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Health IT and the Stimulus Bill

Jan 16, 2009• 2

By CHARLIE BAKER

I’ve written before about the limits and opportunities of health
information technology. HIT, as it’s more commonly known, is just that
– health information technology. It can be an important and useful
tool. But it is the user of that technology – the clinician, the
pharmacist, the administrator, the analyst – who ultimately determines
its value. If the user invests in it – financially, psychologically
and intellectually – then great things can happen. Otherwise, it’s
just a tool. Nothing more.

So when people start talking about spending $25-50 billion on HIT as
part of an economic stimulus bill, I get a little uncomfortable. $50
billion would be twice the size of the annual NIH budget – a very big
number. Are we sure the funding – and whatever technology comes of it
– will be incorporated in a way that maximizes its use and value, or
not?

A Shakespearean Approach to Health Care Reform

Jan 15, 2009• 5

180pxfirst_folio2_2 By Roger Collier

With the opening of the new Congressional session, the latest health care reform effort is off and
running, with HHS Secretary-designate Tom Daschle telling senators at his confirmation hearings of his desire to work collaboratively and listen to diverse ideas.

One thing about Washington DC, there’s never a shortage of diverse ideas, and with the possibility of passage of some version of reform, there’s an especially impressive number. Daschle’s problem is going to be how to pick and choose among them.

Every reform plan—whether from Baucus, McCain, Obama, Clinton, Wyden-and-Bennett, Kennedy, Stark, Dingell, or elsewhere—comes with its own strengths and weaknesses, and cross-aisle consensus is certainly missing. But maybe it’s possible to take a little of this plan, a little of that, and so on, to create the magic mixture that can reform our system and achieve the critical sixty vote support in the Senate.

Perhaps it’s time to consider a recipe from Macbeth:

Eye of newt, and toe of frog, Wool of bat, and tongue of dog, Adder’s fork, and blind-worm’s sting, Lizard’s leg, and howlet’s wing…

Shakespeare’s witches didn’t provide precise measures, and we may have to substitute for some of the ingredients, but we’ll go ahead and start adding items to our cook pot anyway…

Commentology

Jan 15, 2009

Alan Rosenstein MD’s post on "Disruptive Physician Behavior: Fact versus Frenzy" displeased several readers. One fired back:

"How about disruptive administrators? Those who destroy
clinical departments thru incompetence, inexperience, and just plain
egotistical stupidity? What about arrogance, and general ahole-like
behavior? Got a regulation for that?"

JROSSI had this to say in response to David Reece’s Tuesday post "Confessions of a Cultural Anthropologist: The Real Reason for High Healthcare Costs"

"Why is there a primary care shortage? I have been a family doctor for 19 years. Finally, the NEJM has touched the nub of the matter–I’ve been telling people this for years now. It’s the new medical students who are increasingly bottom-line focused. They were raised in a culture that is bottom-line oriented, and they’re not going to change. More money, less work (this is also a crucial factor that the editorial doesn’t discuss). Cultural, cultural to the core."

David Kibbe’s posting on the National Research Council’s much talked about report on "The Healthcare IT Chasm" drew this response from Peter Basch, MD.

"Kudos to the National Research Council for their comprehensive and
sober analysis of the state of health information technology as it
exists today, and for their thoughtful recommendations. These
recommendations reflect not just their research and editorial advice,
but the current conventional wisdom and implementation approach of
nearly all clinical informatics leaders.

A physician calling themselves J Bean had this to say in the same thread:

"I spend most of my evenings entering data into our new, multi-million dollar EMR and no longer have much free time except on Wednesdays. I’ve stopped seeing patients one day per week so that I can have more time to wrestle with the computerized input of useless dreck …I was a systems and software engineer for a decade before I went to
medical school and I’m pretty under-impressed by what I’ve seen in the
field … It’s amateurish at best. It certainly doesn’t meet any kind of
standards for good user interface design. It does a remarkably poor job
of data aggregation. It doesn’t have a search function or even allow
easy access to older data, much less provide "decision support". It has
made my job harder rather than easier."

Health 2.0 Group Chicago, meets Thurs 15th

Jan 14, 2009• 7

Calling all Chicagoans – Some attendees of the Health 2.0 Conference would like to create a regional Health 2.0 group in your area—FIRST MEETING IS TOMORROW!

The Purpose: To form a group within the greater Chicagoland area to connect, to discuss, and to inform on all things health and technology.

Unpacking the Ingenix Settlement

Jan 14, 2009• 12

By ROBERT LASZEWSKI

Earlier this week, New York Attorney General Andrew Cuomo announced a "victory" in his battle with the insurance industry over how out-of-network physician claims are paid. Cuomo had argued that the industry’s use of its out-of-network "customary and reasonable" database "defrauded" consumers and he sued the database’s manager, United Health’s Ingenix, over the controversy.

In a February 2008 post I said, "In a few months, we will hear that Ingenix paid a big fine and agreed to fix something (that no one will understand) and Cuomo will have another notch in his belt."

Here’s how the settlement will work: Ingenix will pay $50 million to
set up an independent not-for-profit to operate the customary and
reasonable database. The industry gets to continue determining what
customary and reasonable
physician charges are through this non-profit and just exactly how they
do it will continue to be done by systems gurus the way systems gurus
do things–pretty much in a "black box." While an undetermined
university will operate the system, the industry, who will finance it,
will presumably have a great deal of input into
it. The industry’s use of the database will be more defensible since
one of its own is no longer arguably directly controlling the entity.

