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The Fine Print

Nov 19, 2010• 11

By MARGALIT GUR-ARIE

Last week the American Medical Informatics Association (AMIA) released a position paper titled
“Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: a report of an AMIA special task force.” The paper shines a bright light on the alleged contracting practices of EHR vendors and their notorious “hold harmless” clauses, which indemnify the EHR vendor from all liability due to software defects, including liability for personal injury and death of patients. What this means in plain English is that if a software “bug” or incompetency caused an adverse event, and if you (or your hospital) are faced with a malpractice suit, the EHR vendor cannot be named a co-defendant in that suit and you cannot turn around and bring suit against the vendor for failure to deliver a properly functioning product.

The AMIA paper also asserts the existence of contractual terms preventing users and purchasers from publicly reporting, or even mentioning, software defects, including ones that may endanger patient safety. The AMIA report goes on to challenge the ethics of both buyers and sellers engaging in such contracts, with an emphasis on the EHR vendors’ primary responsibility to shareholders and the bottom line in general.

As expected, the authors call for Government regulation of HIT products and processes and suggest that contracts should, of course, reflect a shared responsibility between vendors and customers and while public reporting should be allowed (or required) for certain types of software defects, users should be mindful of the vendor’s intellectual property. The interesting portion of the report is the rather novel recommendation for formal Ethics education amongst vendors and purchasers. Presumably, vendors and their customers need to be taught the difference between right and wrong and need to be informed that placing corporate profits (or personal comfort) ahead of patient safety is indeed wrong and therefore unethical. To borrow from the Windows 7 phone commercials, “Really?”

Augmenting My Reality

Nov 19, 2010

By ALEX EPSTEIN

When I first heard about Augmented Reality, I thought – this is really cool. Let me try and augment mine.

And I had a vision that included Scarlett Johannson (just kidding, sweetheart) and a home totally free of weekend honey-do’s and totally full of perfectly happy, compliant teenage children.

Hell, if I am going to augment reality… I might as well go for it.

How naive.

Imagine this – in the not too distant future a wearable device will display a seamless series of “helpful” tags on top of what you are actually seeing, so as to make your viewsing more effective.

Maybe you are part of surgical team involved in a complicated intervention, and your technology is superimposing real-time CT scans over your actual view of the operating field, hopefully improving outcomes. O0ps, that is happening now! The tags, and decision support, which will make things even mo betta will happen later.

Or say you are 18 and a Marine trying to repair a complicated hunk of your war machine (or maybe just a flat tire) in the desert or the jungle – special goggles will augment your reality with a layer of digital information that shows you how to fix your stuff in real time.

The Seduction of Primary Care

Nov 18, 2010• 83

By ROB LAMBERTS, MD

Hey there, big, smart, good-looking doctor….

Are you tired of being snubbed at all the parties? Are you tired of those mean old specialists having all of the fun?

I have something for you, something that will make you smile. Just come to me and see what I have for you. Embrace me and I will take away all of the bad things in your life. I am what you dream about. I am what you want. I am yours if you want me….

Seduce: verb [ trans. ]

attract (someone) to a belief or into a course of action that is inadvisable or foolhardy : they should not be seduced into thinking that their success ruled out the possibility of a relapse. See note at tempt .

(From the dictionary on my Mac, which I don’t know how to cite).

If you ever go to a professional meeting for doctors, make sure you spend time on the exhibition floor. What you see there will tell you a lot about our system and why it is in the shape it is. Besides physician recruiters, EMR vendors, and drug company booths, the biggest contingent of booths is that of the ancillary service vendors.

“You can code this as CPT-XYZ and get $200 per procedure!”

“This is billable to Medicare under ICD-ABC.DE and it reimburses $300. That’s a 90% margin for you!”

This is an especially strong temptation for primary care doctors, as our main source of income comes from the patient visit – something that is poorly reimbursed. Just draw a few lab tests, do a few scans, do this, do that, and your income goes up dramatically. The salespeople (usually attractive women, ironically) will give a passing nod to the medical rationale for these procedures, but the pitch is made on one thing: revenue.

Biotech Grant Funding: Are a Few Crumbs Better Than No Crumbs At All?

