The KHIT Blog: "The Health Care Handbook" considered

Wednesday, July 18, 2012

"The Health Care Handbook" considered

So, yesterday, I ran across this post on The Health Care Blog, wherein the (anonymous) "reviewer" waxed effusive.

The book is the work of two medical students, Elisabeth Askin and Nathan Moore. When Elisabeth and Nathan worked to educate themselves about the American health care system they couldn’t find a source that was comprehensive, understandable and non-biased – so they decided to write it themselves. After thousands of hours of research, writing, and consulting with dozens of national experts, the Health Care Handbook is now available. It’s rigorously researched and scrupulously unbiased yet written in a conversational and humorous tone that’s a pleasure to read and illuminates the convoluted health care system and its many components. The book is essential reading for health professionals, health professions students, and anyone who interacts with the U.S. health care system.

$7.99 Kindle edition? Safe bet. 1-click Whispernet, whoosh...

I downloaded and read it. Nicely done. If you've been immersed in the health care system for as long as I have, you won't find much new detailed information here, but, as the authors note, that's not the principal audience.

We’re students ourselves, so we have firsthand insight about what students don’t know, what they want to know, and what they need to know. As such, students are our primary focus for this book...

We think the book will hold the most value for the following:

Students in undergraduate, graduate, and professional programs focused on medicine, nursing, dentistry, pharmacy, allied health, medical research, biotechnology, public health, public policy, economics, finance, health care administration, business, and law. Heck, throw in history and political science, too!

Health care professionals who want to expand their knowledge about what affects them in the workplace or who want a reference for continuing education.

Lay readers who are sufficiently interested in learning more about health care to have started reading a book about it. In short, if you ever find yourself confused by a news article about what an Accountable Care Organization is, or you don’t have quite enough information to argue with your Uncle Dan about pharmaceutical companies, or you’re annoyed that everything you read has an agenda— then this book is for you.
(Kindle Locations 179-180)

I find it indeed balanced and comprehensive -- at a (probably appropriate) "survey course" level. It has been worth my money and my time. See also the NY Times' recent "Two Medical Students Navigate the Health Care Maze."

My only laments go the the short shrift given HIT (in addition to an equally cursory treatment of clinical "statistics"):

Health Information Technology

While the technology used in medical devices continues to improve, health care communication and organization systems at most institutions are stuck in the pagers-and-faxes era. (Unfortunately, they've ditched the acid-washed jeans.) Health information technology (IT) is a simple concept: the application of electronic systems in organizing and using health data, from writing prescriptions to transmitting MRI results digitally. However, as with many aspects of health care, this simple concept quickly becomes extremely complicated when put into practice. For one, health IT goes by many different names, such as electronic health records (EHR), electronic medical records (EMR), and personal health records (PHR). Different software systems may all call themselves EHR, which would suggest they are comparable; however, they may not perform the same functions or have the ability to communicate with each other. The best definition and system may not be clear for those who are actually using it to provide care.

What is clear is that health IT has the potential to significantly improve the efficiency and error rate of health care systems. (Spell check is pretty great and all, but ending the tyranny of physicians’ messy handwriting is a true feat: now 25% of prescriptions are issued electronically.) Of course, potential doesn’t necessarily equal results— the largest study to date failed to show any improvement in quality of care, cost, length of stay, or readmission rates for hospitals that have implemented EHRs. Health IT penetration is still relatively low in the U.S. — only 1.5% of hospitals have comprehensive EHR systems, while 7.6% operate a basic EHR. Nevertheless, the federal government has prioritized health IT and has unveiled a range of measures to encourage the adoption of EHRs across the country. Interestingly, the one area in which health IT has already been implemented quickly and universally is medical billing— 99% of hospitals have computerized patient billing systems. Money has an uncanny ability to speed anything along, doesn’t it? (Kindle Locations 2256-2271)

That's pretty much it. Also, search on "health information exchange," "HIE," "interoperability," "meaningful use".

Nada. Zilch. "0 matches found."

Well, another resource that fills in some of the blanks. Recall my March 28th, 2012 post, wherein I reviewed Fred Trotter's excellent "Meaningful Use and Beyond."

This book rocks!

As do Joe Flower's "Healthcare Beyond Reform," and Dr. Toussaint's "Potent Medicine" and "On The Mend" (scroll down in the latter two posts), to cite just a few of my top 10.

