The HHS Regional Extension Center

Oops

2012-01-27T20:05:00.001-08:00

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

Down in the Weeds'

2012-01-16T20:02:00.000-08:00

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...

The Permanente Journal/ Summer 2009/ Volume 13 No. 3

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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.
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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.
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More shortly...

Shovel Ready

2012-01-08T20:18:00.000-08:00

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 coördination 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]
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“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]
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“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]
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“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]
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“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.GOV

Nice 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.

THIS JUST IN FROM CMS...

EHR Incentive Program Analysis

View another webinar from Brian Ahier

JAN 12TH UPDATE

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

Click the logo image above. 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.
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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?

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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.
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2012: ruminating on the year ahead in HIT

2012-01-01T12:08:00.000-08:00

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...

The twisty politics of HIT

2011-12-18T18:37:00.000-08:00

..."Shortly before the passage of the 2009 federal economic stimulus package, Gingrich criticized the legislation as a "big politician, big bureaucracy, pork-laden bill." However, at the same time, Gingrich praised a provision of the stimulus package that allocated $19 billion to promote the use of health IT. He said, "I am delighted that President Obama has picked this as a key part of the stimulus package."

Under the stimulus package, health care providers who demonstrate meaningful use of certified electronic health records can qualify for Medicaid and Medicare incentive payments...

"I am delighted that President Obama has picked this as a key part of the stimulus package."

Right, Mr. Gingrich. Insofar as it was then politically convenient, 'eh? (Click here or the image above for the link.)

Apropos of the forgoing. Monday morning news:

...Regulatory pressure is building on the industry to achieve the goals of Presidents George W. Bush and Barack Obama to provide most Americans with access to an electronic medical record by 2014. An early fissure as a result of that pressure comes as Dr. Farzad Mostashari, head of the Office of the National Coordinator for Health Information Technology, supports a federal advisory committee's recommendation in June that the CMS extend by one year the compliance deadline for Stage 2 meaningful use for some early adopters of health information technology...

Once we get the total head count and subsequent relative proportions of "early adopters" (those who attested in 2011), we'll have a better picture of how this all might shake out going forward. Pushing back Stage 2 was a good and necessary idea, IMO.

Also noteworthy in the Modern Healthcare article:

Breaches and privacy lapses make headlines again in 2011 as healthcare organizations suffer record data losses during the year. In September, in its report to Congress, the Office for Civil Rights at HHS says there have been more than 30,500 breaches, most with fewer than 500 records, since it began counting them in late 2009. By year's end, the office's public “wall of shame” lists 372 major breaches (involving 500 or more records each) totaling nearly 18 million records. Military healthcare payer Tricare Management Activity and its data backup services vendor, Science Application International Corp., tops the wall with the largest breach of the year at 4.9 million records.

I guess as the penetration of HIT increases, we should expect an increase in PHI breach incidents. Which brings to mind the following (click to enlarge):

HIPAA Security Rule Toolkit

The NIST HIPAA Security Toolkit Application is intended to help organizations better understand the requirements of the HIPAA Security Rule, implement those requirements, and assess those implementations in their operational environment. Target users include, but are not limited to, HIPAA covered entities, business associates, and other organizations such as those providing HIPAA Security Rule implementation, assessment, and compliance services. Target user organizations can range in size from large nationwide health plans with vast information technology (IT) resources to small health care providers with limited access to IT expertise...

I've installed it and have been kicking the tires. 492 questions (some of them conjunctive clause compound questions) spanning the gamut of 45 CFR 164.3. More on this shortly.
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DEC 19th P.M. UPDATE

The NIST HIPAA toolkit is a bear. Lots of compound questions, e.g., the first 13 questions:

164.308(a)(1)(i) Standard: Security management process. Implement policies and procedures to prevent, detect, contain, and correct security violations.
Has your organization developed, disseminated, reviewed/updated, and trained on your Risk Assessment policies and procedures?
Does your organization's risk assessment policy address: purpose, scope, roles and responsibilities management commitment, coordination among organizational entities, training and compliance?
Has your organization disseminated your Risk Assessment policies and procedures?
Has your organization disseminated its Risk Assessment procedures to the work staff/offices with the associated roles and responsibilities?
Has your organization defined the frequency of your Risk Assessment policy and procedures reviews and updates?
Has your organization reviewed and updated your Risk Assessment policy and procedures in accordance with your defined frequency?
Has your organization identified the types of information and uses of that information and the sensitivity of each type of information been evaluated (also link to FIPS 199 and SP 800-60 for more on categorization of sensitivity levels)?
Has your organization identified all information systems that house ePHI?
Does your organization inventory include all hardware and software that are used to collect, store, process, or transmit ePHI, including excel spreadsheets, word tables, and other like data storage?
Are all the hardware and software for which your organization is responsible periodically inventoried, including excel spreadsheets, word tables, and other like data storage?
Has your organization identified all hardware and software that maintains or transmits ePHI, including excel spreadsheets, word tables, and other similar data storage and included it in your inventory?
Does your organization's inventory include removable media, remote access devices, and mobile devices?
Is the current information system configuration documented, including connections to other systems, both inside and outside your firewall?

OK, and then the last section, first subsection:

164.316 POLICES AND PROCEDURES AND DOCUMENTATION REQUIREMENTS

164.316(a) Standard: Policies and procedures. Implement reasonable and appropriate policies and procedures to comply with the standards, implementation specifications, or other requirements of this subpart, taking into account those factors specified in subsection

164.306(b)(2)(i), (ii), (iii), and (iv). This standard is not to be construed to permit or excuse an action that violates any other standard, implementation specification, or other requirements of this subpart. A covered entity may change its policies and procedures at any time, provided that the changes are documented and are implemented in accordance with this subpart
Does your organization have policies and procedures for administrative safeguards, physical safeguards, and technical safeguards?
Does your organization have in place reasonable and appropriate policies and procedures that comply with the standards and implementation specifications of the HIPAA Security Rule?
Does your organizations security policies and procedures take into consideration: 1) your organization's size, complexity and the services you provide. 2) your organization's technical infrastructure, hardware and software capabilities, 3) the cost of your organization's security measures, 4) the potential risks to day-to-day operation including which functions, and tools are critical to operations?
Does your organization have procedures for periodic revaluation of your security policies and procedures, and update them when necessary?
Does your organization change security policies and procedures at any appropriate time, and document the changes and implementation?

My take on this is that it would take a provider/organization 2-5 days to get thoroughly and forthrightly through it. And, really, this is just about the ePHI "Security" piece. "Privacy" is a different -- and potentially much more difficult -- issue. I wrote about the Security stuff back in June, and I continue to work on the privacy issues more recently for our HIE.
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MEANINGFUL USE CORE 15:
WHAT ARE YOU PEOPLE THINKING?

So, my wife and I are devoted Mac snobs at home. Consequently, I was thrilled to recently see an iPad app get certified for meaningful use.

The product looks great, and I'll bet it's quite functional.

HOWEVER...

I was not happy to see this regarding the Meaningful Use Core 15 criterion ("Protect Electronic Health Information"):

We've taken care of this one for you!

All of the items below are done automatically through drchrono.com (web) drchrono EHR (iPad)

Access Control: Each user must have a unique identifier. Assign a unique name and/or number for identifying and tracking user identity and establish controls that permit only authorized users to access electronic health information. §170.302(o)

Emergency access: Plan for emergency access for authorized users. Emergency access. Permit authorized users (who are authorized for emergency situations) to access electronic health information during an emergency. §170.302(p)

Automatic log-off: Turn on session timeouts.

Automatic log-off: Terminate an electronic session after a pre-determined time of inactivity. §170.302(q)

Audit log: Maintain audit logs.
(1) Record actions. Record actions related to electronic health information in accordance with the standard specified in §170.210(b).
(2) Generate audit log. Enable a user to generate an audit log for a specific time period and to sort entries in the audit log according to any of the elements specified in the standard at 170.210(b).

Integrity - Provide integrity check for recipient of electronically transmitted information. §170.302(s)
(1) Create a message digest in accordance with the standard specified in 170.210(c).
(2) Verify in accordance with the standard specified in 170.210(c) upon receipt of electronically exchanged health information that such information has not been altered.
(3) Detection. Detect the alteration of audit logs.

Authentication - Verify user identities and access privileges. Verify that a person or entity seeking access to electronic health information is the one claimed and is authorized to access such information. §170.302(t)

Encryption - Use encryption where preferred. §170.302(u) General encryption. Encrypt and decrypt electronic health information in accordance with the standard specified in §170.210(a)(1), unless the Secretary determines that the use of such algorithm would pose a significant security risk for Certified EHR Technology. §170.302(v) Encryption when exchanging electronic health information. Encrypt and decrypt electronic health information when exchanged in accordance with the standard specified in §170.210(a)(2).

Accounting of disclosures - Record PHI disclosures. §170.302(v) Record disclosures made for treatment, payment, and health care operations in accordance with the standard specified in §170.210(e).

Conduct a security risk analysis and implement security updates.

Gotta love the last little orphan sentence. OK, everything associated with §170.nn has to do with the NIST EHR Certification specs, and nothing to do with complying with MU Core Measure 15:

Conduct or review a security risk analysis per 45 CFR 164.308(a)(1) of the certified EHR technology, and implement security updates and correct identified security deficiencies as part of its risk management process.

Beyond having a CHPL blessed system, it's the last item that counts for MU.

I emailed them regarding this and gave them more than a week. Silencio. Nada. Zip. Zilch.

This is not the first time I've encountered this precise misinformation from an EHR vendor.

So, what if you got audited? "Well, they told us we were automatically in compliance..."

"Conduct or review a security risk analysis per 45 CFR 164.308(a)(1) of the certified EHR technology, and implement security updates and correct identified security deficiencies."

So, who cares?

Digital Data on Patients Raises Risk of Breaches
By NICOLE PERLROTH
NY Times. Published: December 18, 2011

One afternoon last spring, Micky Tripathi received a panicked call from an employee. Someone had broken into his car and stolen his briefcase and company laptop along with it.

So began a nightmare that cost Mr. Tripathi’s small nonprofit health consultancy nearly $300,000 in legal, private investigation, credit monitoring and media consultancy fees. Not to mention 600 hours dealing with the fallout and the intangible cost of repairing the reputational damage that followed...

Shall we tally up an estimate of the entire cost of not having corrected "identified security deficiencies" per HIPAA 45.CFR.164.3 et seq?
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ERRATA: HEDIS 2011 THOUGHTS

I blogged a bit about the 2010 HEDIS measures last year. I've been reading the 2011 report lately. Notwithstanding the new stratification of HMOs vs PPOs (and vs Medicaid as well), I can't really see that a whole lot has changed with respect to the major chronic indices. e.g.,

Overall, we still see the aggregate nil Pearson-R "quality vs cost" proxies' scatter. And, even where there are enticing (wish-fulfillment?) wafts of quadrant differentials, the small composite "N's" ought give one pause.

Maybe we'll make tangible progress on these fronts in the next few years (we must if we are not to go BK as a society). IMO there are two concomitant (and intertwined) "fronts" -- care delivery process improvements (X-axis) and clinical outcomes improvement (Y-axis). The latter of which is to a significant extent moreso a moving target.

"Value," my friends: Outcomes Quality / Cost. Hope it doesn't become this decade's Powerpoint / Seminar / Consulting / Book Sales cliche. (But, then, They Had Me at Deming.)
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12/11 "PIONEER ACO" announcement

Interesting. Healthcare Partners of Nevada is one of the 32 announced today. We already work with them via our new HIE.

CMS MEANINGFUL USE PAYMENTS UPDATE

I played around a bit today with an app free trial that converts PDF tables to Excel files. CMS has updated its payments-to-date data (it says "November 2011" but it's not clear whether it's begin or end of month), so I downloaded the new PDF and converted it (click to enlarge).

I added the 4 "pct" columns on the right, and sorted the data down by aggregate payment rank. The top 12 states account for 2/3 of the money. Texas, with ~8% of U.S. population, is now at 16.4% of the cash -- and nearly 3/4 of theirs is Medicaid.

Be fun to also drop in the Census data to do comparative "per capita."

We'll see how all of the Medicaid Year One "A/I/U" free money crowd does in 2012 when they have to actually meet the MU criteria, for an entire calendar year attestation.

They have other tables that break things out by EPs vs Hospitals (Medicare, Medicaid, and aggregate), which would tell us where the bulk of the money is going vis a vis those strata (like we don't already know).

I may buy that utility -- if they have a Mac version.
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MORE TWISTY POLITICS:
THE LOOMING MEDICARE REIMBURSEMENT CUTS

27.4% reduction ensues on January first absent Congress passing the "Doc Fix" in the tax cut renewal bill. The health press is fairly abuzz.

Another quick little Excel screen-scrap cut & paste. The 2012 estimate is mine for these two CPT codes, btw. Just an estimate. The whole Medicare SGR formulation is inscrutably complex (and uniformly hated by primary care docs).

Who will blink first, Boehner or Obama?
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HOLIDAY CODA

I'm off 'til the 30th. To all of my awesome REC colleagues (both within our office walls and across the RECs), I wish you a joyful and safe Holiday season.

My dear friend, the breathtakingly talented Lenny Lopez on vocal.

Facts © ™ ®

2011-12-12T07:43:00.000-08:00

...So on the one hand, we have the push from the government and insurers to have electronic medical records and health outcomes research (HITECH Act), the Sentinel Initiative for postmarketing surveillance of electronic medical records for adverse events, and Medicare reimbursements linked to “meaningful use” (i.e., providing data) of the EMR. On the other hand, we have the specter of HIPAA and more draconian penalties for breaches of personal privacy...

- Judy Stone, MD, Molecules to Medicine: Pharma Trumps HIPAA?

Which "facts" about you can be "owned" by you or others (or no one at all)? i.e., what data/information can be legitimately considered "property," the "title" to and controlling use of which will be defended and enforced by the society at large?

According to traditional copyright principles, the only copyrightable elements of a factual work are the author’s presentation, selection, and arrangement of facts. The underlying facts themselves cannot be copyrighted. In the past, this approach was sufficient to protect factual works against the most opportunistic forms of copying by competitors. Because facts were usually displayed narratively or in tables, authors generally made enough decisions concerning presentation, selection, and arrangement to protect their factual works against wholesale appropriation.

But the rise of electronic and on-line databases has cast doubt upon the validity of the traditional approach. These databases collect and display facts in a pure form, allowing the user to extract them as she sees fit. By dispensing with conventional modes of presentation, selection, and arrangement, they can easily fail to satisfy traditional standards for copyrightability, leaving them with virtually no legal protection against copying. [Michael Steven Green, PhD, Copyrighting Facts (pdf), Indiana Law Journal Vol 78]

Well, more broadly, it goes to the "value" of the facts to various parties. I have blue eyes. Who cares? I am 5'10" and weigh 173 lbs. With those two metrics you can quickly calculate my BMI (Body Mass Index -- mine is 24.8), which is of some economic interest to health insurors and others. I am typing this post in my study located at geocoordinates N36º 2.4018' W115º 8.5265'. Who might want to know that?

What about my blood pressure, my lipids panel results, my PSA? My DNA?

Data ownership refers to both the possession of and responsibility for information. Ownership implies power as well as control. The control of information includes not just the ability to access, create, modify, package, derive benefit from, sell or remove data, but also the right to assign these access privileges to others (Loshin, 2002).

...Scofield (1998) suggest replacing the term ‘ownership’ with ‘stewardship’, “because it implies a broader responsibility where the user must consider the consequences of making changes over ‘his’ data”.

According to Garner (1999), individuals having intellectual property have rights to control intangible objects that are products of human intellect. The range of these products encompasses the fields of art, industry, and science. Research data is recognized as a form of intellectual property and subject to protection by U.S. law.

Importance of data ownership:

According to Loshin (2002), data has [sic] intrinsic value as well as having added value as a byproduct of information processing, “at the core, the degree of ownership (and by corollary, the degree of responsibility) is driven by the value that each interested party derives from the use of that information”...

Considerations/issues in data ownership

Researchers should have a full understanding of various issues related to data ownership to be able to make better decisions regarding data ownership. These issues include paradigm of ownership, data hoarding, data ownership policies, balance of obligations, and technology. Each of these issues gives rise to a number of considerations that impact decisions concerning data ownership

Paradigm of Ownership – Loshin (2002) alludes to the complexity of ownership issues by identifying the range of possible paradigms used to claim data ownership. These claims are based on the type and degree of contribution involved in the research endeavor. Loshin (2002) identifies a list of parties laying a potential claim to data:
Creator – The party that creates or generate data
Consumer – The party that uses the data owns the data
Compiler - This is the entity that selects and compiles information from different information sources
Enterprise - All data that enters the enterprise or is created within the enterprise is completely owned by the enterprise
Funder - the user that commissions the data creation claims ownership
Decoder - In environments where information is “locked” inside particular encoded formats, the party that can unlock the information becomes an owner of that information
Packager - the party that collects information for a particular use and adds value through formatting the information for a particular market or set of consumers
Reader as owner - the value of any data that can be read is subsumed by the reader and, therefore, the reader gains value through adding that information to an information repository
Subject as owner - the subject of the data claims ownership of that data, mostly in reaction to another party claiming ownership of the same data
Purchaser/Licenser as Owner – the individual or organization that buys or licenses data may stake a claim to ownership [Data Ownership, Responsible Conduct in Data Management]

It all gets rather complex rather quickly. And, nowhere as complex as with respect to personal health information.

