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Wednesday, December 12, 2012

#ONC2012 #HealthIT #RegionalExtensionCenters

So, today, while taking and making REC calls, I watched a bunch of the Day Three ONC2012 live webcast in my cube, also watching the live twitter feed that was embedded on the page.

I had a tweet question of my own for one of the speakers, Georgia Republican Congressman Dr. Phil Gingrey.

Transcript of his talk. You decide.

We have another special guest with us today, and unfortunately our guest Congressman Phil Gingrey Georgia 11th district does have a vote to run to, so left us without too much of an overlong instruction, if everyone could take your seats and get started Congressman Gingrey is a member of the energy commerce meet, over activities we have here at ONC and also as a physician, OB-GYN who trained at memorial hospital, did residency at medical college of Georgia, he also has been a major driver and chair of the GOP doctors caucus, and provides that clinical perspective to the health policy discussions and activities that have been going on.

And I want to thank Congressman Gingrey for being with us today, and turn it over to the Congressman. Thank you. (Applause.)

Well, thank you. Thank you very much for that. It's certainly an honor to be asked to speak, to say a few words and to be introduced by the national coordinator of ONCHIT. I'm always a little hesitant to use that acronym because with the least bit of speech impediment God knows how that comes out.

But we had a little side bar conversation as I was coming in. I have been a supporter of electronic medical records for a long time. I spent 26 years in the private practice of medicine, the specialty of obstetrics and gynecology in my congressional district, the 11th of Georgia, northwest Georgia, the County could be the town Marietta and I know all about shuffling papers, and charts of patients, looking for a report, not being able to find it, when the patient had their last PAP smear.

So clearly I do understand and support. In the interest of full disclosure, although you probably already know, as a Republican member I was not very supportive of patient protection and affordable care act, and I was not very supportive, you could either support it or not support, so yea or nay on the stimulus bill.

But definitely, this aspect of ARRA, American recovery reinvestment act of was it what, February of 2009, I believe, it just struck my eye immediately as something that I thought had the potential and has the potential to get this effort toward a fully integrated electronic medical record system adopted nationwide to every single office of every physician in this country all, what, 850 to 900,000 physicians in the United States.

It is just hugely important, and bottom line of course is that we're talking about not just saving money, and I feel like that if this had been the only thing that we did and accomplished to its full conclusion, and not 1.7 trillion dollars on other things, it would have gone a long way -- and it will go a long way, toward bringing down the cost of health care.

But as I say more important, the ability to save lives, and not make mistakes, and errors.

And I think ultimately, too, I think it will result in in probably better physician provider reimbursement. In fact the numbers to date so far bear that out.

The part of the American recovery and reinvestment act, the stimulus act, of course that I'm talking about, is the HITECH provision. And this idea of trying to incentivize providers, whether it's a hospital or as a designee the professional provider, the doctors, to do that through this incentivize them for meaningful use of electronic medical records.

It really doesn't do a whole lot of good, does it, as all of you know, those of you, many of you I'm sure are vendors, for physician practices to purchase hardware and software and long-term contracts for maintenance and upgrades, and to be able to maybe get rid of the charts in their own offices and have that electronic, but not have the ability to communicate once that patient leaves the office. And maybe even goes to a provider, another provider, another specialist in the same town. But how about if they go across the country or across the pond? That's why ultimately this is so important, and why I continue to be a very, very strong supporter.

Now, saying that, obviously we've got a lot of work to do. And when I'm home in my district and meeting with physicians that are maybe not just constituents who support me with their vote, but constituents who support me financially, and yes indeed there are some doctors that do that, although they're not the easiest nuts to crack from that perspective, you all know that too.

But the last time I was meeting with a group, and I thought it was going to be a kind of a social meet and grate and kind of have a good time enjoy a drink, holiday season -- boy, I got blasted, I really got blasted. And these were maybe 15, 20 of my best friends.

A lot of the doctors that I had actually practiced with, although it's been 10 years now since I was in clinical practice. And they -- there were even some comments to the effect that we don't even want this. We wish it would go away, you know, it's more trouble to us than it's worth.