As does the compelling "Medicine in Denial," which I've cited multiple times.

IN OTHER NEWS

Why the EHR market is on the brink of mass consolidation
July 18, 2012 | Robert Rowley, MD, Healthcare and health IT consultant, practicing family physician

The number of vendors of Electronic Health Records products seems unsustainable. Stimulated by federal Meaningful Use incentives, plus the irresistible tide of pressures and encouragement from all sides (specialty societies, peers, licensing boards, insurance payers), the uptake of EHRs has been steadily increasing...

This scenario seems ripe for consolidation. Market forces, however, are rather Darwinian – novel approaches abound (“mutation”), but many will not achieve market penetration (“selection”). Failure of products, even well-designed ones, are part of the startup experience – true in all market spaces, not just health care.

There will likely be some consolidation. As is seen in other sectors, when companies buy other companies it is more a purchase of their market footprint than it is a purchase of their technology. In fact, examples of mergers with ultimately incompatible technologies behind them abound...

So, nearly half of the "certified" EHRs have no attestors to date? I'm havin' a Clinic Monkey Moment.

Yes, there will indeed be a "shakeout."

More Dr. Rowley:

Market analysis of the EHR industry is compiled from 2011 Meaningful Use data. This 116-page comprehensive document is intended to be an indispensable resource for those who want a detailed understanding of the current state of the EHR industry – consultants, vendors, and investors will find this an important reference manual as they view the competitive landscape of Electronic Health Records (both ambulatory and hospital).

$6.90 a page. Can you say "nano-niche market"?
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BACK DOWN UNDER THE OpenEMR HOOD

As of today 141 relational tables (these people are busy). I'm working on tallying up all of the vars and their cumulative data storage and bandwidth overhead. This (above) is a snip from the audit log dictionary.
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HIPAA / OCR UPDATE

Nice presentation deck here (PDF).
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THE NEW ONC MU DASHBOARD

Dashboard.HealthIT.gov

This is nicely done. You can click state by state (and by other criteria) for interactive statistical graphics.

Click to enlarge. Note that, as of "04/31/2012," (red oval annotations) our Utah brethren were kicking our Nevada butts. But, they have one major vertically integrated system (IHC) and one major metro area to service as a priority. We have to deal with Clark (S) and Washoe (N) counties (far flung, comprising ~90% of the state population), and have a number of competing delivery systems along with our (ever-declining) independents.
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More to come...

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Brave New Health

Commonwell Health Alliance

Another important read (pdf)

I love this kind of stuff. It sustains and humbles me. "As politicians, advertisers, salesmen, and propagandists for various political, economic, moral, religious, psychic, environmental, dietary, and artistic doctrinaire positions know only too well, fallible human minds are easily tricked, by clever verbiage... Common language—or at least, the English language—has an almost universal tendency to disguise epistemological statements by putting them into a grammatical form which suggests to the unwary an ontological statement. A major source of error in current probability theory arises from an unthinking failure to perceive this."

Quotes

"An economist is a person who sees something that works in practice and tries to figure out whether it will work in theory."

- J.D. Kleinke, medical economist
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"The only person who enjoys change is a baby with a wet diaper."

"Every misspent dollar in our health care system is part of somebody's paycheck.

- Brent James, M.D., M.Stat

“We could do healthcare, at markedly higher quality, for everyone in this country, without rationing or denying anybody the care that they need, without having the government dictate how doctors practice or whether hospitals could expand, at half the cost we do it now.”

- Health Care Futurist Joe Flower

Most of the sciences, unlike parts of medical science, are not concerned with the impossible. There is not complementary and alternative physics, or chemistry, or biochemistry, or engineering. These disciplines compare their ideas against reality, and, if the ideas are found wanting, abandoned."

- Mark A. Crislip, MD

"Q: How much alcohol is too much?
A: More than your doctor drinks."

- a physician I once heard speak during a CME presentation

“Just because science doesn’t know everything, doesn’t mean you get to fill in the gaps with whatever fairy tale most appeals to you.”

- Dara O’Briain

'[I]t is one small step from using the computer for "helping" doctors to monitoring them, judging them, dictating to them what to do, and withdrawing payment for computer non-compliance. The use of computer data is a multi-edged sword. It can be used for the "good," facilitating diagnosis and treatment and making it more accurate and up-to-date, and for “evil,” invading privacy, inviting security breechs, and making decisions based on the opinions of remote authorities rather than those present at the patient-doctor encounter.'