Some recent thoughts on this:

...While banks tend to keep information internally, health care data is handled by many more organizations, said Tom Srail, Cleveland-based senior vp with Willis North America Inc. “The nature of the health care business requires the sharing of that same information,” he said.

Patrick Moylan, New York-based senior associate with Dubraski & Associates Insurance Services L.L.C., said health care institutions are increasing their Internet activity with partners that include physicians, health plans and pharmacies.

Having “more people in the line of that chain that have the potential to handle sensitive data simply increases the risk that data will be accessed by accident, or by a third party,” with the potential that it could be used fraudulently, he said.

The sheer breadth of personal information that health care institutions hold complicates the issue.

“More than any other industry, the health care industry really has all of a complete set of information security and privacy exposures to contend with,” said Mr. Economidis.

Mr. Srail said retailers may have credit card numbers and financial institutions may have Social Security numbers, but health care entities “have all that as well as protected health care information,” so “it really can be problematic for those organizations when that data is lost and troublesome to its customers.”

“There's so many ways that the information gets compromised” and “just when you think you've got it figured out, you've got a twist in it,” said Lynn Sessions, counsel at law firm Baker & Hostetler L.L.P. and a former risk manager at Texas Children's Hospital, both in Houston.

Robert Parisi, senior vp at Marsh Inc.'s FINPRO practice in New York, said, “hospitals tend to be less secure than banks, and you've got a situation that obviously can be fairly risky and financially troubling to any medical center.”

Meanwhile, a black market for stolen medical identities has developed among people who are underinsured or have no insurance, observers say.

By some estimates, medical information is twice as valuable as more traditional identity information, said Mr. Silvestri. “That becomes a motivation for the criminal element to actually target that so they can sell it to the black market,” he said...

"Twice as valuable"? I'd never thought of it that way. Makes sense upon reflection, though. No one can really profit from the fact that I have blue eyes. But, other information about me can indeed have commercial value to others (particularly if they are of the sort not directly observable but instead only explicable via intermediary measurement/assay -- ranging from the simple arithmetic of BMI to the complex methods of DNA analytics).

Continuing:

...Federal law pulls health care institutions in opposite directions, said Mr. Srail. On one hand, it “wants health care to be open and portable and interactive” and to facilitate the process so the patient has choices in his health care with accessible medical information. On the other hand, however, “everything has to be kept secret” with no privacy breaches.

In addition, state laws, while similar, also differ from each other and federal law. HIPAA, for example, requires notification of data breaches within 60 days, while several states have a 45-day notification period, said Ms. Sessions.

Another complication is that hospitals must abide by the laws of the jurisdiction where their patient is a resident, even if it is in another state. Because the patients' resident state is the determining factor, Texas Children's Hospital, for instance, which has patients from all 50 states and foreign countries, must comply with all these jurisdictions' statutes, said Ms. Sessions...

My Nevada HIE Privacy and Security Task Force attorneys are gonna love that last paragraph.

Yeah, they'll probably love this too. On Dec 7th 2011 the California Office of Health Information Integrity (CalOHII) issued a patient consent/privacy report entitled "Research and Background For Patient Consent Policy Recommendation White Paper," (large PDF) wherein across pp 154-157 is a table of various states' PHI/HIE privacy policies to date. On page 156 is the reference to Nevada:

Click to enlarge. In the "Education" cell on the right is a link to my July 12th, 2011 blog post, in which I voiced concerns regarding some of our facile assumptions made regarding Nevada HIE privacy policy.

Interesting. Nice to know that someone is reading my stuff.
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Dec 15th O/T UPDATE

Yet another interesting blog to read.

Dear friends and colleagues,

This is a watershed moment for the U.S. healthcare system. Costs continue to climb, tens of millions of Americans lack insurance, and there is unacceptable variation in quality. Politicians from across the ideological spectrum are proposing potentially far reaching policy changes. Some of the proposals are promising; too many others seem fraught with danger. After 25 years as a researcher, teacher, and policy analyst, I continue to be disappointed by the lack of basic understanding of health economics among those who are most vocal about effecting change. No one has done more to shape my thinking about the links between economics and policy than my friend and colleague, William White, who is the director of the Sloan Program in Health Administration at Cornell University’s School of Human Ecology. Over the past two decades, we have had long conversations about virtually every aspect of our healthcare system, from the rise of HMOs in the 1980s to current trends in consumer driven healthcare.

Will and I have decided to put our conversations into a blog and share them with our friends at Kellogg and Human Ecology. We have even asked some of the nation’s top economists to take a look. We will respond to the best of your comments as time allows. We promise not to grade them!

There is a lot at stake in the upcoming years. We hope that this free exchange of ideas can help bring about positive change in our healthcare system.

Sincerely,

David Dranove
Walter McNerney Distinguished Professor of Health Industry Management
Kellogg School of Management

I've read Dr. Dranove's stuff for a while now (mostly at The Health Care Blog), but had never seen this blog. Lots of great new material to read, I would guess.
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More to come...

Meaningful Use Reimbursements Update

2011-12-04T11:07:00.001-08:00

CMS just released the most recent data (PDF) on Meaningful Use reimbursements to date (actually to Nov 7th).

Notice the dark green Lone Star splotch. Texas EPs and hospitals have thus far gotten 20% of the $1.24 billion thus far paid out nationally ($247.5 million in TX). Of that, 83% went to the Medicaid side ($205.6 million).

Texas comprises ~8% of U.S. population.

On the Medicaid side all you have to do for Year One Stage One is attest to “A/I/U” — Adopt / Implement / or Upgrade to a CHPL Certified system. You don’t have to report on any MU measures, which is why vendors such as Practice Fusion are touting the “free money” aspect of it.

Maddeningly to me, CMS has yet to report on the relative proportions of EHR vendors whose clients have attested to date. We ran that all the way up the internal ONC/CMS flagpole and got blown off — they’ll release those tabulations in “Q2 or Q3 or 2012.”

No HHS-vendor opacity politics there, ‘eh? I'd like to see relative percentages of successful attestations to date by vendor, broken out by Medicare vs Medicaid (and further stratified by MU "registrations" to date).

Just sayin'.

DEC 15th UPDATE

CMS is now happily touting that they are going to exceed $2 billion in MU incentive payments in 2011. As reported by GovernmentHealthIT.com

Almost 30 percent of eligible providers and 60 percent of hospitals have now registered for the incentive programs.
Total incentive payouts under Medicare and Medicaid are now over $900 million each through November,
Thus, total payouts for 2011 will easily exceed $2 billion – of which close to a third of total incentive payouts for 2011 occurred in November alone.

This was to be expected. After all, a huge year-end bubble of 2011 MU attestors will complete their 90-day attestation period by 12/31 and file for the year one money.

(More broadly, I'm hearing that HHS is frantically shoveling money out the door for a breadth of initiatives, probably to get funding "obligated" to help immunize the money from looming deficit-hawk budget cuts.)

The article continues:

Still there are cautionary signs.

As we noted earlier, year 1 requirements under Medicare and under Medicaid are substantially less burdensome than subsequent years. While eligible providers have registered for one or other of the programs, only 4 percent have actually qualified for incentives. Also, interoperability-related criteria were among the least popular menu objectives. In addition, 2012, not 2011, is likely to be the pivotal year.

The pace must pick-up and be sustained if meaningful use is to reach its full potential, particularly for interoperability to coordinate care among providers. We expect the proposed rules for Meaningful Use Stage 2 by the end of January, if not sooner. Now that HHS has announced that providers will not have to meet Stage 2 criteria until January 2014, providers have an extra year under Stage 1 criteria without new interoperability requirements.

One observation for now. Pushing back stage 2 means that early adopters (2011 MU attestors) will spend 3 years in stage 1, during which they will have collected the bulk of the reimbursement money (~86% for Medicare EPs -- e.g., $18k, $12k, and $8k respectively, or $38k of the total $44k five year potential).

Draw your own conclusions as to the risk this might pose to the program's subsequent stages.

PROVIDER CONCERNS: "WILL THEY CUT OFF THE MONEY IN 2012?"

Some of our staff have fielded this question. My $0.02 response to the REC team:

Chief amid the most plausible speculation is the Obama veto hole card should some HIT incentives clawback legislation even get through the Senate (doubtful, IMO). Moreover, given that the funding was written into HITECH as not contingent on annual appropriations bills going forward, that would seem to insulate the money even further. Given all the acrimonious front-burner stuff facing the Hill at the moment for 2012, I am guardedly optimistic that MU money will still flow in 2012.

I think it’s safe to say there will not be any mounting of a 2/3 veto override vote regarding any emergent clawback legislation (very low probability in any event, given Senate rules) – the most overt of which has been H.R. 408, which has gone nowhere in a year (the salient recission clauses of which are SEC 301, 302 – btw, which are identical in its equivalent Senate Bill 178).

The Senate is key. The House is principally “all sound and fury, signifying nothing.” Now, in that regard, Senator Coburn – an MD, no less -- is on record favoring killing MU money (and, he has an actual vote, unlike all these Beltway HIT pundits). Nonetheless, I’m not seeing any traction on his proposal thus far.

Deven McGraw is a good cite as well, I would think, given her various insider perches.

One caveat, though: keep tabs on the accruing Poison Pill amendments to otherwise unrelated “must-pass-by-12/31” bills.

Long view big picture: the ROI case is there in any event. So, go after the MU $$$ while they are there; after all, they’re front-loaded to favor those who get in ASAP. Moreover, adroit HIT/HIE will be vital to health care organizational success irrespective of this or that federal initiative (IMO).

I could be wrong, though.

Here's what Senator Tom Coburn -- an MD, no less -- wrote in July:

“Back in Black” pp 215 – 216 Senator Tom Coburn July 2011

“End Federal Subsidies for Health Information Technology

A provision of the 2009 failed Stimulus law (American Recovery and Reinvestment Act) massively expanded the federal government’s role in health information technology. The aims many attribute to the Health Information Technology for Economic and Clinical Health (HITECH) Act sound good: using a variety of policy levers to promote the widespread adoption of health information technology and support digital sharing of clinical data among hospitals, physicians, and other health care stakeholders. However, a closer look at the data shows [sic] that Congressional action was the wrong mechanism to accomplish these goals.

Lawmakers in Congress may have been well-intended when they supported the HITECH Act, but the massive federal intrusion into health information technology is wasteful and duplicative of current business practices. According to the nonpartisan Congressional Budget Office, the use of health information technology was already projected to be widespread by the end of the decade – even without the adoption of the HITECH Act. CBO projected that, without the HITECH Act, two-thirds of physicians, approximately half of hospitals, and at least one in five critical access hospitals would still be robustly using health IT by the end of the decade. Some reports have suggested private sector health information technology in a multi-year period is far more than the federal government is projected to spend on health IT over the next decade. In fact, in a recent survey, more than half of respondents replied they have a fully operational electronic health record in at least one facility in their organization, and only 1 in 50 respondents had not yet begun to plan for the use of an EHR. The facts make it pretty clear that massive federal handouts and mandates are unnecessary to subsidize a behavior that is already being adopted on a widespread basis in the marketplace.

Additionally, the private sector has already developed compelling models for utilizing health information technology. Major health systems like the Mayo Clinic and the Cleveland Clinic all have adopted state-of-the-art health IT systems—without federal involvement. Private enterprises are leading the way in developing completely innovative approaches to health IT. Some are even exploring the development of open software for innovators to write electronic health record applications. Such an “open source” model of current business practices. According to the nonpartisan Congressional Budget Office, the use of health information technology was already projected to be widespread by the end of the decade – even without the adoption of the HITECH Act. CBO projected that, without the HITECH Act, two-thirds of physicians, approximately half of hospitals, and at least one in five critical access hospitals would still be robustly using health IT by the end of the decade. Some reports have suggested private sector health information technology in a multi-year period is far more than the federal government is projected to spend on health IT over the next decade. In fact, in a recent survey, more than half of respondents replied they have a fully operational electronic health record in at least one facility in their organization, and only 1 in 50 respondents had not yet begun to plan for the use of an EHR. The facts make it pretty clear that massive federal handouts and mandates are unnecessary to subsidize a behavior that is already being adopted on a widespread basis in the marketplace. [ did Jonathan Bush ghostwrite this part? – BG ]

Additionally, the private sector has already developed compelling models for utilizing health information technology. Major health systems like the Mayo Clinic and the Cleveland Clinic all have adopted state-of-the-art health IT systems—without federal involvement. Private enterprises are leading the way in developing completely innovative approaches to health IT. Some are even exploring the development of open software for innovators to write electronic health record applications. Such an “open source” model could help increase competition, flexibility and lower costs – all without federal action."

One way or another, we'll know before too much longer.

So many topics and issues, so little time

2011-11-16T19:33:00.000-08:00

Trying to get caught up after my Mom died. Coming this week...

The authors gave me a final pre-publication copy for review and commentary. I love it thus far.

Overview

Essential to health care reform are two elements: standards of care for managing clinical information (analogous to accounting standards for managing financial information), and electronic tools designed to implement those standards. Both elements are external to the physician’s mind. Although in large part already developed, these elements are virtually absent from health care. Without these elements, the physician continues to be relied upon as a repository of knowledge and a vehicle for information processing. The resulting disorder blocks health information technology from realizing its enormous potential, and deprives health care reform of an essential foundation...

...First, from the outset of care, relevant patient data must be chosen, and its implications determined, based on the best available medical knowledge, independent of the limited personal knowledge of the practitioners involved. Patient data must be systematically linked to medical knowledge in a combinatorial manner, before the exercise of clinical judgment, using information tools to elicit all possibilities relevant to the problem situation, while defining and documenting the information taken into account. Practitioners’ clinical judgments may add to, but must not subtract from, high standards of accuracy, completeness and objectivity for that information.

Second, in complex cases, particularly in cases of chronic disease, the organization of data in medical records must be optimized for managing multiple problems over time. This means that each medical record must begin with a complete list of carefully defined patient problems, and that other clinical information in the record must be linked to the problem or problems to which it relates.

I. Introduction: Building a new system

A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs— is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information...

...Contrary to what the public is asked to believe, physicians are not educated to connect patient data with medical knowledge safely and effectively. Rather than building that secure foundation for decisions, physicians are educated to do the opposite—to rely on personal knowledge and judgment—in denial of the need for external standards and tools. Medical decision making thus lacks the order, transparency and power that enforcing external standards and tools would bring about...

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

...Medical practice is thus trapped in a subjective realm. 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 be- comes 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...

...Missing is a total system for enforcing high quality care by all practitioners for all patients.

...At first glance, this subject matter may seem like just a varia- tion on current policy concerns with using “health information technology” to bring “evidence-based medicine” to “patient-centered” care. Yet, current policy fails to comprehend the needed discipline in medical practice and thus fails to define precisely what is needed from health information technology. A dangerous paradox thus exists: the power of technology to access information without limits magnifies the very problem of information overload that the technology is expected to solve. Solving that problem demands a meticulous, highly organized, explicit process of initial information processing, followed by careful problem definition, planning, execution, feedback, and corrective action over time, all documented under strict medical accounting standards. When this rigor is enforced, a promising paradox occurs: clarity emerges from complexity.

...[W]ere we to close the gap between medical practice and patient needs, society then could find enormous opportunities to harvest resources now going to waste. These wasted resources include not only vast sums spent on low-value care but also a vast body of medical knowledge that all patients and practitioners could use more effectively, simple tests and observations that in combination could uncover solutions to patient problems, patients who could become better equipped and motivated to improve their own health behaviors, routine patient care that could become a fertile source of new medical knowledge, and the firsthand insights of practitioners and patients who could participate in harvesting that new knowledge for their own benefit.

Closing the gap between medical practice and patient needs would transform how medicine is personally experienced by practitioners and patients alike. Practitioners could find their work to be less exhausting and more rewarding, emotionally and intellectually, than what they now undergo. The physician’s role could disaggregate into multiple roles, all freed from the impossible burdens of performance that physicians are now expected to bear. The expertise of nurses and other non-physician practitioners could deepen, and their roles could be elevated. All practitioners could follow time-honored standards of care that in the past have been honored more in the breach than the observance. All practitioners and patients could jointly use electronic information tools for matching data with medical knowledge, radically expanding their capacity to cope with complexity. All could use structured medical records, whose structure would itself bring order and transparency to the complex processes of care. Inputs by practitioners could thus be defined and subjected to constant feedback and improvement. A truly evidence-based medicine could develop, where evidence would be used to individualize care rather than standardize it. And a system of checks and balances could develop, where patients and practitioners would act on incentives for quality and economy far more effectively than before...

Buy the book (I'm not shilling it; I don't know them and I don't get anything from it). Extremely thought-provoking.

___

Below, I have a complete copy of this IOM Report as well.

