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Friday, January 27, 2012

Oops


Yeah, charitably, we
know what was intended. But, really? FORBES.com?

That little graphical y-axis faux pas aside, I wouldn't get all that worked up over a relatively weak apparent Pearson-R associated with the depicted U.S. "outlier-censored" linear trend line. I'd want to see median vs "average," for one thing. Yeah, spend more, live longer, of course.

Loosely.
But, I'd drill down deeper (and I'm sure others are doing so).

Not to dismiss the obvious fact the we are not getting our money's worth here, in the U.S. overall. We know that (empirically if not polemically).
to wit

Having just finished contributing to a CMMI "Innovations Challenge" proposal having to do with care coordination via "health coaching" (see my January 8th post), I ran across a cautionary CBO report "Lessons from Medicare’s Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment" (PDF).

Forthwith, John Goodman PhD posted this on The Health Care Blog: "Why The Pilot Programs Failed"

"Failed?" Dr. Goodman's summary:
  • On average, the 34 programs had little or no effect on hospital admissions.
  • In nearly every program, spending was either unchanged or increased relative to the spending that would have occurred in the absence of the program.
Love this one: "spending was either unchanged or increased relative to the spending that would have occurred in the absence of the program."
Would have occurred? Rather speculative, that one.

OK. Here's the main graph from the CBO report.

So, on cost-containment and acute inpatient re-admissions, the various programs comprised ~ a net wash, with a rather large +/- distribution around the wash. Thought experiment; imagine a vertical center line in the bar graph. Push the image over, and see it as 3-D.

To me the above graphic is conceptually the equivalent of the findings of HEDIS data (regarding which I've written before), e.g.,


At the risk of nominally conflating "apples" with "oranges," it appears that we have long demonstrated ~zero "cost vs quality" for quite some time, no matter what we try, no matter what proxy correlative metrics we proffer, no matter who the payor (like we didn't already know that). But, I want to know what the respondents in the upper left quadrant of the HEDIS graphic (representative of all of the major Chronics, btw) are doing right within the overall shotgun scatter. Similarly, I'd want to study further the "successes" part of the "Pilot Programs."


Spin as "failure"? To just summarily frame an evaluation as "Why The Pilot Programs Failed" could not be more transparently partisan. Perfectionism Fallacy 101 (one which conveniently ignores the pesky fact that most private sector bootstrap or VC-funded initiatives also "fail" in one way or another).

SO, WHAT'S THE CONNECTION?

I don't think anyone intends that we do the same thing over and over. For example, a core component of HealthInsight's grant proposal -- in addition to that of "health coaching" for patient self-management support -- is that of "clinic coaching," i.e., workflow analysis and re-design training for clinic staffs, with a specific emphasis on optimizing HIT use, through which to improve care and outcomes while reducing the FTE burden of HIT use. This maps right to the observations made by Messrs Weed in "Medicine in Denial" (we will head back Down in the Weeds' shortly).

APROPOS


ONC: Health apps among big trends of 2012

By: Brian Dolan | Jan 30, 2012
Last week Dr. Farzad Mostashari, the National Coordinator for Health Information Technology at the US Department of Health and Human Services, penned a column on his top five health IT predictions for the year ahead. Not surprisingly, Mostashari expects consumers to use eHealth to get more involved in managing their own health. “I believe this year we will see consumers and patients use information technology to become better informed about their health and more engaged with their own care than ever before,” Mostashari writes. “In large part, this will happen because it’s becoming easier for consumers to electronically access their own information. Personal health records are becoming easier to use as more data holders make it possible to download information through tools like Blue Button. Many health care providers are setting up patient portals which are directly connected to their EHRs. The Medicare and Medicaid EHR Incentive Programs already require providers to give patients access to their electronic health information, and I anticipate future stages will build on that notion. And the work that is being done on standards and interoperability will help make consumer access to their health information more seamless and more useful.” Mostashari also noted his office’s push to encourage developers to create more meaningful health apps through its series of app challenges that it puts on through Health 2.0, which received a $6 million grant to conduct the challenges. “In addition, developers are coming out with more apps for mobile devices that make it easier for consumers and patients to get information about different diseases and track their own health over time. Along those lines, several Beacon Communities have launched txt4health, a consumer engagement campaign that uses cell phone text messaging to deliver information about diabetes care and management,” Mostashari writes. “ONC will diligently keep encouraging the marketplace to develop mobile apps and other consumer-friendly platforms that get patients engaged by sponsoring challenges like the Healthy Apps Challenge. Once consumers start to see their own information, they will be more empowered to be partners in their own care and come to expect that providers will use health IT as a tool to help deliver high-quality care.”...
Yeah, but, a lot of this "innovations" stuff has distinct vestigial wafts of the Dot.com era of a decade ago.


As I recently observed in the comments in "The Entrepreneur’s Dilemma,"
why, it's



More thoughts on this shortly, which, for one thing, is gonna take me Back Down in the Weeds'...
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ANOTHER MINOR "OOPS"

So, I got to this link in the wake of reading a couple of articles on health care at Forbes.com

Yeah! Yet another "innovation" effort, I guess, this one by Forbes contributor Dan Munro. So, we're just supposed to summarily "recommend," "tweet," or "invite" without knowing any details? "Share the news"? WHAT "news"?

I clicked on "Like Us on Facebook" to perhaps learn more.

Only to get this.

Whatever. In fairness, their "blog" link works.

CODA

Dr. Kent Bottles reports on the recent CMS Care Innovations Summit over at The Health Care Blog.

PS- one more "Oopsey" for your HIT enjoyment:

Monday, January 16, 2012

Down in the Weeds'

OK, I have just finished an intense red-penned, yellow-highlighted, margin-noted initial cover-to-cover pass through "Medicine in Denial" (which I have heretofore cited in a number of recent prior posts).

One hardly knows where to begin. 267 pages of unmitigated butt-whup. It has to have its own post (note that I put a permanent link to the book on Amazon, over on the right; get a copy). Suffice it to say at the outset here that, if I ruled Health Care, this would be the first required text in med school. Maybe even before that.


