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Sunday, May 22, 2011

Health Policy Research: a promising new resource

Interesting news item here:
ANN ARBOR, Mich., May 20, 2011 /PRNewswire-USNewswire/ -- A new health care policy institute – one that is expected to become one of the largest of its kind in the nation – will be established at the University of Michigan's North Campus Research Complex.

The Institute for Healthcare Policy and Innovation was approved May 19 by the University of Michigan Board of Regents. The Institute's mission is to enhance the health and well-being of local, national and global populations through innovative, interdisciplinary health services research.

"The research done at our new Institute will inform and influence public policy and enhance public and private efforts to improve the quality, safety, equity and affordability of health care services," says James O. Woolliscroft, M.D., Dean of the University of Michigan Medical School and Lyle C. Roll professor of medicine...

I hope that among the topics investigated will be subjects such as HIT "usability" and effectiveness (a contentious issue that I've written about at some length in prior posts) and, relatedly, health care delivery process improvements, among other things.

To the latter point, I am again reminded of the words of John Toussaint and Roger Gerard in "On The Mend" -

Governments can tweak payment systems and probably get some temporary fiscal relief. But until we focus reform efforts on where most of the money goes, which is healthcare delivery, we will remain stuck in a revolving door of near disaster and narrow escapes. To get to the point where all people have access to high-quality healthcare, affordably, we must focus our attention on how the healthcare delivery system determines costs and quality. Then we need to change that delivery model entirely.

In fact, hospitals, physicians, and nurses—all of healthcare—must change. First, we must emphasize the science of medicine over the art. This means turning to evidence-based medicine, which is already underway in some sectors. But we are also talking about evidence- based delivery, work that has barely begun...

...We do not mean to suggest, however, that the external environment of healthcare—payment systems, insurance coverage, and regulations—does not need to be overhauled. It is a badly broken system requiring major surgery. But we are convinced that the healthcare debate needs to start from a deep understanding of how healthcare value is actually delivered.

This is an understanding we all need—policy makers and patients, as well as medical professionals.We all have a role to play in reforming healthcare. Caregivers need to rethink their priorities and remake their working environments. Lawmakers need to rewrite the rules to ensure that value is rewarded instead of waste. And patients must understand how healthcare works in order to demand truly effective change.

Only when we all have clear insight into the work going on inside the black box can useful reforms be crafted...



I call him "Sensei."
How to Blow the Big One: A Methodology

Healthcare has, right now, the greatest opportunity we have seen in our lifetimes to make a big change, to rebuild itself in a hundred ways to become better for everyone, and cheaper—to get cheaper by getting better. We’re not talking “bending the cost curve,” cutting a few points off the inflation chart. We’re not talking a little cheaper, a little less per capita, a few percentage points off the cut of GDP that healthcare sucks up. We’re talking way cheaper. Half the cost. You know, like in normal countries...

His "Five Frameworks" papers are among the very best I've ever read on health care, btw.

"Half the cost. You know, like normal countries."

Yes, well, notwithstanding that laudable goal, Let us not forget the Really Big Numbers that will remain with us. Below, from the recent California Health Care Foundation report (PDF):

The CHCF report posits an economically enervating $8,666 per capita health care expenditure this year, based on a population estimate of ~312.7 million people. A few observations:
  • A 50% reduction would still leave $4,333 per capita, or roughly $1,444 per month for a family of four;
  • Health care expenditures have never been nor will they ever be uniformly distributed and billed. According to recent AHRQ data, ~5% of the population account for nearly half of health care costs while half of the population spend little to nothing per year on health care (hence the "free rider" problem), and the rest of us are somewhere in between (and moving inexorably toward the age-correlated ever-higher cost strata).
  • Also on the subject of "per capita," we should also necessarily recall that the adult taxpaying cohort of the aggregate population is far less than 312.7 million.
It will remain a vexing, seemingly intractable (and mostly dishonest) political fight over how these costs -- many of them frustratingly irreducible -- get distributed in the coming decades. While it has indeed been fashionable in recent years to reflexively demonize the for-profit corporate health care sector, the industry does have its defenders. As noted by Wendy Lynch, PhD (May 27th):
Eliminating profit motive is not the answer.

I sometimes hear people discussing healthcare who place blame on businesses for wanting to make a profit on other people’s misery. However, we cannot assign fault to medical device-makers or drug manufacturers any more than we can blame hospitals for maximizing revenue, or doctors for lobbying lawmakers to cover their services under Medicare. Every stakeholder does what they can to secure survival and success. Even undertakers make a living providing necessary services, as much as we wish we didn’t need them. It isn’t distasteful for medical professionals to make money, but it is offensive to do so by hiding prices from the public and hoping consumers never ask...

