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Thursday, June 28, 2012

PPACA Upheld

Apparently the "Mandate" survives under Congress's "taxing authority." From SCOTUSblog:
Our precedent demonstrates that Congress had the power to impose the exaction in Section 5000A under the taxing power, and that Section 5000A need not be read to do more than impose a tax. This is sufficient to sustain it.
5-4, Chief Justice Roberts writing for the majority.
Amy Howe (SCOTUSblog live feed, 10:32 EDT): In Plain English: The Affordable Care Act, including its individual mandate that virtually all Americans buy health insurance, is constitutional. There were not five votes to uphold it on the ground that Congress could use its power to regulate commerce between the states to require everyone to buy health insurance. However, five Justices agreed that the penalty that someone must pay if he refuses to buy insurance is a kind of tax that Congress can impose using its taxing power. That is all that matters. Because the mandate survives, the Court did not need to decide what other parts of the statute were constitutional, except for a provision that required states to comply with new eligibility requirements for Medicaid or risk losing their funding. On that question, the Court held that the provision is constitutional as long as states would only lose new funds if they didn't comply with the new requirements, rather than all of their funding.

The 193 page Opinion is now posted (pdf).


Justice Roberts' nice smackdown of Scalia's echoing of the slippery slope Feds-Will-Make-You Eat-Your-Broccoli canard:
[A]lthough the breadth of Congress’s power to tax is greater than its power to regulate commerce, the taxing power does not give Congress the same degree of control over individual behavior. Once we recognize that Congress may regulate a particular decision under the Commerce Clause, the Federal Government can bring its full weight to bear. Congress may simply command individuals to do as it directs. An individual who disobeys may be subjected to criminal sanctions. Those sanctions can include not only fines and imprisonment, but all the attendant consequences of being branded a criminal: deprivation of otherwise protected civil rights, such as the right to bear arms or vote in elections; loss of employment opportunities; social stigma; and severe disabilities in other controversies, such as custody or immigration disputes.

By contrast, Congress’s authority under the taxing power is limited to requiring an individual to pay money into the Federal Treasury, no more. If a tax is properly paid, the Government has no power to compel or punish individuals subject to it.
Emphasis mine. Nicely stated.

OK, so, Section 5405  ("Primary Care Extension Program") survives, along with everything else. I'd be jumping on it, pronto, "REC Trade Association." Seems to me like you might have better long-term funding luck hitching your wagon to AHRQ. ONC's interest in further promoting the REC cause with dollars seems dubious to me at this point.

I'd also be getting off the dime and launching my web presence. Time's a wastin'.



And, relatedly...

With its 5-4 ruling upholding Obamacare the US Supreme Court has joined with the Executive and Legislative branches of the federal government in abandoning the Constitution, the Rule of Law, and with that ruling abandoned the People.  All of us are now simply chattel of the government to be used and ordered about as they choose.   The history books will mark this date as the day our constitutional republic was killed.  It will now rest with We The People to decide if it will be resurrected or left to rot in the shallow grave dug for it.

Where is the weeping and wailing?  Where is the anger and outrage?  Do the people of the country realize what has just been stolen from them?  Do the people of the world recognize that the shadow of darkness is now fallen upon them as well and that there remains no defender of their feeble freedoms?  The all out oppression of all people has begun.

Those “occupiers” now controlling the three federal branches of government have joined together in rejecting all Constitutional restraint and in doing so they have severely violated their oaths to support and defend the Constitution of the United States.  Together they now stand as blatant usurpers of power and have reduced our constitutional republic, along with all of its freedoms, to nothing more than a dictatorial junta.  Becoming a banana republic is next.

When a gang of criminals subvert legitimate government offices and seize all power to themselves without the real consent of the governed their every act and edict is of itself illegal and is outside the bounds of the Rule of Law.  In such cases submission is treason.  Treason against the Constitution and the valid legitimate government of the nation to which we have pledged our allegiance for years.  To resist by all means that are right in the eyes of God is not rebellion or insurrection, it is patriotic resistance to invasion.

May all of us fall on our faces before the Heavenly Judge, repent of our sins, and humbly cry out to Him for mercy on our country.  And, may godly courageous leaders rise up in His wisdom and power to lead us in displacing the criminal invaders from their seats and restore our constitutional republic.

Roy Nicholson
Mississippi Tea Party
OK, "[T]he US Supreme Court has joined with the Executive and Legislative branches of the federal government in abandoning the Constitution, the Rule of Law, and with that ruling abandoned the People."

So, the three branches of government, by passing, signing, and then ruling upon a law via the processes set forth within the Constitution have "abandoned" it?

I must have slept through that day in ConLaw in grad school.

But WAIT! There's MORE!
Former GOP Spokesman: 'Is Armed Rebellion Now Justified?'
Lansing attorney does not like Supreme Court Obamacare ruling
By TOM GANTERT | June 28, 2012

A Lansing-based civil rights attorney who has held positions with the Michigan Republican Party and Department of Corrections, questioned in a widely distributed email today whether armed rebellion was justified over the Supreme Court ruling upholding Obamacare.
Matthew Davis sent the email moments after the Supreme Court ruling to numerous new media outlets and limited government activists with the headline: “Is Armed Rebellion Now Justified?"
..."If government can mandate that I pay for something I don't want, then what is beyond its power?" he wrote. "If the Supreme Court's decision Thursday paves the way for unprecedented intrusion into personal decisions, than has the Republic all but ceased to exist? If so, then is armed rebellion today justified? God willing, this oppression will be lifted and America free again before the first shot is fired."
Latest report is that Davis now trying to walk that one back a bit.


John Roberts, Constitutional Traitor: Chief Justice Approves Obamacare Tax Mandate
Posted on 28 June 2012 by William Grigg

...Roberts’ ruling is applied Leninism – a pragmatic way of justifying the government’s intention to exercise “power without limit, resting directly on force.” Money and time are essentially the same thing; one earns money by investing his time – an irreplaceable and finite quantity – in commerce or labor. Through taxation the State steals life incrementally, rather than destroying it outright.

In his decision, Chief Justice Roberts has placed the High Court’s imprimatur on the proposition that the regime ruling us can steal our lives incrementally in order to force each of us to participate in a health care program that will regulate every aspect of the lives that remain – and either kill or imprison those of us who refuse to participate. 
This last writer has a serious reading comprehension problem, probably exacerbated by a serious aversion to actually reading SCOTUS rulings in full (along with any inclination to expending the first bit intellectual energy on honestly understanding them). I'm surprised he didn't throw in "Kenyan Anti-Colonialism" aside Lenin for good measure.