SUMMARY

The Institute of Medicine (IOM) report To Err Is Human estimated that 44,000-98,000 lives are lost every year due to medical errors in hospitals and led to the widespread recognition that health care is not safe enough, catalyzing a revolution to improve the quality of care.

Despite considerable effort, patient safety has not yet improved to the degree hoped for in the IOM report Crossing the Quality Chasm. One strategy the nation has turned to for safer, more effective care is the widespread use of health information technologies (health IT). The U.S. government is investing billions of dollars toward meaningful use of effective health IT so all Americans can benefit from the use of electronic health records (EHRs) by 2014. Health IT is playing an ever-larger role in the care of patients, and some components of health IT have significantly improved the quality of health care and reduced medical errors. Continuing to use paper records can place patients at unnecessary risk for harm and substantially constrain the country’s ability to reform health care. However, concerns about harm from the use of health IT have emerged.

To protect America’s health, health IT must be designed and used in ways that maximize patient safety while minimizing harm. Information technology can better help patients if it becomes more usable, more interoperable, and easier to implement and maintain. This report explains the potential benefits and risks of health IT and asks for greater transparency, accountability, and reporting. In this report, health IT includes a broad range of products, including EHRs,3 patient engagement tools (e.g., personal health records [PHRs] and secure patient portals), and health information exchanges; excluded is software for medical devices.

Clinicians expect health IT to support delivery of high-quality care in several ways, including storing comprehensive health data, providing clinical decision support, facilitating communication, and reducing medical errors. Health IT is not a single product; it encompasses a technical system of computers and soft- ware that operates in the context of a larger sociotechnical system—a collection of hardware and software working in concert within an organization that includes people, processes, and technology.

It is widely believed that health IT, when designed, implemented, and used appropriately, can be a positive enabler to transform the way care is delivered. Designed and applied inappropriately, health IT can add an additional layer of complexity to the already complex delivery of health care, which can lead to unintended adverse consequences, for example dosing errors, failing to detect fatal illnesses, and delaying treatment due to poor human–computer interactions or loss of data. In recognition of the rapid adoption of health IT, the Office of the National Coordinator for Health Information Technology (ONC) asked the IOM to establish a committee to explore how private and public actors can maximize the safety of health IT–assisted care. The committee interpreted its charge as making health IT–assisted care safer so the nation is in a better position to realize the potential benefits of health IT.

OK. Another good read. Moving along...

High on the list of breakthroughs expected to transform medicine is personalized medicine – the use of new methods of molecular analysis to better manage a patient’s disease or predisposition to disease. Personalized medicine is likely to change the way drugs are developed and medicine is prescribed.

Yet the regulatory and financial systems that will support personalized medicine are not yet in place. The mission of the PMC is to build the foundation that underpins the advancement of personalized medicine as a viable solution to the challenges of efficacy, safety and cost.

The Personalized Medicine Coalition (PMC), was launched in 2004 to educate the public and policymakers, and to promote new ways of thinking about health care. Today, PMC represents a broad spectrum of more than 200 academic, industry, patient, provider and payer communities, as we seek to advance the understanding and adoption of personalized medicine concepts and products for the benefit of patients.

What is Personalized Medicine?
As defined by the President’s Council on Advisors on Science and Technology, “Personalized Medicine” refers to the tailoring of medical treatment to the individual characteristics of each patient…to classify individuals into subpopulations that differ in their susceptibility to a particular disease or their response to a specific treatment. Preventative or therapeutic interventions can then be concentrated on those who will benefit, sparing expense and side effects for those who will not.

What they're mostly advocating here is genetic molecular biochemistry and its place in HIT for Comparative Effectiveness Research. to wit, consider this paper I got from their site:

With federal officials pursuing the goal of a personal human genome map under $1,000 in five years (White House, 2010), it is possible to envision a future where treatments are tailored to individuals’ genetic structures, prescriptions are analyzed in advance for likely effectiveness, and researchers study clinical data in real-time to learn what works. Implementation of these regimens creates a situation where treatments are better targeted, health systems save money by identifying therapies not likely to be effective for particular people, and researchers have a better understanding of comparative effectiveness (President’s Council of Advisors on Science and Technology, 2010).

Yet despite these benefits, consumer and system-wide gains remain limited by an outmoded policy regime. Federal regulations were developed years before recent advances in gene sequencing, electronic health records, and information technology. With scientific innovation running far ahead of public policy, physicians, researchers, and patients are not receiving the full advantage of latest developments. Current policies should leverage new advances in genomics and personalized medicine in order to individualize diagnosis and treatment. Similarly, policies creating incentives for the adoption of health information technology should ensure that the invested infrastructure is one that supports new-care paradigms as opposed to automating yesterday’s health care practices...

...This paper outlines the challenges of enabling personalized medicine, as well as the policy and operational changes that would facilitate connectivity, integration, reimbursement reform, and analysis of information. Our health system requires a seamless and rapid flow of digital information, including genomic, clinical outcome, and claims data. Research derived from clinical care must feed back into assessment in order to advance care quality for consumers. There currently are discrete data on diagnosis, treatment, medical claims, and health outcomes that exist in parts of the system, but it is hard to determine what works and how treatments differ across subgroups. Changes in reimbursement practices would better align incentives with effective health care practices.

Furthermore, we need privacy rules that strike the right balance between privacy and innovation. These rules should distinguish health research from clinical practice, and create mechanisms to connect data from multiple sources into databases for secondary research usage and population cohort analysis. More balanced rules would improve innovation. It is nearly impossible to evaluate treatment effectiveness without being able to aggregate data and compare results. Faster knowledge management would enable “rapid learning” models and evidence-based decision-making on the part of physicians and public health officials...

Click the title image above for the full pdf. See also

and (pdf)

I find triangulating all of this so very interesting. Much more to come on the health care QI implications of all of the foregoing.

EPIGENETICS

(Nov 19th) I was chatting with my VP for Medical Affairs Dr. Jerry Reeves tonight at a social event about my interest in and intense study now regarding the pharmacogenetic stuff. He brought up the topic of "epigenetics," which I'd read about but had not reviewed lately. Another tie-in. Just what I needed, more to read and think about.

What is Epigenetics?

Conrad Waddington (1905-1975) is often credited with coining the term epigenetics in 1942 as “the branch of biology which studies the causal interactions between genes and their products, which bring the phenotype into being”. Epigenetics appears in the literature as far back as the mid 19th century, although the conceptual origins date back to Aristotle (384-322 BC). He believed in epigenesis: the development of individual organic form from the unformed. This controversial view was the main argument against our having developed from miniscule fully-formed bodies. Even today the extent to which we are preprogrammed versus environmentally shaped awaits universal consensus. The field of epigenetics has emerged to bridge the gap between nature and nurture. In the 21st century you will most commonly find epigenetics defined as ‘the study of heritable changes in genome function that occur without a change in DNA sequence‘...

Add it to my pile.

ALSO, ADD IN "HIA" TO THE MIX

Health Impact Assessment

Health impact assessment (HIA) is commonly defined as “a combination of procedures, methods, and tools by which a policy, program, or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population”...

The major steps in conducting an HIA include
Screening (identify projects or policies for which an HIA would be useful),
Scoping (identify which health effects to consider),
Assessing risks and benefits (identify which people may be affected and how they may be affected),
Developing recommendations (suggest changes to proposals to promote positive or mitigate adverse health effects),
Reporting (present the results to decision-makers), and
Evaluating (determine the effect of the HIA on the decision).
HIA is similar in some ways to environmental impact assessment (EIA). The National Environmental Policy Act (NEPA) requires federal agencies to consider the environmental impact of their proposed actions on social, cultural, economic, and natural resources prior to implementation. Proposed actions may include projects, programs, policies, or plans. HIA, unlike EIA can be a voluntary or a regulatory process that focuses on health outcomes such as obesity, physical inactivity, asthma, injuries, and social equity. HIA has been used within EIA processes to assess potential impacts to the human environment.

See also the World Health Organization site on HIA.

Then there's this:

Section 6301 of the PPACA (pdf), a.k.a. "ObamaCare," established the "Patient Centered Outcomes Research Institute."

"The Patient-Centered Outcomes Research Institute (PCORI) is an independent organization created to help people make informed health care decisions and improve health care delivery. PCORI will commission research that is guided by patients, caregivers and the broader health care community and will produce high integrity, evidence-based information.

PCORI is committed to transparency and a rigorous stakeholder-driven process that emphasizes patient engagement. PCORI will use a variety of forums and public comment periods to obtain public input throughout its work."

As with the case of the ACOs (Accountable Care Organizations; Section 3022 of the PPACA), I can't help but wonder about the fate of PCORI should SCOTUS strike down the Affordable Care Act in toto.

Beyond that, it will be interesting to see what extent of "transparency and a rigorous stakeholder process" ensues between all of the entities that will need to pull together. Notwithstanding that "transparency" is the feel-good term of the decade, opacity in service of turf protection (economic or otherwise institutional) will remain a risk.

e.g., let me return yet again to one of my favorites, the esteemed medical economist J.D. Kleinke:

Health Care’s ‘Prisoners’ Dilemma’
Joe Wilson’s health insurer back in Pittsburgh might have a clear financial interest in a system that would allow it to feed various streams of Joe’s clinical information to the Las Vegas hospital, to improve the quality and reduce the cost of his medical care. But doing so would be massively expensive for the insurer, not just in direct and indirect costs, but in incalculable strategic costs. If the company invested millions to create the open infrastructure required to connect its hospital, physician, pharmacy, and lab claims information systems to every hospital in Pittsburgh—let alone to every hospital in the United States—all of the other health insurers in Pittsburgh could connect to the same network for a fraction of the cost. While Joe’s insurer did the heavy lifting, its competitors would bear none of the massive up-front costs and could price their health plans well below the cost of Joe’s, for all of the years that his insurer was investing in that system.

If health care’s IT problems are a reflection of its broader economic problems, then the strategic conflicts within the health insurance and hospital industries themselves—the two most obvious beachheads for HIT development—are sufficient explanation for why we have no interoperable health care infrastructure. Notwithstanding the happy talk of their advertising, health insurers aim to attract and lock in healthy people and drive away sick ones. The less masqueraded goal of the hospital is to attract and lock in sick people and market to those who are not sick yet. Having an interoperable HIT system that allows patients to shop around, with their fully portable EMRs, for a higher-quality or lower-cost health insurer or hospital works directly against these goals.

For insurers in particular, this strategic conundrum over HIT is a redux of the broader managed care conundrum about prevention, which is essentially the prisoners’ dilemma at the heart of game theory. The prisoners’ dilemma always results in an unfortunate ending: All actors in the game would be rewarded if they cooperated and did the right thing by each other. But none will do the right thing without assurance that the other players will all follow, and so they each do exactly the wrong thing, limiting their own downside and thus creating a suboptimal outcome for all. The best way for a health insurer to use HIT to cope with the prisoners’ dilemma is to design a proprietary system that makes it easy for healthy members to sign up; difficult for sick members who need good information to find it and thus remain satisfied with their plan; and even more difficult for everyone outside the insurer’s own organization (that is, everyone looking to get paid) to navigate it. The worst way to cope with the prisoners’ dilemma is to provide an open, interoperable system that works equally well for all members and can exchange data with all other health insurers.

Yeah. More specifically, I would pose this troubling question regarding "personalized medicine." A health dx/px/rx care solution targeted specifically to me has a market potential of precisely one. That's not how Big Medicine/Big Pharma/Big Payors make their money. Now, were I Warren Buffet or Bill Gates or (the late) Steve Jobs or Paul Ryan, maybe I wouldn't care -- 'I'll have the lobster and filet mignon at market price.'

Beyond that, how indeed shall we "realign reimbursements"?

Also in this regard, I have to scoff at unregulated "free market" theorists and their beloved panacea "efficient markets hypothesis." They uniformly gloss over or grossly ignore the very real and fundamental -- if inconvenient -- corollary that the most "efficient" markets are also, by definition, the lowest margin.

Think about it. How could it be otherwise? The Sum of Self-Interested Rational Actors, All Having Transparent Access To The Same Information Upon Which to Act Upon And Express Their Value Preferences?

Right. Get serious. Gimme a break.

Twelve words, from a generation ago:

"In the gap between perception and reality, there's money to be made."

- Michael Milken

Ask Yves Smith as well. Hat tip to her for her pithy, bulls-eye debunking observation on the "efficient markets" point (I'm reading her new book "eCONNED" at the moment; been following her blog for quite some time).

HOW ABOUT A LITTLE KLEINKE CODA?

...The very idea of a public works project (at least within our own borders) sounds like an artifact from an era eclipsed by nearly three decades of hostility toward government-based solutions to domestic problems, combined with a seemingly religious belief in marketplace solutions for all of them.

As this paper makes unambiguously clear, the marketplace will not solve the HIT problem. If so, it would have solved it under the watchful eye of "managed care" or as part of the Y2K conversion or during the most recent Health Insurance Portability and Accountability Act (HIPAA) compliance scramble. There is indeed a collective business case for a national HIT system, but it is one well beyond the reach of the health care marketplace. The federal government may be unable to finance and build that system for political reasons, but it can do far more than trying to jawbone the private sector into building it on its own.

If health care’s chronic IT failure is steeped in economic reality, then the solution should be as well. The obvious entry point is reimbursement. The federal government, directly or indirectly, purchases half of U.S. health care... [Market Failure And The Creation Of A National Health Information Technology System]

Again, published in 2005. Could have been yesterday.

SBM CRASHES THE PHARMACOGENOMICS PARTY

From Science-Based Medicine: David Gorski's "Woo-omics"

A prelude to woo-omics: Genomics, proteomics, everywhere an “omics”
One of the most difficult problems in science-based medicine is how to do a better job identifying which patients will respond to which treatments. Clinical trials, by their very design, have to look at average responses in populations. In essence, a treatment is compared to either placebo or standard-of-care, a choice mainly driven by ethics and whether effective treatments exist for the condition being studied. It is then determined using statistics whether a significant difference exists between the two groups. The difficulty, as any clinician knows, is applying the results of clinical trials to individual patients. In any population, there is, after all, a range of responses to any drug or treatment, and it would be desirable to be able to predict which patients will fall at the end of the bell-shaped curve where the treatment is most effective and which will fall at the end of the curve where the treatment works poorly or not at all...

...[T]hese days, the search for predictors of response, prognosis, and therapies most likely to do good has moved into the realm of what we now call “omics.” The term “omics” as it is used today originally came from genomics, which is, put very simply, the study of the entire genome (i.e., all the genes in an organism). It then expanded to be used for proteomics, which, again put very simply, is the study of all the proteins expressed by a cell type, organ, or organism. Since then, the term has metastasized to many, many areas of biology, such as metabolomics, secretomics, lipidomics, and many, many others. Here’s a general schema of what I’m talking about:

The problem with all these “omics” is that they are hideously complicated, with interactions of thousands of genes, proteins, and other entities that must be made sense of in order to understand what is going on. Indeed, arguably the reason we never bothered with these sorts of analyses before is that, until the last 10-20 years quite simply they were impossible. The computing power and algorithms necessary to do them simply didn’t exist and had to be developed. Neither did the technology. Then, beginning in the late 1990s, techniques were developed to measure expression profiles that included every known gene in the human genome. Building on techniques developed for the Human Genome Project and other genomics initiatives, in the early 2000s, we had cDNA microarrays, the ability to scan thousands of single nucleotide polymorphisms (SNPs) and look for associations with diseases, and the like...

The result of the new systems biology and “omics” has been a torrential flood of data that’s far ahead of our ability to analyze it fully. As the cost of sequencing a genome has fallen from hundreds of thousands of dollars to less than $10,000 (soon to be less than $1,000), genome sequencing will soon fall to within the price range of other commonly used medical tests. (CT scans and MRIs cost around $2,000 or so, and the Oncotype DX test, for example, costs around $3,000.)

Unfortunately, even as the flood of data accelerates, successful strategies for actually using that data clinically have been elusive. Indeed, last year, around the time of the tenth anniversary of the completion of the Human Genome Project, there were a series of articles asking, basically, “Where are all the cures we were promised?” Of course, as I’ve pointed out before, the sequencing of the human genome (and now all these other genomes, as is being done in the Cancer Genome Atlas, for example) has been the easy part. The hard part is making sense of it all and relating differences in individual genomes to specific diseases and to the discovery and validation of biomarkers for response to specific therapies. Just looking at one example can demonstrate why it’s so hard to make sense of this data and to figure out how to use it to develop cures to diseases like prostate cancer. Does all of this mean that all the information we’ve gathered and connections we’ve made so far in the Human Genome Project, the Cancer Genome Atlas, and other similar projects that have tried to relate genomics data to human disease, prognosis of disease, and response to therapies useless? Of course not. It’s just that the speed with which this data will result in real cures was arguably oversold. Right now, the situation is confused and uncertain. and we are still very far from the vision of truly personalized medicine that so many see “omics” as the path towards...