It has been even more fashionable of late to "blame the victims," i.e., the patients themselves. It is argued that were we not all such Crappy Shoppers unconcerned with price, health care costs would be well below current levels. The theory that "Shopping" for health care services is no different than shopping for flat panel HDTVs, clothing, automobiles, Carnival Cruises, or groceries, etc.

Begs far too many Socratic questions to delve into here. I looked into some of these questions two years ago on one of my other blogs.
I will by no means be the first to note that our medical industry is not really a "system," nor is it predominantly about "health care." It is more aptly described as a patchwork post-hoc disease and injury management and remediation enterprise, one that is more or less "systematic" in any true sense only at the clinical level. Beyond that it comprises a confounding perplex of endlessly contending for-profit and not-for-profit entities acting far too often at ruinously expensive cross-purposes...

...Irrespective of your preferred data source, suffice it to observe for the purposes of this essay that Americans undeniably spend approximately twice per capita on health care than do their comparable industrial nation "consumer"/patient counterparts. I suppose that such would be defensible were we getting twice the "bang for the buck" (in terms of clinical outcomes quality and concomitant public and personal health) but, sadly, the aggregate data suggest significantly otherwise...

The U.S. health care policy morass

If you're not confused, you've not been paying attention, IMHO.


Apropos of the foregoing policy thoughts, a great New Yorker piece, Atul Gawande's commencement address to the Harvard Medical School class:
Cowboys and Pit Crews May 26th, 2011

...The distance medicine has travelled in the couple of generations since is almost unfathomable for us today. We now have treatments for nearly all of the tens of thousand of diagnoses and conditions that afflict human beings. We have more than six thousand drugs and four thousand medical and surgical procedures, and you, the clinicians graduating today, will be legally permitted to provide them. Such capabilities cannot guarantee everyone a long and healthy life, but they can make it possible for most.

People worldwide want and deserve the benefits of your capabilities. Many fear they will be denied them, however, whether because of cost, availability, or incompetence of caregivers. We are now witnessing a global societal struggle to assure universal delivery of our know-how. We in medicine, however, have been slow to grasp why this is such a struggle, or how the volume of discovery has changed our work and responsibilities...

...We are at a cusp point in medical generations. The doctors of former generations lament what medicine has become. If they could start over, the surveys tell us, they wouldn’t choose the profession today. They recall a simpler past without insurance-company hassles, government regulations, malpractice litigation, not to mention nurses and doctors bearing tattoos and talking of wanting “balance” in their lives. These are not the cause of their unease, however. They are symptoms of a deeper condition—which is the reality that medicine’s complexity has exceeded our individual capabilities as doctors.

The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. One needed only an ethic of hard work, a prescription pad, a secretary, and a hospital willing to serve as one’s workshop, loaning a bed and nurses for a patient’s convalescence, maybe an operating room with a few basic tools. We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills...

Read all of it. It is excellent. His summation:
The problems of making health care work are large. The complexities are overwhelming governments, economies, and societies around the world. We have every indication, however, that where people in medicine combine their talents and efforts to design organized service to patients and local communities, extraordinary change can result.


ACOs will fail, say Senate Finance Committee members

Accountable care organizations can't seem to catch a break lately. On the heels of the American Hospital Association's report that ACO costs may be higher than federal agencies realize, seven members of the Senate Finance Committee sent a letter this week to Department of Health and Human Services Secretary Kathleen Sebelius and Centers for Medicare and Medicaid Services (CMS) Administrator Donald Berwick, MD, voicing their concerns about the regulation of ACOs...

...All 10 members of the Physician Group Practice (PGP) CMS demonstration project have expressed reservations about the regulation’s current construction, the authors added. “It is troubling that their participation is doubtful, since these PGP members and experience are cited more than 75 times in your Agency’s 400+ page proposed rule as a model for the ACO regulation.”

Citing feedback from providers, who said incentives and accountability are misaligned, the committee members branded the proposed regulations as a failure that will not accomplish the intended purposes. “Therefore, we respectfully ask that you withdraw this proposed rule and re-engage experienced stakeholders to craft a new rule that fulfills the promise of ACOs.”

Another good recent article on the challenges of ACOs and HIT: Advanced Health IT Needed For ACO Initiatives
Key technologies will enable an ACO to deliver on its promise of providing efficient care that contains costs, Hanover said. These include the following:
  • Clinical applications such as electronic health records and computerized physician order-entry systems. These are essential to collecting the data that providers will need to measure and start to affect the performance of the ACO. These systems must adhere to meaningful-use requirements.
  • Clinical decision support systems. These allow providers to implement interventions at the point of care. By identifying those interventions, providers can improve care coordination, care quality, and outcomes for patients, which will lower costs.
  • Data analytics tools. These tools allow providers to analyze clinical, administrative, and financial data to help ACOs better manage their operations in order to optimize and begin to perform and profit as an organization.
  • Care management applications. The function of an ACO is to coordinate care; to engage members in their care; and to help to coordinate the service providers, the members, and the payers in order to deliver the best outcome to patients and help with compliance.
  • Data center technologies that help to cut costs. These include virtualization and service-based technologies for storage and server management.
  • Revenue cycle management technology. This prepares ACOs for ICD-10 and 5010 HIPAA electronic transaction requirements as well as future revenue cycle challenges associated with accepting, negotiating, and managing a bundle payment structure.