Welcome to The Idiocracy. It'd be funny were it not so.

Enough. Back on topic (REC stuff) shortly...

Sunday, June 24, 2012

Tick, tick, tick...

OK, SCOTUSblog is saying that the PPACA ruling will be announced Thursday June 28th, last day of the current term.

 The Mandate:
Uhh.h..., oops..., Heritage Foundation, 1989

June 27th, 9 pm PDT

Really? So, should SCOTUS uphold it...? Well, never mind.
We'll know in about 10 hours.

Thursday, June 21, 2012

The Association of Regional Centers for Health Information Technology (ARCH-IT)

National Association Created to Represent Regional Extension Centers for Health Information Technology

New national group formed to provide a strong voice for the 62 Regional Extension Centers that provide assistance and guidance for the adoption and use of health information technology.

Silver Spring, MD (PRWEB) June 21, 2012 -- A new national association has been formed to provide a strong voice for the 62 Regional Extension Centers that provide assistance and guidance for the adoption and use of health information technology. The Association of Regional Centers for Health Information Technology, or ARCH-IT, represents Regional Extension Programs and the unique needs of the independent health care providers served by RECs in every state across in the United States.
“We are excited about this development and look forward to working with the Office of the National Coordinator and other stakeholders to promote health information technology adoption through the country,” said Jonathan Fuchs of the Arkansas Foundation for Medical Care, ARCH-IT’s President.

The intent and mission of ARCH-IT is to compliment [sic] activity in the HIT environment, create enduring sustainable organizations and “to promote and facilitate the integration of operational efficiency, clinical efficacy and revenue maximization in clinical practices through the adoption and use of health information technology.”

In 2009, Congress passed and President Barack Obama signed into law the Health Information Technology for Economic and Clinical Health (HITECH) Act, which aimed to advance the goal of promoting EHR adoption. It was out of the HITECH Act that the REC program was born. As of April, more than 140,000 health care providers had enrolled in REC programs nationwide; more than 77,000 have installed an EHR; and nearly 11,500 have already demonstrated “meaningful use” of EHR technology.

“In the short time they have been operational, RECs have become trusted advisors for the health care providers they serve and play a crucial role in helping small practices adapt to the rapidly evolving health care environment,” noted Lisa K. Rawlins of the South Florida Regional Extension Center, ARCH-IT’s Vice President. REC programs are modeled on extension center programs such as the Department of Commerce’s Hollings Manufacturing Extension Program and the Department of Agriculture’s Cooperative Extension System which provide vital technical assistance as part of a long-standing tradition of public-private partnership.

The formation of ARCH-IT comes at a critical point in the history of the REC program, as there is no scheduled federal support for the program beyond 2013, even while the small medical practices that desperately need REC services are facing another decade of major technological challenges and operational reform.

“In the near future, these small practices will see significant changes affecting all aspects of their performance: from revamped payment models to Stage 2 and 3 of Meaningful Use, and from privacy and security compliance to the transition to ICD-10. The need for unbiased, trusted advisors like RECs will only grow,” said Greg Schieke of the Nebraska/Wide River Technology Extension Center, ARCH-IT’s Treasurer.

ARCH-IT’s officers include representatives from many of the REC programs across the country, representing some of the leaders and vanguards in health information technology today. The officers include Jonathan M. Fuchs, HITArkansas, President; Lisa K. Rawlins, South Florida REC, Vice President; Greg Schieke, CIMRO of Nebraska/Wide River Technology Extension Center, Treasurer and David M. Bergman, Executive Director.

I wish them all well in this effort. I don't think one can overstate the difficulty the REC effort faces. I'm probably too radioactive to be of any direct help.
REC programs are modeled on extension center programs such as the Department of Commerce’s Hollings Manufacturing Extension Program and the Department of Agriculture’s Cooperative Extension System which provide vital technical assistance as part of a long-standing tradition of public-private partnership.

Yeah. See my immediate prior post, "ObamaScare Section 5405."


False congratulations on the road to meaningful use
Ed Burns, June 22, 2012 

...The numbers certainly are positive. They indicate that the nation is making progress toward the goal of achieving a fully networked healthcare system. But is the new data and the accomplishment of this supposedly ambitious goal really worth celebrating?

Reading the HHS release, in which very serious government officials congratulated each other for this remarkable progress, brought to mind the so-called “You’re not Special” commencement speech delivered recently by a high school teacher in Wellesley, Massachusetts. In the speech, David McCullough bemoans the fact that “we have of late… to our detriment come to love accolades more than genuine achievement.” Could it be that government officials are putting self-congratulations ahead of actual achievements?

Let’s look at the numbers. Sure, 110,000 physicians is a lot. As the HHS release notes, one in five Medicare and Medicaid eligible professionals has already started receiving incentive payments. What’s more, 133,000 primary care physicians and 10,000 specialists were working with Regional Extension Centers by the end of May. That’s a lot of doctors preparing to attest.

But at the time when Mostashari and Tavenner set the goal for attestation progress, more than 59,000 physicians had already started receiving incentive payments, by the pair’s own accounting. Furthermore, about 120,00 doctors were already working with Regional Extension Centers.

With physicians needing to complete attestation by mid-2012 in order to qualify for the full amount of meaningful use incentives and the high numbers of doctors already started on the road toward meaningful use, did the officials really believe it would be a challenge to get some 40,000 eligible professionals to complete the process over the course of the year?

Of course, we should not belittle the hard work of government agencies and medical professionals that helped bring the nation’s healthcare system to this point. Progress is being made. This much is hard to deny. But while we shouldn’t belittle this hard work, we also shouldn’t preemptively congratulate people for achieving something that has yet to be accomplished.

Yes, a good deal of progress has been made in a relatively short period of time. But a significant amount of work remains to be done before the healthcare system is on solid footing again. The problems of runaway costs and relatively poor treatment outcomes call for immediate action. They won’t wait while public officials congratulate themselves on a job well done.

So rather than crow about every minor gain in technology adoption – another 10,000 physicians receiving incentive payments, another $1 billion in bonuses distributed – perhaps officials should let us know when the meaningful use program starts making some meaningful progress toward accomplishing its true goals of creating a healthcare system that efficiently delivers high value by affordably keeping people well. That would be a real sign that congratulations are in order.