Increasingly mindful of avoiding the pitfalls of "confirmation bias," I've held further observation and commentary until actually finishing all of it. It is one profound piece of work. I am extremely grateful to co-author Lincoln Weed for the post-pub proof copy. He admonished
"be aware that this is not a quick read."


Indeed. And, it has been worth every minute, every hour.
Building the infrastructure and changing the culture of medicine cannot be left to the medical profession alone. Leaders outside the profession, and especially the general public, need to understand the transformation that is possible. But writings like this book will not make that happen. A recurring pattern in the history of medicine is the persistence of ineffective or harmful practices, and resistance to needed innovations. What is needed to change that pattern is public understanding of why the status quo is bankrupt, a shared vision of an alternative, and an external compulsion to change...

...It does little good to subsidize the purchase of EHRs if their inputs are not guided and defined by knowledge coupling software compatible with the EHR design. It does little good to equip practitioners with knowledge coupling software if they are left free to exercise judgment on when to use the software or what data to collect. It does little good to design interoperable EHRs for exchanging patient data if the design does not also organize the data for coordinated care of multiple problems by multiple practitioners over time. It does little good for multiple EHR vendors to separately design such EHRs if variations reduce interoperability and ready comprehension by all. [pg 174]
This is an important book. It goes to the very core of the work I now do, work I believe in, but work that needs much more clarity of purpose.

Interview with Lawrence Weed, MD — The Father of the Problem-Oriented Medical Record Looks Ahead
A Final Question

LJ: Dr Weed, you have had an amazing career implementing a needed change in how patient data is handled through the POMR. Today, you outlined another major change that needs to be incorporated if the practice of medicine is to be improved. On the basis of your experience as an innovator, and knowing what you know today about medical education and the practice of medicine, are you optimistic such changes will be forthcoming?

LW: Based on what I know about all the vested interests in the present medical education system and in the present practice of medicine, I am not optimistic such changes will be forthcoming...

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QUICK DIVERSIONARY ERRATUM


Well, that can't continue much longer. Click the graph for the link (PDF). The red text above is my text annotation (avg annual increase $1,127, linear R-sq 0.9979). Drop the numbers into Excel and extrapolate to the end of the decade.

Notwithstanding that the statistical +/- confidence limits around a linear projection will bow the further you go into the future, the implications should be clear (moreover, [1] the bowed CIs cut both ways, and, [2] nominal aggregate annual spending will not be as telling as "spending per service rendered," i.e., decreased "UTIL" -- self/household-rationing as a contributory function of increased cost).

NOTE: the Milliman report is silent as to whether their cost data are inflation adjusted.
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AMA WORKFLOW TUTORIAL

So, today (18th) I saw a news item regarding a new HIT online workflow tutorial posted by the AMA.

Click the graphic above for the link. Not bad. I signed up and went all the way through it. Nicely done. They give docs CME credit for completing it, but others (clinic staff and interested people like me) get a "Certificate of Participation."


I found it well worth my time -- only took me about 90 minutes, and, it bookmarks where you left off if you have to do something else prior to completing the tutorial. Nice.

Nothing really that I didn't already know, and lacking some core stuff I'd have liked to seen included (e.g., task times-to-completion and error rates; see my "Workflow 4 Anyone" Powerpoint), but I came away from it with a sharpened attention to workflow issues pertaining to "pre-visit planning," which will be something to be more fully considered in our upcoming PCMH'ish CMS Innovations Grant should we get the award (see my prior post). Not to mention "Accountable Care" more broadly.

Sub-MD staff "Health Coaches" and all that.

Which segues neatly back into

DOWN IN THE WEEDS: "COOKBOOK MEDICINE"


“Physicians are right to condemn forms of control that involve exclusion of information and power over decision making. But physicians are in denial about the extent to which they themselves impose these forms of control on patients. Physicians are right to reject impoverished, cookbook medicine, but they are in denial of how impoverished is their own know-how. So too are they in denial when they view themselves as “highly skillful,” because their levels of skill would be far greater within a disciplined system of care. Physicians are right that “one cannot separate the decision from its context,” and they are right to reject uninformed controls by ‘outsiders.’“ But they are in denial of how much they themselves are uninformed outsiders to patients’ lives, outsiders whose exercise of control inevitably separates medical decision making from its context. And they are in denial of the need to submit to different forms of control over their own inputs to care—both decision making inputs and execution inputs.

Execution inputs were the primary focus of the Institute of Medicine’s To Err is Human. That report highlighted the need to protect patient safety by exercising tight control over execution of medical procedures. When we turn from execution to decision making, it is best to think in terms of not controlling but defining inputs, that is, making explicit the inputs that form the basis for decisions.

The basic inputs to decision making are (1) medical knowledge, (2) patient data and (3) the processing of that information. All three of those inputs are undefined and uncontrolled when they originate from the unaided minds of physicians. No one can know exactly what information physicians take into account, nor can we know how they take it into account, nor can we reliably improve the cognitive processes involved. All we know for certain is that medical decisions are enormously variable. The outcome is that patients have no assurance of reliable decision making…

In contrast, a system of defined inputs means first that the knowledge and data taken into account, and the processing of that information, are explicitly defined. Second, it means exercising some degree of control over the manner in which the defined elements are combined. Defining inputs to decisions in this way does not dictate those decisions any more than defining the elements of writing (an alphabet and standards of spelling and grammar) dictates the content of writing.

The need for tight definition and control over inputs goes without saying when the inputs are drugs and medical devices. An elaborate regulatory scheme controls entry into the marketplace and ongoing manufacture of drugs and devices. Yet, nothing comparable exists for the most important medical devices of all—the minds and hands of physicians. Graduate medical education, state law credentialing and board certification purport to regulate the entry of new physicians into the marketplace, while various ad hoc interventions (such as malpractice litigation and licensure board disciplinary proceedings) purport to regulate ongoing performance. Yet, no one trusts these forms of control. Epidemics of medical error, unnecessary care and irrational spending confirm that trust is not warranted. The reason is that existing regulation fails to define and control inputs to care comprehensively.