Party Poopers. ;)

As always, the comments at SBM are as interesting as the articles, e.g.,

# cervantes on 21 Nov 2011 at 10:01 am

John Ioannidis has written some very important papers about data mining in genomics. People have finally gotten the message, that they should have understood from the beginning, that if you go through a whole lot of data points — in the case of these studies of the association between genetic variants and diseases, we’re talking thousands — you will find spurious correlations. The p value can only be interpreted in light of Bayes theorem. If the prior probability of an association is very small, then it is still highly unlikely, even if your p value is also small. Science is a process of learning — it builds continually on prior evidence. If something doesn’t make sense based on what we already know, it’s unlikely to be the explanation for an observation. (Bayes theorem is extremely important, and in biomedical research, we’ve gotten stuck in a Gaussian world that many of the people who do research, even some prominent investigators, fundamentally do not understand. As Ioannidis demonstrated, most published findings are false.)

Yeah, John Ioannidis, I'd forgotten about him. And, don't get me started on "p-values" or Gauss. I'll see your Gauss and raise you a Chebychev.

ON DECK

More on privacy (apropos to a great degree of the above): who owns your health information? res privatae? res litigosae? res nova? A complicated question I've dwelled on at some length in prior posts. An issue that, again, varies by state, type of data, and proposed use of the information. One that goes to the core of Comparative Effectiveness Research initiatives and breakthroughs in "Personalized Medicine."

Also, an ONC certified EHR vendor (I won't name them -- for now) has had so many bug issues they've issued a "upgrade release recall." I'm not making that up. One of my REC client clinics is on that platform. The O.M. told me today she has 87 open/unresolved support tickets. It is a mess.

Oh, and this is interesting:

...Nearly 250,000 doctors age 55 and over are facing the same choice—take on time-consuming obligations to document quality care and the real possibility of cuts in what the government pays them if they slip up, or just get out before penalties kick in. These older practitioners make up 32 percent of the physician workforce, according to the American Medical Association’s data from 2009, the most recent year available.

Early retirement could worsen what the Association of American Medical Colleges already predicts will be a shortage of 63,000 physicians in 2015. And that’s before an estimated 30 million more people sign on for health insurance in 2014, many of them seeking out a regular doctor for the first time.

The health care law and the 2009 economic-stimulus package transformed some now-optional programs for doctors—such as using electronic health records or tracking quality of care—into requirements for treating Medicare patients. Where the federal government now uses carrots, mostly in the form of bonus payments to participating physicians, it will start to use sticks in a few years. Doctors will face cuts in their reimbursement from Medicare if they don’t successfully use electronic medical records and report on their quality of care. In 2015, doctors will lose 1 percent of their Medicare reimbursement for not using electronic medical records, and 1.5 percent for failing to report quality data, such as whether they checked patients’ blood pressure or blood-sugar levels. Every year you miss the goals, the penalties go up.

The requirements aim to make the anachronistic U.S. health care system more efficient, and the vast majority of doctors would say they want to provide high-quality care. Providing better care will also bring down overall costs by keeping patients healthier and preventing duplicative tests. But as doctors cope with these new requirements, they also must deal with others that will change how they run their practices. For starters, they’ll have to switch to a new medical-coding system by October 2013 that balloons from 18,000 codes to nearly 140,000 to describe medical services.

Physicians also face the perennial uncertainty of Medicare reimbursement levels because Congress has repeatedly failed to agree on a permanent solution. Unless Congress acts—and lawmakers often wait until the last moment to pass the “doc fix”—physicians will absorb a nearly 30 percent cut in 2012...

Relatedly,

Primary Care Workforce Facts and Stats

...Primary care is a foundational element of the U.S. health care system and is required to meet our Nation's triple aims of improving quality, containing costs, and improving patient and family experience. Primary care is also critical to ensuring access to health care for all Americans and reducing health care disparities. Whether the focus is on the individual, a population, or the health care system, good access to primary care is associated with more timely care, better preventive care, avoiding unnecessary care, improved costs, and lower mortality.

...Primary care by some measures is the largest aspect of our health care system. In 2008, 490 million visits were made to primary care physicians—a bit more than half of all visits to physicians' offices. But primary care's share of visits has been declining.

The U.S. primary care system is struggling under increasing demands and expectations, diminishing economic margins, and increasing workforce attrition compounded by diminishing recruitment of new physicians, nurses, and physician assistants into primary care.

Approximately one-third of physicians currently practice in primary care but fewer than one-fourth of current medical school graduates are going into primary care. The Council on Graduate Medical Education is concerned that the trend, if unchecked, will progress to fewer than one-fifth of medical students specializing in primary care...

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JUST IN...

Make sure the way you use an EMR doesn't unwittingly look like fraud
Technically Speaking. By PAMELA LEWIS DOLAN, amednews staff. Posted Nov. 21, 2011.

...Apparently many vendors advise practices to shut off the audit function to help speed up the system, Dr. Gelzer said. But turning off the audit function means the physician is not HIPAA compliant, Warner warned.

These potential problems are being exacerbated, some say, by the financial incentives created under the Health Information Technology for Economic and Clinical Health Act of 2009 to encourage EMR use. To qualify for incentives, physicians must demonstrate meaningful use of EMRs that are certified by organizations approved by HHS.

Meaningful use certification is designed only to ensure that EMRs meet the individual meaningful use objectives and measures, said Karen Bell, MD, chair of the Certification Commission for Health Information Technology, one of the organizations contracted with the ONC to test and certify EMRs for meaningful use. But Dr. Gelzer is concerned that physicians may feel a false sense of security knowing that their systems were certified to meet government-mandated standards.

The Dept. of Health and Human Services Office of the Inspector General included in its 2012 Work Plan a look at the relationship between certified EMRs and fraud and abuse vulnerabilities.

"I would take this to mean that the OIG is seeing problems," Dr. Gelzer said...

Interesting.
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More to come.

Blog Hiatus for a bit

2011-11-15T09:23:00.001-08:00

My Mom passed peacefully in her sleep early Thursday morning, after four years in long-term care here in Vegas. I have lots of new REC blog material, but it will have to wait just a bit.

ACOs? "Another Crock of, uh, Government"?

2011-10-25T17:40:00.000-07:00

So, CMS released the CFR "Final Rule" (PDF) governing the incipient Medicare "Accountable Care Organizations" (ACOs) last Thursday (Section 3022 of the PPACA), and I'm busily trying to wrap my head around its 696 pages of regulatory provisions to discern to what extent they might bleed into my REC work. I've already keyword/phrase-searched and indexed everything relating to our space (e.g., "meaningful use," "certified EHR," "HIE," "information exchange," "HIPAA," etc).

ACOs are a pretty politically hypercharged topic, to be sure. In some quarters, outgoing CMS Administrator Dr. Donald Berwick is viewed as a Commie Devil Incarnate.

Pretty nice summation of the ACO intent here:

10 things to know about ACOs

By Michelle McNickle, Web Content Producer
Created 10/25/2011

NEW YORK CITY – A recent report published by the Institute for Health Technology Transformation gave some interesting insight into accountable care organizations (ACOs). Among sections focusing on the origins of the ACO concept and their current state, the report detailed 10 basic things you need to know about ACOs.

1. A physician's role will change dramatically. "The economics of patient-centered care will create significant financial incentives for doctors to do more to coordinate care - most importantly, increase collaboration with other medical professionals," the report read. And in addition, this collaboration, according to the report, will occur within the confines of firm, evidenced-based medicine. "...Physicians will be incented to work in patient-centered, evidence-based practices, interfacing with other physicians and care providers to optimize the patient's health at the lowest possible cost."

2. Patients must be engaged in their care. The report stated ACOs build a competitive edge by engaging patients in the delivery of their healthcare. "ACO models propose patient engagement in decision making that requires consideration not only of the best scientific evidence concerning medical treatment, but also the opportunity for patients and their families to assess prospective treatment approaches in light of their own values and convictions." ACOs promote this type of patient engagement as well as possession of basic knowledge for the patients. This enables them to maintain good health, all while avoiding preventable medical conditions and knowing how to manage existing conditions. And, eventually, this will cause accountability to extend beyond the ACO and into the general public.

3. ACOs will create winners and losers among providers. The report cited Harvard business professor Clayton Christensen and said ACO models can be thought of as disruptive business models. "These disruptive models will need to create alignment of interests of the individual doctor and the team, and all will share accountability when patient care goals are not met." Therefore, for ACOs to be successful and sustainable, they must compete for consumers. "Successful ACOs must give consumers a value proposition that is competitive locally, nationally and globally," the report stated. "Providers that are not accountable and transparent will 'lose,' and those that meet patient needs and improve care will 'win.'"

4. ACOs are a team sport. According to the report, today’s siloed patient care approach won't function in a world of accountable care. In fact, an effective transition to an environment that’s more patient-centered and information-rich requires leaders to become informed consumers of the products of improvement science. "These new approaches will change the way the physicians interact with patients, payers and other clinicians," the report read. "While there will be examples of ACOs established by physicians in isolation from hospitals and health plans, this may not be the ideal approach. The reality is that physicians, hospitals, health plans, and many other healthcare stakeholders each bring unique skills and experiences to help deliver accountable care."

5. Transparency will empower consumers and motivate providers. The report makes clear it’s not possible to have accountable care without having at least one party that the healthcare system is accountable to. "In the case of ACOs, the assumed beneficiary has traditionally been the federal government," the report stated. "Since accountable care models are supposed to save money by doing a better job of coordinating care and making wise treatment decisions, the government (and thus the taxpayer) is better off as a result." But, this view doesn’t reveal the whole story, said the report. In fact, it's the consumer that stands to benefit the most from regulations that improve transparency. "Since providers differ widely on cost and quality, widespread adoption of quality measures is likely to improve patient access to this information."

6. ACOs will require health system redesign. According to the report, this redesign will be more than simply tinkering with business models. "ACOs have become synonymous with the Medicare Shared Savings/Pioneer Programs," it said. "However, this is a serious misnomer. These programs have served as models for increasing accountability and integration within the health system, but do no represent the end goal of health reform." Instead, ACOs seek to align patient and physician incentives and provide sustainable outcomes-based compensation systems. "To that end, the accountable care program is another step on the road to integrated patient-centered care... ACOs are a catalyst for dramatic transformation in the way patient care is delivered in the United States."

7. ACOs must be dynamic learning organizations. "High performing ACOs tend to be learning organizations, where the workforce excels at creating and sharing knowledge," read the report. "This exists where there is a supportive learning environment, concrete learning processes and practices and leadership behavior that reinforces and supports learning." It's no surprise this type of environment engages the workforce, which then leads to successful accountable care. This includes consistent focus on the customer, process and quality improvement, improved efficiency and, in the end, better health outcomes and experiences for the patients.

8. An ounce of prevention is worth a pound of cure - and costs a lot less. According to the report, health systems delivering accountable care could change the way the U.S. health care system works. For example, focus should shift from episodic, acute care provision to wellness and prevention. "This can be achieved through patient engagement and empowerment, improved chronic disease management processes, effective predictive modeling and population health management," said the report. It also added providers need to "be in the business of health, and not just in the sickness business. Emphasis should be placed on wellness and prevention programs, which have shown to improve health outcomes when properly administered."

9. Expect a significant change in transitions of site care and delivery mechanisms. Remote and virtual care will become the norm, said the report. "The value-based care expected of ACOs is a complete diversion from the fee-for-service system, which encourages higher volume of patient visits." As ACOs seek to keep patients healthier, the report stated we’ll likely see a centrifugal shift from hospitals to ambulatory sites. "Additionally, increased utilization of remote patient technologies is feasible," it said.

10. Primary care should be a major focus in the ACO environment. "Because of the potential for improving health and avoiding costly complications of chronic diseases, many of the ACO performance measures relate to performance in primary care," the report read. Additionally, it's recognized that increased investment in primary care is needed to slow the overall rate of growth in healthcare spending. "Together, this supports that it will be critical for ACOs to have a strong foundation of high-performing primary care and to practice evidence-based medicine."

We shall see. Smells like Teen Spirit HMOs to skeptics.

More cautionary observations, from:

One basic problem remains – a problem that is built into the core of the Shared Savings Model: at best, the model permits an ACO to receive 60 percent of the savings that it created, with CMS taking the other 40 percent. To create a dollar in savings, the hospital or medical group must give up a dollar of Medicare revenue. This dollar of gross revenue would make a contribution to both the fixed costs of keeping the hospital or medical group operating and to the marginal cost of providing the service that, if provided, would gain the dollar of Medicare revenue for the organization. Each organization will have to decide whether the sixty cents in shared savings that it can, at most, receive is worth more than the dollar in gross revenue that it is giving up.

But the calculation cannot end there – the organization must also consider the cost of creating and operating an ACO. CMS estimates that the average ACO will need $580,000 in start-up costs and $1,270,000 in annual operating expenses. Even after spending this money, there is the possibility that the organization will incur the costs of creating and operating the ACO but will not receive any shared savings bonus from CMS, because it fails to generate savings and/or fails to score highly enough on quality metrics.

Additionally, an ACO that chooses the second track (the track that permits it to receive 60 percent, rather than 50 percent, of savings generated), risks having to pay CMS a share of any costs that exceed the predicted costs for the ACO’s population of patients.

In other words, the shared savings “bonus” is not really a bonus. Under the program as designed even an efficient, high quality ACO will gain less money from sharing in savings than it would have earned if it had simply continued with business as usual. And there is no real bonus for quality – at best, an ACO can receive the maximum amount of shared savings possible – i.e., at most 60 percent of the savings it created for CMS – but no additional funds for quality. This is a fundamental flaw in the design of the program – a flaw created by Congress, and which only Congress, not CMS, could remedy.

Hmmm... Click the Health Affair Blog graphic above for the link to the full article.
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Apropos of the broad topic...

Company Tries Common Sense Approach To Improving Health Care

A California-based health care company has found some common sense approaches to improving care while cutting costs for its Medicare customers.

For example, CareMore offers free rides to the doctor’s office to avoid missed visits; they clip toenails to make sure patients don’t trip on rugs; they’ve set up a wound center to ensure a small cut doesn’t lead to an amputated foot in diabetic patients. These sound like little things, but the company says they’ve had a major impact.

In fact, CareMore reports overall costs are 18 percent lower than the industry average and hospitalization rates are 24 percent below average. The company also points to hospital stays that are 38 percent below normal and amputation among diabetics are an astounding 60 percent lower than average.

CareMore operates 26 centers across the Southwest, with more than 50,000 Medicare Advantage patients. But its philosophy could be spreading now that the massive health care company, Wellpoint, Inc., bought CareMore for $800-million, with 34-million patients nationwide.

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Tech note: if you don't see a horizontal embedded mp3 player above, get the plugin.

BTW: Interesting that I had cited in my prior post the Atlantic article "The Quiet Health-Care Revolution" they discussed.

"Here and Now" is a great NPR radio show, btw.

Below, this is pretty interesting (click the graphic):

Brochure here (PDF).
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OCT 29TH UPDATE: 2 FINE ACO WHITE PAPERS

First, from Mede Analytics:

This paper is excellent. Thorough, a quick read, and non-partisan. You have to register to get the full free PDF copy. Well worth it. to wit:

Background
The “accountable care organization” (ACO) is a major topic of discussion in American health policy. While many definitions of an ACO have been proposed, a general consensus has emerged, defining an ACO in simple terms as a voluntary group of physicians, hospitals and other healthcare providers that is willing to assume responsibility for the quality and cost of healthcare for a clearly defined population attributed to them on the basis of patients’ use of primary care services. If the ACO meets quality benchmarks and reduces per-beneficiary spending below what would otherwise have been expected, it will receive a share of the savings.

Though the ACO label has been around since 2006, it was mentioned in numerous healthcare reform bills proposed in 2009 and was ultimately included in section 3022, the Medicare Shared Savings Program, of the Patient Protection and Affordable Care Act (ACA), which was signed into law on March 23, 2010. Section 3022 did not address many details of the program, leaving it to the Secretary of Health and Human Services (HHS) to make decisions to expand and refine the program within the context of a notice of proposed rulemaking (NPRM) procedure...

Tone of the Final Rule
In view of the continued rancor surrounding healthcare reform and the 1,320 public comments on the proposed rule—some of which were quite critical—the final rule and public announcements made by government officials about it seem to reflect a tone of accommodation and optimism. The final regulation repeatedly points out how CMS has incorporated suggestions made by the public. In the press release announcing the final rule, HHS Secretary Kathleen Sebelius stated, “We are excited to give doctors, hospitals and other providers the flexibility and support they need to work together and focus on making sure patients get the care they need.”2 Similarly, in his op-ed in The New England Journal of Medicine, Berwick expressed his hope that the changes from the proposed rule “create a more feasible and attractive on-ramp for a diverse set of providers and organizations to participate as ACOs.”...

Organization of the Final Rule
At a high level, the final rule’s 696 pages are organized primarily into four sections. It starts with a background section (pages 7-17) that includes an introduction to and overview of value-based purchasing, which provides the philosophical underpinnings of ACOs. The background section also covers the statutory basis for and overview and intent of the Shared Savings Program, as well as a recapitulation of high-level public comments received on the proposed rule.