In addition to all the health care / HIT stuff I have to and want to read, here are just a few other items of late.

I finished "Debt: the first 5,000 years" a couple of weeks ago (compelling; emblematic of the word "scholarly"). I've been aware of David Friedman's "Law's Order" for quite a while, and have been reading the online draft episodically for a number of months. I coughed up last night via the deadly "one-click" for the published Kindle edition. And, I just started Dr. Farnsworth's "The Legal Analyst." Loving it thus far. The competing practical and ethical implications of ex post and ex ante considerations and all that.

The three, taken together, are presenting me with a nice triangulation -- which in concert don't have anything to do with health care per se, except to the extent of their mapping to the various health care economics arguments.

David Friedman:
If there were only one man in the world, he would have a lot of problems, but none of them would be legal ones. Add a second inhabitant, and we have the possibility of conflict. Both of us try to pick the same apple from the same branch. I track the deer I wounded only to find that you have killed it, butchered it, and are in the process of cooking and eating it.

The obvious solution is violence. It is not a very good solution; if we employ it, our little world may shrink back down to one person, or perhaps none. A better solution, one that all known human societies have found, is a system of legal rules explicit or implicit, some reasonably peaceful way of determining, when desires conflict, who gets to do what and what happens if he doesn’t.
Indeed. David Graeber:
Here we come to the central question of this book: What, precisely, does it mean to say that our sense of morality and justice is reduced to the language of a business deal?
Ward Farnsworth:
We have spoken of minimizing waste. We also could have called it maximizing wealth. A trade increases wealth by making the parties to it better off (that's the only reason both sides would agree to it); this is another way to think about a point discussed a moment ago: the value of contracts.
Is health care just another consumer commodity, one properly governed by contract law in the service of "efficient markets"?

What, indeed, is the moral justification of "markets"? Simply caveat emptor / winner-take-all?
"A trade increases wealth by making the parties to it better off."
Well, I would alter that to read "to the extent that it make the parties to it better off." "Win-win." Easy to advocate; difficult to effect. But, even in a large zero-sum or negative-sum game, there are -- short-term, anyway -- "winners."

Therein lies the difficulty. In the socioeconomic drama sine wave that comprises the evolutionary path of post- hunter/gatherer human history, you can "Texas Sharpshooter" cherry-pick your way into whatever empirical historical trending segments suit your pre-ordained fancy. Kind of like citing Bible verses or otherwise pet philosophers, buttessed by tactically proffered "stories." (See "Why Do Humans Reason?" and "This Time is Different.")

See also Michael Lewis' "Boomerang" for a niftly recent travel guide through the worldwide whack-a-mole propagation of financial risk obligation repudiation, an international Three-Card-Monty game that continues apace at this writing (I think my favorite chapter might be "Beware of Greeks Bearing Bonds").

Yeah, that stuff starts to "exceed my [REC grunt] scope."


Well, yes, that's our whole QC/QA/QI schitck, isn't it, at root? (I've documentably drunk the Kool Aid.) "Improvement" by definition "reduces waste" (and, "Lean" theory makes waste elimination the explicit goal. See The-Money-Is-In-The-Margins John Toussaint. And, see Deming, and Shewhart before him). But, Farnsworth points out that "minimizing waste," by some accounts, comprises the entire moral justification basis for a system of law. I'd never really thought about it acutely and at length that way. A criminal prosecution or a tort action diverts resources away from otherwise productive endeavors. More centrally, people who do wrong, either intentionally or through negligence are wasting resources.

Notwithstanding, it begs a ton of questions. Is "efficiency" the underlying sine qua non of human socioeconomic existence and progress? I'll have to think about that a bit more. The very notion of a perfectly frictionless economy escapes me.

Cars (and governments) will continue to come equipped with brake pedals, and will continue to operate at less than 100% theoretical "mechanical efficiency."

None of which is to argue that we shouldn't always try to improve things -- to the net benefit of society in the aggregate, I would insist.


UPDATE: From a recent Thedacare white paper
Linking cost and quality of patient outcomes to drive organization and industry improvements
February 2012

Few in the United States are satisfied with the quality of healthcare and the escalating costs to deliver that care. The United States spends more per capita on healthcare than any other industrial country — nearly 18% of gross domestic product — but ranks in the bottom quartile for life expectancy. Despite criticism of U.S. healthcare performance — from patients, employers, insurers, government, and those working in and supporting the industry — the ability to link quality of care with the cost of care (healthcare value) has been elusive.

Gradually efforts have emerged around the country to enable healthcare professionals and consumers to better identify provider costs and quality performance. Recent work performed by the Wisconsin Collaborative for Healthcare Quality (WCHQ) establishes new ground in blending quality and cost into a single, actionable healthcare value measure specific to a healthcare condition. WCHQ proved that such a condition-specific value measure is possible, paving the way for broader development and dissemination of healthcare value measures...

...Quality data provided by WCHQ provider organizations, and Diabetes standard cost data, provided by the WHIO, which consisted of claims-based data submitted by WHIO insurer or payor organizations.

RUWG participants included representatives from several WCHQ organizations and strategic partners who have experience working with resource use data.

The RUWG developed a methodology by which the data from these two different sources could be merged to create a meaningful measure that would provide new insights about the value of the care provided to diabetic patients in Wisconsin. The first set of diabetes value-measure reports was presented to WCHQ members in December 2011. No timetable has yet been set to release the findings publicly. The December release lists diabetes value metrics for each WCHQ organization meeting the criteria for which “apples-to-apples” quality and cost comparisons could be applied, and displays the value metric in a quadrant-analysis format — high quality/high cost, low quality/high cost, low quality/low cost, and high quality/low cost (greatest value):

X axis = cost index (ranked 0.0 to 2.0), and
Y-axis = percentage of all-or-none diabetes control measure (0% to 40%)

(Click the title for the full paper.) Well, where have we seen this kind of nil Pearson buckshot before? e.g., HEDIS 2010 (scroll down, Oct 2010 post):

Can we methodically find the ops correlates connecting process efficiencies with clinical effectiveness? One of the many difficulties here is that of shooting at a moving target, i.e., therapeutic advances frequently surface randomly, once adopted they create their own demand (particularly should they be of the life-saving variety), and uniform workflow processes for their effective deployment do not simply fall into everyone's lap fully-formed.

