Rob Weisman and Liz Kowalczyk report in today’s Boston Globe that the US Justice Department is investigating possible antitrust violations against Partners Healthcare System, the dominant hospital and physician provider group in Massachusetts.
The letter, obtained by the Globe, said the probe sought to determine whether the practices violated the Sherman Antitrust Act, which bars companies from using their market power to limit trade or artificially raise prices.Continue reading…
Until about 8 years ago, inspections by the Joint Commission (TJC) were predictable and fairly silly. Hospitals were given a couple of years’ notice of the week that “The Joint” would be visiting. Everybody scurried around preparing – waxing the floors, locking up all the medications, that sort of thing. (It always struck me as the most dangerous day to be in the hospital, since nobody could find any of the medications, and the floors were slippery as hell). After arriving, the inspectors spent most of their time sealed in a conference room, pouring through policy manuals (we dusted them off before the visit) and meeting with administrators, exposed to whatever reality the hospital wanted them to see. It was an ineffectual kabuki dance.
Last week, the Joint Commission visited UCSF Medical Center. Luckily, our director of regulatory affairs, Jolene Carnagey, is tasked with checking the TJC website every Monday at 7:30 am to see what hospitals they’ll visit that week. Because of this, we had advance notice of our inspection – by about 15 minutes! Once Jolene spotted UCSF on the TJC schedule, she sent stat alerts to our key people, like a parental phone tree on a school snow day.
By 7:45 am, there were half-a-dozen TJC accreditors in our hospital lobby.
As important as the unannounced visits (which are, of course, what you’d want if you were a patient), TJC has made other major improvements over the past decade. The inspectors spend far more time walking around on clinical units – talking to docs, nurses, hospital administrators, and patients – and less time wading through policies and procedures. Their agenda is a bit less focused on the nitpicky “Standards” and more on a series of National Patient Safety Goals that TJC began issuing in 2003 – things like the pre-operative time out and developing methods to analyze errors and use the results to improve safety. The important stuff.
One reporter changed the behavior of every health plan in California all by herself.
Even before Tuesday’s announcements, however, health insurers in California had all but stopped the number of policy cancellations, state records show. Last year, only four such cancellations were reported to the managed healthcare department, down from 1,552 in 2005.
Where the hell is her Pulitzer prize?
Everyone’s favorite Harvard Business School professor is back in the news. Those of you with long memories may remember that at THCB I’ve been a tad critical of Regina Herzlinger’s ideas, her presentation of said ideas and—resulting in a letter from her lawyer whose previous gig was writing the Patriot Act—her stewardship of the shareholders and other stakeholders of Wellcare. Wellcare is a pretty scummy Medicare and Medicaid HMO in Florida. The scuttlebut I heard about Wellcare a few years back was that it was hiding money offshore in some weird re-insurance arrangement with a fully owned subsidiary, and was essentially faking profits a la Enron.
While that may or may not have been exactly accurate, Wellcare was certainly overcharging its client, the taxpayer in Florida. It was raided by the FBI and eventually settled with the state.
What did one of its best known directors says when she joined the board in 2003?
Dr. Herzlinger said, “WellCare is a case study of a successful public-private partnership, and a model for delivering quality affordable healthcare. Over the years to come, companies like WellCare that reach out to members with information, wellness planning and screenings will be agents of change in the delivery of managed care under government programs.
So by late 2007 Herzlinger had been on the board for four years. What had been her major achievement given the the close-to-criminal activity that was going on the company? Oh yes, it was selling nearly $2.3m worth of stock—completely coincidentally—three months before the FBI raid when the stock was worth 5 times what it fell to shortly afterwards.
And then early last year (2009) Wellcare was suspended from Medicare sales for more bad behavior. Did Regi resign at that stage? Uh….no.
But on Friday she actually did quit!
Last week Indu and I were on the Patient Power show run by Andrew Schorr and Peter Frishauf (who is an old friend and founded Medscape). It’s a show aimed at consumers and we’re very interested in getting the word out about Health 2.0 direct to consumers. Here’s the show and it’s both well done by Andrew and Peter, and Indu (at least) sounds very intelligent!
In addition I and a team of cohorts will be starting a (brief) spot twice a week on KOMO 1000AM/97.7FM a news radio station in Seattle. I have also recorded my first spot about technology and policy for doctors for ReachMD—a radio channel exclusively for physicians with which THCB has a new agreement. So watch out for yet more radio stardom.
By the way, the full excerpt from Educating Rita is:
In reply to the question, “Suggest how you would resolve the staging difficulties inherent in a production of Ibsen’s Peer Gynt” you have written, quote, “Do it on the radio.”