Below, perhaps of interest in light of the foregoing:
Health care goes unwired
In the fast-changing technology of medicine, physicians are turning to iPads rather than fax machines to deliver test results.

MIAMI - When Dr. Jose Soler got a late-night call about a critically ill patient, he grabbed his iPad and checked the results of the electrocardiogram test that just had been administered. Thanks to an app that zooms within half a millimeter of every heartbeat rhythm variation, Soler made a diagnosis within two minutes.

Before the Northwest Medical Center cardiologist began using the AirStrip Cardiology mobile application, he had to wait for a nurse to fax him a printout or log into a computer to load the data in PDF format, which was often hard to read.

"Having the ability to get that information on your iPhone to make a quick decision versus looking for a fax machine -- it just changed the paradigm," Soler said.

Soler is among 40 cardiologists at HCA East Florida Hospitals who are the world's first physicians to incorporate the EKG-reading app into their practices. Doctors at three HCA hospitals began using it recently on their personal iPads and iPhones.

Increasingly, doctors are using mobile apps to access patient information. Hard data is scarce. For instance, the annual market for mobile monitoring devices is estimated to be a $7.7 billion to $43 billion industry, as cited by a PricewaterhouseCoopers report, "Healthcare Unwired," released in September 2010.

But the trend is clear.

"This level of adoption is unprecedented. Things are changing very quickly," said health care innovation analyst Chris Wasden of PricewaterhouseCoopers...

Information flow alignment at the point of care.


From the folks at comes "Uncovering the ONC-ATCBs: What’s the Difference?" Pretty comprehensive article covering the current crop of six Meaningful Use certifiers.

The passage of the HITECH Act under ARRA has brought whirlwind changes and generated many questions in the electronic health record field. The ONC certification program is among the new changes that have impacted the way EHR vendors operate in the current climate. To ensure that their product meets meaningful use criteria, vendors must submit their EHR system for rigorous testing and certification processes by an ONC Authorized Testing and Certification Body (ONC-ATCB). While EHR vendors have quickly realized that their EHRs need to be ONC certified to remain viable in the marketplace, vendors may have trouble understanding which ONC-ATCB to seek these services from. While the six ONC-ATCBs have been approved to administer ONC-approved testing and certification, there are differences between each of them that encourage competition in the marketplace...

Definitely worth your time.


Apropos of ONC EHR "Certification," I ran across this curious bit of "letter from the CEO" misinformation on a vendor's website recently:
EHR Certification

I am sure that by now you have heard of the HIT certification program where if you have fully certified documentation software system, and are an allowed provider, you can be paid up to $44,000.00 over the next 4 or 5 years by the Federal Government. You are also probably aware that the amount paid to you is based upon 75% of your Medicaid or Medicare billed dollar volume.

There are many requirements that have to be met both by EHR vendors and by you the provider. Our company has been hard at work for nearly a year to meet these requirements and it has been moving along nicely. Some of the requirements are good and some are specific for a medical type practice.

The reason it takes so long to get certified is because we have to incorporate many features that our clients may never use, features that are geared directly for a medical practice. But to be eligible for payments you have to have a fully certified package which means you have to have purchased all of these features, not just the ones you would use. Features like drug-drug interaction software and drug allergy software. As silly as this sounds, in late December this was confirmed as true by the Federal Government.

Some have asked why we haven’t gotten certified as a module? We could get certified as a module right now but that would be of no value to you as you have to have a fully certified package to receive payment. So being certified as a module is a bit of a scam. You think you are getting something but it’s not what you need. Maybe it makes people buying a new package feel better, but in reality it doesn’t help them. It’s fully certified or nothing!

Now for the kicker, just a few weeks ago the U.S. House of Representatives submitted a bill that would fully defund the program which would in fact cancel it. This bill is H.R. 408. Now people say this bill will never get by the Senate and the President would veto it. That is most likely true. However, the $27 billion to pay doctors is not automatically funded. It must still pass through the House to get approval to spend. In this political and economic climate I just can’t see that happening. How are you going to justify to the American people that 27 billion dollars needs to be spent paying doctors to computerize, when they are looking at having to cut spending nearly everywhere?

Recently a House Republican was asked what this meant for the future of the HIT program. The response was that it would not get funding so consider it repealed.