The second section (pages 17-589), covering the provisions of the proposed rule, summary of and responses to public comments, and provisions of the final rule, accounts for over 80 percent of the document. As with the same section of the proposed rule, it has a “discussion” feel to it, generally presenting for each issue three items: 1) selected public comments or summaries of public comments; 2) HHS’s response to the comments; and 3) the final decision on the issue...

The third section (pages 589-621) is a regulatory impact analysis, which provides an assessment of the impact of the final rule on affected entities and beneficiaries.

The fourth and final section is the text of the final regulation (pages 623-694)...

Conclusions
The long-awaited final rule—lengthy, highly detailed and mind-numbingly complex—constitutes the end of the road for the Medicare Shared Savings Program’s rulemaking process. While the draft regulation was collaborative in tone, it faced numerous critical reviews and a large volume of recommended changes during an extremely active and engaging public comment period. While the Medicare ACO debate has seemed to go on interminably, from the passage of the ACA until the release of the final ACO rule, commercial ACOs—led largely by innovative health plans—have continued to develop and flourish.

True to CMS’s promise to give serious consideration to each and every suggestion for improvement, the final rule strikes the dual tones of accommodation and optimism. In almost every aspect of the regulation—notably with respect to quality measures and the financial models—the final rule is more generous, flexible and supportive to providers. Time will tell whether this voluntary program will regain the momentum and sense of optimism about Medicare ACOs that preceded the proposed rule...

Again, a fine piece of work. It really helps me with my own vetting (which continues). Below, Ken Perez, Mede Analytics SVP of Marketing and Director of Mede's Healthcare Policy Team, addresses the ACO Final Rule topic.

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Below, another fine, timely paper, which focuses in particular on a couple stakeholder perspectives:

Executive Summary

...what appears to be growing interest and willingness among both providers and commercial health plans nationwide to collaborate in implementing value- based payment models such as accountable care organizations (ACOs). Providers and health plans are being motivated by a growing sense that costs and budgetary constraints will inevitably require significant movement away from the fee-for-service model. In addition, new payment rules and initiatives within the Medicare and Medicaid programs, such as the value-based purchasing program, hospital readmission penalties, bundled payment demonstrations, and the Medicare Shared savings program are motivating providers to develop the kinds of care platforms and information technology capabilities believed necessary to succeed in a value-based payment environment. Likewise, new provisions in the Affordable Care Act are having a significant motivating impact on health plans, such as the new medical loss ratio standards, new rules tying payment to performance under the Medicare Advantage Star Rating System, the federal authority and enhanced state resources to review “unreasonable” premium rate increases, and new laws to support establishment of state-level health insurance exchanges...

Factors Driving Provider Interest in ACO Contracting
In light of present day conditions, with health care program reimbursement cuts, apparently unsustainable government budget deficits, federal health care access and payment reform attempts, and consensus within the policy community that the government and private sectors must shift away from fee-for-service medicine, many providers have concluded that adoption of value-based payment models are a necessity and will eventually become the dominant form of payment for health care in the United States...

Again, registration is required for access to the free PDF report.

Update: yet another interesting report:

Click the image above for the PDF report. You don't have to register for this one.

High-Performers and New Models of Care Require Advanced Health IT

Our nation’s highest performing health care organizations and practices exhibit many of the attributes of new models of care to promote higher quality, lower cost and greater access. Understanding the attributes that these high-performers share (listed below) and the critical role that health IT plays in enabling them can help shape decisions about the most effective allocation of health IT resources.

STRONG ORGANIZATIONAL AND CLINICAL LEADERSHIP
Health IT enables health care organizations to optimize clinical, administrative and operational data, including patient and community information, to set goals, identify opportunities for improvement and monitor progress.

AN ORGANIZATION-WIDE FOCUS ON THE NEEDS OF PATIENTS
Being truly patient-centered includes giving patients electronic access to information in their health care records; educational resources; and self- monitoring and tracking tools between visits. Patient-centered organizations support shared decision-making and secure electronic communication between patients and their providers, and incorporate patient preferences and, increasingly, functional status in health care records.

ACCESS TO INFORMATION
Health IT and health information exchange enable all providers who care for the patient, as well as patients and family caregivers (or “care leaders”), to access, from across the range of settings, the right information at the right time while effectively managing privacy and security. Such information is drawn from patient records within hospitals and physician offices, as well as information generated by laboratories, pharmacies, health plans and the patients themselves.

THE DELIVERY OF EFFICIENT, COORDINATED CARE
The secure exchange of patient data provides an essential platform for care coordination and helps clinicians, care teams and patients to track and manage the patient’s journey through the health care system. Online access to patient data across settings and over time, as well as feedback on performance and “virtual consultations,” enable effective coordination that increases quality, efficiency and access. Reminders and alerts for patients and health care professionals help to eliminate gaps and duplication in care.

EMPHASIS ON PREVENTION, WELLNESS AND HEALTHY BEHAVIORS
Through electronic educational resources, interactive tools, preventive care reminders and electronic communication with care teams, health IT can help patients more effectively understand and manage their health and wellness.

ACCOUNTABILITY, ALIGNMENT OF INCENTIVES AND PAYMENT REFORM
Health IT and health information exchange enable organizations to collect and analyze clinical, administrative and patient-generated data to set goals, identify areas for improvement, assess effectiveness of interventions, and monitor performance related to cost, quality and patient experience – all of which support accountability, transparency and payment reforms.

TIMELY ACCESS TO CARE
Online and electronic patient tools, including portals, facilitate timely communication among care teams and patients between visits. Online scheduling and reminders help patients arrange timely access to care when they need to be seen, and “e-care” is more accessible and convenient when face-to-face visits are not required...

Call it P4P, call it ACO, call it Lean Patient-Centered Care, call it Mayo Model, call it whatever. We know what needs to be done. Whether we can muster the constructive, adult, big-picture political will to do it all is entirely another matter. Recall my June 18th, 2011 post "Use Case," wherein I cited medical economist J.D. Kleinke:

As I remarked at the time, "This article was published in the fall of 2005. Change a few NHE numbers and then- leading wonk names, it could have been written yesterday. Read it closely, all of it. It is excellent."

The words of health care futurist Joe Flower continue to ring resonant.

Health care is more unstable than it has been at any time in living memory. That’s pretty scary, but that instability may turn out to be its most important asset in this moment, as the whole industry becomes open to profound change.

As long as I can remember, thoughtful analysts have been saying, “We need to do this differently. This is not working.” In this century, the voices became louder and more insistent, and they spread. But health care has been very slow to evolve in any fundamental way. Even health care reform, when it came through extraordinary political pain and maneuver, was more a way to bolster business as usual, a way to shore up revenue streams and patch holes in the fee-for-service business model, than it was any fundamental restructuring.

Now the ground under our feet is liquefying.

Indeed. I'm just an ordinary citizen, and my REC work is "technical assistance," not "policy" (as my bi-state REC Executive Director curtly reminded me upon learning that I'd launched this personal blog -- for "exceeding your scope"). But, I've been mulling over and writing about all this stuff for quite some time now on my personal "policy blog," predating my current tenure with HealthInsight, and I will keep pushing on.

Not that I claim to have many answers, but I do know what questions need be posed, questions too often lost in the din of our clownish bumper sticker infotainment political culture.
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More to come. Including, do EHRs actually raise malpractice liability rates? (PDF) And, (still, again) what precisely do we mean by "obtain consent" with respect to HIT/HIE? Relatedly, who "owns" your PHI/ePHI? (And, is that really a Red Herring question?)

Stay tuned...
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OCT 30th ERRATA

Wow. I wish I could just take a couple of days off and study this. A great read thus far. What a life.
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HIT AND MEDICAL LIABILITY

...As more providers adopt new EHR technology, software design flaws will be identified as the systems are tested. Data coding errors, implementation challenges, and operational failures will occur as the systems are utilized. These errors should decrease over the long term as vendors, providers, and medical liability carriers monitor the new systems and develop process improvements, but there will be early challenges that will also serve to develop case law through legal action. Medical liability claims may also increase as patients gain easier access to their electronic data and discover that their provider may not have followed one or more treatment protocols that are embedded therein. The authors expect that the cost of defending against these claims will increase as more attorneys use electronic legal discovery for both the data and the metadata. These factors are likely to drive up the cost of medical liability insurance until:
the software vendors effectively resolve numerous medico-legal flaws and limitations in their EHR technology and
best practices in selection, implementation and operation become wide spread.
Until these challenges are addressed, medical liability insurance costs are likely to increase even faster than their historical controls in order to compensate the liability carriers for their increased professional liability payouts...

Interesting. Full paper here (PDF). Recall my post last year "First, do no 'Hold Harmless'." I follow these developments intently. I champion what I see to be the major net upside of HIT/HIE, but I am acutely aware of the trust that must be earned -- trust that can easily be destroyed if patients' data are misused (intentionally or otherwise) beyond a miniscule, random degree.

As we push forward with now accelerated widespread HIT/HIE deployment, I have to admit to concerns that critical issues may get glossed over amid the hubbub.

As we move toward the operational launch of our HealthInsight Nevada HIE, for example, we continue to chew over the nuances and implications of patient "consent" under both the baseline provisions of HIPAA regulations and Nevada Senate Bill 43 (PDF), which authorizes the state to initiate and administer a Health Information Exchange and regulate any other HIEs (such as ours) that come online here.

Our HIE Privacy and Security Task Force (within which I nominally serve as a "staff resource") curiously concluded early on that "Nevada is an opt-in state," notwithstanding that the statute does not say that. The word "opt" appears only twice [15(2)(b) and (c)], each time followed by the word "out." **

Apropos of that:

I belong to a school, a small but hardy school, called “textualists” or “originalists.” That used to be “constitutional orthodoxy” in the United States. The theory of originalism treats a constitution like a statute, and gives it the meaning that its words were understood to bear at the time they were promulgated. You will sometimes hear it described as the theory of original intent. You will never hear me refer to original intent, because as I say I am first of all a textualist, and secondly an originalist. If you are a textualist, you don’t care about the intent, and I don’t care if the framers of the Constitution had some secret meaning in mind when they adopted its words. I take the words as they were promulgated to the people of the United States, and what is the fairly understood meaning of those words.

I do the same with statutes, by the way, which is why I don’t use legislative history. The words are the law. I think that’s what is meant by a government of laws, not of men. We are bound not by the intent of our legislators, but by the laws which they enacted, which are set forth in words, of course. As I say, until recently this was constitutional orthodoxy.

- Justice Antonin Scalia

SB 43 is internally inconsistent on the topic of consent, and looks in places to be a marginally coordinated multi-contributor cut & paste pastiche. But, when you gripe about things like that, the attorneys (we have two on the task force) tend to blow you off with a polite "well, you just don't understand Statutory Construction" reply.

Ahhh... (apologies to Justice Scalia), we must look to "legislative intent" to divine how the lawmakers "construed" their effort. Such was also the conclusion of the Outside Counsel we hired to review our lawyers' "SB 43 Memo."

OK. I read every on-the-record word (click the graphic above for the legislative progress record). Pretty interesting stuff. e.g.,

Subcommittee of the Senate Committee on Health and Human Services March 31, 2011 Page 2 (PDF)

SENATOR KIECKHEFER: Is the intent of section 5, subsection 1, paragraph (e) of the proposed amendment, Exhibit C, to allow the director of the Department of Health and Human Services (DHHS) to determine ownership by regulation?

MARSHEILAH LYONS (Policy Analyst): The intent is to have the director create regulations that address ownership and stewardship of information and data.

LYNN O’MARA (Project Manager, Office of Health Information Technology, Department of Health and Human Services):

The health information exchange (HIE) cooperative agreement needs some requirements to ensure the privacy and security of data, including stewardship and ownership, are addressed. It is an issue on which we are to be receiving additional guidance.

SENATOR KIECKHEFER: I understand the concept of rules governing stewardship of information and data, but ownership is an issue I do not feel comfortable allowing to be decided by regulation.

MS. O’MARA: The Health Insurance Portability and Accountability Act (HIPAA) is clear. The individual decides who can see personal information, so it is like a de facto ownership to the individual. [emphasis mine].

Really? HIPAA says no such thing. Anywhere. PHI "ownership" is neither stipulated nor implied by any stretch. (to be fair, Ms. O'Mara is neither an attorney nor a legislator.)

But, then, Outside Counsel also recommended that reviews of HIPAA/HITECH federal "legislative intent" might also be warranted.

Right. Comp me a Lexis/Nexis and Westlaw account. I'll do it.

For free.

** You have to wonder whether this is where they glommed onto SB 43 "opt-in."

Senate Committee on Health and Human Services February 17, 2011 Page 9

Ms. O’Mara: ... Section 8 contains the requirements for transmission and participation in HIEs.

SENATOR WIENER: I see this as an “opt-in” law. It is not mandatory for providers to participate. If that is the case, what does it mean to providers who would prefer not to opt-in?

MS. O’MARA: Providers are not required to participate.

Providers, not patients.

This privacy issue gets really complex (once the laywers get off and running, at umpty-hundreds of dollars per hour). But, is "own/not own" a false dichotomy? Where does PHI/ePHI fit within the legal confines of "intellectual property"? And, does "privacy" hinge of answering those questions?

No, IMO.

Much more to come...

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O/T HALLOWEEN UPDATE

I've been sitting on this for quite some time. It's official as of today.

They solicited staff input for our new HIE name. And, they chose mine. I was actually surprised. I like the "pulse" tag line they came up with. Mine were OK, but too much. The graphic above, btw, is just another of my 5-minute Photoshops for temporary concept illustration. They just let the RFP for /logo/graphics/web design. Contact Kym if you want to bid (or know of someone): KRoundtree@healthinsight.org.

I gave them four quick Photoshop renderings (all using stock art), each from patient and provider POVs.

You could render the concept a hundred ways. None the foregoing represent our HIE's official logo/artwork, which are TBA. Just my $0.02. Pleased to have contributed.
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NOV 2nd UPDATE

Docs turn to Google, Yahoo for health info, survey finds
November 01, 2011 | Molly Merrill, Associate Editor, HealthcareIT News

PHILADELPHIA – Google and Yahoo were cited by 46 percent of physicians in a recent survey as a frequent source of information used to diagnose, treat and care for patients.

The Wolters Kluwer Health 2011 Point-of-Care Survey found that another 32 percent of physicians used these general browsers as an occasional resource. Sixty-three percent of physicians also reported they have changed an initial diagnosis based on new information accessed via online resources/support tools...

That's pretty interesting. Be nice to see a breakdown of what resources are being searched. I also have to wonder what SOAP documentation requirements these queries might fall into (e.g., EHR audit logs).
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More to come...

Telemetry (and other stuff)

2011-10-16T10:18:00.000-07:00

From Innovation is alive and well

Corventis – "Can our bodies become wireless transmitters? The people at San Jose-based Corventis think so. Their Nuvant Mobile Cardiac Telemetry System can detect early heart arrhythmias using a small (2x6 inch) device mounted on a patient’s chest. This sensor sends a constant stream of data to a transmitter that then relays it to a monitoring center. It won FDA approval last year. Even more intriguing is work being done at the University of Illinois where ultrathin, electronic medical monitors are being designed that can be attached to a patient’s skin, like a tattoo..."

I'd already heard about the "tattoo" thing, and had meant to post about it. Getting difficult to keep up with everything; to wit,

THE QUIET HEALTH CARE REVOLUTION

Or, "Hot Spotters for nicer people." In the November Atlantic:

ELLEN, AN 82-YEAR-OLD widow, lives in Anaheim, California. One Wednesday morning last year, she got on her scale, as she does every morning. One hundred and forty-six pounds—wasn’t that a little high? Ellen felt vaguely troubled as she poured herself a bowl of oat bran.

Half an hour later, the phone rang. It was Sandra at the clinic. She too was concerned about Ellen’s weight, which had jumped three pounds since the previous day. Sandra knew this because Ellen’s scale had transmitted its reading to the clinic over a wireless connection.

Given that Ellen had a history of congestive heart failure, a three-pound weight gain in 24 hours was a potentially dangerous development, a sign of possible fluid buildup in the lungs and increasing pressure on an already stressed heart. Sandra wanted her to come in for an immediate visit: the clinic would provide a car to pick her up and bring her back home. Ellen’s treatment began that very morning and continued for two weeks until she was out of danger. Had the warning signs not been noticed and addressed so quickly, she might easily have suffered a long, painful, and expensive hospitalization.

Dan, a retired letter carrier, is a patient at a clinic in the same system. At 87, he is decidedly frail, his once-sturdy legs now weak and unsteady. He is a classic candidate for a fall of the kind that has injured many of his friends, in some cases leading to weeks in the hospital and months of rehab. The elderly are prone to falls for many obvious reasons, including weak limbs, impaired vision, and medication side effects. But Dan’s doctors knew that some less obvious causes included shag carpets and long, untrimmed toenails. Because of this, they’d sent someone from the clinic to visit Dan’s apartment and make sure that his daughter replaced the 1980s-vintage carpets with low-pile rugs. Dan also visits the clinic regularly for light muscle-training sessions and periodic toenail clipping. Due to these preventive measures, Dan and his fellow clinic patients are one-fifth as likely as comparable patients elsewhere to suffer falls.

