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Thoughts on the PCAST Report

Dec 17, 2010• 4

By MARGALIT GUR-ARIE

The President’s Council of Advisors on Science and Technology (PCAST) released a report this month ambitiously titled “REALIZING THE FULL POTENTIAL OF HEALTH INFORMATION TECHNOLOGY TO IMPROVE HEALTHCARE FOR AMERICANS: THE PATH FORWARD”, complete with current state of HIT analysis and authoritative recommendations to ONC, CMS and HHS on how to proceed going forward. Initially, I skimmed through the 90 pages of the report and very much liked what I saw. PCAST is recommending a federated model for health information, with medical records stored where they are created and a comprehensive view aggregated on the fly on an as-needed basis by authorized users, including patients and their families. PCAST is urging ONC to significantly accelerate efforts in this direction. Perfect. And then I took a deeper dive into the details of the report, and disappointingly came across a series of misconceptions and questionable assumptions surrounding what is basically a very good, albeit expensive, strategy.

The State of Affairs

The classic opening to all HIT reports seems to be the obligatory comparison to “other industries”: “Information technology, along with associated managerial and organizational changes, has brought substantial productivity gains to manufacturing, retailing, and many other industries. Healthcare is poised to make a similar transition, but some basic changes in approach are needed to realize the potential of healthcare IT”. While this is true, we should also recognize that medicine is very different than other “industries” in that it lacks 100% repeatable processes. For example, the entire process of manufacturing, packaging, ordering, delivering, stocking and selling a box of Fruit Loops is exactly the same for every single Fruit Loops box. Automation of such process is easy. Unfortunately, people are not very similar to Fruit Loops boxes, and paradoxically, the lack of appeal and utility of current EHRs is in large part due to EHR designers thinking about Fruit Loops instead of the many ways in which people express Severity or Location.

Will Avatars, Robots, and Video Games Replace Doctors?

Dec 16, 2010• 10

By KENT BOTTLES, MD

I have never met Dr. Joseph C. Kvedar of Partners HealthCare’s Center for Connected Health, Susannah Fox of Pew Research Center’s Internet and American Life Project, or Professor Andy Clark of Edinburgh University face to face in the real world. And yet they have all profoundly changed the way I think about health care’s most vexing problem: how are we going to take care of all these Baby Boomers who are starting to retire and get sick?

Kvedar nicely summarizes this supply and demand problem on one slide in a talk I watched on YouTube; he notes that there are currently 24 million Americans with diabetes, and the rate is increasing 8% every year. One in three Americans over 20 years old have hypertension, and Kvedar wonders where we are going to get all the doctors to care for these patients. His answer is we need to form trusting relationships with technology in a process he terms Emotional Automation. (http://e-patients.net/index.php?s=fox)

I had never heard of Kvedar or the Center for Connected Health until I saw a Fox twitter link to her blog post about robots, enchanted objects, and networks. (http://e-patients.net/index.php?s=fox) Fox and I follow each other on Twitter, so I read her blog, which included the embedded YouTube video of Kvedar speaking about Emotional Automation. In a way Fox is also responsible for me knowing about Professor Clark’s views on “embodied cognition” and “the extended mind.” One Sunday Fox noted in a tweet that my habit of aggregating the health care news every morning at 5:30 AM was helpful to her and the rest of my twitter tribe. That one pat on the back encouraged me months later to scour the New York Times blogs where I found Professor Clark’s Opinionator blog titled “Out of Our Brains.”

Will ACO IT Models Be Walled Gardens or Open Platforms?

Dec 16, 2010• 5

By VINCE KURATIS, JD

Will ACO (accountable care organization) IT models be walled gardens or open platforms? i.e., will ACO IT platforms focus on exchanging information within the provider network of the ACO, or will they also be able to exchange information with providers outside the ACO network? (If the question still isn’t clear, click here for a further explanation.).

One POV: ACO’s Will Need Open IT Platforms

Mike Cummens, M.D., associate chief medical information officer at 750-physician Marshfield Clinic in Wisconsin, is quoted in a recent article in Healthcare Informatics. Dr. Cummens argues for an open ACO IT approach:

There will be an emphasis on transfer-of-care summaries and how to facilitate information sharing across the full continuum of care, he said. “For instance, you will have to work into care management plans the notification of home health agencies,” Cummens added. “In an ACO model, you will have to have methods in place to communicate all this information to providers who are not part of your own organization. People will have an option to see providers outside an ACO, so you will need to be able to transfer care summaries and discharge summaries outside the ACO.”

Also, because patient involvement is a key part of ACOs, the IT infrastructure will have to support patients signing off on their care plans and document their progress toward reaching goals, he noted. That will involve some type of self-management tools and personal health record access to their own data.