This means continually optimizing care at every step of decision making and execution. Optimizing care means not only enforcing high standards of care but also continuously incorporating feedback and new scientific advances. This continuous and comprehensive improvement entails a constant assault upon the status quo—upon the habits and roles and economic claims that take root from established practices…” [“Medicine in Denial” pp 44-45]


Click the above Dr. Richard Gitomer quote for the link to the location from where I appropriated the last two graphics. Emory University, Woodruff Health Sciences, "Cookbook Medicine."

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APROPOS OF THE FOREGOING


Click the title above. This got cross-posted today on The Health Care Blog (wherein the always impolitic and sometimes reactively irascible BobbyG commented).
The good old days

In the good old days, I could pick up a chart from the rack outside the door, and in what seems life a few seconds, familiarize myself with with my patient’s history (because I kept a great paper chart if I do say so myself…) before opening the door to greet her. During the visit, I could sit with the chart in my lap, jotting down notes as we spoke, my focus on my patient and my thoughts rather than a user interface. Once the visit was over, a few brief jotted notes and some well-placed check marks on the encounter form summarized the visit, a few scribbles on a prescription pad or radiology order form clipped to the chart finished the orders (the rest taken verbally by my tech), a check off or two on the superbill and I was done.

Indeed. Well, I'm as romantic and nostalgic as anyone. When I was in grade school
(George Washington Elementary) in Morristown NJ in the 1950's, our family doc Dr. Renna, MD did Normal Rockwell-esqe house calls, replete with his iconic Little Black Bag.

I have no idea how he got paid or how good his charts were.

That was then, this is now.
___

BACK TO THE WEEDS'

This post is interesting (yet another cool blog).

...We need to affirm the necessity of having a transparent objective scientific standard for medicine. Otherwise, there is no standard of care. There would be no way of determining which treatments were legitimate and which were not. This question has many practical implications – which professions should be licensed, which treatments covered by insurance, which practices allowed under the scope of practice of each profession, what should be taught in medical, nursing, and other health-related curricula, and which practices constitute malpractice. Without a science-based standard, there are no answers to these questions...

...Further – we can’t have a double-standard. Within medicine there is a pretty clear consensus as to what the scientific standard is. It is slowly evolving, if anything becoming more stringent as we root out more and more subtle ways of subverting best scientific practice...
Indeed. But,
A core justification for the enormous time and expense of physician training, and for the legal monopoly and high compensation conferred on physicians, is their scientific training. Presumably that training enables physicians to apply medical science to patient needs with scientific rigor. Yet, one of the leading medical schools in the world here describes itself as failing to provide adequate experience in the elements of clinical medicine, failing to provide good learning conditions in either hospital and ambulatory settings, failing to provide uniformity of content, failing to enforce educational rigor, failing to reliably evaluate students’ core competency and failing to integrate basic science and clinical medicine. [Medicine in Denial, pg 199]

One gets the spins from all of this.
___

More shortly...

Sunday, January 8, 2012

Shovel Ready

Very funny.

So, this past week I got collared into writing a piece of our CMS "Innovations Challenge" proposal. Get out my rhetorical shovel and pile on the persuasive verbiage.


"The Health Care Innovation Challenge will award up $1 billion in grants to applicants who will implement the most compelling new ideas to deliver better health, improved care and lower costs to people enrolled in Medicare, Medicaid and CHIP, particularly those with the highest health care needs.
"


