Above the Fold

Musings on Integrating Care at the IOM

Feb 26, 2009• 5

By Matthew Holt

So I’m in
DC figuring out how the East coast medical policy elite tries to change the world. While the rest of DC is buzzing about Obama’s speech and budget, The Institute of Medicine is having a conference on Integrative Medicine. But most people think it should be called integrative health.

What is integrative health, you ask? Good question.

The majority of the panelists are mainstream health care players like Bill Novelli (AARP), George Halvorson, (Kaiser Permanente), Ralph Snyderman, (Duke). They’re talking about integrating coordinated allopathic health care and information across an individual’s personal health plan. Snyderman, said we need to move from “find it, fix it” to a “personal health plan”. Halvorson said (surprise, surprise) that we need electronic health data on every patient, and to not just replicate the current silos of care in our new data strategy. Novelli went straight at the environmental factors—smoking, fast food et al. And to not ignore them. Mehmet Oz (he of the Oprah show) said that

Consumers Need All of the Facts in the Privacy Debate

Feb 26, 2009• 14

By David St. Clair

The economic stimulus package that President Obama has signed contains upwards of $20 billion to create electronic health records for most Americans within five years. The president has been very outspoken in his belief that EHRs are essential to health care reform and that the subsequent savings they’ll generate will help to strengthen the larger overall economy.

Whenever the subject of proliferating EHRs catches the national spotlight, you can bet that debates about privacy aren’t far behind. Indeed the privacy issue has already started to gain some traction in the media. In this video clip, CNN’s Campbell Brown and Elizabeth Cohen examine how easy it is for someone to obtain private medical information online by simply using someone’s Social Security number and date of birth.

While this assessment may be accurate, it’s a bit light on the fairness
scale. Brown and Cohen only make a very brief mention of facts like
President Obama’s plan to appoint a chief privacy officer and to
implement unprecedented privacy controls to safeguard the EHR
transformation. Instead they emphasize the more sensational angle
implying that electronic health information just isn’t safe. They also
seem to downplay the fact that a simple thing like creating a password
can protect one’s private information.

Dartmouth Atlas — cool new tool

Feb 26, 2009• 2

By Matthew Holt

The Dartmouth Atlas releases this afternoon a really cool interactive atlas showing the disparity in Medicare spending between states AND showing the relative growth rates in spending between metro areas. Fabulous graphics, fantastic research and much much more grist for the mill — why was annual average growth in Medica spending from 1992 to 2006 in Miami, FL, 5% while it was only 3% in Los Angeles, California?

And don’t forget what Einstein said about compound interest.

Flash Player Required

Why Technology is No Longer Optional in Public Health

Feb 25, 2009• 5

By ANDRE BLACKMAN

So I just got back from a very informative & interactive event
where I learned about the application of
mobile technologies in
creating social change. It’s here at this meeting of the
socially-conscious minds and the focus of impact creating technology,
that I began thinking about the real ways in which cutting edge tools
are being used in the public health world.Let’s face it, we’re living in the year 2009 and whether you are a young kid or much older,
technology has been integrated into our lives – both for work and play.
Several industries and disciplines have been traditionally linked with
technology (e.g. science, engineering) however in recent years with the
advent of the Internet and social media, fields such as PR/marketing and education have latched onto emerging technologies and have been making quite a bit of use of them – making things better.

How are they making things better you ask? Well, they are doing a couple things:

Medpedia: Who gets to say what info is reliable?

Feb 25, 2009• 4

By e-Patient Dave

Unless you’ve been offline since last week, you know that Medpedia
has gone into public
beta. I
have a concern about the reliability of
their model, based on my personal experience and the self-education
I’ve been doing for the past year. I want to lay out the concern, my
reasons, and a proposal.

It was a year ago that I first learned of the e-patient white paper, E-Patients: How They Can Help Us Heal Healthcare (available free in PDF or wiki), which lays out the foundational thinking for what we’re now calling participitory medicine. The Wikipedia definition of the term includes this:

"Participatory medicine is a phenomenon similar to citizen/network
journalism where everyone, including the professionals and their target
audiences, works in partnership to produce accurate, in-depth &
current information items. It is not about patients or amateurs vs.
professionals. Participatory medicine is, like all contemporary
knowledge-building activities, a collaborative venture. Medical
knowledge is a network."

In this context, I’ll lay out my concerns.

First, I understand the need for evidence and the desire to to filter out flaky assertions.