Getting at "value" in health care is pretty messy.

Again. from Dr. Toussaint's "Potent Medicine" -
Physicians and healthcare leaders have relied too much on a strategy of revenue growth in recent years. We would buy a new gizmo or gadget—more advanced MRI machines or the latest in robotic surgery equipment—enabling us to charge more and, hopefully, grow market share by advertising new capabilities. With healthcare fast approaching 20% of the nation’s gross domestic product, however, this strategy is unsustainable. The nation cannot afford us.
Actual revenue for the healthcare system will decrease. We all see this coming. The questions are how we will live in the new reality and who will take the hit.
The answer is in the value stream. Organizations that see the value streams by which we deliver healthcare to patients, end to end, and learn to identify and remove waste will survive. Those that understand we are paid to maximize the health of patients will thrive.
Achieving financial stability in the new reality will mean removing waste from the system faster than revenue drops. When organizations reduce the cost of care, there will be money left over. When quality improves, there are fewer complications, infections, and readmissions due to error. When we perform fewer unnecessary procedures, less duplicative tests and consultations, wasted time and money is returned to the bottom line. The money, again, is in the margins. (Kindle Locations 2010-2017)
So, the margin will have to grow as a percentage relative to gross revenue, the latter of which has to decline ("Bending The Cost Curve"), per capita, anyway.

Tall order.

So, in recap,

Is health care just another consumer commodity, one properly governed by contract law in the service of "efficient markets"?

I would take issue with the framing assumptions implicit in the conventional question. The "Health Care Market" is anything but monolithic. Moreover, even countering "no, it's a right" need not assume a blank check. Some aspects might well be best served by private markets nimbly, "efficiently" serving their respective niches (I have to agree with that, btw). But, as I expressed 3 years ago on another blog of mine,
How can we say that people have an "intrinsic right" to military defense, or to police and fire protection, (or to safe food and water, or to otherwise safe products that won't electrocute us when we plug them in)? Well, we simply say it. And then we codify it. And, then, having codified it, we don't lie awake nights worrying that everyone will demand a Special Forces FOB dug into his or her front yard, or an occupied Metro PD Black & White, an ambulance, and a hook & ladder truck parked at the curb 24/7.



Doctors Say Medicare/Medicaid EHR Guidelines Onerous
Posted on June 21, 2012 by Amber Walsh

Doctors and organized medical associations are voicing their objections to proposed Stage 2 Medicare and Medicaid guidelines, saying the new standards are far too demanding for many smaller and less-sophisticated medical practices. Practitioners are asking that requirements be within a physician’s control and not rely on a third party’s use of technology; e.g., a patient or laboratory. The AMA, as well as 98 state and specialty societies, also argue that EHR penalties should not be backdated. These organizations also strongly oppose CMS (Centers for Medicare & Medicaid Services) plans to cut rates by 1% in 2015 and 2% in 2016 for not meeting ‘meaningful use standards’ by October 2014. It should be said that CMS has provided exemptions from penalties in certain practices...

Yeah. I have my doubts that RECs will be around to assist with this..

More to come...

Saturday, June 16, 2012

ObamaScare Section 5405

"and other purposes."

"Facilitating Improvement in Primary Care: The Promise of Practice Coaching"

My friend Dr. Joe Fortuna, outgoing ASQ Health Care Division Chair, sent me a copy of the above-titled Issue Brief the other day. While I knew that "ACOs" and a raft of other "improvement/innovation" initiatives were authorized by the soon-to-be-SCOTUS-ajudged  PPACA (derisively, "ObamaCare"), this Section had escaped me.
Practice coaching in health care is rooted in the agricultural extension agent model of the early 20th century. In 1903, the U.S. Department of Agriculture started a program by which agricultural experts would visit farmers, develop ongoing collaborative relationships, suggest improvements, and facilitate the sharing of best practices. The program was highly successful as farmers, seeing the increased yields and profitability of early adopters, improved their agricultural methods. In 1914, Congress created the Agricultural Extension Service (AES)—now the Cooperative Extension Service—and, by 1920, 7,000 extension agents were working in almost every county of the nation.
Many primary care services in the United States are delivered by relatively small, independent private practices and community health centers lacking the robust quality improvement infrastructures found in hospitals and big medical groups. Just as small farmers were most in need of the kind of support provided by the AES, it is these smaller physician practices that are most in need of help. Donald Berwick, M.D., then president and CEO of the Institute for Healthcare Improvement, recognized this reality when he wrote in 2003 that “American health care could benefit greatly from the establishment by the federal government of a Health Care Extension Service modeled on the AES.” In 2009, physicians Kevin Grumbach, M.D., and James Mold, M.D., detailed how a health care cooperative extension service for primary care might look, with practice coaches serving as extension agents to spread the best practices of early adopters to primary care practices across the nation.
A year later, the Affordable Care Act of 2010 authorized creation of the Primary Care Extension Program along the lines proposed by Grumbach and Mold, and in 2011 the Agency for Healthcare Research and Quality—the agency charged with implementing the program—issued a call for proposals to award three states grants for primary care extension programs. Although Congress has not appropriated funds to implement the nationwide program, the many state and regional models of practice coaching being implemented—for example, by the Vermont Blueprint for Health, Colorado HealthTeamWorks, LA Net in Southern California, and federally funded regional extension centers promoting meaningful use of electronic health records [emphasis mine]—affirm the belief in many quarters that most practices cannot undertake needed transformation without such a mechanism in place.
Practice coaching can be viewed as analogous to self-management health coaching for patients. Coaching patients with chronic conditions means imparting patients with the knowledge, skills, and confidence to self-manage. Coaching does not do things for patients; it helps patients do things for themselves. The practice coach helps physicians and their staff gain knowledge and skills in the science of improvement so that they can continue to improve long after the coach is gone. Empowering practices to become their own agents of change is one of the features that distinguishes coaching from consulting...
Interesting. Two years ago RECs started out with all this noble rhetoric about helping "physicians and their staff gain knowledge and skills in the science of improvement...Empowering practices to become their own agents of change..."  -- and I am personally no exception, being a quarter century True Believer in QI; e.g., see my standard introductory workflow improvement deck (PDF) I use to try to sell the effort to small practice staffs. I am always frank to acknowledge that "if you burn up all of the MU incentive money in added labor cost resulting from more onerous workflows, what's the point?"