Joe, a 79-year-old diabetic, cut his foot when he banged it against a door. When it didn’t heal after a couple of days, he limped into the office of his family physician. After glancing at the cut, his doctor immediately sent Joe to a clinic in the same system as those that treated Ellen and Dan. For diabetics, even small cuts can be a serious matter: untended, they can become infected and contribute to an alarmingly high rate of amputation. At the clinic, a nurse practitioner cleaned and dressed the wound, and told Joe she wanted to see him there in two days so she could inspect and treat it again—and two days after that, and two days after that, until it was fully healed. The clinic would arrange for transportation if needed. Thanks to the steady, regular care, Joe’s foot healed without any infection or threat of amputation.

Ellen, Dan, and Joe are all real people, though their names have been changed...
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Interesting. Well, this is a good time to get around to the "tattoo telemetry" stuff as well.

Electronic 'second skin' blurs technology and biology

SALT LAKE CITY -- In the Aug. 12 issue of the journal Science, Ma (Jack) Zhenqian g of the department of electrical and computer engineering at the University of Wisconsin published a new scientific paper detailing a hair-thin electronic patch that adheres to the skin like a temporary tattoo. Actually, patches are a common way to deliver medications now, but the new patch looks more like a circuit board diagram and is loaded with electrical engineering firsts. The patch will soon replace medical monitoring equipment cables and some other devices, making them wireless, self powered and more accurate...

...Incorporating these devices in patches similar to tattoos would enable biological readings to be remote and unobtrusively recorded day and night, so important events such as a heart arrhythmia or a spike in blood sugar levels are sure to be noticed.

In a very real sense, it is like being able to have a tabletop doctor's office —including sensors, circuits and elements for drawing power and transmitting data — are stuck to the surface of a 30-micrometer- thick, breathable plastic sheet...
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So, is there a waft of Creepiness Factor in all this (e.g., like GPS surveillance tracking of your cell phone or OnStar)?

"LAB ON A CHIP"

Blueprint for Innovation Encouraging computerized medical device invention
Sandy Weinberg, Ph.D., Ronald Fuqua, Ph.D.

A patient swallows a computerized capsule, providing his physician with a series of images of the gastrointestinal tract. Another patient accesses the computer control on her wheelchair, which raises her to a standing position and follows a carefully designed exercise program to keep her legs from atrophying. A computerized “lab on a chip” provides toxicologists with a complete analysis series from a single sample...

Or, how about

ePetri: a Smartphone-Based Petri Dish
by STANLEY DARMA on Oct 6, 2011

...The culture is placed on an image sensor chip and the phone’s LED screen functions as a scanning light source. The ePetri device is then placed in an incubator, with the image sensor chip connected to a laptop outside the incubator through a cable. The image-sensor takes pictures of the culture, the data is sent to the laptop and so cultures can be monitored as they grow. The technique is apparently particularly useful in the imaging of cells that grow very close to one another.

Instead of using a large, heavy instrument, they now have a lightweight microscope providing high-quality images of cells. The ePetri is able to monitor the entire field, but can still zoom in on areas of interest within the culture. The research team sees many possibilities for their technology, such as drug screening and detection of toxic compounds. It could even provide microscopy-imaging capabilities for other portable diagnostic lab-on-a-chip tools. Right now the team is also working on a more comprehensive system that would include a small incubator, transforming the ePetri into a desktop diagnostic tool.

Makes your head spin, all these developments. I guess, beyond the technology issues ("accuracy and reliability," e.g., sensitivity, specificity, durability) is the business case at the provider of record destination. Will I get paid for having to examine and assess this looming on-call-all-the-time tsunami of data 24/7?

'eh?
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BOSTON – Physicians who once only grappled with learning the language of medicine must now also cope with a health care world that has turned hospitals into factories and reduced clinical encounters to economic transactions, two Beth Israel Deaconess Medical Center physicians lament.

“Patients are no longer patients, but rather ‘customers’ or ‘consumers’. Doctors and nurses have transmuted into ‘providers,’ Pamela Hartzband, MD and Jerome Groopman MD, write in the Oct. 13 edition of the New England Journal of Medicine.

“We are in the midst of an economic crisis and efforts to reform the health care system have centered on controlling spiraling costs. To that end, many economists and policy makers have proposed that patient care should be industrialized and standardized. Hospitals and clinics should be run like modern factories and archaic terms like doctor, nurse and patient must therefore be replaced with terminology that fits this new order.”

The problem, Hartzband and Groopman, note, is that the special knowledge that doctors and nurses possess and use to help patients understand the reason for and remedies to their illness get lost in a system that values prepackaged, off-the-shelf solutions that substitute “evidence-based practice” for “clinical judgment.”...

"...Now some prominent health policy planners and even physicians contend that clinical care should essentially be a matter of following operating manuals containing preset guidelines, like factory blueprints, written by experts.”...

Difficult, all of it. Click the title image above for the full BIDMC article. Click here for my prior musings on issues of clinical judgment, cognitive traps, and Dr. Groopman.
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VERY COOL PODCASTING SITE

Click the graphic. Well worth your time.
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DIVERSION:
TIP 'o THE HAT TO MY REC COLLEAGUE ERICK
(Uh, I think he's my Sup now)

Yeah, I hate those things.
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OCTOBER 19TH UPDATE

Text Messaging Among Providers Prevalent Despite HIPAA Compliance, Security Concerns
By Kendra Casey Plank

A majority of physicians use the text messaging capabilities on their so-called smart phones to exchange information about patients with other health care providers, but doing so could be a violation of federal privacy and security rules, a health information technology firm executive said Oct. 17...

HIPAA Concerns
Adam Greene, an attorney with Davis Wright Tremaine LLP, explained to the webinar audience that the HIPAA Security Rule applies to all electronic protected health information and that the broad definition of PHI could apply to data contained in text messages.

For example, a text message between two treating physicians could be considered containing PHI if it includes admission or discharge date information that could lead to the identification of an individual patient. Similarly, a message between a doctor and patient could be considered PHI, and thus covered by HIPAA, if it indicated a treatment relationship, Green said...

Uh, OK, see the proposed "HIPAA Privacy Rule Accounting of Disclosures Under the Health Information Technology for Economic and Clinical Health Act." While inter-clinician text messages are surely not explicitly part of a "Designated Record Set," I wouldn't lean too heavily on that going forward.

to wit:

45 CFR 164.501: Designated record set means:

(1) A group of records maintained by or for a covered entity that is:

(i) The medical records and billing records about individuals maintained by or for a covered health care provider;

(ii) The enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or

(iii) Used, in whole or in part, by or for the covered entity to make decisions about individuals.

(2) For purposes of this paragraph, the term record means any item, collection, or grouping of information that includes protected health information and is maintained, collected, used, or disseminated by or for a covered entity.

Direct treatment relationship means a treatment relationship between an individual and a health care provider that is not an indirect treatment relationship.

You tell me. ePHI is ePHI. Doctors are "covered entities."
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OCT 2OTH UPDATE:
ACO FINAL RULE ISSUED BY CMS

696 pages of light bedtime reading (PDF). For starters, I've indexed all pages citing "meaningful use," "certified EHR," "HIPAA," and "covered entit(ies)."

From Bloomberg:

Health Rules Prod U.S. Hospitals to Form Networks for Care
By Carol Eisenberg and Alex Wayne - Oct 20, 2011 1:12 PM PT

...The U.S. Department of Health and Human Services issued final rules today for so-called accountable care organizations for the elderly and disabled, a centerpiece of the health-care law designed to save as much as $940 million in three years. Savings would be shared between providers and the government.

Participants can keep more savings after reaching targets, and will need to meet about half as many quality measures as first outlined in March. The delayed rule marks a victory for hospitals, clinics and large doctors’ practices that have lobbied to alter draft regulations they viewed as too burdensome and financially risky...

Quality Standards
An ACO’s potential reward will depend on its performance on almost three dozen quality standards. Other changes include a flexible start date in 2012, providing a list of likely patients up front and expanding participation to include rural health clinics and organizations where specialists provide primary care. Health-care providers won’t be required to pay back the government if they don’t hit savings targets...

We shall see. Give that this is tied to the PPACA ("ObamaCare"), should SCOTUS strike down the PPACA over the "Individual Mandate" issue, the ACO piece goes down with the ship.
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More to come...

2011 Nevada Health Care Forum, Oct 11th

2011-10-10T19:47:00.000-07:00

It'll be a full and an interesting day, no doubt. I attended last year, and wrote about it in my October 13th, 2010 blog update (scroll down).

My CEO Marc Bennett (pdf) will be on the HIE panel. I've known Marc since 1993. He just exudes comprehensive knowledge.

This year I'll take my good camera. Stay tuned, more to come...
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JUST IN

ONC, Health 2.0 launch popHealth app challenge
October 10, 2011 | Mary Mosquera

The Office of the National Coordinator for Health IT and the Health 2.0 entrepreneurial organization have opened a contest for developers to innovate with the popHealth tool beyond its reporting functions so healthcare providers can learn more about their patient populations and improve their care.

popHealth is an open source reference implementation software service that can automate the calculation and reporting of the ambulatory care clinical quality measures in stage one of meaningful use. Its data gathering and calculation capabilities make it easier for providers to discern trends in patient populations...
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ICD-10 And Meaningful Use Dominate AHIMA 2011
October 11, 2011, Ken Congdon, editor in chief, Healthcare Technology Online

Last week marked the 83rd annual American Health Information Management Association (AHIMA) convention. This year's event was held in Salt Lake City, and attendance seemed a bit lighter this year than in years' past — perhaps the result of fiscal cautiousness given our struggling economy. However, one contingent of the AHIMA membership community was at the conference in full force — coders. This attendance, no doubt, was heavily influenced by the upcoming transition from ICD-9 to ICD-10 code sets scheduled to take place in October 2013. ICD-10 will increase the sheer number of codes by nearly five times — from 14,000 to almost 70,000 — and changes the format of codes overall. For example, an ICD-9 code could only be up to five characters in length, where an ICD-10 code can be up to 7 characters long. These changes require upgrades to coding software and supporting backend systems, as well as significant change management on the part of the coding community. As expected, a number of ICD-10 solutions and services were on display in the AHIMA 2011 Exhibit Hall geared toward helping healthcare facilities meet these new coding requirements...

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THIS IS A GROANER

Law firm loses hard drive with patient records
Attorneys represent St. Joseph cardiologist sued for malpractice
By Tricia Bishop, The Baltimore Sun
8:31 p.m. EDT, October 10, 2011

A Baltimore law firm lost a portable hard drive containing information about its cases, including medical records for 161 stent patients suing cardiologist Dr. Mark G. Midei, a firm client, for alleged malpractice at St. Joseph Medical Center in Towson.

The drive was lost Aug. 4 by an employee of Baxter, Baker, Sidle, Conn & Jones who was traveling on the Baltimore light rail, according to a letter obtained by The Baltimore Sun that was sent to one of the stent patients last week — two months after the drive went missing.

The storage device held a complete back-up copy of the firm's data, including medical records related to the stent malpractice claims, along with patient names, addresses, dates of birth, social security numbers and insurance information...

...But it's unclear if the law firm would be covered by the medical record privacy law, the Health Insurance Portability and Accountability Act, commonly known as HIPAA. The incident may have exposed a loophole, said Marc Rotenberg, executive director of the Electronic Privacy Information Center in Washington and an adjunct professor at Georgetown University Law Center.

HIPAA regulates the protection of patient information by "covered entities" — providers of health care or health plans and data management companies. But malpractice attorneys aren't expressly mentioned.

"Under HIPAA, covered entities have an affirmative obligation to encrypt" data, Rotenberg said, adding that it "may be the case that a law firm is not a covered entity." He called the lost drive a "serious issue, particularly considering the sensitivity of medical information" and said that situation could pose a "problem for the firm, because people might say they were being negligent."...
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More to come later. I'm off to the Nevada Health Care Forum.

POST-FORUM NOTES

Above: The calm before the storm. I got there early. Below, the crowd filled in. Nice turnout.

Above, my CEO, Marc Bennett, on the HIT/HIE panel.

Below, presentation of the day. The Mayo Clinic. Dr. Swensen: "Half of what we spend every year nationally on health care is recoverable waste."

Throw it down, Sir! You are not alone.

Indeed.

ThedaCare by any other name. Regarding which I've been harping for quite some time.

Above, also from the Mayo Clinic presentation. Something to do with IQ. I'm not kidding (more to follow on that slide, lol). I hope we can get copies of his presentation deck.

Below, a lunch break presentation from the Green Valley High School Choir. Very, very nice.

Met a lot of cool people today.

More to come. Tired tonight. Both me and my new shelter rescue puppy.

Carlos. Woof.
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ACOs?

There was much discussion at the Forum regarding the potential viability of "Accountable Care Organizations" (and a lot of hedging; justifiably so). Apropos of the subject, from AmedNews:

ACOs face steep funding shortfall, learning curve
A survey says there's "still a lot of confusion" about accountable care organizations and a lack of resources dedicated to them.
By VICTORIA STAGG ELLIOTT, amednews staff. Posted Oct. 11, 2011.

A majority of hospitals, medical centers and physician groups are developing accountable care organizations, but few have dedicated the resources necessary to build one successfully.

An understanding of how this part of health system reform works is sometimes lacking, according to the Accountable Care Organization Readiness Study released Sept. 21 by the management consulting firm Beacon Partners in Weymouth, Mass.

The Patient Protection and Affordable Care Act states that accountable care organizations for Medicare beneficiaries will launch on Jan. 1, 2012. On March 31, the Centers for Medicare & Medicaid Services issued a proposed rule on ACOs. A final rule is under development.

Beacon queried about 200 executives at hospitals, academic medical centers, ambulatory clinics and physician practices during the summer. About 92% were in the planning stages of an ACO, and 30% said they had an operational ACO.

Although significant work is required to create an ACO, the survey found that few health systems were devoting sufficient resources to establish one. CMS has estimated that an ACO will take $1.8 million to launch and run. The American Hospital Assn., however, has data indicating that $11.6 million to $26.1 million is needed to operate an ACO...
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There was also a lot of Forum discussion on the likely outcomes and impacts of the current SCOTUS challenges to the PPACA ("Obamacare"). No one, however, noted that ACOs are legislatively established by the PPACA -- Section 3022, to be precise.

I also find it noteworthy that ACO activity is to commence this coming January 1st, yet we still have no operationally governing CFR Final Rule.

Moreover, should the law be struck down in toto, the ACO piece goes down with the ship, I would think.

BobbyG's 15 second Photoshop musing.

OK, BELOW, WHAT WILL BE THE UPSHOT OF THIS NEWS?

Health information technology: Incentives may not always serve intended purpose

Survey suggests some awards are going to doctors who have been using electronic health records for years
By Josh Israel and Kimberly Leonard

About half of the first batch of federal dollars meant to encourage doctors and hospitals to switch to electronic records went to providers who were converts to the technology long before the stimulus program was announced, an iWatch News analysis suggests.

The analysis could raise questions about whether the government will be able to meet its goal of widespread adoption of health information technology. While these early numbers are hardly conclusive, they suggest that a large swath of payments intended to be an incentive for new adoption of electronic health records are merely rewarding health providers for minor adjustments to systems they have had in place for years...
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Well, yeah, the "low hanging fruits," 'eh?

THIS IS PAINFULLY FUNNY

I recently receive a letter from another specialist I had occasion to consult. It was an excellent evaluation, clearly dictated, and in a style not yet of the computer-generated boilerplate type that is becoming commonplace now that the electronic medical record is taking hold...

Click the image for the link.
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NICE HIE BLOG FIND

Very smartly presented, clean, well-organized, and easy to navigate. Great resource. I put them in my blogroll. Click the banner to check it out.

GREAT NEW HIE ARTICLE

Excerpt from the full AHIMA Journal article (original link here):

Legal Considerations in Joining an HIE
By Chris Dimick
…
State Law versus HIPAA
Another legal HIE issue comes when state law is more strict than HIPAA when it comes to exchanging and releasing medical records. This especially comes into play with state laws centered on protecting specially protected records like substance abuse and HIV/AIDS data.

Typically the trained HIM professional is responsible for dissecting a record request by a neighboring state and reconciling the two state laws. But when requests come from unfamiliar states, HIM professionals need to carefully consider the two states’ laws and decide what is legal to send through the HIE. EHR systems complicate matters as currently most cannot truly segregate all parts of a person’s record that fall into a certain protective category. An HIM professional can pull complete protected records, but usually hints to things like mental health and disease are viewable in other sections of the record, like medication history. HIV treatment records could be blocked, but an HIV drug cocktail on the medication list might get sent unnoticed.

“When I transmit the medication history for a patient, I probably have not weeded out those medications that are only related to the individual’s treatment for their mental health illness,” Egan says. “That is the sort of crossover that folks really have to sit down and figure out how they are going to do that.” There are two current solutions to this legal risk. An organization can over-block records, excluding everything with a diagnosis code related to the specially protected information. Or an organization can stretch their patient consent document to cover multiple years and include consent for exchanging specially protected information in an HIE. “That is harder on the lawyer side because you are really stretching the knowing consent into ‘I agree that you can release this for anything that might come up in the next couple of years,’” Egan says. “That is a little bit of a harder case.”