Nov 18, 2010• 1

By GLENN LAFFEL, MD

After assuming control of the House in the mid-term elections, Republicans vowed to eviscerate the Affordable Care Act, the health reform law signed by the Big O last March. Thank heavens therefore, that the Boehners were too busy congratulating themselves to even notice those federal helicopters dumping $1 billion in cash on some needy biotech companies just as the election results were being tallied.

Yep, it happened. Federal disbursements in the form of grants and tax credits were made last week, as required by a provision in the reform law known as the Qualifying Therapeutic Discovery Project Program. According to the terms of this Program, biotech and life sciences companies with less than 250 employees could apply for federal funds to cover research costs they had incurred in the last 2 years, so long as the research focused on the prevention, diagnosis and treatment of chronic diseases.

The Program amounted to a nod by the Feds to biotech and life sciences, 2 industries that had been battered to near oblivion by the Great Recession of 2008-2010. Biotech and life sciences fared worse than most industries because the core of their business, research and development, consumes enormous capital early-on and there are long delays before these projects hit pay-dirt–if they ever do. Early-stage companies in these industries are therefore high risk investments, the sort VCs steer clear from when the going gets tough.

Unfortunately for the targeted industries, the Program turned out to be a small nod, indeed. It attracted 5,600 applications, far more than expected, and by rule all 4,600 that met congressional requirements had to be funded. With the pool capped at a bil, qualifying projects attracted far fewer dollars than requested.

Saving the Good in Healthcare Reform

Nov 18, 2010• 20

By JANE ORIENT, MD

Some have suggested piecemeal repeal of the most obnoxious features of the Affordable Care Act (ACA). The risk of this approach is comparable to that in cancer surgery: you might not get it all. In 906 pages of arcane statutory language, a lot can be hidden.

I suggest instead that we wipe the slate clean with a total repeal, and then consider reenacting any features that most agree are good. This would be the most efficient method because the list of items is shorter. Much shorter.

The most popular part is probably the elimination of “pre-existings.” You can’t eliminate the uninsurable condition of course, only the insurance company’s ability to deny coverage to people who have it. How would such an isolated law work?

In a free market, coverage for people with pre-existings might well be available, without any law—if insurers could simply charge a premium reflecting their risk, or limit the potential pay-out. The premium, naturally, could be very high. That would be a strong incentive to buy insurance when young and healthy, and resist temptations to spend the premium money on iPods and new cars instead. But for many it is already too late.

The U.S. already has the equivalent of fire insurance for those whose house is burning down. It is called Medicaid. Roll into the emergency room desperately ill, and the hospital will treat you, and probably enroll you in Medicaid—likely after you have spent through any assets and lost your SUV and your home.

To prevent such personal tragedies, how about a law that simply said: “Insurance companies must take all comers, without price discrimination for pre-existing conditions.” This is called “guaranteed issue” and “community rating” (GI/CR).

Hospital Price Dispersion

Nov 18, 2010• 6

By DAVID DRANOVE, PhD

A study by the Center for Studying Health System Change that will be released today shows that hospitals receive different prices for treating the same diseases. Center President Paul Ginsburg says this about the findings:

“The variation in hospital prices found in this study are (sic) inconsistent with highly competitive markets—at least for markets outside of health care,” said HSC President Paul B. Ginsburg, Ph.D.,

Hospital markets may not be highly competitive, but this argument is silly. One might as well say “The variation in automobile prices is (not “are”) inconsistent with highly competitive markets.” But one would be wrong in either case.

Vertical quality differentiation (i.e., some sellers are better than others) generates price dispersion in competitive markets. It is only in the most basic treatment of competition — in the first week of an intro economics course — that vertical differentiation is ignored. Observed price dispersion is not incompatible with competition.Continue reading…

Rating the Raters: Physician Compare

Nov 18, 2010

By NAOMI FREUNDLICH

Let’s say you’ve enrolled in a new health insurance plan and need to find an internist who participates. How do you decide which doctor to choose? My (long deceased) grandmother made her choices by using the following criteria: She looked for a male doctor with a Jewish-sounding last name who graduated from an American medical school—preferably one located in New York City. Nowadays her narrow (and culturally biased) criteria would have excluded some of the most esteemed practitioners around.