Cummens noted that the patient-centered medical home is geared toward an individual practice, and meaningful use metrics are geared toward providers, but ACOs will require managing data across enterprises. “When we visualize this and realize we are dealing with multiple electronic health records, the infrastructure for ACOs really has to ride on top of that,” he said. He sees the need for a new type of system, probably outside the EHR, that can bridge organizations, allow for risk assessment and analytics and reach down into tools for day-to-day management. That’s a tall order.

High Stakes Health Reform ‚Äì Employers: In or Out?

Dec 15, 2010

By MICHAEL TURPIN

It‚Äôs high noon for private healthcare. Over the last decade, large, medium and small employers that procure and manage over $1T of private healthcare spend for an estimated 180M Americans have been engaged in an expensive game of Texas Hold ‚ÄòEm ‚Äì – wagering with and against a continuum of stakeholders that all seem to possess more powerful hands. As providers consolidate, insurers retrench and the government wrestles with obligations of an uncontrolled fee for service Medicare, the costs of staying at the final table are taking its toll.

To many veteran observers, it appears that employers may be on the brink of folding their cards. As finance and HR professionals consider the table stakes and costs to remain in the game, the Affordable Care Act (ACA) has suddenly provided a potential golden opportunity to step away from a fifty year obligation without incurring onerous near term financial consequences.

As individuals and small business have continued to lapse into the ranks of the uninsured, those small and mid-sized businesses choosing to continue to offer health insurance are coming to the realization that the Affordable Care Act will not result in the moderating of double digit medical trends. In the near term, some contend costs will continue to rise by much as 25-40% before the launch of 2014‚Äôs guarantee issue health exchanges.

Larger employers are already cynical to whether reform will actually work for them or against them. Bigger firms and collectively bargained plans are beginning to understand that if small and mid-sized employers drop out of offering private healthcare, the decline of employer plans will leave them as the sole remaining source for private insurance cost shifting. As the cards are turned, the outcomes are far from certain ‚Äì – and as we have come to discover, business hates uncertainty.

High Stakes Health Reform – Employers: In or Out?

Dec 15, 2010• 18

By MICHAEL TURPIN

It’s high noon for private healthcare. Over the last decade, large, medium and small employers that procure and manage over $1T of private healthcare spend for an estimated 180M Americans have been engaged in an expensive game of Texas Hold ‘Em – – wagering with and against a continuum of stakeholders that all seem to possess more powerful hands. As providers consolidate, insurers retrench and the government wrestles with obligations of an uncontrolled fee for service Medicare, the costs of staying at the final table are taking its toll.

Larger employers are already cynical to whether reform will actually work for them or against them. Bigger firms and collectively bargained plans are beginning to understand that if small and mid-sized employers drop out of offering private healthcare, the decline of employer plans will leave them as the sole remaining source for private insurance cost shifting. As the cards are turned, the outcomes are far from certain – – and as we have come to discover, business hates uncertainty.

Health 2.0 Announces its Starting Five for the 2011 Developer Challenge

Dec 15, 2010

Following the success of the 2010 Health 2.0 Developer Challenge, we are excited to get the ball rolling again for 2011. Within the short time the Developer Challenge has been live, we have had six winners, who were able to present their solutions at the Health 2.0 Fall Conference in San Francisco, October 7-8, 2010, and two challenges that came to an end in late November. We are incredibly proud of the achievements of the participants in the 2010 Developer Challenge and we are delighted to announce the starting line-up for the 2011 Health 2.0 Developer Challenge.

Now here are the starting five:

The myHealthyPeople Challenge, sponsored by Healthy People 2020 Splash, asks to develop a “myHealthyPeople” application for the thousands of Healthy People stakeholders using national health objectives and related health indicator data as part of Healthy People 2020, the national agenda for health promotion and disease prevention that outlines a set of health objectives for the US to achieve over a 10-year period.
Analyze This!, sponsored by Practice Fusion and Microsoft, invites teams to use medical research data to answer pressing public health questions. Access the free Windows Azure Marketplace DataMarket dataset from Practice Fusion to visualize healthcare trends, find adverse drug reactions, chart chronic disease, mash up the results with other sources or build applications.
Engage with Grace Challenge, sponsored by Engage with Grace, asks the question: Can you make an application that uses the power of today’s software and data to incorporate a much broader range of options, and a process for communicating information around those options, regarding end of life preferences?
WWHI / VAi2 Veterans Health Wireless Innovation Challenge, sponsored by West Wireless Health Institute and VAi2, challenges teams to design an award-winning wireless device or application targeting a problem specific to the Department of Veterans Affairs regarding care for our Veteran population, through apps that wirelessly connect hardware with cell phones (or some type of wireless technology), and target identified Veterans health problems.
Food Find: Putting Healthy Food Choices in the Path of Everyday Life, sponsored by the American Heart Association, is a challenge to developers to help consumers/communities put healthy food choices in the path of everyday life. Create a tool to look at food desert issues, triggers that drive people to healthier food choices and/or analysis that drive communities to identify and activate on food access issues in new ways.