Intellectual Property Rights
Sometimes more than just a patient’s record gets exchanged during health information exchange, like intellectual property. Business processes, database details, facility-developed patient data, and software details can all be revealed when an organization exchanges data through an HIE…

Malpractice
The use of an HIE, or lack thereof, could lead to lawsuits in the future. While no cases have been filed yet, Egan and Orth see the potential for malpractice lawsuits being filed if a provider had access to vital information through an HIE but failed to review the information.

In the past record transfers have not been immediate enough to constitute a lawsuit stemming from a provider not accessing an exchanged record. But as HIEs improve their processes and speed up their delivery, malpractice suits could appear. Facili- ties would need to modify their practice procedures to ensure staff has checked whether there is further relevant information about each patient by way of an HIE... [pp 62-64]

I am sort of the Office Crank on the topic of "obtaining consent" (see prior posts). Nice to see this.
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A SHOUT-OUT TO ONE OF MY COLLEAGUES

Fern Percheski, our resident Sensei of All Things Grant Related, is one of the authors (Chapter 9) comprising this book just released and now available on Amazon.

Click the book cover image. Fern and I go back to my first stint with HealthInsight in the early 1990's. She is the best.

Oxford University Press, 'eh?

IF AIR TRAVEL WORKED LIKE HEALTH CARE

2011-10-07T07:40:00.000-07:00

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TIME-SENSITIVE:
MY NOTE REGARDING YEAR-ONE STAGE-ONE ATTESTATION

Click to enlarge. No time left to putz around with this.
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My heart goes out to Steve Jobs' family and friends

2011-10-05T17:25:00.000-07:00

From Apple:

If you would like to share your thoughts, memories, and condolences, please email rememberingsteve@apple.com

BILL GATES

“I’m truly saddened to learn of Steve Jobs’ death. Melinda and I extend our sincere condolences to his family and friends, and to everyone Steve has touched through his work.

Steve and I first met nearly 30 years ago, and have been colleagues, competitors and friends over the course of more than half our lives.

The world rarely sees someone who has had the profound impact Steve has had, the effects of which will be felt for many generations to come.

For those of us lucky enough to get to work with him, it’s been an insanely great honor. I will miss Steve immensely.”

__

I hope others can step up to fill this void and keep the momentum going. This is a huge loss for humanity in addition to the heartbreak his family and friends are undeniably enduring.

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Apropos of this blog's purpose, e.g.,

FaceTime is HIPAA compliant and encrypted, could change the way physicians and patients communicate

Healthcare communications is rapidly changing – patients now routinely email their physicians, physicians connect with each-other via mobile-based professional networks, and more. The introduction of Apple’s FaceTime video chat sparked excitement and discussion in the healthcare community about its possible use in telemedicine. However, many were wary about associated patient privacy issues and HIPAA compliance.

It seems that this question has now been answered. According to Apple, calls made via FaceTime can be HIPAA-compliant with the appropriate security configuration. The news that this ubiquitous, free communications platform meets these rigorous standards has potentially wide implications for how patients, physicians, and others in healthcare communicate...

...FaceTime has the potential to broaden the exchange of information among physicians, provide greater convenience to patients, and improve the quality of patient care...

There could be no better way to honor his memory than to forge ahead with such innovations.
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National Health IT Hype Week, Sept 27th

2011-10-02T10:46:00.000-07:00

I would have loved to have been there, actually (personal reasons aside), given that we're in a period of "Let A Thousand VC-funded Flowers Bloom."

John Moore of Chilimark Research has a great cross-post up on The Health Care Blog ("Trickle Down Health") summarizing his reactions:

While Health 2.0 can get overwhelming with the number of rapid fire, albeit shallow demos from the multitudes of vendors who are all trying to make their mark in a market that has experienced a significant amount of churn, the event is invigorating for the passion that is shown. Sure, everyone is hoping to make a living on their next greatest innovation, but unlike virtually any other health IT related conference, those at Health 2.0 have passion. They are on a mission. They want to truly change healthcare. They want to make a difference. That passion is contagious. Unfortunately, that passion appears to be confined to the digerati.

Looking around at the Health 2.0 audience one sees a sea of almost exclusively upper, middle class professionals that are tapping away on their iPad, smartphone or laptop. When one sits back and thinks about the many demos seen, virtually all of them seem to be designed for this audience...

LOL. When I first read "a market that has experienced a significant amount of churn," my bleary pre-coffee Sunday morning eyes saw "chum." Apropos, I guess.

Unsurprisingly, HIT seems to be a new dot.com bubble arena to a great degree. I can't get those after-images of the old circa 2000 Superbowl TV ads out of my head.

See "8 Dot-Coms That Spent Millions On Super Bowl Ads And No Longer Exist."

My fav from those days is one I cannot find online anywhere. It was called "Mrs. Barky," wherein this too-young startup guy is trying to explain his vaporware concept to this wealthy bejeweled tea-sipping dowager mark, hoping to extract some big seed money. When she inquires as to the name of his company, he, seeing her yapping little spoiled lapdog, grins slyly and says without missing a beat, "Mrs. Barky."

John Moore continues:

...Maybe the most disturbing part of the event was the on-stage interview with a mother of eight kids (she was white, middle age and clearly upper middle class) showing how her family is tapped into the quantified self movement with the various Apps they use to track their health and fitness. This is not representative of the broad swath of the American populace who are the ones that will drive our healthcare system off the proverbial cliff. It is that grandmother in Indiana who is caring for her diabetic, overweight husband, two grandchildren, a daughter suffering from an addiction and a son-in-law who is unemployed and has no health insurance that we need to talk to, have up on stage to tell us what they need to better manage their health and interaction with the healthcare system. And we need not go to that extreme, how about just having someone from a safety-net clinic talk about their needs? Sadly, no such representatives were to be found at Health 2.0...

As I noted in the comments 'I am reminded of Gawande’s “The Hot Spotters”.'

...Every country in the world is battling the rising cost of health care. No community anywhere has demonstrably lowered its health-care costs (not just slowed their rate of increase) by improving medical services. They’ve lowered costs only by cutting or rationing them. To many people, the problem of health-care costs is best encapsulated in a basic third-grade lesson: you can’t have it all. You want higher wages, lower taxes, less debt? Then cut health-care services.

People like Jeff Brenner are saying that we can have it all—teachers and health care. To be sure, uncertainties remain. Their small, localized successes have not yet been replicated in large populations. Up to a fourth of their patients face problems of a kind they have avoided tackling so far: catastrophic conditions. These are the patients who are in the top one per cent of costs because they were in a car crash that resulted in a hundred thousand dollars in surgery and intensive-care expenses, or had a cancer requiring seven thousand dollars a week for chemo and radiation. There’s nothing much to be done for those patients, you’d think. Yet they are also victims of poor and disjointed service. Improving the value of the services—rewarding better results per dollar spent—could lead to dramatic innovations in catastrophic care, too...

More to come shortly. The second cup of coffee beckons...
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ASA RASKIN'S "MASSIVE HEALTH"

No denying the chops of this kid. We'll see what comes of this initiative. There's finally some content on the website.

With healthcare costs rising faster than inflation, a crisis looms on the horizon. Health happens between doctor visits. We need tools to address our health that we love to use. More than 750 people have applied to work with us, over half of them doctors and health professionals. Why? Because everyone knows change is necessary...

...we also help your docs by giving them better insight into trends and issues, by doing the statistical and visualization work for them. That lets them focus on helping you, rather than wasting time staring at numbers.

"Statistical and visualization work"? Like, uh, Stratasan, whom I've mentioned before?

Or, Gapminder?

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Apropos of the foregoing:

The HIT of ACOs, part 2: Beyond HIE
September 29, 2011 | John W. Loonsk, MD, CMO CGI Federal

Will accountable care organizations follow the lead of HIEs in analyzing data across participating providers, or surpass them?

In this series, we are examining ways health IT can best support the goals of accountable care organizations (ACOs) for health reform.

In our first article we focused on how clinical care and administrative data, as well as software tools, can be arrayed to support quality and efficiency analytics and reporting for an ACO. Data analytic technology usually operates retrospectively on non-transactional data that can be accumulated from diverse systems. As such, while not easy it is perhaps the easiest part of architecting an ACO technical infrastructure. There are analytic challenges in accumulating, normalizing, linking and processing the “iceberg” of both data visible in measures and the greater quantities of less-visible, supportive data needed for analytics and reporting...

Indeed.

Of equal -- no, even more timely interest:

UnitedHealthcare sees lower ER use with data exchange
September 29, 2011 | Mary Mosquera, Government Health IT

MINNETONKA, MN – UnitedHealthcare is beginning to experience reduced hospital and emergency room use as a result of payers and providers sharing patient data through health information exchange in its eight patient-centered medical home pilots around the country.

What is emerging is that the exchange of clinical information for medical management is getting comprehensive enough at the point of care to be able to evaluate the cost effectiveness of the service, according to Sam Ho, MD, executive vice president and chief medical officer, UnitedHealthcare.

With that data, “medical necessity determinations can be made closer to real time and obviate the need for unnecessary diagnostic settings and unnecessary treatment referrals,” he said in a recent online presentation sponsored by the eHealth Initiative, a non-profit organization that promotes health IT...

Well, yes, but "reduced hospital and emergency room use" comes out of some entities' hides, 'eh?

Very interesting. New, sustainable business models must emerge.
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FIRST MONDAY IN OCTOBER

Obama's healthcare law tops new Supreme Court term

WASHINGTON (Reuters) - President Barack Obama's sweeping healthcare overhaul will top the agenda in the new Supreme Court term that opens on Monday and could be the most momentous in decades...

...Returning from its three-month recess, the nation's highest court will confront legal challenges seeking to strike down Obama's signature domestic policy achievement and a host of other charged issues in its 2011-12 term.

The healthcare law, Obama's signature and most controversial domestic achievement that figures to be a prominent issue in the U.S. elections in November 2012, already has overshadowed the term's other cases.

The law, which aims to provide more than 30 million uninsured Americans with medical coverage and to slow soaring costs, has wide ramifications for the health sector, affecting health insurers, drugmakers, device companies and hospitals.

"That of course would be the big enchilada," said former U.S. Attorney General Dick Thornburgh in discussing the healthcare cases and the new Supreme Court term at a briefing sponsored by the conservative Washington Legal Foundation.

RULING COULD GO EITHER WAY

Legal experts said it was impossible to predict how the Supreme Court might rule on the healthcare law and said a decision could hinge on whether Congress exceeded its powers by requiring that Americans buy insurance or face a penalty.

"It will be a close case," Jonathan Cohn, a former deputy assistant attorney general at the U.S. Justice Department in the George W. Bush administration, said at the briefing...

Well, like Yogi, "I never make predictions, especially about the future," but I've seen some intriguing ones by a number of pundits with SCOTUS-watching cred. Like, say, "5 to 3 to uphold, Kagan recusing."

Yeah, I know, that cuts against the assumed Roberts Court grain, but...
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UPDATE FROM THE "I'M IN THE WRONG BUSINESS" NEWSWIRE

ONC awards E-Consent Trial project to APP Design
October 03, 2011 | Molly Merrill, Associate Editor, HealthcareIT News

WASHINGTON – The Office of the National Coordinator for Health IT recently awarded a contract to APP Design, Inc., to be part of its electronic consent pilot project...

...[which] will seek to find an efficient, effective and innovative way to help patients better understand their choices regarding whether and when their healthcare provider can share their health information electronically, including sharing it with a health information exchange organization...

Contract No. HHSP23320110023WC, $1,239,908.99

Interesting.
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More to come...

The only person who enjoys change is a baby with a wet diaper

2011-09-26T07:30:00.001-07:00

YEAH. to wit

The Challenge of ICD10 Adoption
by John Halamka

On October 1, 2013, the entire US healthcare system will shift from ICD9 to ICD10. It will be one of the largest, most expensive and riskiest transitions that healthcare CIOs will experience in their careers, affecting every clinical and financial system...

...Most small to medium healthcare organizations are desperate. They are consumed with meaningful use, 5010, e-prescribing, healthcare reform, and compliance. They have no bandwidth or resources to execute a massive ICD10 project over the next 2 years...

And don't forget PQRS, HIE, and various QIO 10th Scope HIT related initiatives. At times it all seems pretty crazy. One astute commenter in the foregoing Halamka post:

ICD-10 is one piece of a much larger picture. What is the common denominator of: meaningful use, value based purchasing, the March ACO regs, Medicare’s hospital and physician quality reporting initiatives? They all impose “nice to have” documentation requirements which subtract clinician time from direct patient care in the name of “transparency” and “accountability”.

Health care providers added one million jobs since 2007, despite declining utilization in virtually every category of service (hospital admissions, physician visits, etc.). A lot of those jobs were to cope with the escalating complexity of reporting requirements in the payment transaction.

Halamka is exactly right: we need to be simplifying and consolidating payment transactions, and reducing the documentation burden on caregivers. And it isn’t for provider convenience (or enabling them to hide quality defects) , but for the impact on cost and the patient’s experience of care. The micromanagement of medical practice has reached crisis stage.

FROM ACROSS THE POND

September 27, 2011, 7:40 AM
Lessons From Britain’s Health Information Technology Fiasco
By STEVE LOHR, NY Times

Government press releases tend to be bland, earnest blather. But not one posted on the British Department of Health’s Web site last Thursday. Its headline: “Dismantling the NHS National Programme for IT.”

To translate the acronyms a bit, the NHS is Britain’s state-run National Health Service and the program in question was the ambitious drive to computerize England’s health records and let doctors, clinics and hospitals share patient information electronically. The project, begun in 2002, was budgeted at £12 billion (about $19 billion) and the government hailed it as “the world’s biggest civil information technology program.”

The British digital health project has been a slow-motion train wreck for some time with last week’s announcement mainly confirmation — and a pledge to change course. (The announcement was also a political gesture, as the Conservative government of David Cameron tries to get as much distance as it can from an unpopular initiative, begun by Tony Blair’s Labor government.)

Yet the United States is about to begin its own government-funded drive to accelerate the adoption of electronic health records, with Washington set to hand out more than $20 billion in incentive payments over the next five years. So what are the lessons to be learned from the English experience? ...

OK, first lesson? Guess.
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A SHOUT-OUT TO MY WIREC PEEPS

I was on a HITRC Practice Workflow and Re-design CoP call and web presentation yesterday (9/27) during which we had a presentation by WIREC, the Washington-Idaho REC, a QualisHealth QIO REC contract initiative (like our own).

They are all over it (and, they are not the only ones). I cannot say enough good about these people. One slide that I screen-captured:

Bring it. Lean.

I started this blog on May 10th 2010 touting Lean for health care.
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QUICK UPDATE FROM THE DEPARTMENT OF
"IS OUR CHILDREN LEARNING?"

Yeah, I know...
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OCTOBER 1ST UPDATES

First, from The Health Care Blog:

Adverse Events is an interesting place.

As is Stratasan.com.

More shortly...

National Health IT Week, Sept 12 - 16

2011-09-12T07:21:00.000-07:00

Comprehensive health care reform is not possible without system-wide adoption of health information technology, which improves the quality of healthcare delivery, increases patient safety, decreases medical errors, and strengthens the interaction between patients and healthcare providers.

With Meaningful Use now providing the way forward, eligible providers across the country increasingly understand the benefits for themselves and their patients, and are adopting Meaningful Use compliant electronic health records...

www.healthitweek.org

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A CAUTIONARY OBSERVATION

'[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...

…Most clinical decision-making is gray, not black and white. What I would like to see is a comprehensive study is how computers affect issues in the gray world - how computers impact or improve the totality of decision-making on sociological and psychological problems, which may be more subjective rather than objective.'

- Richard Reece, MD

Interesting. I've written about these clinical decisionmaking issues before. Difficult stuff.

UPDATE; Apropos of the foregoing comes this (PDF) from Health Affairs:

Today’s ‘Meaningful Use’ Standard For Medication Orders By Hospitals May Save Few Lives; Later Stages May Do More

ABSTRACT The federal government is currently offering bonus payments through Medicare and Medicaid to hospitals, physicians, and other eligible health professionals who meet new standards for “meaningful use” of health information technology. Whether these incentives will improve care, reduce errors, and improve patient safety as intended remains uncertain. We sought to partially fill this knowledge gap by evaluating the relationship between the use of electronic medication order entry and hospital mortality. Our results suggest that the initial meaningful-use threshold for hospitals—which requires using electronic orders for at least 30 percent of eligible patients—is probably too low to have a significant impact on deaths from heart failure and heart attack among hospitalized Medicare beneficiaries. However, the proposed threshold for the next stage of the program—using the orders for at least 60 percent of patients, a rate some stakeholders have said is too high—is more consistently associated with lower mortality. Our results suggest that the higher standard that will probably follow in the second stage of meaningful-use regulations would be more likely than the first-stage standard to produce the improved patient outcomes at the heart of the federal health information technology initiative.