I have the "workforce" piece. Specifically to address these questions: -->
  • How will the model will address the need for a transformed workforce and demonstrate a plan to update skills of existing health professionals, identify and train new types of workers to enhance care delivery, and/or expand the use of team-based care?
  • How will the proposed workforce model support the three-part aim?
  • How will staff be recruited, hired, trained, and deployed as well as the specific skills for which additional training may be required?
  • Does the proposal address the initial education or training of health professionals?
  • What workforce-related metrics which will be used to assess the impact of the model on the health workforce and to evaluate the workforce needs associated with system delivery changes, including the ratio of staff to participants?
We propose to focus on three pressing clinical areas: Cardiometabolic Syndrome, Asthma, and COPD. Basically a PCMH approach (Patient-Centered Medical Home) using "patient coaches" comprised of an increased staff of RNs. I could not agree more in principle; to wit:
“A recent Medicare demonstration program, given substantial additional resources under the new health-care-reform law, offers medical institutions an extra monthly payment to finance the coordination of care for their most chronically expensive beneficiaries. If total costs fall more than five per cent compared with those of a matched set of control patients, the program allows institutions to keep part of the savings. If costs fail to decline, the institutions have to return the monthly payments.”
“Several hospitals took the deal when the program was offered, in 2006. One was the Massachusetts General Hospital, in Boston. It asked a general internist named Tim Ferris to design the effort. The hospital had twenty-six hundred chronically high-cost patients, who together accounted for sixty million dollars in annual Medicare spending. They were in nineteen primary-care practices, and Ferris and his team made sure that each had a nurse whose sole job was to improve the co√∂rdination of care for these patients. The doctors saw the patients as usual. In between, the nurses saw them for longer visits, made surveillance phone calls, and, in consultation with the doctors, tried to recognize and address problems before they resulted in a hospital visit. Three years later, hospital stays and trips to the emergency room have dropped more than fifteen per cent. The hospital hit its five-per-cent cost-reduction target. [Atul Gawande, MD “Hot Spotters,” The New Yorker, Jan 24th, 2011, pg 46]
__
“Non-physician practitioners may prove to be better candidates than physicians to function in a system designed for external information tools, informed decisions, reliable execution and genuine accountability…”
“…In health care, patients and very inexpensive paramedical people who are already a permanent part of a community must be taught to use the problem solving guidance in their own records and eventually in computers. After all, rescue squads with remarkable skill in heart and lung disease have been developed all over the country, and people with only a high school education or less have been taught to do sophisticated medical work. Surely we all can learn to deal with many of the less life-threatening disorders such as sore throats and body aches if we have our records and the right guidance tools. Expensively trained medical professionals should be reserved for specialized tasks that we cannot master and cannot do for ourselves. They also should be used to build the guidance in the tools and to monitor occasionally our records and behaviors to make sure that we are behaving in a disciplined and reliable manner.” [Lawrence L. Weed MD and Lincoln Weed, JD, “Medicine in Denial,” 2011, pp 212 and 262]
__
“Our work groups began meeting on a regular basis to identify activities being performed by physicians that could be performed by other members of the care team. We used evidenced based measures, developed clinical practice guidelines and physician approved order sets. We built quick electronic reference tools for support staff, established written workflow protocols, trained personnel and monitored their activities. This enabled non-licensed clinical staff to perform services without asking the physician every time, i.e. EKG, strep screens, pneumovax, etc.”
“We configured population management reports on our EHR, assigned responsibilities for running them on a regular basis, along with the task of calling patients and scheduling them for services based on clinical practice guidelines (I.e. calling diabetic patients to schedule an HgA1c.) We designed electronic chart alerts so that a secretary taking a telephone request from a patient with a URI calling for a same day appointment could be prompted to also schedule that patient for a mammogram or colonoscopy.” [Mike Cracovaner, CEO New Pueblo Medicine, “Building ‘Top of License’ Care into Your Medical Home” Medical Home News, November 2011, pg 3]
__
“The Institute of Medicine defines self-management support as ‘the systematic provision of education and supportive interventions to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems and problem-solving support.’ Similarly, the Chronic Care Model defines self-management support as assisting and encouraging patients to become informed and activated in the management of their own chronic conditions. It considers self-management support a fundamental task of the clinical practice team. [Tom Bodenheimer, MD, and Sharone Abramowitz, MD, “Helping Patients Help Themselves: How to Implement Self-Management Support,” California HealthCare Foundation (CHCF), December 2010, pg 2]
__
“Providers will need to be trained to work in interdisciplinary teams, and financing and delivery systems need to support this interdisciplinary approach. Care needs to be seamless across various care delivery sites, and all clinicians need to have access to patients’ health information, as well as population data, when needed. Health information technology, such as interoperable electronic health records and remote monitoring, needs to be used to support the health care workforce by improving communication among providers and their patients, building a record of population data, promoting interdisciplinary patient care and care coordination, facilitating patient transitions, and improving quality and safety overall. Giving providers immediate access to patient information, especially for patients who are cognitively impaired and unable to provide their own clinical history, may reduce the likelihood of errors, lower costs, and increase efficiency in care delivery.”
“Efficiency can be further improved by ensuring that health care personnel are used in a way that makes the most of their capabilities. Expanding the scope of practice or responsibility for providers has the potential to increase the overall productivity of the workforce and at the same time promote retention by providing greater opportunities for specialization (e.g., through career lattices) and professional advancement. Specifically, this would involve a cascading of responsibilities, giving additional duties to personnel with more limited training in order to increase the amount of time that more highly trained personnel have to carry out the work that they alone are able to perform. While the necessary regulatory changes would likely be controversial in some cases, the projected shortfall in workforce supply requires an urgent response. This response will most likely have to involve expansions in the scope of practice at all levels, while at the same time ensuring that these changes are consistent with high-quality care. The third principle is that older persons need to be active partners in their own care, except when they are too frail, mentally or physically, to do so. Such partnerships need to include the adoption of healthy lifestyles, self-management of chronic conditions, and increased participation by the patient in decision making. By becoming participants in their own care, patients can improve their health, reduce unnecessary treatments, and reduce the need for reliance on formal or informal caregivers.” [Retooling for an Aging America: Building the Health Care Workforce, Committee on the Future Health Care Workforce for Older Americans, Institute of Medicine, 2008, http://www.nap.edu/catalog/12089.html, pp 77-78]
Yeah, HHS is frantically shoveling yet another billion out the door. We are obligated to pursue our potential piece of such funding, risk of PPACA at SCOTUS this spring notwithstanding (CMMI, like the ACO thing, is part of "ObamaCare").

Whatever keeps the doors open.

CMS requires that innovation grant applicants adequately address its central "three part aim" -- improved patient health, improved population health, and reduced cost.

The CHCF report, however, contains some cautionary findings with respect to the 3rd aim:

To learn more about how self-management support is being implemented in primary care organizations, 42 early adopters of self-management support were identified and surveyed. Thirty-eight subsequently provided extensive information.

The survey revealed a number of broad findings, including the following: The most common conditions for which self-management support is being implemented are diabetes, hypertension, and obesity. The primary care team members most commonly offering self-management support are RNs, physicians, nutritionists, health educators, and nurse practitioners/physician assistants. In only eight of the organizations do MAs provide self-management support. Twelve organizations have at least one team member providing self-management support full-time; most dedicate considerably less staff time. For 28 of the organizations, self-management support is an expense and not a revenue source, and 24 organizations reported that self-management support is not financially sustainable [pg 5].
Well, OK.

More to come...
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ATTESTATION UPDATE, FROM HEALTHDATA.GOVNice Excel spreadsheet available for download and some data grinding. You're quite welcome to download and use my copy (.xlsx file, 2.8 mb).

Basically, 10 EHR vendors account for 2/3 of the EP attestations nationally through November. And, Epic lapped its second place competitor eClinicalWorks by better than a factor of three.

Drilling down into these data at our state levels (NV, UT) at the moment.

 

JAN 12TH UPDATE

Just saw a press release concerning a new Meaningful Use player.

www.CareCloud.com

Surf their site. Pretty interesting. The aesthetics certainly put me in a good early morning mood. I was particularly interested in their "Advanced Analytics" section. Far too many "certified" EHRs have reporting functionality that is simply primitive.

Gotta love all the Mac imagery, too, Mac snob that I am.

But, much more to learn about CareCloud's "usability" and their pricing model.
___

MORE UPDATES

This is interesting. Click the banner below.



Nurses know that healthcare is in a crisis with soaring costs and rising epidemics of preventable diseases. Many nurses are calling for change to mobilize nurses in a nationwide effort. They propose that leadership provided by a National Nurse for Public Health would strengthen efforts by nurses in every community to assist in initiating a nationwide shift to prevention to yield improved health outcomes.