And clearly, they just need to be more patient. They need to understand that the bottom line of course we all understand, that you maybe take two steps backwards and then hopefully eventually four forward. But the initial investment, the cost of, I don't know, 35, 40, $50,000 per provider, that might not be so difficult if you're talking about a big hospital system that can absorb that kind of investment, but for a small single specialty group practice of two or three in rural America, it's very, very difficult. And then to have a learning curve of six months or so, where your productivity is decreased because you're looking at that computer screen and you're trying to figure out what the right inputs are, and you ultimately hope that you have some time to turn around and look at the patient and examining the patient.

These are some of the concerns that I hear as a former doctor, and now of course as a member of Congress.

My position currently in the Congress, on the House side, is on the energy and commerce committee, one of what's considered exclusive House committees, there are four or five of those, and we're only permitted to be on the one committee because the workload is so heavy.

On energy and commerce, one of my assignments is to the health subcommittee, and along with the ways and means committee. That's where the authorization, we have health information technology is one of the many things that we oversee, on energy and commerce, of course, it's the Medicare part B, all of Medicaid, the SCHIP program.

And there is, you know, a little bit of concern. And I think you all are aware that recently there was a letter sent to secretary Sebelius from both energy and commerce committee and ways and means signed by the chairman of the two committees as well as the chair persons of the two health subcommittees, saying look, you're not -- you're not really progressing rapidly enough through the stages of meaningful use, and maybe you should just suspend the program. Even though I think some seven or $8 billion has already been spent in regard to incentivizing doctors and hospitals to adopt meaningful use.

I have some statistics here somewhere, if I can pull those up. Well, let's see. Between the start of the payments in the spring of 2011 and September of 2012, just over a year, over $7 billion have been paid to providers. In 2012, 72 percent of office-based physicians used electronic health records, which is up from only 48 percent in 2009.

That doesn't mean that they have even reached stage 1, however, of meaningful use.

More than 120,000 eligible health care professionals and more than 3,300 hospitals have qualified to participate in the program.

But as I say, there is this concern, and when you get a letter from the chairman of ways and means and chairman of energy and commerce, saying maybe you should suspend the program for awhile until you get it right, that is a little scary. I mean, it's pretty serious, and it scares me, and I did take the opportunity to read that letter, although I was not part of the discussions and the decision to send such a letter, but it was based on -- and I have these reports with me, obviously not time to go into them in any depth, but I was reading these at 5:30 this morning, I want you to know.

But one from the office of inspector general of the Department of Health and Human Services, and it's titled early assessment finds that CMS faces obstacles in overseeing the Medicare electronic health record incentive program. This is one report that I think the letter was based on.

The other is a government accountability, GAO report, even thicker, titled electronic health records, first year of CMS's incentive programs shows opportunities to improve processes, to verify providers met requirements.

This is all about -- well, was the $7 billion that was spent, has been spent, in the first 14 months of the program, was it taxpayer money well spent. Were these providers eligible, and were they supplying the data that they were required to supply, to the department and to CMS, that would justify giving them the incentive under phase 1 or phase 2. I don't guess the final rule on phase 3 is here yet, but, you know, it brings up some real serious questions. That there is more work to be done, and there are challenges. And, you know, the political landscape, you have to deal with opposition from, say, folks like me to what -- and I don't say this pejoratively, because he has embraced the term, Obamacare or back in 2009 the opposition from the minority, of which I was a part, to spending $850 billion to stimulate the economy and the concerns that, you know, that that wasn't successful.

But I don't want to see any of that opposition destroy something as important as electronic medical records and the universal adoption of that and the interoperability of it, and the security of it. I'm still, as I stand here today -- and again, I thank you for giving the opportunity, I know you've heard from senator Warren on a lot of other great experts in the field, in the space.

And my knowledge is just, you know, maybe a mile wide and an inch deep, that's one of the reasons why I'm not taking any questions. Thank God I've got votes to get me off the hook.

But you know, I think about stage 3, where patients have the ability, maybe, to share with their providers information in their records, or maybe they have the opportunity to directly access those records, and to know what's in their medical records.

I think that's a good thing. It certainly reminds me, though, of the Seinfeld episode when Elaine went to the dermatologist with a rash, and she looked over the receptionist's shoulder at her chart and found out that she was a, difficult patient. You all remember that episode? I am an absolute fanatic over Seinfeld, I think I've seen every episode at least five times.