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ONC STRATEGIC PLAN 2011 - 2015 (PDF)

"The technologies collectively known as health information technology (health IT) share a common attribute: they enable the secure collection and exchange of vast amounts of health data about individuals. The collection and movement of this data will power the health care of the future. Health IT has the potential to empower individuals and increase transparency; enhance the ability to study care delivery and payment systems; and ultimately achieve improvements in care, efficiency, and population health.

However, these technologies – including electronic health records (EHRs), personal health records (PHRs), telehealth devices, remote monitoring technologies, and mobile health applications – are remarkably underutilized today. In 2010, only 25 percent of physician offices and 15 percent of acute care hospitals took advantage of EHRs. Even fewer used remote monitoring and telehealth technologies. While many consumers access their banking information online daily, only 7 percent have used the web to access their personal health information..."

We shall see shortly the extent to which Congress will permit these initiatives to continue.

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THIS IS NICE (the ACO M.O.?)

Oh The Jobs (Debt?) You'll Create! from Marketplace on Vimeo.

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THE JUNTA -- UH, DEFICIT REDUCTION COMMITTEE -- COMETH

1. Presidential Support: President Barack Obama proclaims September 11-17 National Health IT Week. Techies everywhere rejoiced that an entire week will be devoted to health IT. An excerpt from the proclamation reads, “Health information technology connects doctors and patients to more complete and accurate health records. Tools like electronic health records and electronic prescriptions help patients and providers make safer, smarter decisions about health care.” Support from the White House is paramount to the continued success of health IT initiatives in the future. It’s refreshing to have Presidential-level support for that work.

2. The Super Committee: Technically speaking, it’s the Joint Select Committee of Deficit Reduction, and there was a lot of talk about the Committee and its work. The bi-partisan assembly composed of six members of the House and six from the Senate is charged with finding more than $1 trillion in savings over the next 10 years. That means the couch cushions will be over turned and every drop of savings matters. Even something as detailed and technical as health IT will be considered for cost savings and efficiencies. So, it’s crucial that the health IT community maintain an active dialogue with the Super Committee members about the integrity and importance of HITECH funding.

3. Minority Health: Numerous workgroups held Congressional briefings on the state of their affairs. One of those groups launched earlier this year is the HIMSS Latino community. Together with the HHS Office of Minority Health, they are addressing significant issues facing minority populations and how health IT can ease some challenges they face. In their Congressional briefing, the group shared a community-wide concern for healthcare provider shortages and ways to close the disparity gap in minority populations. They also discussed the increasing importance of patient involvement in the healthcare process and how health IT initiatives like patient messaging can improve the delivery of care.

UPDATE: APROPOS OF #2 ABOVE

...While there has been no overt effort to repeal the HITECH Act, which authorized up to $27 billion in incentives for Meaningful Use of EHRs, anything is considered possible as Congress moves to reduce the size of the federal budget deficit. So HIMSS' appeal is more than just pro forma.

"National efforts to transform healthcare delivery systems and to bend the cost curve, including implementation of improved quality measures and reporting systems, are entirely dependent on the widest possible adoption of EHRs and [health information exchange]," HIMSS says in its recommendation to Congress. "Meaningful Use of EHRs supports quality reporting that helps providers analyze and continually improve the quality of care they provide."

Moreover, HIMSS adds, many small practices and smaller community hospitals would not have the resources to implement EHRs without government financial support...

From the Sept 16th FierceHealthIT.com article HIMSS urges Congress: Create a national patient identifier

Yeah, the HIT field ought to be a bit anxious.
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BUDGET CUT CASE IN POINT

From the blog of the CEO of the American Society for Quality:

The Fight for Baldrige–What’s Next?
Posted on September 16, 2011 by borawski

Well, it’s come to this.

On Wednesday, the Senate Appropriations Subcommittee on Commerce, Justice and Science voted to zero out for the Baldrige Program for fiscal year 2012. Yes, I’m disappointed. It’s likely though that Congress will not pass a budget and resort to a continuing resolution. It’s already on the floor and could extent funding for Baldrige.

But this really shouldn’t be such uphill work As I said in ASQ’s public statement, Congress should be shining a light on Baldrige recipients and point with pride to their accomplishments as an example of what the best can do. Baldrige recipients are creating jobs, saving lives and enriching students. It’s discouraging that the Subcommittee apparently doesn’t understand how valuable the government’s role has been. In these challenging times, model programs — like Baldrige — should be showcased, not eliminated...

Dicey times ahead. Let's hope initiatives like this (below) don't fall victim to the meat axe.

About the Health Data Initiative

The Health Data Initiative is a major new public-private effort that aims to help Americans understand health and health care performance in their communities -- and to help spark and facilitate action to improve performance.

The fundamental approach being taken by the initiative is to catalyze the advent of a network of community health data suppliers (starting with HHS) and “data appliers” who utilize that data to create applications that (1) raise awareness of community health performance, (2) increase pressure on decision makers to improve performance, and (3) help facilitate and inform action to improve performance.

A lot of good work being done, with great promise. I hope it continues. Let's hope we don't end up with this by the end of the year.

Yeah, I know, I have a vested interest. And, I certainly have my detractors (just about all of them using anonymous or otherwise untraceable screen names). This one is one of the more civil ones.

"Academic dilettante." Gotta love it.
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September 11, 2001

2011-09-11T13:31:00.000-07:00

I simply and humbly reflect on our heroic First Responders of that ghastly day a decade ago, and on the subsequent life-and-limb sacrifices of so many thousands of my countrymen and women is its wake.

If blood will flow when flesh and steel are one
Drying in the colour of the evening sun
Tomorrow's rain will wash the stains away
But something in our minds will always stay
Perhaps this final act was meant
To clinch a lifetime's argument
That nothing comes from violence and nothing ever could
For all those born beneath an angry star
Lest we forget how fragile we are

On and on the rain will fall
Like tears from a star like tears from a star
On and on the rain will say
How fragile we are how fragile we are
How fragile we are how fragile we are...

- Sting

Another "Use Case"

2011-09-07T07:37:00.000-07:00

NORTH KINGSTOWN, RI, Sep 07, 2011 (MARKETWIRE via COMTEX) -- Improved outcomes for patients is believed to be an important benefit of using electronic health records, yet few physicians can cite specific instances where such software has made a life-saving difference. Dr. Shankar Santhanam of Lawrenceville, NJ, is a notable exception. He recently used the Amazing Charts electronic health record (EHR) system to save a patient's life by following the evidence-based, decision-support recommendations offered by the software...

Story link here.

Anecdotal, to be sure. Nonetheless...
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And, how about this, from The Health Care Blog?

The Cleveland Experiment

By JOHN MOORE

There have been a number of research studies published that question the value of Electronic Health Records (EHRs), particularly as it pertains to improving quality of care and ultimately outcomes. Chilmark has always viewed these reports with a certain amount of skepticism. Simple logic leads us to conclude that a properly installed (including attention to workflow and thorough training) of an enterprise software system such as an EHR will lead to a certain level of standardization in overall process flow, contribute to efficiencies and quality in care delivery and ultimately lead to better outcomes. But to date, there has been a dearth of evidence to support this logic, that is until this week...

Electronic Health Records and Quality of Diabetes Care
NEJM | August 31, 2011 | Topics: Health IT, Quality of Care
Randall D. Cebul, M.D., Thomas E. Love, Ph.D., Anil K. Jain, M.D., and Christopher J. Hebert, M.D.

One commenter was unimpressed:

The study is flawed by selection bias and investigator bias. This report simply reaffirms that wealthy and educated people are more compliant and achieve better outcomes. The pro HIT bias of the NEJM and the ONC is more than evident.

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VOICE RECOGNITION UPDATE

Apropos of that, see

Natural Language Processing Coming to HIM Depts.

Natural Language Processing technology can take transcribed text, structure it into computable data, and apply SNOMED CT and other terminologies or codes for richer data abstraction and analysis.

During an educational session at the American Health Information Management Association annual convention, Oct. 1-6 in Salt Lake City, two NLP experts will walk through the technology and its potential. They'll cover tagging and preparing data for electronic health records meaningful use reporting, identifying caps in ICD-10 coding, and tools needed for data mining, among other issues. "We want the audience to walk away understanding how NLP works," says Dee Lang, vice president of product management and strategy at Precyse Solutions, Wayne, Pa...

...Educational session 7142, "Driving Your Organization to Meaningful Use with Data Analytics," is scheduled on Oct. 3 at 4:45 p.m. More information is available at ahima.org.

See also the Praxis article "Why Templates Don't Work."
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More to come...

Talk Dirty to Me

2011-08-24T18:53:00.000-07:00

Recently, on The Health Care Blog:

Just because my electronic systems didn’t end up costing me anything, it turns out that even though I bill Medicare less than $25,000, I’m still eligible to apply for some of the stimulus money. So just for shits and giggles, I hooked up with a government funded entity whose stated purpose in life is to help me get that money. Cool.

I’ve had a couple of visits with them so far. It turns out that my freebie EMR has features which I hadn’t bothered using yet, mainly because they didn’t seem particularly useful in the provision of medical care — that’s what I do, remember? — to patients. One of them was a so-called “Demographics” section, right below such vital information as patient name, address, phone numbers, and birth date. This section contains three pieces of information I have to enter, one from a set of radio buttons, and two from pick lists, mechanisms that allow for the collection of what is known as “structured data” instead of just information I type into the EMR “free form”.

The first item is “Ethnicity”. There are three radio button options: Hispanic, Non-hispanic, and Unspecified (the default).

The second item is “Preferred Language”, to be selected from a pick list. I can only enter one option.

The third item is “Race”, again to be selected from a pick list. They include “African or African American”, “Asian or Asian American”, “European or Caucasion American”, plus several other basically meaningless classifications. (For example, what entry do I use for an individual from the Indian subcontinent?) Unlike “Language”, I can enter as many of these options as I wish.

What? The? F?

Wow. Click the link. Read the entire post.

"...features which I hadn’t bothered using yet, mainly because they didn’t seem particularly useful in the provision of medical care..."

Really? I know everyone is focused these days on the Boogeyman "government wanting these data for use in 'disparities CER' for cost and Lifestyle Control," but, I have to ask, "aren't you at all interested in analytically mining your own patient data for some stratified intel on where you might be hitting and missing?" Any statistician would kill for 4-5,000 structured data records per year (per provider) via which to gain some useful insights.

Don't Ask, Don't Know.
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More to come...

2011 ONC Regional Conference in Hollywood

2011-08-11T20:31:00.001-07:00

Just got back home (Thursday evening). Lots to blog about. I learned a lot, from a lot of very smart, dedicated people. Below, Farzad Mostashari, MD, ScM, ONC head. Great guy. Inspiring speaker.

Well, what I'd thought might be The 800 lb. Gorilla in the Ballroom was dispensed with by about the 3rd question from the floor during Farzard's post-speech Q&A: that concerning the looming deficit "triggers" mandating deep cuts in federal discretionary spending should the "Junta" -- ahem, Bipartisan Congressional Super Committee -- be unable to agree on what to reduce or eliminate by Thanksgiving week 2011.

"I'm not losing a lot of sleep over it."

OK. "Broad Bipartisan Support" yadayada, and all that. What else could he say, though, that wouldn't precipitate a rush for the fire door exits and a spike in new members at TheLadders.com et al?

I guess we'll know soon. The entire 4-yr REC program cost is a spit in the budgetary ocean. We're invisible; we're, like, what? -- a week in Afghanistan? But, the Meaningful Use provider reimbursement money is a whole 'nuther deal. Pull those funds and it's Game, Set, And Match for the RECs.

But, then, there's stuff like this recently:

In July, House Majority Leader Eric Cantor, R-Va., released his own list of health care spending cuts totaling approximately $350 billion in federal savings over 10 years. Rep. Cantor has provided limited details about his proposals, but the broad concepts include:
Increasing penalties for health care providers failing to adopt electronic health records under Medicare “meaningful use” requirements would save $1 billion..

Cantor, no less. Maybe we will be spared. Maybe. But, consider the fevered, anxious gnashing of teeth already underway with the looming prospects of DoD cuts: "Defense cuts loom large for 'super committee'."

Not surprisingly, Defense Secretary Leon Panetta has described the automatic cuts as the "doomsday mechanism." He's warned that the prospect of nearly $1 trillion in reductions over a decade would seriously undermine the military's ability to protect the United States.
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August 16th headline update

Need I say more?

Gonna be a perversely interesting 3 months. I hope we will get to continue our work, as indeed "The Time is NOW."

Above, recent Vermont Governor Jim Douglas, who addressed "The Emerging HIT Landscape on our Evolving Roles" during the opening keynote session. He was great.

Below, they set up a photo booth, and asked us all to have our pictures taken for the ONC "Putting the 'I' in Health IT" public awareness campaign.

On the subject of "public awareness," involvement, and resources, check out these sites:

Click the images for the links.
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I attended a number of the breakout sessions: Public Awareness Campaign, Privacy, Security, Behavioral Health, and Workflow Redesign (I was on the panel on that one). The public awareness session was great, because none of this stuff will work effectively long-term absent public awareness and buy-in. They presented a fine campaign plan.

The back-to-back Privacy and Security sessions were held in a conference room so cold you have hung a side of beef in there. Tons of detail, most of which I'd already been studying at length (see prior posts). I still don't have a good answer to my question "does 'express consent' uniformly dictate a 'wet signature'?" (My feeling is "no, it does not.")

"Behavioral Health" was really just about the SAMSHA/HIPAA myriad strict disclosure constraints pertaining to drug and alcohol treatment programs, not at all about other aspects of mental/behavioral health more broadly. Useful information in any event.

The Workflow session was OK. I was a bit disappointed in my contribution to it, quite frankly. And, it was the first session right after the big buffet lunch. You could detect a lot of Food Coma setting in.

Live and learn.

All in all, a very worthy conference.

Note of appreciation: one of my REC counterparts from another state whom I'd met last year at the 2010 Regional in Salt Lake City came up and greeted me and said "Keep blogging. We all read your blog all the time. You say the things we all think about but won't say out loud."

That's pretty humbling and gratifying. I really have had no idea. I don't track my traffic stats on this blog (like I did on my now-suspended Santa Fe blog). It's not why I do this. I had one fellow HIT blogger criticize me recently over the length of my posts, i.e., that were I to chop stuff up into short bites posted more frequently, I'd get better hits.

Yeah. Understood. Well, there's enough of that already. And, again, it's not why I write this blog.

UPDATE ERRATUM

Dr. Fortuna (ASQ Health Care Division Chairman) copied me on a PDF of this new IOM report, Engineering a Learning Healthcare System: A Look at the Future - Workshop Summary:

The fundamental notion of the learning healthcare system—continuous improvement in effectiveness, efficiency, safety, and quality—is rooted in principles that medicine shares with engineering. In particular, the fields of systems engineering, industrial engineering, and operations research have long experience in the systematic design, analysis, and improvement of complex systems, notably in such large sectors as the airline and automobile industries. Working cooperatively with the National Academy of Engineering (NAE), the Institute of Medicine (IOM) organized Engineering a Learning Healthcare System: A Look at the Future to bring together leaders from the fields of health care and engineering to identify particularly promising areas for application of engineering principles to the design of more effective and efficient health care—a learning healthcare system. This report presents the summary of the meeting’s discussions.

Currently, the organization, management, and delivery of health care in the United States falls short of delivering quality health care reliably, consistently, and affordably. As health care continues to increase in scope and complexity, so will the challenges to efficiency. In part, the capacity to address these challenges will depend on the ability to develop information about the relative effectiveness of interventions in a fashion that is more timely and practical than is typically the case for individually designed prospective studies, such as randomized clinical trials. It will also depend on the ability to design delivery systems in which the dynamics at the component interfaces are much more efficient. In both cases, the adaptation of engineering principles to facilitate continuous learning will be key.

Workshop Premises
Health care is substantially underperforming on most dimensions: effectiveness, appropriateness, safety, cost, efficiency, and value.
Increasing complexity in health care is likely to accentuate current problems unless reform efforts go beyond financing to foster significant changes in the culture, practice, and delivery of health care.
Extensive administrative and clinical data collected in healthcare settings are largely unused for new insights on the effectiveness of healthcare interventions and systems of care.
If the effectiveness of health care is to keep pace with the opportunity of diagnostic and treatment innovation, system design and information technology must be structured to ensure application of the best evidence, continuous learning, and research insights generated as a natural by-product of the care process.
Engineering principles are at the core of a learning healthcare system—one structured to keep the patient constantly in focus, while continuously improving quality, safety, knowledge, and value in health care.
Impressive transformations have occurred through systems and process engineering in service and manufacturing sectors—e.g., banking, airline safety, automobile manufacturing.
Despite the obvious differences that exist in the dynamics of mechanical vs. biological and social systems, the current challenges in health care necessitate an entirely fresh view of the organization, structure, and function of the delivery and monitoring processes in health care.
Taking on the challenges in health care offers the engineering sciences an opportunity to test, learn, and refine approaches to understanding and improving innovation in complex adaptive systems.

A 341 page "summary"? LOL. I'm going through it. "[P]romising areas for application of engineering principles to the design of more effective and efficient health care"?

Yeah, that'll be universally loved. Notwithstanding the truth of it.
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More to come...