I put this organization in my links on the right. All of the nurses I have known (and those I continue to work with) have been uniformly totally astute and dedicated. Linchpins of health care, they are.




Apropos if this, our CMMI Innovation Challenge proposal I'm now helping with calls for expanded employment of RN "patient coaches."

MORE ON PATIENT SELF-MANAGEMENT
AND "PATIENT COACHES"

Yet another "Medicine in Denial" cite:

The course of a chronic disease depends on numerous variables, none of which the practitioner personally experiences, most of which the practitioner does not control and some of which the practitioner is not aware. In diabetes, for example, blood glucose levels depend on not only insulin levels but also diet, exercise, emotion, medications, infections and co-existing medical problems, among other variables. The patient has more knowledge and control of some of these variables than the provider ever will. Managing chronic conditions demands keeping track of these variables over time and examining them for medically significant patterns and relationships…


…The patient feels the effects of the disease and its treatments, and quickly sees correlations between those subjective symptoms and detailed data on physiological parameters. Without any formal education, the patient is in the best position to observe these correlations. To that extent, information asymmetry exists in favor of the patient, not the expert provider. What the patient needs is not the broad, sophisticated scientific understanding of a physician but rather a basic understanding of principles and data that bear specifically on choosing among individually relevant options. And it is not unusual to see patients who develop more than this basic understanding. For example, diabetics of long-standing whose disease is well-controlled are frequently more knowledgeable about the disease and their personal version of it than their physicians. Most of all, the patient is the one who must summon the resolve to make the behavior changes that so often are involved in coping with chronic disease. If the patient does not feel responsible for deciding what has to be done and is not heavily involved in developing the informational basis of that decision, then very often the result is “noncompliance” with doctors’ decisions. Noncompliance may or may not be appropriate, depending on the situation. The point is that if patients are equipped to become decision makers, the problem of noncompliance with their doctors’ decisions is transformed into a problem of personal commitment to their own decisions. Patients will be more committed to their own, informed decisions than to decisions made for them by experts…[pp 224-225]
OK, in that context, consider the following (again, click the graphic below).


Providing a Bridge Between Patient Experience and Provider Expertise

Project HealthDesign is a groundbreaking national program of the Robert Wood Johnson Foundation, designed to spark innovation in personal health technology. The program advances a vision of personal health records (PHRs) as springboards for action and improved health decision-making.

Our first nine teams embarked on a user-centered design process to create health IT tools that ranged from a mobile medication management system that alerts children with cystic fibrosis when to take various medicines to a PDA that tracks patient-sourced pain and activity data. Our five current teams are examining how personal health applications and devices can integrate observations of daily living (ODLs) into personal health decision-making and clinical care.

Examining Observations of Daily Living (ODLs)

Because patient-sourced data about ODLs and symptoms provides clinicians a richer picture of an individual's health from day to day, technologies that enable individuals to track these types of data outside the clinical setting may be the most important feature of PHRs and mobile health technologies.

ODLs are sensations, feelings, thoughts, attitudes and behaviors that provide cues to a person about their health state. Our current teams are working with patients and clinicians to identify which ODLs patients value and how they can be tracked and interpreted by patients and clinicians to result in better care...
All very interesting and encouraging. Not to understate the myriad current and prospective barriers.
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FRIDAY JAN 13th NOTES

OK, this is cute. Courtesy of WBUR.org.


MIT economist Jonathan Gruber calls health care reform the “biggest social policy legislation since Medicare.” So what better way to explain such a serious, complex and far-reaching topic than through comics?
___

CODA

This is swell.

Dr. Mike Gorman, a family physician in Logandale, Nev., recently took out an SBA loan to keep his practice running and pay his five employees.

"It is embarrassing," he said. "Doctors don't want to talk about being in debt." But he's planning a new strategy to deal with his rising business expenses and falling reimbursements.

"I will see more patients, but I won't check all of their complaints at one time," he explained. "If I do, insurance will bundle my reimbursement into one payment." Patients will have to make repeat visits -- an arrangement that he acknowledges is "inconvenient."

"This system pits doctor against patient," he said. "But it's the only way to beat the system and get paid."
Dr. Gorman is one of my REC clients. Very nice man. He finally got his Amazing Charts v6 MU Certified upgrade at the end of July. We visited with him mid-August, and his dashboard numbers were already looking good. He did his 90-day without major incident and attested by December.

Which will all be rather pointless if his practice goes under.___

Sunday, January 1, 2012

2012: ruminating on the year ahead in HIT


It will be a busy and contentious year, no doubt. I have a ton to reflect upon and write about. Per my prior post, it looks like Boehner blinked on the tax relief / unemployment extension / Medicare SGR "Doc Fix" bill. For now, that is. We're now getting government in recursive partisan election year two-month brinksmanship dramas, and we're right on the cusp of the next irritating episode.
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MY HOLIDAY READING LIST

Cheryl and I went to her Mom's in northern Alabama on the family farm for the Christmas holiday.
Seems like all I did was eat, sleep, watch football, and read for nine days. I read and finished two books, and have three more well on the way to completion (click the images below for links).

ECONNED is depressingly astute and thorough. Perversely nice to know I got a lot of things right in my earlier policy blog posts on the topic, here, here and here.
Among my long treasured hardcopy books are the Kahneman / Tversky / Slovic works "Judgment under uncertainty: Heuristics and biases" and "Choices, Values, and Frames." "Thinking, Fast and Slow" comprises a wonderful, general-reader accessible recap of an esteemed career work to date. For a nice summary by noted writer Michael Lewis ("Moneyball" of late), see "The King of Human Error" in Vanity Fair (I have all of his books).

Apropos of the latest work by Dr. Kahneman is "Medicine in Denial," which I cited in an earlier REC blog post.

"Medicine in Denial" is a serious, serious throw-down to the profession (not that I buy it all uncritically; more on that as I go along). I am almost all the way through my gratis pre-pub copy. 267 pages of thoroughly, intelligently reasoned and exhaustively documented argument. My copy is now freighted with sticky notes, red pen margin notes, and yellow highlighter markups.