But and then finally in that episode, you know, she actually grabbed her medical records and went running out of the office with them tucked under her arm, and they caught her at the elevator.

Well, I guess once we get to phase 3 that will no longer be necessary, that people will have access to their medical records. And again, I think bottom line is it's all about saving lives and saving money. And right now we're still struggling with saving money. We have, I think, the greatest health care system in the world, I'm extremely proud of having chosen medicine as my profession and having been 31 years since medical school and practicing all those years and delivering lots of babies, and I miss it very, very much.

And I do empathize with the providers now who are facing all of these burdens and rules and regulations and, you know, whether we're talking about the meeting these requirements and hoping to get a little plus up in their reimbursement on either the Medicare or Medicaid program. You can understand. I think you do understand. And maybe more attention needs to be directed. You're so busy developing hardware and software and making things better and quicker and smaller, and all of the wonderful things that the people in this room do from the industry perspective, but, you know, if you don't have someone to purchase and you're not going to be successful if it's just a few huge hospital systems across the country, you need to sell it to every nook and cranny, every practice across this country.

So that's what it's all about, and I think that gives me a little bit different perspective, and I wanted to come today and share that with you.

Thank you very much for the opportunity, I appreciate it. (Applause.)
Lord, I was born a Ramblin' Man...

Do you support the continuation of the Meaningful Use incentive reimbursement program or not, sir?

Gotta love the poison-the-well conflation of the Meaningful Use program with both "ObamaCare" and the rest of the ARRA stimulus, amply seasoned with foggery allusions to the Sternly Worded Sebelius Letter and the OIG and GAO Reports.

Two words: Concern Troll.


Out with a bang.

Health IT and the Three Part Aim
  • David Wennberg: CEO, Northern New England Accountable Care Collaborative at Health Dialog;
  • George Halvorson: chairman and chief executive officer of Kaiser Permanente, headquartered in Oakland, Calif;
  • Karen DeSalvo: New Orleans Commissioner of Health.

It's a long transcript. Way worth reading.
David Wennberg

Thank you Judy this is a world of small separation I don't know if it's 2 degrees always but you have known George for quite awhile because my previous job Kaiser was one of my clients, and my anecdote which I'll tell which is appropriate for this audience is one time I was going to Kaiser in Oakland and I got in the cab and we were driving in the cab and the cabdriver leaned over to me and said you must work for epic. I said why would I work for epic? Because we just keep taking people up there and back there all the time.

But it's great. And then Karen and I actually had the honor -- I had the honor of working with Karen after Katrina, and have known -- and she's a dine a mo, so really for me it's very humbling to be on this panel.

So the northern health care collaborative it was just started officially started in March we've been working at it for about 18 months, since after the affordable care act had been passed but before NAVCO regulations have been -- had been written.

And it was started, like many of these sort of collaboratives have started in a very grassroots way it happened in '02 of the CEOs of the health care systems in New England and directly and through reputation, the other two entities.

And co-s, we had talked I had been individually talking with them about getting ready for accountable care, whatever it was going to be like.

And I had the benefit of being in northern New England where the relative patterns of care are quite conservative, and so they had been looking for new opportunities to move away from the fee for service environment.

And so these four streams had been going on between the four systems, and actually Dartmouth college which is the other entity that's part of our group.

And I got tired of both driving across north New England and secondly talking about the same thing, and I said look you guys are all talking about the same thing. I had this sort of crazy idea that instead of you each building your own infrastructure of building accountable care what if you came together, the reason we were successful in bringing those two groups, though, is they were only moderately competitive they were more cooperative in terms of how they delivered care across the state. But they also had this understanding that if they did things together it would accomplish two things. One it would probably lower the cost of ownership of building an infrastructure, but more importantly, and I think this is a really part which is a really interesting aspect of the technology, is that if they did things together and actually learned from each other they would actually accelerate their movement into this new world.

In a way -- and sort of this is the underpinnings of our group is that technology is necessary, but it's clearly not sufficient to get to where we need to get to.