But, the boots-on-the-ground  REC technical assistance staffing reality largely dictated Milestone progress body counts.

So, today, we end up with stuff like this:

A Funny thing Happened on the way to Meaningful Use
Rob Lambert, MD
This July will mark the 16th anniversary of the installation of our electronic medical record.

Yup.  I am that weird.

Over the first 10-14 years of my run as doctor uber-nerd, I believed that widespread adoption of EHR would be one of main things to drive efficiency in health care. I told anyone I could corner about our drive to improve the quality of our care, while keeping our cash-flow out of the red. I preached the fact that it is possible for a small, privately owned practice to successfully adopt EHR while increasing revenue. I heard people say it was only possible within a large hospital system, but saw many of those installations decrease office efficiency and quality of care. I heard people say primary care doctors couldn’t afford EHR, while we had not only done well with our installation, but did so with one of the more expensive products at the time. To me, it was just a matter of time before everyone finally saw that I was right.

The passage of the EHR incentive program (aka “meaningful use” criteria) was a huge validation for me: EHR was so good that the government would pay doctors to adopt it. I figured that once docs finally could implement an EHR without threatening their financial solvency, they would all become believers like me.

But something funny happened on the way to meaningful use: I changed my mind. No, I didn’t stop thinking that EHR was a very powerful tool that could transform care. I didn’t pine for the days of paper charts (whatever they are). I certainly didn’t mind it when I got the check from the government for doing something I had already done without any incentive. What changed was my belief that government incentives could make things better. They haven’t. In fact, they’ve made things much worse...

...My dream of universal acceptance of EHR has turned sour. I am beginning to hate the words: “meaningful use.” I am starting to fantasize about a life without it, and maybe even a life without anybody else’s definition of what the care I give should look like. I want to be a doctor.  I want to take care of my patients. I want them to be the most important thing, not the other people enticing me with their big checks. Can I stay in our system while still giving care that is meaningful?
Ouch. And, this doc is no Luddite crank. Read the entire post.

Also of late, apropos of the issue.

Unraveling the IT Productivity Paradox — Lessons for Health Care
Spencer S. Jones, Ph.D., Paul S. Heaton, Ph.D., Robert S. Rudin, Ph.D., and Eric C. Schneider, M.D.
N Engl J Med 2012; 366:2243-2245June 14, 2012

There is ongoing debate about the wisdom of the $27 billion federal investment driving the adoption of health information technology (IT) under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. Proponents expect IT to catalyze the transformation of health care delivery in the United States from a fragmented cottage industry plagued by poor quality and high costs to a highly organized, integrated system that delivers high-quality care efficiently. Skeptics suggest that the productivity benefits of health IT have been overstated, arguing that it may create safety problems and could even increase costs...

New health IT systems risk failure if usability isn't carefully addressed. User-centered design calls for end users to be involved in every stage of product development. The principles of user-centered design have improved usability for many IT products. The merits of such design processes are illustrated by the evolution of “smartphones,” from their early monochromatic displays and clumsy thumb keyboards to today's high-definition touch screens that use the electrical properties of the human body to enhance responsiveness...

...The resolution of the original IT productivity paradox suggests that current conclusions about the value of health IT investments may be premature. Research suggests three lessons for physicians and health care leaders: invest in creating new measures of productivity that can reveal the quality and cost gains that arise from health IT, avoid impatience or overly optimistic expectations about return on investment and focus on the delivery reengineering needed to create a productivity payoff, and pay greater attention to measuring and improving IT usability. In the meantime, avoiding broad claims about overall value that are based on limited evidence may permit a clearer focus on the best ways of optimizing IT's use in health care.
Another good article.

So, where does all of this leave us?

Absent replenished funding from some source, RECs are effectively done next summer. As I've noted before, we are not funded for Stage 2 (which now doesn't ensue until 2014), and were I a 2011 Meaningful Use Attestor (Medicare EP), I'd have collected 87% of the total reimbursement potential ($38k/$44k) just for Stage One. OK, I'm trying to understand my ROI prospects for Stage Two here.

There are some looming barriers here, leaving aside the carping HIT critics (and I in no way mean to imply that Dr. Lambert is among them; he's one of the good guys). The brave, fashionable REC talk of "sustainability" these days has to leave one dubious.

I have made no secret of my frustration with this recent headline.

My comment?
I’d be interested in any initiatives aimed at “Positioning REC for Continued Success.” I have a concern that a brain drain may soon ensue.
Silencio. Zip, Zilch, Nada. Two years ago ASQ's Dr. Fortuna offered the good offices of the ASQ Health Care Division, pro bono, to ONC to help with in-the-trenches improvement efforts of the sort envisioned in the "practice coaching" and Primary Care Extension Centers concepts alluded to above. Those polite discussions went nowhere.

The need remains. The need goes beyond ONC being politically seen as a "success" in Secretary Sebelius's eyes.

Beneath the Jurassic DC Rain Forest Canopy that is HHS roam a number of territorial beasts of varying defensive perimeter ferocity: CMS, AHRQ, ONC among them. PPACA Section 5405 bestows upon AHRQ the authority to establish and administer "Primary Care Extension Centers." Yeah, that'd go over well in other Beltway shops.

Beyond turf contention considerations, and assuming PPACA survives the looming SCOTUS challenge decision (wholly or in pieces), I would think it to be an extreme long shot for 5405 initiatives to get publicly funded, given both the 2012 election year and the larger federal budget deficit problems that will await the next President and Congress.

But, again: the need remains.
Dr. Toussaint's new book sheds some useful light on addressing the need (it just came out on Kindle, so I can now more conveniently cite passages from it).

Change is bearing down fast on healthcare in the United States—not small change but a full overhaul of the system that will be as disruptive as it is inevitable because we can no longer afford to pay huge bills for substandard care.

As a doctor, a Chief Medical Officer and then CEO of major regional health system, I know that our biggest challenge is the immense waste in our care delivery system that causes poor quality and inflated costs. The magnitude of this opportunity is mind-boggling. The Institute of Healthcare Improvement reports that 30–50% of care delivery is wasteful, meaning that it is of no use to the patient. Translation: $750 billion per year could be saved if we get rid of the waste.