...We began by asserting the need for a secure foundation for care. With buildings, the value of a secure foundation is obvious, even though it gives no assurance that the rest of the building is well designed, constructed or maintained. That lack of assurance does not make the foundation any less important. On the contrary, if the foundation is not secure, then the rest of the building, no matter how well designed, constructed or maintained, is untrustworthy. And in medicine, the complex processes of patient care are untrustworthy if relevant, available information is not taken into account at the outset of care.

E. Objections to the combinatorial approach

Physicians naturally view the judgmental approach, and the elaborate training needed for the unaided mind to apply it, as inherent in scientifically advanced medical care. By comparison, a tool-driven, combinatorial approach seems to impose both crude standardization and excessive detail—”cookbook medicine” taken to a compulsive extreme...
Enter Dr. Kahneman:

...Not surprisingly, then, the idea that a mechanical combination of a few variables could outperform the subtle complexity of human judgment strikes experienced clinicians as obviously wrong. The debate about the virtues of clinical and statistical prediction has always had a moral dimension. The statistical method, Meehl wrote, was criticized by experienced clinicians as “mechanical, atomistic, additive, cut and dried, artificial, unreal, arbitrary, incomplete, dead, pedantic, fractionated, trivial, forced, static, superficial, rigid, sterile, academic, pseudoscientific and blind.” The clinical method, on the other hand, was lauded by its proponents as “dynamic, global, meaningful, holistic, subtle, sympathetic, configural, patterned, organized, rich, deep, genuine, sensitive, sophisticated, real, living, concrete, natural, true to life, and understanding...

This stuff is all fabulous. Bracing yet inspiring. I triangulate the foregoing with the observations found in Sperber and Mercier's "Why Do Humans Reason?" (PDF, another epistemological kick in the pants).

This quote from "Medicine in Denial" stings:
Policymakers recognize that transformation requires more than technology. Accordingly, certification and “meaningful use” of electronic health records (EHRs) are required to receive subsidies to purchase EHRs under the 2009 economic stimulus legislation. But the requirements for certification and meaningful use as currently conceived are primitive...

...Failures of quality in medical records, paper and electronic, are a root cause of the health care system’s failures of economy. The HITECH Act reforms effectively acknowledge this reality, but fail to remedy it...

...Health information technology has only recently become prominent in health care reform debates. The traditional focus of health care reform has instead been economic incentives. Yet, incentives are not the central problem. No arrangement of economic incentives is perfectly aligned with patient interests, especially within an out-of-control system [pp 37-38].
Hard to disagree with that, my current HIT evangelist job notwithstanding.

But wait! There's more!
Abstracting knowledge from the problem-solving activities to which it should relate has damaging effects at many levels. One effect is that formal education becomes focused unduly on personal intellect. Cultivating a narrow range of intellectual skills and temperaments that foster academic success, the culture of education takes interpersonal skills for granted, and devalues manual skills. And it fails to instill the intellectual behaviors and perspectives that foster effective problem-solving (see part V).

In particular, traditional schooling fails to instill high standards of achievement. In most schooling, time is the constant and achievement the variable—precisely the opposite of what true education demands. Students are allotted a fixed amount of time to learn and then permitted to pass exams and courses with a B or C or worse. Inevitably, given the widely varying abilities and inclinations of individual students, not many will have the experience of passing courses at a high level of achievement. This tolerance of lesser achievement is especially harmful when learning is cumulative, that is, when success at one level requires understanding of the material from an earlier level.

Failure to enforce high standards of quality arises from the premise that schooling should instill a fixed core of knowledge, as distinguished from a core of behavior. Teaching high standards of intellectual behavior and teaching a fixed core of knowledge are mutually exclusive when a fixed time is allotted to achieving these goals. One of the three variables (time spent, amount covered and degree of mastery) has to be held constant at a high level, and that constant should be the degree of mastery. Students would differ in the amount they master and the speed with which they do so, but not in the degree of mastery they attain.

Mastery of a core of knowledge should not be the goal of education — especially in an era when knowledge is constantly becoming obsolete and when information technology confers rapid access to more knowledge than anyone can learn and more processing power than anyone’s mind possesses. The goal should be mastering the behaviors involved in applying knowledge to solve problems effectively and efficiently.

Because these principles are ignored, many students pass through 12 or more years of schooling without ever experiencing mastery, while constantly undergoing invidious comparisons to the best students. This system is harmful even for those best students, for they may acquire elitist attitudes, superficial understanding and misplaced confidence that their academic proficiency will translate into effective problem solving. For less successful students, schooling is too often experienced as a caste system rather than a vehicle for personal development. Many students emerge from their schooling with their natural abilities undeveloped and their natural optimism defeated. To fight back, some adopt an attitude of disdain towards education and intellect. These reactions to formal education are like the reaction of dying canaries in a coal mine—highly sensitive indicators of toxic conditions. In varying degrees, many students are left without the capacities and confidence that only achievement can confer and without the expanded horizons that only education can provide. [pp 229-230]

Love it. Let's summarize, shall we? "
when information technology confers rapid access to more knowledge than anyone can learn and more processing power than anyone’s mind possesses. The goal should be mastering the behaviors involved in applying knowledge to solve problems effectively and efficiently."

Yes.
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Other works in progress at this writing:


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JAN 2nd UPDATES

Lots of cool new stuff over on The Health Care Blog this morning. Below, from the comments, a common refrain voiced by HIT skeptics.

"Widespread iatrogentic EHR diseases?" Really? Any data, sir? When I see phrases like "directly proportional," I reflexively react "data?"

Not that I disagree with the notion regarding continual evaluation and improvement of any medical technology.

Moreover, you have to give informed naysayers their due, e.g., "IT Malpractice? Yet Another "Glitch" Affecting Thousands of Patients. Of Course, As Always, Patient Care Was 'Not Compromised'."
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I commented in this post (below). Fits with what I'm working on at the moment.