Healthline has been a company that we’ve been looking at since we very first started talking about Health 2.0. Check out the very first podcast about Health 2.0 on THCB with Healthline’s Dean Stephens back in late 2006. In fact its roots go back to Yourdoctor.com in the halcyon days of the late 1990s, but these days Healthline uses its taxonomy based search to provide search and content for not only Healthline.com, but also enterprise software for Aetna & UnitedHealth Care, as well as powering health search on several media sites like Ask.com, US News & World Report and AOL. It’s been a hectic couple of weeks for Healthline and I spoke with CEO West Shell about several new developments.
Matthew: First off, tell me about the new funding, and tell me about the state of the business.
West: Healthline just raised another $14M led by new lead Investor Growth Capital. Several previous investors including GE/NBC and Reed Elsevier also were in this round. We doubled the scale of the business last year and this round is designed to add some incremental investment in our R&D for the network services business. We’re doubling down to accelerate the growth of the company. The total capital we raised is now $50m, and this follows on from our last round about 2.5 years ago. We’re already cash-flow positive and profitable, and although we’re not releasing figures, but we have about 100 people—so you can make your own educated guess.
Matthew: You run your own web site, you provide software for enterprise clients, and you have your own advertising network. Where do you aim to spend the money?
West: Essentially we’re investing heavily in expanding R&D. We’re hiring more engineers, more medical informatics staff. We think that this combination is why the big partners are choosing us. Taking on new partners means we need to build out our network services business. We need to support customers and we need to keep delivering the search, content and advertising that they’re looking for.
We’re also investigating some M&A opportunities; we looking both at some technology and content assets. We think that there are some interesting Health 2.0 technologies that would make a good addition to our current portfolio. Lots of small companies have built innovative tools but they don’t have the scale that we have—now over 100 million visits across all our network—so we can help monetize what they’ve built.
I am writing this as a representative of the examination room – one who sits facing patients, dealing with our healthcare delivery “system” on a daily basis. I am writing this as one who will bear the brunt of what you accomplish or fail to accomplish in your attempts to reform our “system.” I write this as a primary care doctor who makes a living (or not) by what I earn from that “system.” I write as someone who has seen people not take medicine they need, not get the help they should, and not care for themselves as they should because of our “system.”
I talk to patients every day about what you folks are doing, and let me tell you what they are saying: nobody has any confidence in you whatsoever. Whether conservative or liberal, insured or not, black or white, elderly or young, all of my patients express frustration, disillusionment, and pessimism over your chances at getting it right. Nobody is confident, nobody is all that passionate anymore, and nobody is holding their breath.
Although healthcare reform has its supporters and detractors, healthcare IT reform – the use of technology to improve the quality, safety and efficiency of healthcare throughout the country – has broad support from all stakeholders.
The passage of last year’s $787 billion economic stimulus bill brought with it a healthcare IT modernization program that could inject about $30 billion into the economy. Since Massachusetts is a leader both in the use and the manufacturing of healthcare IT systems, this could translate into over a $1 billion for the Commonwealth of Massachusetts.
This isn’t a “cash for computers” program though – it’s much more than that. The stimulus bill was crafted very wisely. It’s not a field day either for the doctors and hospitals who would receive these funds, or for the vendors selling this hardware and software. That’s because in order to get these dollars, physicians and hospitals have to not only buy the new systems, they have to prove that they’re using them to improve care before they’ll qualify to get any money back from the government. What does it mean to improve care? The requirements are actually quite specific and include: improving care coordination, reducing healthcare disparities, engaging patients and their families, improving population and public health, and ensuring adequate privacy and security protections.
The health IT modernization program promotes the use of advanced tools which could significantly improve the quality and efficiency of healthcare in the country today. Massachusetts is well positioned to lead this charge.
The genius of the program is that it is carefully tailored to fit our
uniquely American economy and culture. We are a society that prizes
individual initiative and rejects “top-down” solutions, and no other
part of the economy is more reflective of that than health care
delivery. We also believe in the power of markets to allocate resources
where they’ll create the most value and to drive innovation that
improves peoples’ lives. So unlike other countries where the government
is creating its own infrastructure and dictating which systems the
medical community must use, the Obama Administration’s health IT
program uses federal dollars to give an adrenaline boost to the market.
By
Adoption of Electronic Medical Records (EMRs) by physicians – particularly by primary care physicians – has been a challenge, for a number of reasons. The Office of the National Coordinator for Health IT (ONC) has been charged with encouraging physicians to adopt Electronic Health Record (EHR) technology, as envisioned in the American Reinvestment and Recovery Act of 2009 (ARRA).