So what are we? We have -- we're really a product and a services entity. We're a shared services organization that support these four entities as they're moving into accountable care, and actually we'll be supporting many more as we grow.

And our mission -- and I didn't ask to be on this panel for the mission, I don't think or wasn't asked to be on the mission, but it actually is to deliver products and services to support providers as they migrate from fee for service is, production oriented care, into care that's paid for by capitation and other end global budgets. While delivering efficient and high quality care, aligned with the triple aim. So the triple aim is actually the ending of our mission statement.

The products we're developing is really an integrated information system. We take data from a whole variety of sources, from EPIC, CERNER and Centricity, from a whole core of lab entities including quest and LabCorp.

We get information from the Lowell HIE we get ATD information as well as from that lab entity. And we haven't started yet but we'll be getting patient reported measures in the second quarter of next year.

And we also have claims data. The data is integrated into a patient centric longitudinal record, and it becomes a sole source of truth for the applications that sit on top of that. And as we all know, there is no such thing as truth in health care data. But there is an agreed-upon standard that we can have in terms of what we agree to call truth.

And what we're trying to do by having a single source of truth essentially is to keep everybody on the same page from an information standpoint, so that we can argue about the care we deliver but not about the data and how it's aggregated and organized.

Once the data are in we do a whole variety of product models triggers and alerts and create essentially a population management health management system or as we call it health population one person at a time. And on top of that application care coordinators for physicians and administrators who are looking for the contract performance, if you will.

And again all built onto the same information technology.

We've tried to do some things which are a little bit difficult in terms of having the full nuanced value of a data warehouse with near realtime information and the way we've done that is really through our selective and practical applications of realtime data. And a perfect example of that is our connections with the health info net which is the HIE E in Maine we get HL 7 ADT messages from them essentially in realtime. And those ADT messages are parsed into the critical aspects for managing populations which are transitions from management, ER free standing facilities and that data bypasses the EMR and shows up at the care physicians and care coordinators so they actually know within minutes somebody has been discharged from an emergency room for example.

The application suite we started building in July our first application is rolled out the care coordinator application on Monday, so this is going to be a long weekend.

The physician application is the next, and then the administrator application is the third. We've done something which is a little bit tricky from those of you in the vendor world out there, which is our investors, founders, owners, or also our clients, and that is always a double edged sword but they're actually building the product, we're building a product with them and for them. So that's actually been very fun for me to do that.

And our aggressive timeline is to have the last two applications out before the end -- before July 1st. And the reason we're actually able to do that is we've taken, again, a very practical approach which is we don't want to have it perfect, we'd rather get it out, used, feedback, and then iteratively build that on top of that.

Our goal from an information standpoint is to have not just a regional population based using it systems hospitals and health care providers, but actually reach out across the country. And our goal there is that we have a very intensive benchmarking data in terms of best practices along the triple aim, and the more systems that are involved with that and the more variation, which there's tons of variation, is there, can inform us as we move forward.

I'll stop with the technology and then add the last piece before I turn it over to Karen, which is we're also realize that the information is just as necessary as I said before, but insufficient. So we actually have collaborations around the technology, and we're trying to create a word that in my old age is hard for me to say but I'm getting used to it an ecosystem if you will of users of the information.

So our first one is the new care models so each of these organizations are either pioneer ACOs, or shared saving program -- MSSP ACOs. Three of the four already have commercial ACO contracts, which I didn't talk before but we're actually having Medicare data as well as Medicaid data all into the same information system.

Our first model is the new care model. They all have patient centered medical homes but as you know a patient centered medical home varies dramatically from area to area, and we're starting to get enough data now that we can actually see insights from the way they're constructed, the patient medical home in terms of how they're doing in terms of getting patients actively involved in shared decision-making, improving the care, and reducing the cost.

And that ecosystem, if you will, of data feedback not only is great for product improvement standpoint, but it's really going to be the critical aspect for what we're trying to accomplish here in the end, which is really care associated with the triple aims.

I could go on, but I won't.