The Crash of Air France 447: Lessons for Patient Safety
By BOB WACHTER, MD

BobbyG says:
January 2, 2012 at 11:34 am

”We need to ensure that our personnel have the skills to manage crises caused by the malfunction of technologies that they’ve come to rely on. We should continue to push crew resource management training and work on strategies to bolster situational awareness (I haven’t found anything better than the old House of God rule: “In a Code Blue, the first procedure is to take your own pulse.”) We need to redouble our efforts to promote realistic simulation training, and to build systems that allow us to learn from our mistakes and near misses so we don’t repeat them.”
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This is precisely a core takeaway point from Drs. Weed & Weeds’ excellent book “Medicine in Denial.” (now available on Amazon. They sent me a pre-pub proof, which is now loaded down with yellow marker, red pen margin notes and stickies; it’s excellent. Highly recommended)

to wit:

“The minds of physicians do not have command of all the medical knowledge involved. Nor do physicians have the time to carry out the intricate matching of hundreds of findings on the patient with all the medical knowledge relevant to interpreting those findings. External tools are thus essential. But the tools are trustworthy only when their design and use conform to rigorous standards of care for managing clinical information.

Without the necessary standards and tools, the matching process is fatally compromised. Physicians resort to a shortcut process of highly educated guesswork…

…We use the term “guesses” because these key initial judgments are made on the fly, during the patient encounter, based on whatever enters the physician’s mind at the time. That mind may be highly informed and intelligent, but inevitably its judgments reflect limited personal knowledge and experience, and limited time for thought. Euphemistically termed “clinical judgment,” physician thought processes cause a fatal voltage drop in transmitting complex knowledge and applying it to patient data. The outcome is that the entire health care enterprise lacks a secure foundation.

Equally insecure are the complex processes built on that foundation: decision making, execution, feedback and corrective action over time. Responsibility for all these processes falls on the mind of the physician. Here again the mind lacks external tools and accounting standards for managing clinical information.” [pp 2-3]
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I’m now triangulating all this stuff with Kahneman’s “Thinking, Fast and Slow,” Groopman’s “How Doctors Think,” Sperber & Mercier’s “Why Do Humans Reason?” etc. Fascinating.

I’ll be citing your article on my REC blog. Fits right in with my latest topics.

There's so much to learn. One more Weed & Weed money quote for now:
Unlike scientific practitioners, medical practitioners do not operate in an objective realm, where the contents of thought and knowledge exist independently of the individual mind, a realm where knowledge can be reliably transmitted and applied, where new knowledge can be rapidly translated into practice, where all knowledge can be tested against patient realities. Isolated from this objective realm, the mind becomes a negative force, a cause of confusion and disorder. Physicians are not equipped to fulfill their immense responsibility safely and effectively. Other practitioners are not equipped to share that responsibility with physicians. Patients are not equipped to work effectively with multiple practitioners, nor to assume the ultimate burden of decision making over their own bodies and minds. Third parties are not equipped to create order out of this chaos. Practitioners and patients are not accountable for their own behaviors, while third parties are left free to manipulate disorder for their own advantage.

In short, essential standards of care, information tools and feedback mechanisms are missing from the marketplace. These missing elements are in large part already developed (see parts IV and VI below). Yet, the underlying medical culture does not even recognize their absence. This does not prevent some practitioners from becoming virtuoso performers in narrow specialties or skills. But their virtuosity is personal, not systemic, and limited, not comprehensive. Missing is a total system for enforcing high quality care by all practitioners for all patients. [pg 3]

"
[I]nformation tools and feedback mechanisms are missing from the marketplace"? Well, "third parties are left free to manipulate disorder for their own advantage."

Medical economist J.D. Kleinke would find that totally unsurprising.

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ERRATUM: This is interesting.

Judge orders UPMC deposition in Presby death lawsuit

Monday, November 14, 2011
By Sean D. Hamill, Pittsburgh Post-Gazette


An Allegheny County judge today ordered UPMC to allow an official to be deposed in a medical malpractice case about whether he altered the electronic health record of a man who died while in UPMC Presbyterian Hospital.

UPMC's attorney, John Conti, had attempted to shield Richard Simmons, UPMC Presbyterian's head of quality assurance, from being deposed during a hearing before Judge Ronald W. Folino.

Mr. Conti argued that Dr. Simmons was performing "peer review" work -- which would protect him from being deposed -- when he entered the electronic health record of Samuel Sweet three days after the 62-year-old Cheswick man died at the hospital in 2009...

That certainly bears following.
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Ahhh... The state of health care politics...
Really? Well, you learn something every day.

Back to the real world.

Dr. Kahneman on "Defending the status quo"

Animals, including people, fight harder to prevent losses than to achieve gains. In the world of territorial animals, this principle explains the success of defenders. A biologist observed that “when a territory holder is challenged by a rival, the owner almost always wins the contest—usually within a matter of seconds.” In human affairs, the same simple rule explains much of what happens when institutions attempt to reform themselves, in “reorganizations” and “restructuring” of companies, and in efforts to rationalize a bureaucracy, simplify the tax code, or reduce medical costs. As initially conceived, plans for reform almost always produce many winners and some losers while achieving an overall improvement. If the affected parties have any political influence, however, potential losers will be more active and determined than potential winners; the outcome will be biased in their favor and inevitably more expensive and less effective than initially planned. Reforms commonly include grandfather clauses that protect current stake-holders—for example, when the existing workforce is reduced by attrition rather than by dismissals, or when cuts in salaries and benefits apply only to future workers. Loss aversion is a powerful conservative force that favors minimal changes from the status quo in the lives of both institutions and individuals. This conservatism helps keep us stable in our neighborhood, our marriage, and our job; it is the gravitational force that holds our life together near the reference point. [pg 305, Thinking, Fast and Slow]
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ON "PERSONALIZED MEDICINE"

I put up some linked excerpts and thoughts regarding "personalized medicine" in my November 16th post. So, I found this interesting today (click the graphic for the link).