If you are like most people, you don’t depend on your grandmother’s advice to find a physician, but rather ask friends, colleagues or other doctors for recommendations. But taking one person’s experience with an internist or surgeon as a signal that he or she is “really good” is still far from the optimal way to choose a practitioner.

Over the years, several commercial websites like HealthGrades and Angie’s List have cropped up that provide such consumer-friendly information as the distance a doctor’s office is from the patient, and whether foreign languages are spoken there. They usually include ratings that reflect consumers’ personal experiences with the practitioner. For people who want to dig deeper, most state medical boards collect data that can be searched to find out where your doctor went to medical school, where he did his residency and what board certifications she has. In some states you can also search to see if the doctor in question has received disciplinary action or been sued for malpractice.

This is a lot of on-line legwork for the average person—a task that even professionals can find difficult. Chip Amoe, assistant director for federal affairs at the American Society of Anesthesiologists told a group recently, “When I tried to go find a primary care physician, I couldn’t. You know, it was very difficult. I had to go on several different Web sites to be able to find [one].”

Cousin Jimmy Syndrome

Nov 17, 2010• 2

By JOHN HALAMKA, MD

I have great respect for my colleagues in the IT industry. It’s a challenging profession that requires a mixture of technical knowledge, people skills, and the emotional stability to deal with customer dissatisfaction when technology fails.

However, there’s a downside to being an IT professional. No matter how much expertise you have or what your reputation may be, many customers will not be able to distinguish between a polished industry expert and a self-promoting IT groupie.

I call this the “Cousin Jimmy Syndrome”.

Here’s how it happens. You join a meeting to discuss a major IT project. You talk about issues such as security, disaster recovery, change management, training, and support.

Then someone says, “Oh yeah, we’ve got ‘Cousin Jimmy’ doing that.” Or Bob who lives in his parents’ basement. Or Carol who knows how to use Excel and serves as the go to technology guru.

Unfortunately, when Jimmy, Bob, or Carol have an opinion, their colleagues trust them over you, since professional IT organizations may appear less nimble, less focused, and less accommodating than dedicated local experts.

Health 2.0 Fall Conference Videos

Nov 17, 2010

By Bianca Grogan

The annual Health 2.0 Fall Conference was held October 7-8 in San Francisco and opened with this presentation from founders Matthew Holt and Indu Subaiya. More videos with keynote speakers, panels and product demonstrations may be found at Health 2.0 TV.

Antibiotic Resistant Bacteria in Hospitals: A Time for Action

Nov 17, 2010• 20

By ARJUN SRINIVASAN. MD and RAMANAN LAXMINARAYAN, PhD

Every few years there are reports of antibiotic resistant microbes that prompt a series of predictions about “the end of antibiotics.” It happened in the 90s with multi-drug resistant tuberculosis and then again earlier this decade with methicillin-resistant Staphylococcus aureus or MRSA. It’s happening again with carbapenem-resistant Enterobacteriaceae or CRE. Predictably, over time these bacteria have become resistant to more and more antibiotics. Almost just as predictably, they could be treated by a category of powerful antibiotics known as carbapenems – until now.

Today, 35 states have reported cases of CRE infection to the Centers for Disease Control and Prevention in Atlanta. And they are dangerous. In a recent study of almost 100 cases, more than a third of the patients died from the infection. The concern over these bacteria is compounded by the fact that there are no new antibiotics to treat them coming anytime soon. Most experts agree that even in the most optimistic scenario it will likely be about 10 years before effective new drugs are developed. A variety of efforts are being debated to speed the development of new antibiotics, but these discussions often overlook one critically important issue. One of the reasons our current antibiotics are losing their effectiveness is because we don’t use them properly. Studies have shown, repeatedly, that up to 50% of antibiotic prescriptions are either unnecessary or inappropriate – a statistic that is disappointingly consistent across both in-patient hospitals and out-patient clinics. Not only does this overuse reduce the effectiveness of our current antibiotics, it threatens the utility of any new antibiotics that come along in the future.