Karen DeSalvo

So David was a knight on a Whitehorse and came down to Louisiana when we were still in a debris field to help us rethink how we would build our health care system in a better frame I'm going to get to that but I also want to publicly thank Kaiser Permanente because also immediately after the storm but consistently year after year, your employees volunteer to come to the gulf coast and help our communities continue to rebuild. So we really appreciate that spirit of volunteerism and it's always joyous for them you can tell they love it, we really appreciate that. (Applause.)

So the story that I want to share with you is about the transformation of our health, the care culture, towards reform, and how IT has fit into that, and talk a bit about how the triple aim mirrors that and where we're going for us, really health is the place we are right now with the triple aim, we're beginning to think about how IT forms it.

For Louisiana, we have unfortunately been consistently at the bottom of the pile with respect to care indicators, high costs, poor quality irrespective of payer, and unfortunately have a black box of some 20 percent of our population for whom we really don't know anything about the kinds of care that they're receiving, or the cost of that care, that's our uninsured population.

And for adults that age window of 19 to 64 it's upwards to a third of the population.

And that is unlikely to change, in the near future, but we have found some good end rounds that help us understand. What we did do is we said given that the flood waters of hurricane Katrina closed all of our hospitals essentially and created an opportunity for us to work together in a different way, what would we build.

And we pulled together key stakeholders be it hospital association, physicians, nurses, nursing homes, legislature, academics, and rag tag other people like myself and created a charter with a set of values and a goal that called for everyone to have access to an affordable health insurance product to use health information technology to improve care, to found the new system on primary care and prevention, and to create a culture of quality in a place where we could sit and talk about quality. So it was really four big items for us.

Statewide we've had a lovely resurgence in united care and although in the health rankings we, in Orleans we're in the top 10 percent in primary care providers per capita and that is a deliberate policy action taken after the storm to create a great work environment for primary care, use incentives to recruit and retain providers, and the great environment really was not only the medical home but the opportunity to use data to make decision at a population level so that was using electronic health records primary care structure, Louisiana in particular New Orleans was a place that had relied on the hospital health care system for generations so we did not have health care for insured we have done successly, greater 20 percent of the population uses medical homes and some 100 points of care that range from federally qualified health centers that offer robusts services from dental and medical health specialty care, and just a few mobile units hanging on at some of our harder hit areas like some of the lower parishes

That means that now the uninsured in particular have access to great quality care which we know because their NCQA recognized and/or are a part of a network that uses quality based care, and are part of a collaborative which has formed which I'll get to a little bit later, but we are now it's not just -- it's care but it's good care so we have been able to define that, and define that as a state and as a community, that this is what we should expect for our population.

The quality piece was that we decided we wanted to create a safe place where data could be shared and conversations could be had about health care quality. We established the Louisiana health care quality forum, which carried forward a lot of this blueprint in four areas and continues to this day. The forum became the recipient of a multipayer data base that hebd dialogue, helped to us create. It has now undergone additional iteration and is ready for analytics, I have to tell you after all these many years we're finally getting there.

And has been the leader for two of our ONC grants, the health information exchange, which has been a successful statewide endeavor that has touched the majority of the parishes, counties and states, and has enrolled over 40 hospitals already, and nursing and ambulances and home health agencies thinking about linking together a broader system of care, a recent extension grantee has exceeded the goal in enrolling providers, primary care now specialty care having people obtain meaningful use to the Congressman's point earlier.

The third area that we wanted to look at was health information technology, and how that would enable better care, not just at the point of care, but really thinking at the population level. So for us, this means that when we had this experience that the city flooded and we were shut down for 30 days, under mandatory evacuation, and people were scattered all across the nation, I suspect people in this room sheltered and took care of people.

Those folks left with pieces of paper describing their medications, it was a very unsafe situation particularly for people on chemotherapy regimens or on on anticoagulants so there was a very acute sense for doctors in the community as well as the systems, that we needed to fix that because in times of disaster we need to be more prepared to help people maintain their care, whether that was for, you know, HIV or TB or chemotherapy for cancer.