The ONC vision is that a transformed healthcare delivery system which is able to reduce medical errors, implement best-practices standards as they emerge, reduce disparities in care delivery, involve patients in their care, and encourage the coordinated delivery of health care – all of this needs, as a base, the widespread adoption of EHR technology by physicians in all settings of care, across the country. Getting there is the challenge before us all.
EHR adoption has been seen mainly in hospitals, clinics and other large institutions – the costs of traditional EHR systems (both the direct costs, and the indirect costs of needing to build and maintain a local network system in order to make it work) have been prohibitive to smaller practice settings. However, it is precisely those smaller practice setting where the majority of healthcare is delivered in this country.
Fortunately, newer technologies – like secure web hosting, which removes the need to install anything locally – and new business models – like having alternative revenue sources subsidize the web-based EMR so that the system can be offered for free to physician end-users (e.g. Practice Fusion’s free EMR) – have overcome many of the barriers to adoption that have prevented smaller practices from adopting EHR technology.
In light of the recent Health 2.0 in the Doctor’s Office conference, with its focus on newer technologies, we wanted to review some EMR adoption strategies that might help clinicians move from paper-based offices to electronic ones. As a practicing family physician, and relatively early adopter of EMR technology – we have not had paper charts in our practice since 2004.
Hardware recommendations
Regardless of the cost of the EMR system in the first place, a certain investment in hardware will need to be made. With a web-based EMR, this can be pretty minimal. I would discourage the use of fixed, in-exam-room computer equipment (risk of damage when unsupervised, need to close and then log back in when you leave the room in order to keep HIPAA privacy). Instead, I would recommend a wireless laptop or notebook (costs of these are now in the $400-$800 range) – one per clinician – which can be used to carry around the office. Nurses might want to have a fixed desktop computer at their nursing station (these are about $100-$200 less than a notebook these days). Front desk personnel should have a fixed desktop computer – this has been the tradition for some time.
If a locally-installed EMR system is chosen, then there is the whole burden of housing a server, with hardware redundancy to guard against failure, and software costs for that server – operating system, anti-virus, firewall, possibly license fees for the database system used. In addition, there will be the need to do data backup. Such local systems have a vulnerability of theft of Protected Health Information (PHI), which can expose the clinician to a HIPAA breach. Web-hosted EMRs avoid this whole back-end burden.
With a web-based system, internet connectivity is critical. I would recommend a good broadband connection (T1 lines run about $400/month, though DSL services for about half that may be sufficient as well). For safety, a 3G cell phone fail-over backup is also advisable, in the event of breakdown of the internet connection (a rare event these days).
Workflow redesign
Apart from cost, workflow disruption is another barrier to adoption. This is especially true in primary care practices, which function very close to the margin in the first place – any dip in productivity can cause the practice to dip below profitability for a while. Therefore, an intuitive, easy-to-use and flexible EMR design is critical. All the workflows encountered by physicians in an ordinary day need to be facilitated, not disrupted, by the EMR.
There are 7 workflows in an ambulatory practice, which need to be addressed in order to fully abandon paper charts: (1) billing and accounts receivable; (2) scheduling; (3) in-house messaging; (4) documentation of patient interactions; (5) processing refill requests; (6) reviewing and acting on lab results; and (7) managing external correspondence about patients. A way of dealing with each of these items needs to be addressed in order to successfully embrace EHR technology and abandon paper.
Small medical practices have faced challenges in their path toward adopting EHR technology – cost and workflow disruption are the main ones. Newer technologies and business models have overcome many of those barriers. Achieving the “meaningful use of certified EHR technology,” which qualifies a clinician to access ARRA/HITECH incentive payments beginning in 2011, can be achieved through these newer technologies. The old paradigm of massive, burdensome, and stand-alone systems is giving way to novel approaches which can result in widespread EHR adoption, as we have seen from our experience to date.
ROBERT ROWLEY, MD, is the chief medical officer at Practice Fusion, a San Francisco based company.
Clinical Groupware is rapidly gaining acceptance as a term describing a new class of affordable, ergonomic, and Web-based care management tools. Since David first articulated Clinical Groupware's conceptual framework on this blog early last year — see here and here — we've been discussing Clinical Groupware with a growing number of people and organizations who want to know what it is, where it's going, and what problems it may solve, particularly for small and medium size medical practices, their patients and their institutional/corporate sponsors and networks.
Clinical Groupware heralds a shift away from medical applications that are primarily based in local hardware and software. It creates a more fluid functionality in those applications, and empowers communications as well, by leveraging Internet connectivity, Web-based data resources, and new services (i.e., capabilities) performed upon these data by agents or applications.
In other words, Clinical Groupware is about platforms that can integrate modular applications, which in turn are supported by subsystems of data services. Although it is still in its infancy, Clinical Groupware is an end-to-end digital revolution in health IT.
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