Health costs increase despite recession

Feb 24, 2009• 3

By Merrill Goozner

The latest one- and ten-year outlook for health care spending from
the Center for Medicare and Medicaid Services projects health care
spending growing 50 percent faster than growth in the overall economy.
By 2018, health care will account for fully one in every five dollars
of gross domestic product, according to the projection. The biggest
jump in health's share of economic activity will come in the next two
years as the sector continues to grow while the rest of the economy
shrinks.

And that's the good news.

There were several unrealistic assumptions built into the
projections. First, the CMS economists assumed Medicare's physician
payments will be cut by 20 percent at the end of next year when the
current payment fix expires. As anyone who follows that issue closely
knows, that never happens. Congress always steps in and restores the
cuts.

Commentology

Feb 24, 2009• 1

Michael Millenson had this response to a commenter in the thread on his recent post looking at web sites that offer the public data about provider performance. (' Just OK Quality or the Best? ')

"Why does HealthGrades get so many more visitors than HospitalCompare? I think you're correct that it's because of promotion, but the context is the magnitude. HealthGrades constantly promotes, via Google-sense ads, via press releases to the trade and mainstream media, via the ads taken out by hospitals touting their ratings and via search engine maximization. And they've done this for many years, acting as if their economic future depends on it (which it does). The government promotes its site kind of the way you see those "stop smoking" public service announcements.

Getting “the CCHIT question” wrong

Feb 24, 2009• 8

By Matthew Holt

Matthew Holt

There’s been a lot of blather from one commenter (who may or may not be a front for a group of malcontents) on the WSJ Health Blog and lots of other blogs about CCHIT and whether it was doing business without a license in Chicago, and/or was a front organization for HIMSS or EHRA. All summarized on Neil Versel’s blog. Indeed I did get a call from one well known blogger telling me that HIMSS’ lawyers had asked for him to take those comments down—not too bright a piece of PR on HIMSS’ part IMHO.

MrHISTalk thankfully did what I certainly could not be bothered to and actually looked into the “CCHIT is not a licensed corporation” situation and figured out that it’s basically being run legitimately. I myself cracked the joke privately that if CCHIT/HIMSS/EHVRA/Leavitt et al had only managed to get $2m (or $7m for that matter) out of the Bush Administration, they needed to go to the Haliburton school of “how to stick it to the taxpayer properly.”

The other wisecrack I’ve heard is that the way to determine the list of functions an EMR needs to have to get CCHIT certified was to copy the feature set of Allscripts TouchWorks. (Of course you can insert the name of any of the other big EMR vendors here too).

OK, so we’re kidding around here, but underneath this discussion are some serious points. And those serious points have got little to do with what has indeed been a pretty close relationship between the powers that be at HIMSS,EH(V)RA, CCHIT & HITSP.

In any case I assure you that the back room dealings and conflicts of interest are nothing compared to how the rest of the Federal government has colluded with industries it regulates for the last 8 years. The money given from ONC to CCHIT wouldn’t even be a rounding error on what’s been completely lost in Iraq in cash in suitcases. let alone what Blackwater, Halliburton et al have stolen, And there’s no evidence that the Feds didn’t get what they/we paid for from CCHIT, which is a certification process.

So if this is a non-story, what are the actual issues?

1) Part of the justification for a certification process is that there is a great deal of fear and trepidation among physicians who have heard the horror stories about EMR implementations, and are now being bribed (and later to be threatened) by the Federal government into installing EMRs. Given the plethora of vendors out there, and the fact that these providers are more or less Federal contractors who tend not to understand IT, it’s not unreasonable to suggest that the Federal government (or someone) gives authoritative guidance as to what’s a robust system that has the right features and functions. Remember that the nation’s biggest and richest integrated provider organization trashed not one, but two national investments in EMRs before getting it right at try three. Having recalled that it becomes reasonable to agree that most providers need some help. And of course there is some slight protection for the taxpayer if the providers who are about to get their $40K have to do more than just claim that they bought an EMR from Sonny on the corner.