Health 2.0 Will Benefit from Obama’s HIT Stimulus

Jan 14, 2009• 8

By Peter Schmidt

The Obama team is talking very seriously about including health information technology in his “main street” stimulus package. While I generally agree with the predictions of doom and gloom for providers saddled with the burden of data entry, this creates a potentially huge opportunity for Health 2.0.

As very publicly warned in this forum and others, a stimulus package focused entirely on existing EMR/HER technology would not only offer no proven health benefits (Linder, et al. Arch Intern Med. 2007) but also would financially harm clinical practice. Kaiser Permanente’s Hawaiian experiment with EMR added approximately an hour a day of data entry work per physician (Scott et al., BMJ 2005).

This impact will fall disproportionately on primary care.

Disruptive Physician Behavior: Fact vs. Frenzy

Jan 14, 2009• 12

By Alan Rosenstein, MD

The Joint Commission has recently proposed in its 2009 Accreditation Standards that hospitals develop and implement a Code of Conduct policy and provide appropriate education and processes that address disruptive behaviors.

Many think the decision is long overdue, while others have expressed concern that it was just another way for administration to weed out physicians who are openly vocal in expressing contrary views to administrative policies and decisions.

Disruptive behaviors include any inappropriate behavior, confrontation or conflict ranging from verbal abuse to physical or sexual harassment. Unfortunately, they’re all too common in the health care arena, and they affect staff morale as well as patient safety.

My top 10 rules for Email Triage

Jan 14, 2009• 3

By John Halamka

I
receive over 600 email messages each day (with virtually no Spam, so
they are all legitimate) and respond to most via Blackberry. How do I
triage 600 messages? I use these 10 rules to mentally score each email:

1.
E-mail marked with a “high importance” exclamation point must pass the
“cry wolf” test. Is the sender a habitual “high importance” e-mailer?
Are these e-mails actually important? If not, the sender’s emails lose
points.

2. I give points to high-priority people: my senior management, my direct reports, my family members and my key customers.

3. I do the same for high-priority subjects: critical staff issues, health issues and major financial issues.

4.
I rate email based on the contents of the “To,” “cc” and “bcc” fields.
If I am the only person in the To field, the e-mail gets points. If I
am in the To field with a dozen other people, it’s neutral. If I’m only
cc’d, it loses points. A bcc loses a lot of points, since I believe
email should always be transparent. E-mail should not be used as a
weapon.

5. I penalize email with emotional words, capital letters or anything less than civil language.

Tone deaf git of the month award

Jan 14, 2009• 33

By Matthew Holt

I’m always amused to see Ivy league professors with tenured appointments and gold-plated group health insurance explaining how the individual market for health insurance works pretty well for, well, quite a few of the well people in it. But this award is not for Mark Pauly.

Today there’s a long piece in the Wash. Post (essentially paid for and scripted by Kaiser Family Foundation—which may be the future model of health care journalism). In it, we see this paragraph:

Experts define the underinsured as those forced to spend at least 10 percent of their income on health care, excluding premiums. But the nonprofit Center for Studying Health System Change found recently that financial pressures on families increase sharply when out-of-pocket spending on medical bills exceeds 2.5 percent of family income. New York’s Commonwealth Fund has reported that 72 million adults under age 65 had problems paying medical bills or were paying off medical debt in 2007, up from 58 million in 2005. Many had insurance, and 39 percent said they had exhausted their savings paying for health care.

Yup, even people with insurance are in real trouble. Two days ago I met a woman in her early 20s who faces 3 more years paying off extra bills from emergency ankle surgery 2 years ago. And yes she had insurance–just not very good insurance.

And so we have around 25% of adults having problems paying medical debts. And of course that’s a 2007 number—in other words pre-recession. So in order to be “balanced,” they get a quote from a resident member of the loony right. And for our tone deaf git of the month award we select this wonderful piece of empathy.

Economist Thomas P. Miller of the American Enterprise Institute, a conservative Washington think tank, said he believes the problem of medical debt has been exaggerated and is a symptom of the broader economic crisis. The solution, he said, should not be "to kill people with kindness" by requiring an overly expansive and expensive benefits package that could "preempt the use of resources for other purposes."

In other words, screw you poor people, you’re on your own and the system works fine.

Confessions of a Cultural Anthropologist: The Cause and Cure of High Health Costs

Jan 13, 2009• 15

By RICHARD REECE

Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms. Add in such pressures as the need to pay off enormous debts, and it is not surprising that students’ choices are dictated by the desire to maximize income and minimize work time.

Pamela Hartzband, MD, and Jerome Goodman, MD
“Money and the Changing Culture of Medicine”
New England Journal of Medicine, 1/08/09

I have a confession to make. I think the cause of high American health costs is straightforward, but it is not simple. It is American culture in general and the physician culture in particular. There is nothing wrong with this, and I point no fingers.

The Way We Are
It is our culture. It is the way we are, the way we’ve been for 232 years. It is our distrust of government and high taxes. It is our want to be free to choose. It is our belief in for equality of opportunity for access to the latest and best of care.

It is the notion, stemming from frontier days and conquering of the West, that action speaks louder than words, that if you do something specifically, it is better than doing nothing generically. “Don’t do nothing, do something,” as the saying goes.Continue reading…