Around the country, various groups have been attacking the issues piecemeal. Several health systems have made great strides toward increasing healthcare quality and reducing medical harm, but are working in isolation and often end up struggling against a system that actually rewards waste and error. Meanwhile, the major proposals for healthcare reform focus on financial structures and money flow, on changing who will be insured, by what rules and by which intermediaries. These proposals do little more than shift around risk and create new layers of guidelines, rules, and laws while the root of the problem—quality—remains untouched. The largest piece of healthcare reform legislation passed in more than a half-century, the 2010 Affordable Care Act, bears an estimated cost of about $1 trillion over the next 10 years, but does not go far enough. We can improve upon it if employers, providers, patients, and governments work together to ensure better quality, affordable healthcare.

We need a healthcare system that focuses on healing, that encourages innovation without dictating how a patient receives care. This will require a systemic overhaul... (Kindle Locations 55-67).

First, we need to see. In order to build a true picture of any healthcare system, we must identify the data that accurately illustrate reality regarding quality and cost, and then publish that data in a way that people understand. When we achieve this type of transparency, everyone will have the same picture.

Next we must redesign the payment system, which is the tail wagging the healthcare dog in this country. Right now we pay for procedures, so Americans get more procedures and pay more for them than citizens of any other industrialized nation. What we really want to pay for is health and appropriate interventions to achieve ongoing health—a goal that can only be accomplished if we have adequate transparency in the system and can see what we are paying for and how much.

Finally, the true purpose of a meaningful redesign is to reorganize healthcare around the needs of the patient instead of the convenience of insurance companies or doctors. Better care for the patient is the real goal and, with every change, we must ask how it serves patient health. Without a healthier population receiving better care, any redesign is wasted effort (Kindle Locations 84-93).
Tall order. Noble and true sentiments. Below, toward the conclusion of the book:
ThedaCare’s decade of experiments with continuous improvement proved there was a minimum 30% waste in our healthcare processes. Often, the wasted time, energy, and materials in a process was closer to 50%. These experiments have been repeated in dozens of healthcare organizations in the United States, Canada, and elsewhere with the same results. 

The United States spends $2.5 trillion in healthcare every year. The 30-percent-waste in healthcare estimate is widely accepted. That means healthcare waste equals $750 billion every year. So, there is a lot of money in the margin. 

Organizations that aggressively remove waste and redesign care-delivery systems will be the ones able to pay physicians, nurses, and therapists better wages. (Likewise, healthcare professionals who take the most waste out of care processes will be highly prized.) In the end, the improvement-focused systems will be able to attract the brightest talent. 

Existing finance mechanisms and vertical silos, however, are deeply entrenched in our healthcare systems. Moving to new compensation techniques that support healthcare value will require some trial and error... (Kindle Locations 2017-2026). 

To find the most workable model, we need to return to the scientific method—observation, hypothesis, testing, and modification of hypothesis or action. Before one payment type will emerge as the clear winner, we need regional health systems to conduct experiments with global and bundled payment for health episodes, and shared savings models. Experiments need to begin now, with reports published in peer-reviewed journals, giving everyone in the medical community an opportunity to see the evidence and join the debate (Kindle Locations 2045-2048).
Continuing with the process improvement theme he proffered in "On The Mend," Dr. Toussaint again exhorts the utility of the lean model:
In a lean environment, physicians and staff use the scientific method to guide their work in the form of PDSA—plan, do, study, act. Instead of searching for a person to blame, they use PDSA to study the cause of error, devise a plan to correct the system—which is usually at the root of error—and then fix the process. This means that errors must be laid bare for everyone to see, as opposed to hidden. This is another type of transparency demanded in a lean environment. When everyone knows that errors exposed are actually opportunities to improve the system through PDSA instead of avenues to shame, people are less likely to hide their errors and compound problems (Kindle Locations 2058-2062).
Color me a believer. From one of my slide decks:

Notwithstanding the truth of all that, a respect for small practice barriers also required this slide in my deck.

"Staff ownership of Lean projects" -- in other words, the result of effective "Practice Coaching," 'eh?

Irrespective of what happens to ObamaScare this month (and Section 5405's "Primary Care Extension Program" proposal) or us RECs, the need will not go away, particularly within the small shop primary care setting -- places where time and margins are stretched so thin as to even make our offers of "free" federally underwritten assistance a tough sell. These are not clinics that are going to pay $125 - $200 per hour (or more) for consulting/"coaching" help.


WALTHAM, Mass.—It is a widely accepted myth that medicine requires complex, highly specialized information-technology (IT) systems. This myth continues to justify soaring IT costs, burdensome physician workloads, and stagnation in innovation — while doctors become increasingly bound to documentation and communication products that are functionally decades behind those they use in their “civilian” life.

Even as consumer IT — word-processing programs, search engines, social networks, e-mail systems, mobile phones and apps, music players, gaming platforms — has become deeply integrated into the fabric of modern life, physicians find themselves locked into pre–Internet-era electronic health records (EHRs) that aspire to provide complete and specialized environments for diverse tasks. The federal push for health IT, spearheaded by the Office of the National Coordinator for Health Information Technology (ONC), establishes an information backbone for accountable care, patient safety, and health care reform. But we now need to take the next step: fitting EHRs into a dynamic, state-of-the-art, rapidly evolving information infrastructure — rather than jamming all health care processes and workflows into constrained EHR operating environments.

We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants. In reality, diverse functionality needn't reside within single EHR systems, and there's a clear path toward better, safer, cheaper, and nimbler tools for managing health care's complex tasks.

Early health IT offerings were cutting-edge, but contemporary EHRs distinctly lag behind systems used in other fields. In 1966, members of Octo Barnett's laboratory at Massachusetts General Hospital invented a highly efficient programming language for the earliest EHRs; the Massachusetts General Hospital Utility Multi-Programming System (MUMPS) partitioned precious computer memory so parsimoniously that with only 16 kilobytes, the earliest personal computers could run an EHR supporting multiple users. But nearly a half-century later, most EHR vendors not only have failed to innovate but don't even embrace existing modular architectures with interfaces that allow extension of product capabilities, innovative uses of data, and interoperation with other software...
...Loss of technological leadership reflects apathy and even opposition by EHR vendors to promoting liquidity of the data they collect. This attitude has thwarted medicine's decades-long quest for an electronic information infrastructure capable of providing a dynamic and longitudinal view of the health care of individuals and populations. EHR companies have followed a business model whereby they control all data, rather than liberating the data for use in innovative applications in clinical care.