As I contemplated what I’d like to write about for the first post of 2012, I happened to come across a post by former regular and now occasional SBM contributor Peter Lipson entitled Another crack at medical cranks. In it, Dr. Lipson discusses one characteristic that allows medical cranks and quacks to attract patients, namely the ability to make patients feel wanted, cared for, and, often, happy. As I (and several of us at SBM) have said before, it’s not necessary to invoke magic, quackery, or pseudoscience in order to show empathy to patients and provide them with the “human touch” that forges a strong therapeutic relationship between physician and patient and maximizes placebo effects without deception. In the old days, this used to be called “bedside manner,” but in these days of capitation and crappy third party payor reimbursement it’s very difficult for physicians to take the time necessary to listen to patients and thereby build the bonds of trust and mutual respect that can augment the treatments that are prescribed. Unfortunately, because of this the quacks have been all too eager to leap into the breach.

One aspect of this tendency of medical cranks is to claim that they somehow “individualize” their treatment to the patient, as Peter points out:

There are a number of so-called holistic doctors in town who claim to practice “individualized” medicine. What this really means isn’t clear. My colleagues and I certainly individualize the treatment plans for all of our patients, using data gleaned from decades of scientific studies of large groups of patients. What “individualized” care seems to mean in this other context is “stuff I made up to make that patient feel more unique and special.”
Yeah. Note doubt the hucksters will always be quick out of the chute to misappropriate scientific mantle keywords and phrases.

As usual, the comments are as good as the posts at SBM.


ConspicuousCarlon 02 Jan 2012 at 2:39 pm
...Except for insanely expensive tailoring, nobody measures a customer’s foot and then creates a custom shoe just for them. The seller measures the customer’s foot, and then gets one of only a handful of different sizes available. Far from being so personalized as to evade scientific study, each given shoe size is actually sold to millions of different people.

And what sort of scientific study might we want to do, if the concept of a shoe had just been invented? Well, we might want to do Phase I trials to find out if shoes are safe to wear, and how big of a shoe can be worn safely. Is the wearer going to experience discomfort or injury if the shoes are too big? How big can the shoe get before the wearer risks twisted ankles and tripping? Does the shoe remain on the foot all day without falling off?

Then we might want to do Phase II trials to find out how much benefit the wearer gains from wearing a shoe within the safe range of shoe size for their foot. If shoes in any size are harmless, but still beneficial, we can sell a nice big shoe which fits everyone. If having oversized shoes produces a risk which outweighs the benefit of going barefoot (and in fact, this is the case in real life), then we would have to sell shoes in multiple sizes so that a person can get a shoe within the safe size range for their foot, just as drugs with potential side effects and overdosing are available in different amounts. The foot’s tolerance for slightly imperfect shoe size will determine how many different shoe doses we have to manufacture for a Phase III trial and mass marketing.

And then we can argue about whether or not commercial shoe production has produced enough size variety for everyone, and weigh the ups and downs of possibly having the government mandate more varied shoe sizes.
LOL. On the other hand, I bet the folks at the "Personalized Medicine Coalition" would take exception to the conflation of alt.med stuff with
initiatives involving pharmacogenomics and epigenetics research, etc.
"My colleagues and I certainly individualize the treatment plans for all of our patients, using data gleaned from decades of scientific studies of large groups of patients."
Yeah, but I think Lawrence and Lincoln Weed would give you some pushback on that.
Medical knowledge is itself an element of the health care system. Like other elements, medical knowledge is distorted by failure to migrate from the realm of subjective, personal knowledge to the realm of objective knowledge, from knowledge as it exists in the mind to its independent existence in external information tools.209 The distortion occurs in the content of medical knowledge, in its organization, and in its capacity for growth.

First, the content of medical knowledge is oriented towards resemblances, not differences, among individuals. Yet, the differences must be taken into account for sound decision making, especially with chronic disease. Thus, individual heterogeneity and uniqueness, no less than patterns of resemblance across populations, must become the subject matter of medical knowledge.

Second, the health care system fails to organize medical knowledge for solving the problems of unique patients, just as the system fails to organize health care providers for delivering patient-centered care. Care is thus fragmented intellectually as well as institutionally. Rather than being oriented towards patient needs, knowledge is organized for comprehension by the unaided minds of physicians. Medical specialties, for example, are defined by body system. That narrow focus reduces the burden of comprehension, but it fails to cope with the reality that patient problems normally implicate multiple body systems. Similarly, the population-based content of medical knowledge is easier for the mind to comprehend than detailed data about individual variation.

Third, the health care system fails to enforce the scientific standards and tools essential to the growth of reliable medical knowledge. Existing “knowledge” is not just incomplete but in part is simply wrong. As with other areas of science, medical knowledge is only a provisional approximation of reality. Practitioners, patients and researchers must constantly test medical knowledge against reality. In caregiving, that testing process demands taking into account all potentially relevant knowledge and patient-specific data at the outset of care, and then carefully monitoring and adjusting whatever course of action is chosen. In clinical research, that testing process demands continuously harvesting feedback on knowledge by examining meticulous records of what happens when knowledge is applied. [Medicine in Denial, VII. The Gap Between Medical Knowledge and Individual Patients, pg 178]
All very interesting.
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CODA: A MASTER'S IN "LAW"?
I'm too old to now go to law school (I'll be 66 in five weeks). But, I recently clicked on Facebook ad (which I nearly never do). It was for the Champlain College (VT) MSL program. Interesting. Enticing.

We believe that in a world dependent on the rule of law, the law is too important to have only a few specialists understand it. As such, we've created our Master of Science in Law to help professionals who are not lawyers think and act confidently in the legal dimensions of their work, prevent needless litigation, and work productively with legal counsel when counsel is necessary.
Dunno. Would that get me any traction with our HIE Counsel who keep politely blowing me off with respect to our Privacy and Security stuff? (See my prior posts. I rather doubt it.) Beyond that short-term utilitarian concern, would there be substantive net academic value? I am always up for more learning, particularly with respect to law, but, what's the likely appreciable margin here?

So, I made contact, but came away from it with disconcerting wafts of a pro forma "admissions counselor" (read call center sales rep) persistently fishing for a credit card number. Among other considerations, I was a bit red-flagged by the relatively low admission requirements.

Dubious.

They have competition, too, so it emerges. Google "Master's in Legal Studies."

Notwithstanding that it remains intriguing, I will have to search a bit longer.
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More to come...