was no statistically measurable difference in quality improvement between hospitals with EHR capability and those without. For hospitals which upgraded their EHR capability, the performance improvement was generally less than for those who didn’t change, including those with no EHR at all.

So, should we forget about EHRs? Maybe defund HITECH?

Not necessarily.Continue reading…

The Remarkable Rise of the Hyphenated-Hospitalist

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By ROBERT WACHTER, MDPicture 16

I recall with fondness many meetings in 1996-98, when the hospitalist field was still in its infancy. We had invented a new medical specialty, and our gatherings were vibrant and purposeful. We were determined to remake the healthcare system, learn from each other’s triumphs and disasters, and chart a course that would improve the care of hospitalized patients. These were heady times.

I experienced déjà vu last week in a nondescript conference room at a San Francisco airport hotel, where the Society of Hospital Medicine and the American Hospital Association gathered a dozen folks to discuss specialty hospitalists. Representing the “traditional” hospitalist field (I never thought I’d say that) were SHM CEO Larry Wellikson, SHM co-founder John Nelson, SHM president-elect Joe Li, pediatric hospitalist Erin Stucky, and me. We were joined by AHA Senior Vice President John Combes. But the real stars were six leading physicians in new subspecialty hospitalist fields: a neurohospitalist (Dave Likosky), two surgical hospitalists (John Maa and Leon Owens), two ob-gyn hospitalists (Rob Olson and Ken Jacobs), and even an ENT hospitalist, Matt Russell. Here’s what I learned:

The Neurohospitalist: “The Neurologists Have Left The Building”

At my yearly hospital medicine CME course, I ask the 600 attendees what topics they believe they need to learn more about. The top answer is always neurology. Why? Because most neurologists are perfectly content to remain in their offices seeing headaches and neuropathy; few want the pressure and hassle of managing acute strokes or status epilepticus. When the neurologist “has left the building,” which is most of the time, medical hospitalists are left to pick up the pieces.

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Dicker With Your Doc? Not So Fast…

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By JESSIE GRUMAN, PhD  Jessie Gruman

“How to Haggle With Your Doctor” was the title of a recent Business section column in The New York Times.  This is one of many similar directives to the public in magazines, TV and Websites urging us to lower the high price of our health care by going  mano a mano with our physicians about the price of tests they recommend and the drugs they prescribe.  Such articles provide simple, commonsense recommendations about how to respond to the urgency many of us feel — insured or uninsured — to reduce our health care expenses.

With unemployment at 9.4 percent and more than 50 million Americans lacking any or adequate health insurance, I understand the impulse of editors to assign this story. Plus, “of all the providers of medical care, physicians are most important in determining how much will be spent,” notes Arnold Relman in the New York Review of Books, since they make all the allocation decisions that “call on the facilities and services of all the other providers of care —hospitals, imaging centers, diagnostic laboratories, manufacturers of drugs and equipment.” The prices charged by these institutions vary widely and therein lies the opportunity to find some savings.

But coming off a wave of big-buck spending related to my recent diagnosis of stomach cancer, I am acutely aware that haggling with my doctor about the costs of my care is neither simple nor is it a matter of common sense.  Rather, it is a matter of 1) understanding in detail both the opportunities and limitations related to my health insurance; 2) being persistent in information seeking, since price lists are often difficult to track down and comparisons of quality (accuracy) of laboratories and testing facilities are nonexistent; 3) using available information and my judgment to weigh options; 4) the willingness to risk the rejection of my request by my provider and perhaps antagonize her and 5) overcoming my pride and asking to be treated well while seeking the best value for my money.

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Is There Something Wrong With the Scientific Method?

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By DAVE deBRONKART Dave-deBronkart

A recurring them on this blog is the need for empowered, engaged patients to understand what they read about science. It’s true when researching treatments for one’s condition, it’s true when considering government policy proposals, it’s true when reading advice based on statistics. If you take any journal article at face value, you may get severely misled; you need to think critically.

Sometimes there’s corruption (e.g. the fraudulent vaccine/autism data reported this month, or “Dr. Reuben regrets this happened“), sometimes articles are retracted due to errors (see the new Retraction Watch blog), sometimes scientists simply can’t reproduce a result that looked good in the early trials.