The Grinch that Stole Obamacare

Dec 15, 2010• 10

By DAVID DRANOVE, PhD

Article 1, Section 8, Clause 3 of the Constitution, better known as the Commerce Clause, states that Congress has the power to “regulate Commerce…among the several States.” To supporters of health reform, the Commerce Clause is the Grinch that stole Obamacare. To opponents, the Commerce Clause might seem like a Sanity Clause (apologies to the Marx Brothers.) One thing now seems certain. Obamacare is on the fast track to the Supreme Court, where a ruling on the Commerce Clause could have far reaching implications for health reform and, frankly, for many other federal interventions into economic activity.

Virginia officials cited the Commerce Clause in arguing that the individual mandate was beyond the power of Congress. U.S. District Judge Henry Hudson agreed with the centrality of the Commerce Clause:

While this case raises a host of complex constitutional issues, all seem to distill to the single question of whether or not Congress has the power to regulate and tax a citizen’s decision to participate in interstate commerce.

Judge Hudson sided with Virginia, stating that “no specifically articulated constitutional authority exists to mandate the purchase of health insurance.”

Judge Hudson does not reject health reform in its entirety. Although he speculates as to whether the bill would have been enacted without the exchange, he notes that the record in the case is insufficient for a final determination and thus he “severs (the individual mandate) with circumspection,” leaving the rest of the bill intact. In doing so he provides a road map to others attempting to strike down the entire legislation, provided they can find some evidence that votes hinged on the inclusion of the exchange.

To Die Well

Dec 15, 2010• 2

By ROB LAMBERTS, MD

Everyone liked him. Though his later years (the only ones in which I knew him) took away his ability to do most things, and though he was in great pain every day, it was easy to see the mischief in his eyes. The subtle humor was still there, coming out of a man who was weak, in pain, dying.

She lived for him. She was always telling me of his pain, frustrated with the fact that he didn’t tell me enough. She was anxious about each complaint of his, wondering if this was the one that would take him away from her. Many of her problems were driven by this anxiety and fears, and she spent many hours in my office giving witness to them through her tears.

As his health failed, I wondered at her future. He was the center of her life, the source of her energy, joy, purpose. How could she manage life without him? How could she, who had so much lived off of the care of this wonderful man, find meaning and purpose in a life without his calming presence?

Then he died.

I saw her in the office recently, and was amazed at the look in her eyes. It wasn’t the empty, lonely look I was expecting. It wasn’t the worried, helpless look that I had seen so many times. It was peaceful, content.

Selecting an EHR for the Patient-Centered Medical Home

Dec 15, 2010• 2

By MARGALIT GUR-ARIE

The conceptual definition of a Patient Centered Medical Home (PCMH) speaks of a physician directed medical practice, oriented to the whole person, where patients have enhanced access to a personal physician and care is coordinated and integrated focusing on quality and safety, nothing more and nothing less, other than appropriate payment to physicians for all activities.

Since concepts are rarely enough, the National Committee for Quality Assurance (NCQA) took it upon itself to provide concrete requirements and formal certification for medical practices desirous of being recognized as Patient Centered Medical Homes. The NCQA PCMH definition consists of nine Standards used to score the practice. This is NCQA’s attempt at translating the original PCMH concept into measurable activities and here is where Health Information Technologies (HIT) and EHR in particular, are formally associated with the PCMH concept. Conspicuously absent from the NCQA standard are the “personal physician” and unless you consider the assessment of language barriers sufficient, so is the “whole person orientation”. Most NCQA PCMH elements are geared towards data collection, data analysis, tracking and reporting. Theoretically, you could earn NCQA PCMH designation without an EHR, but the amount of typing, writing, filing and calculating would easily consume your entire day. If you are serious about PCMH designation, you will need an EHR. But which one should you get? Are some technologies better than others for PCMH purposes?Continue reading…

Categories

Everything you always wanted to know about the Health Care system. But were afraid to ask.

Thoughts on the PCAST Report

Will Avatars, Robots, and Video Games Replace Doctors?

Will ACO IT Models Be Walled Gardens or Open Platforms?

High Stakes Health Reform ‚Äì Employers: In or Out?

High Stakes Health Reform – Employers: In or Out?

Health 2.0 Announces its Starting Five for the 2011 Developer Challenge

The Grinch that Stole Obamacare

To Die Well

Selecting an EHR for the Patient-Centered Medical Home

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