Conducting a Google-style search of an EHR database usually requires involvement of a clinician's information services department and often the specialized knowledge and cooperation of the vendor's technical teams. In reaction, scores of academic medical centers have exported data into a common open-source system where population-level analytics are managed outside the vendor, and results shared across sites...

Commercial EHRs evolved from practice-management (i.e., billing) systems, and in response to the patient-safety movement, vendors tacked on documentation modules and order entry for physicians. Since each EHR product has been built as an isolated silo, the market for any good innovation is fragmented. Additional problems arise when complex software that was never engineered adequately must be reimagined, reinvented, and reimplemented repeatedly...
...Health IT vendors should adapt modern technologies wherever possible. Clinicians choosing products in order to participate in the Medicare and Medicaid EHR Incentive Programs should not be held hostage to EHRs that reduce their efficiency and strangle innovation. New companies will offer bundled, best-of-breed, interoperable, substitutable technologies — several of which are being developed with ONC funding — that can be optimized for use in health care improvement. Properly nurtured, these products will rapidly reach the market, effectively addressing the goals of “meaningful use,” signaling the post-EHR era, and returning to the innovative spirit of EHR pioneers.
One would hope. But, then again, transparency and vendor margin remain inversely correlated. And, it remains to be seen just how much more "ONC funding" will continue to flow (outside the Beltway, anyway). 


I've been an enthusiastic and loyal member since the late '80's, and have benefited much from belonging to the Society (as has my wife). When I returned to HealthInsight in 2010 for the REC effort, I made contact with a number of ASQ division leaders. Joe Fortuna responded enthusiastically, as I have noted before. He went so far as to invite me to participate in a Division Leadership conference in Milwaukee on ASQ-HCD's dime.

Other than Dr. Fortuna, my inquiries yielded only one other response -- from a Software Quality Division official, warning me that I might be using the ASQ logo without authorization.

Seriously, dude? Seriously?

I checked. I don't need "permission."

My whole point in seeking out Software Quality Division leaders was, well, you know, HIT. From the "About" page:
As stewards of the software quality profession, we are the global nexus for knowledge and recognized champion for excellence in software.

To provide members the benefit of collective learning, enabling them to be more effective practitioners of software quality and greater contributors to their employers, customers, and the profession.
The Champion for Excellence in Software. Except, it would seem, where HIT software is concerned. Search their site for "EHR," EMR," or "HIE."

That is pretty discouraging. 

I recall during the early-mid '90's, while serving as the Las Vegas ASQ Section Chair, that we had a "software life cycle quality" meeting presentation put on by a member whose job entailed fighter aircraft avionics software development at Nellis AFB. It was pretty impressive. I would like to think that HIT, within its own "space," is equally mission-critical and deserving of ASQ attention. Ya think?

"Logo use permission"? Seriously?

 Another cute little ASQ head-scratcher. I signed up to join a number of relevant LinkedIn groups a couple of months ago. The status of this one, below (yesterday):

Whatever. So, how're those Lean Enterprise Division quarterly meeting minutes notes coming along?

Carry on...

Maybe we'll get a SCOTUS ruling this week. Maybe not. If not this week, then inexorably next week. I thought it might be last  week. I was wrong.


No SCOTUS ruling today. In other NEW$...

Interesting. We'd applied for one of these CMMI grants. I had to write a section of the proposal, something about "patient self-management coaching" for three major chronic conditions (I had what we called the "clinic coaching" piece -- essentially "practice coaching"). I was dubious. We have some potential conflict of interest, quite frankly.

They awarded 107, out of what I heard was about 5,000 applications. It was a long shot out of the gate, nominally a ~2% probability of getting awarded, all else being equal (which it is most certainly not).

So they're expecting about a 111% 3-year ROI on these (~$.9 billion in grants). Right. Bend.That.Cost.Curve.

Push the money out the door ASAP. "Obligate" those funds against recission.


Still following this one (relative drops in the HH$ bucket, to be sure).
...The outcome of the [$793,456] evaluation will be a report including recommendations for enhancing and improving the Workflow toolkit. The report will provide results about the perceived usefulness of the Workflow toolkit. Results will be produced separately for practices and RECs as well as for both user groups as a whole. The report will also include specific suggestions on how to revise Workflow toolkit to make it more useful to its intended audiences.
AHRQ originally paid $494,028 for the "HIT Workflow Redesign Toolkit" (a rather pedestrian and dated compilation, IMO). Which, they now propose to consume an additional two years and $793k to "evaluate" (and, the evaluation of which looks troubling like it may perhaps involve some of the same entities contracted to produce it in the first place; still running that down).

I'll work for 10% of that, and you'll get a thorough and cogent report by the end of this year.

Seriously, people? This is John Stossel material.


I know the ObamaScare SCOTUS ruling has everyone on edge, but the Omnibus HIPAA HITECH Final Rule is under EO 12866 review at OMB. Their 90 day review period expires this Friday (June 22nd), but Dr. Mostashari recently said that the Final Rule will be released "by late summer." OMB can extend the review period one time for 30 days, but "[U]nder the Executive Order, the review period may be extended indefinitely by the head of the rulemaking agency."

Be nice if they issued it this Friday. It's under wraps until released, so we have no idea to what extent the Interim Rule Public Comment Period recommendations were incorporated.

Tick, tick, tick...


He's right. I read and wrote up his new book a little while back. It dovetails nicely in many respects with Dr. Toussaint's new book "Potent Medicine."

Monday, June 11, 2012


I'm having to help write some core draft "Policies and Procedures" for our new HIE (Breach Notification, Disclosures Accounting, HIE Employee Confidentiality Agreement, etc). I know what I need to do, but I spent a bit of time late in the week seeing what other HIEs have done, to the extent that they've posted stuff on their sites.

I have never seen so much crap.