But an article a month ago in the New Yorker sent a chill down my spine tonight. (I wish I could remember which Twitter friend cited it.) It’ll chill you, too, if you believe the scientific method leads to certainty. This sums it up:

Many results that are rigorously proved and accepted start shrinking in later studies.

This is disturbing. The whole idea of science is that once you’ve established a truth, it stays put: you don’t combine hydrogen and oxygen in a particular way and sometimes you get water, and other times chocolate cake.

Reliable findings are how we’re able to shoot a rocket and have it land on the moon, or step on the gas and make a car move (predictably), or flick a switch and turn on the lights. Things that were true yesterday don’t just become untrue. Right??

Bad news: sometimes the most rigorous published findings erode over time. That’s what the New Yorker article is about.

I won’t try to teach here everything in the article; if you want to understand research and certainty, read it. (It’s longish, but great writing.) I’ll just paste in some quotes. All emphasis is added, and my comments are in [brackets].

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Truth or Consequences

Paul Levy 1 By PAUL LEVY

While we are on the topic of medical errors, let’s see how doctors feel about disclosing them when the patient has not been harmed. Medscape recently surveyed doctors on this question and published the results in a provocative article by Gail Garfinkel Weiss entitled: ‘Some Worms Are Best Left in the Can’ — Should You Hide Medical Errors?” (A subscription is required, but it is free.)

To the doctors reading this, into which camp do you fall? To the patients reading this, what would you expect of your doctor in this kind of situation?

Some excerpts:

In response to the question “Are there times when it’s acceptable to cover up or avoid revealing a mistake if that mistake would not cause harm to the patient?” 60.1% of respondents answered “no,” and the remaining respondents were almost evenly divided between “yes” (19%) and “it depends” (20.9%).

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Ready, Set…ACO?

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By JONATHAN BUSH Jonathan Bush

Happy New Year, everyone!  2010 was certainly action-packed, and 2011 promises the same.

I hear a lot of thunder about getting ready for ACOs.

This isn’t a crystal ball forecast, but I see hospitals spending tons of capex on new HIT from old-fashioned “software-based” companies, and it seems like the EMR is the new “pavilion.”  I see hospitals buying medical practices using arrangements that are certain to require the hospital to subsidize doctor income.  [For another take: Paul Levy on ACO.]

These two major waves are explained by clients and prospects alike as “readiness for ACO.”

I have three thoughts:

  1. Don’t worry.  We at athenahealth will do our part.  If and when ACO payment models emerge, you won’t need to buy a new “module” from us in order to get payment.  We will go get you that money the same way we are getting you the “Meaningful Use” stimulus payments, the P4P money, and the plain old health care reimbursements that we have always delivered.  The changes to our technology and service needed to accomplish all that will be on us.
  2. Don’t turn blue holding your breath waiting for the big bonus opportunity.  The fundamental underlying principle of an ACO is that you will get a bonus in exchange for lower utilization.  If that bonus is bigger than what you’d get from the utilization, then why would Medicare pay it?  If that bonus is LESS than what you are getting now, why would you do it?
  3. I have met newly elected Republican lawmakers of late and few of them are thinking that money will be saved with this approach.  As with other aspects of health reform law, they appear to be eager to… well, let’s just say…scrutinize the mechanics closely.

None of this is certain and there will be exceptions to all the rules anyone tries to write.

This leaves one thing certain.

Do NOT make multi-year investments that depend upon ACO actually happening.

So as far as ACO goes, pay as you go.

With me?

Jonathan Bush co-founded athenahealth, a leading provider of internet-based business services to physicians since 1997.  He blogs regularly at THCB and at the athena blog where this post first appeared. Prior to joining athenahealth, he served as an EMT for the City of New Orleans, was trained as a medic in the U.S. Army, and worked as a management consultant with Booz Allen & Hamilton. He obtained a Bachelor of Arts in the College of Social Studies from Wesleyan University and an M.B.A. from Harvard Business School. He blogs regulary at the athena blog, where this post first appeared.