So what does this mean? We are continuing to program but only the parts of certification that we think people will use. In the mean time, we will be watching to see what the future of the program is. There are a couple of possible scenarios.
  1. The HIT program gets funded somehow and it moves along as originally envisioned. (Not Likely.)
  2. The program continues but doctors don’t receive payment and they impose the penalties starting in 2015. (Possible, but without money would likely get repealed in 2012 depending on elections. Less possible, that it stays in unfunded limbo until the 2012 election when it gets its funding again.)
  3. The HIT program is dead and will fade into the sunset. (In my opinion, this is the most likely outcome.)
So for now, we keep programming and watching and waiting to see what comes about. Maybe, we can also sneak some fun features into the software – features that will actually help you be more efficient and better prepared for what gets thrown at you. I will keep you posted.


{name withheld}, CEO

I sent this vendor an email asking for the source of their information. Someone responded with links to a couple of irrelevant and dated blog articles. I subsequently replied by citing the following:
It is our understanding that the incentive funds are allocated within the CMS budget for the life of the program and not subject to annual appropriations bills – notwithstanding that Congress could in fact try to repeal various provisions of HITECH, but absent veto-proof success with that via both Houses, it’s not going to happen. Yes, we had heard that the Republicans were going to try to claw back “unobligated funds,” but the Meaningful Use incentive reimbursements are in fact “obligated” at this point.


(a) In General- The Secretary shall, using amounts appropriated under section 3018, invest in the infrastructure necessary to allow for and promote the electronic exchange and use of health information for each individual in the United States consistent with the goals outlined in the strategic plan developed by the National Coordinator (and as available) under section 3001…

For the purposes of carrying out this subtitle, there is authorized to be appropriated such sums as may be necessary for each of the fiscal years 2009 through 2013…
I also subsequently rubbed it in by sending them links to articles like this one:

Nonetheless, they have yet to retract the egregiously false assertion (as of May 28th). Interesting marketing strategy, 'eh? We have a great (albeit as yet uncertified) EHR product, but we can't get some basic ARRA/HITECH facts right.


This fellow finally took down his error-ridden "letter from the CEO" and replaced it with a new message that included this:
Over the past few months I have been telling everyone to wait due to statements that were made by Representatives in the House. Fortunately or unfortunately, depending on your political viewpoint, nothing has been done to defund the program as of the time of this writing. Could it still get defunded, sure. Will it, I don’t know. I do know that time wise it is getting too late to just sit around and wait. It is time to move forward as if it was going to happen and going to happen soon.
Uh, OK...


“A new science in informatics is emerging, termed ‘eIatrogentics,’ or studying errors that are caused by technology,” John Poikonen, PharmD, clinical informatics director, UMass Memorial Health Care in Worcester, Mass., told Pharmacy Practice News. He said more centers are adopting the technology and disagreed with the numbers cited by Dr. Cohen.

“From a recent survey [Pharm Purch Prod 2010;7], it’s more like 35% for CPOE and as high as 53% in hospitals with over 400 beds, with 89% saying they will be implementing the technology in the next five years. And 41% now use BCMA [bar code medication administration]. But it is still just 5% for closed-loop medication management systems,” Dr. Poikonen said.

Nursing workarounds are a very large problem with BCMA, he emphasized. “They can give a false sense of error prevention—like the nurse who has all of the insulin bar codes on the inside of her uniform and scans them until she gets the right ‘beep,’” he noted. “Then there is reporting of how many errors were averted because of mis-scans, when all the time the mis-scans were really workflow issues and not averted errors.”

Dr. Poikonen said he believes there is a woeful lack of evidence regarding the true medication error rate and the return on investment with BCMA. “The data and science around workarounds is better than the data from any studies showing value from BCMA,” he said.

Finally, with regard to smart pumps, Dr. Poikonen said that, although national standards would be a good thing, individual health systems should not be waiting for them. “They should be working to standardize at their facilities.”

See Medication Safety Technology Can Cause Its Own Errors


More to come...


  1. Felt compelled to respond regarding this post on HITECH and RECs. I have a post on my own site at Health Train Express,

    HITECH and RECs do not go far enough. RECs totally ignore the need for EMR in specialty practices. It is frankly prejudiced against specialty physicians. The underlying reason given is that specialists make 2X the income of PCP doctors. That statement is highly suspect, since it is an averaged figure and the range of income is significant amongst both PCPs and specialists. Meaningful use is meaningless for many specialists. Do you expect an orthopedic surgeon to give vaccines? MU is designed for public health measurements...not MU in medical practice, nor EMR design for functionality.

    follow @glevin1

  2. Thanks for your comment, though I should note that I am just a lowly REC technical assistance grunt. I don't have any role in HHS/CMS/ONC policy. Moreover, it should be clear from the full breadth of this independent blog to date that I am no uncritical apologist for the Meaningful Use program.

    There are a number of national venues via which your voice can be heard on ARRA/HITECH policy. Use them.

    I added you to my blogroll, btw.