Do these people get paid by the word or page? “Procedures” sections bloated up with what are really redundant regurgitations of policy statements?  Like, what part of the definition of the word “procedure” do they not understand?
  • Policies tell you "what" and "why."
  • Procedures tell you "how," "who, and "when." **
Now, stylistically, we frequently see the "why" stuff put up front in a "Background, Purpose, and Scope" section -- a Preamble, as it were.
** In some industries it is also commonplace to provide a subsection of "Procedures" entitled "Work Instructions" -- a granular level enumeration of short cycle repetitive tasks embodied within a procedure. Procedures and work instructions essentially comprise "workflow" and should reflect specificity, efficiency, effectiveness, and logical coherence.
There are other conventional housekeeping elements whose order and format may vary, to be sure:
  • Definitions, acronyms
  • References
  • Attachments
  • Revision Control
  • Approvals
  • Required Records

A template I recently circulated to staff (I more or less filched this from my wife, though we've both been immersed in such things since the '80's):
I. Background, purpose, and scope
Compose the “Why” statements here, (the legal/contractual/regulatory context, purposes, and limitations). Clearly summarize the need and the boundaries.

II. Policies
Insert the “What” statements here (“Shalls” [the required] and “Shoulds” [the recommendeds, where appropriate]). Declarations of corporate, legal and regulatory compliance requirements and recommendations that map to background, purpose, and scope.

III. Procedures
Insert the “How” (e.g., methods/processes, tools, information, documentation) “Who” (can be generic, i.e., “The Privacy Official or his/her designee”), “When” (how often/frequency) statements here. How shall we go about demonstrably complying with Policy?

IV. Required records
Maps back to procedures (documentation). Answers the question what if we were to be audited? Could we demonstrate that we have procedurally walked our policy talk? Auditors seek to “confirm that what is there is documented and that what is documented is there (and, that it all complies with purpose and scope).”

V. Acronyms and definitions
Insert all that apply.

VI. References
Insert all that apply (e.g., legal, regulatory, industry standards, publications, etc).

VII. Attachments
Note as applicable (usually required forms identified in Procedures sections).

VIII. Approval(s)

Signature: ________________________________________
Date: ______________________

Print Name: ______________________________________

Not exactly rocket science. (I've posted on the topic before).

From two P&P sections a major eastern U.S. HIE:
Title of Policy: Compliance with Law and "HIE" Policies
 Title of Policy: Use and Disclosure of Protected Health Information (PHI)

"Procedures"? Those are ""shall do X" policy statements.

One nice breath of fresh air amid all the rhetorical smog I slogged through was the Policies and Procedures page on the VITL website (Vermont Information Technology Leaders).



Meaningful use’s stage 2: A recipe for failure
The proposed next stage of the EHR incentive program promises to be so burdensome as to discourage embracing the technology it is attempting to promote.
Editorial. Posted June 11, 2012.

Winning over skeptics was, no doubt, a big consideration in crafting the first stage of the federal electronic health records incentive program. The requirements were substantial, but for many physicians, they also appeared to be achievable. With stage 2 on its way, the new unrealistic demands of the program now seem better suited to creating cynics...
Interesting. See also "Missive from the DMZ" on The Health Care Blog. David Shaywitz's "What The Emergence of an EMR Giant Means For the Future of Healthcare Innovation" is equally interesting (the "giant" being EPIC).

Each Indemnifying Party’s indemnity obligations hereunder shall be subject to the Indemnified Party: (a) promptly notifying the Indemnifying Party in writing of the claim (except that any failure to promptly notify the Indemnifying Party shall excuse the Indemnifying Party’s obligation to indemnify only to the extent of any prejudice to the Indemnifying Party resulting from such failure); (b) granting the Indemnifying Party sole control of the defense and settlement of the claim; and (c) providing the Indemnifying Party, at the Indemnifying Party’s expense, with all assistance, information and authority reasonably required for the defense and settlement of the claim.
Okee-Dokee... From a document I had to review. You too can make $500 an hour composing such inscrutable gibberish. You'll pay off those law school loans in no time.


Public health: Where policy is tougher than police work
June 11, 2012 | Tom Sullivan, Editor
WASHINGTON – For anyone who thinks walking the police beat on big city streets is a hard way to earn a living, ONC’s Jason Kunzman might just set them straight.

“I used to think law enforcement was a tough gig,” said Kunzman, a former Baltimore policeman. “Until I got into policy.”

Variations on that theme wove through three public and population health sessions on Tuesday here at the Government Health IT Conference, be that about electronic health records, information exchange, or distributed query, among others.

Kunzman, a project officer at ONC, questioned the perception that health IT will deliver “unbelievable improvements and dramatic changes” as easily as deploying the technology, and asked panelists if their experience proved that?

In Southeast Michigan, six major health systems run a variety of different vendors’ electronic health records products, according to Steven Grant, MD, executive vice president of physician partnerships at Detroit Medical Center.

“If you think they talk to each other or want to talk to each other, then you’re dreaming,” Grant said. “When everybody gets together they all make nice, when they get back to their office, they think about how to beat the brains out of each other so they can be the one standing.” ...
Yeah. Opacity = "Business Intelligence" = Margin.

Courtesy of JDSupra

Last week at the OCR/NIST conference, Building Assurance through HIPAA Security, Linda Sanches of the Office for Civil Rights provided an extensive update on the pilot HITECH audit program, including preliminary findings,  what regulated entities can expect next and suggestions for covered entities concerned about being audited...

...The most common privacy findings included misuse of the PHI of deceased individuals, compliance with the patient confidential disclosures right, disclosures for judicial  proceedings, compliance with the patient access right, failure to follow policies and procedures, no evidence of policy and procedure implementation, insufficient policies and procedures, [emphasis mine - BG] failure to review and update policies on an ongoing basis, and failure of the organization to prioritize HIPAA compliance...

Policies and "Pruh-SEE-jers," folks.


From a nice article by L.A. health law attorney Carol Scott, a couple of money shots.
Physicians Beware, HIPAA Violations can Affect Your Bottom Line Regardless of the Size of Your Practice
Written by  Carol D. Scott, JD, Fenton Nelson, June 13, 2012

...Token compliance with HIPAA is not enough. It is not enough to reprint canned policies and procedures; the provider must train staff, conduct risk assessment of the potential risks and vulnerabilities to the confidentiality, integrity and availability of PHI held by the provider. Practices must appoint a privacy and security officer and ensure that it has reviewed its entire operation for compliance with the Privacy and Security Rules and understand its technology to determine if and under what circumstances PHI can be accessed on its systems. 

Documentation of HIPAA policies and procedures and training is essential, as are disclosure logs, investigations and disciplinary actions....
It's a lot of work. Too much for a lot of small shops to bother with. Until OCR comes knocking.

More to come...