2) Of course once you say that the Federal government will pay out only to those purchasing certified products you then run into two other problems. First, the certification process is going to get somewhat politicized. Despite all the yakking about “volunteers” on all these committees, what we’re talking about is the people with a deep interest in EMRs et al being those “volunteers” and of course they are mostly from the vendor side or users who know the vendors well. I don’t see a way around that unless we really want to develop a civil service that has expertise in health care IT and also is prepared to stay in the job for 30 years like they do in Japan. Second, by its very nature the certification process is likely to run behind the development of technology, which means that vendors building for the certification process are like teachers prepping students for tests, not creating innovations. Again that may not be a terrible thing, but it’s not how innovation works in most other industries. (John Moors at Chilmark has a rather blunter, bleaker assessment of how this might work out)

3) And of course, the reason that you don’t see Federal certification of, say, MP3 players or automobiles is that there’s a somewhat effective market there that means that innovation and user experience gets rewarded. Make a confusing MP3 player, you don’t move the needle much. Figure out how to make it easy and elegant and you’re called Steve Jobs and you sell a gazillion iPods a year. Health care doesn’t have such a market, or even rationally managed incentives from its Federal paymaster.

So I don’t have the answer, but I do have the question. And it’s the same one being posed by the Dogs, in response to the Cats. Can we realistically expect CMS and the rest of the big payers to start rewarding providers for producing the correct outcomes. If we paid for outcomes, providers would change their organizational structure, and their processes, and the technology they use. The ones that worked would succeed and the others would go away. That’s how a market works. And that would create lots of interesting technological innovation of the type that is already happening in the consumer health arena in Health 2.0.

But (beware: run-on sentence coming up so take a deep breath) if we realistically can’t get to some massively enhanced version of pay for performance very soon, and instead are going to insist that providers use EMRs or something like them and the Feds will pay them for it, and we are happy to declare that that solution is as good as we’re going to get while we work on wider health system reform later, then I don’t think that we can complain about the CCHIT process too much. We have to accept that the Feds are going to put a stake in the ground somewhere as to what is an acceptable technology to reward. And those rewards are not going to be market or outcomes-based yet.

So the ultimate question, is what’s the time-scale for junking our stupid current health care incentives and finance system? And the answer is, not in the next 2–3 years.

Which means that if we’re paying directly for technology (which we are as the law is now passed), a certification process is a necessary evil to help providers and to make sure that the tax payer isn’t being defrauded (see we’re back to Iraq again!).

Of course, this doesn’t mean that the certifiers shouldn’t be made to appear to be (as we;; as actually be) completely above board and be watched like hawks to make sure that they’re not putting too many restrictions on smaller companies or discriminating against them. And maybe that kind of oversight demands that we see greater separation between the HIMSS/EHRA/CCHIT/HITSP/ AHIMA players, which would fit in with Obama’s “no lobbyists in the Administration” line.

But I can’t see that this is an issue for anyone to go to the barricades about. And in the end if CCHIT helps providers get better tools than they have now, it’s probably a net positive—even if it may prevent greater innovation happening faster.

Health reform for health’s sake

Feb 24, 2009• 3

By Sarah Arnquist

If the goal of health reform is to improve Americans' health, then the debate needs to broaden to focus on issues outside the medical system that often play a greater role in determining health.

That’s the message Susan Dentzer, editor-in-chief of the health policy journal Health Affairs, gave to an audience Monday at the Johns Hopkins Bloomberg School of Public Health.

Dentzer began her talk by quoting New York Times Columnist David Brooks, who wrote in a column last fall about a “tide of research in many fields, all underlining one old truth — that we are intensely social creatures, deeply interconnected with one another and the idea of the lone individual rationally and willfully steering his own life course is often an illusion.”

Her point was that communities and social networks play a huge role in
setting social norms and determining health status of the population. And Improving population health should be the goal of any national health
reform effort, she said, and accomplishing that requires a focus on determinants
of health outside the medical care system, such as smoking, obesity,
poverty and social networks.

Finding a Faster Route From Patent to Patient

Feb 24, 2009• 4

By Wendy Everett

As the health reform debate intensifies, the rightful role of medical technologies is stuck squarely in the
middle, caught in a simplistic tug-of-war over whether these innovations raise or lower health care costs. Instead of this argument, we should be focused on how to best identify the truly valuable technologies – those with potential to save both lives and money – and get them into the health care marketplace.

So how can we ensure that the U.S. is making smart investments in innovative technologies that pay dividends for patients and the system, something Europe, Canada and many other countries are already doing?

Answering this question would give us a shot at fixing some of the most broken parts of health care. Technologies can play a key role in the redesign of the ailing primary care system by providing quality patient data, assisting in preventive practices, and taking the burden off the backs of primary care physicians. Similarly, technologies can help combat and manage the massive burden of chronic disease, and they can help reduce the costly clinical waste and inefficiency plaguing the system.