- Richard Reece, MD

“[T]here ARE statistics which are non-political. Just because The Washington Post/Fox News reports the temperature is 75 degrees doesn’t mean it’s really snowing and sunscreen is a liberal/conservative plot. Even if you earn a living being ideological.”

- Michael L. Millenson

"It is a generally a fairly convincing argument that people shouldn’t have to be subsidized to undertake a change which is in their best interest.

The reconciliation seems to be that EHR is not supposed to make a doctor’s practice more efficient and higher quality. It is supposed to make the system of care more efficient and higher quality, which is not the same thing. Those of you who took calc recall that maximizing the total of variables is not achieved by maximizing any one variable and this is a perfect example of that.

Those of you have served in combat certainly noticed that too — if everyone works as a team the unit takes fewer casualties. If you try to save your own hide, you might, but at the expense of more casualties overall."

- Al Lewis

"There are two ideas to keep in mind about Bayesian reasoning and how we tend to mess it up. The first is that base rates matter, even in the presence of evidence about the case at hand. This is often not intuitively obvious. The second is that intuitive impressions of the diagnosticity of evidence are often exaggerated."

- Daniel Kahneman, "Thinking, Fast and Slow"

"Physicians apply advanced scientific knowledge, but they must do so without the favorable conditions that experimental scientists create for themselves. Multitasking is forced on physicians, often in chaotic environments and under severe time and resource constraints."

- Lawrence and Lincoln Weed, "Medicine in Denial"

"It’s time to stop the whining about Obama care and acknowledge we already have universal health care. We just pay for it in the stupidest way possible that ensures problems are that much more disastrous and complicated when they’re finally treated."

- Mark Hoofnagle, MD, PhD

"Every act of conscious learning requires the willingness to suffer an injury to one's self-esteem. That is why young children, before they are aware of their own self-importance, learn so easily."

- Thomas Szasz, MD
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"Of course, one reason that process metrics* are so popular is that processes are much easier to define and measure than outcomes."

- The Skeptical Scalpel
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"There is an “illusion of validity” for any random data point, a seductive sense that is colored by what we hope will be true. Mountains of pharmaceutical claims are often made from mere molehills of data."

- Danielle Ofri, MD
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"Joy empowers people. It is a source of energy that enables people to hope and plan and change their lives for the better. Spend some time around someone who is relentlessly negative and how do you feel–drained, right? More and more research shows that joy is not something that just happens to you, like a bolt of lightening out of the blue. Joy is, instead, a habit to cultivate. Negative thinking and despair are the crabgrass of our souls–weeds that take root and spread, sometimes to all areas of life. Joy, in contrast, is a soul’s rose–hardy when cared for, able to put down roots over time and withstand disease and extremes. Like a rose, however, your joy can become blighted from neglect or harsh conditions. We all need to tend to our joy–to prune away the badness, and to know that, even though it may look like a prickly bare root, if you invest time in a joyous outlook, gorgeous things will bloom, even in the harshest conditions."

- Dr. Jan Gurley
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"'Solutions' exist only in mathematics."

- Karen Martin
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"The issue of how to regulate clinical software is, in the long run, indistinguishable from the issue of how to regulate medicine. The only difference is that medicine is practiced in the open, without secrecy, subject to peer review, and under a merit-based state license."

- Adrian Gropper, MD
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"Economist, rope, tree: some assembly required."

- Source unknown

DISCLAIMER:

I write this blog wholly on my own time and my own dime. The views proffered are expressly my own as a concerned and active citizen/taxpayer (in addition to being the result of my substantive experience in the various IT fields), and in no way reflect any policy views of my former employer, notwithstanding that some of the thinking has indeed obviously been spurred by the implications of the work with which I have been doing for them.

FAIR USE POLICY
I cite a ton of news and web sources spanning the breadth of relevant technical and policy domains, sometimes at substantial length. I believe I remain well within the bounds of "Fair Use," as [1] I am not doing any of this for profit, [2] I always provide attribution and links -- which, [3] far from negatively impacting any copyright holders' commercial interests, might actually increase traffic to and interest in their offerings.

Nonetheless, should I post anything of yours regarding which you have any objection, just let me know and I will remove it forthwith.

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Wednesday, July 18, 2012

"The Health Care Handbook" considered

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