We also needed to do a better job every day. And the fact that we were building from the ground up, especially the primary care infrastructure, was a tremendous opportunity. We had no legacy systems to move out of, we started by and large from scratch in electronic health records, and many providers, I've seen some of them are here in the community, they can tell you they've already been through a second iteration, a stepping up to a more sophisticated software system, because it really they realize that they wanted to be able to do more for their patients than what the original systems, or they've got en the system to modify. And we've moved in a direction of having the majority of the providers and ie the patients in this community in the New Orleans area be have access to their health information, on electronic health record that is not only relational database but web based and that means if they have to evacuate et cetera we can find that information for those patients, and that's always important.

But it also means that we're able to do a lot more with respect to population management, in the clinics this is so critical when you have limited resources and you want to know exactly, try to understand who you're taking care of and are you doing a good enough job.

I want to get back into that when I get into payment and the last part of the system. But before I get away from HIT I want to tell you a cultural success and then a real success, to the Congressman's point about doctors not wanting to move into health information technology, I say all that like we just implemented electronic health records and now we have an exchange as though it was just as easy as pie.

And of course, it wasn't. But it was easier than I think you could imagine for a variety of reasons. However, one of the memories that I'll Alaska hold is that our state medical society when they had to sign the charter indicating all the things that we believed in for our future of health care in Louisiana was that they needed to change the policy in the state medical society operations manual that said they oppose the use of computers in medicine.


This was the spring of 2006. And they were so excited to be a part of this movement and know now what they do and even though they were grumpy about the challenges they have really been a champion in our state, the physicians as well as many other organizations, to understand how important this is for quality and safety and for cost reduction. So that is an example of how we have really made institutional change.

We are a recipient of a third ONC grant which is a Beacon -- crescent city Beacon grant part of the Beacon grant that's a chance to take all the pieces we had great primary care electronic health records increasing cultural of quality, and put that together in an effort to linked with hospitals and somewhat specialty care and got us to focus on population level indicators and turn our attention towards cardiovascular disease and diabetes something David encouraged me to do seven years ago but it's hard to herd cats.

The institution has done great job to pull community members to get everyone to agree on a set of standards to define what we need when we say our population, 29 diabetes you all know this better than I but it's been a tremendous exercise to get us all focused on what really matters with respect to the population's health, and now the information is live going into an information exchange for our community, I believe there's 170,000 lives in there right now, and there's notification for ER visits.

It's a really tremendous additional tool for providers, and for the clinics to be able to understand how they can do a better job of improving care.

The last piece is about the cost of care and -- well not the last piece, I have one more and I'll be quick. The cost of care is something we have been experimenting with in Louisiana. I mentioned that we talked about having access to affordable health insurance for everyone as part of our charter. We haven't achieved that, but we have worked on some end-arounds to create a financing mechanism at a minimum for the primary care portion of what we have done that has strung together.

And in so doing for the New Orleans area have learned that capitation based is a great way to pay for primary care it encouraged a development of teams and forward approach to thinking of peoples work encouraged providers to work together even though they were competing they were thinking they are stronger together we are now under 1115 waiver which is different than the original grant we have, we've modified that with the help of the state and CMS into a place that will fit in Medicaid it's not exactly where we want it to be with respect to population management but what we were able to do which we could not do under the last grant is actually use the data of Beacon to understand who we care for, what are our quality indicators and how are we showing improvement in that.

So the bonus system isn't about the structure -- oh, you're a medical home -- it's actually you're making [unintelligible]
in the population health so it's a great step forward for those providers, where some of them see they're going as creating NACO type model so they can use in a for value based contracting as the state moves forward.
I want to say a word about health because I'm a health commissioner and I think about it every day, which is my job, so it's a really -- public health is -- has a paucity of actionable data so the information that I work from is often two, three, four years old.

And it's very difficult for me to know if there are hotspots, where there's asthma, that maybe there's a housing issue that I could work with our housing authority on, or where people who are ability challenges live that might need additional emergency services like in flood or power outage one of the many opportunities I see that we have built as a foundation from the data is to have access to that for public policy decision-making. For making policy but also for really helping the community in a crisis situation like disaster.

We just had Isaac in advance of what happened to the east coast with Sandi and the experiences were similar with respect to the power outage and the challenge for some of the elderly and those who are I am mobile, and I think (immobile and I think having the data that is more realtime and more claims data is a tremendous opportunity within Beacon, because it's clinical, right, it's not a stale.

What we're looking at in New Orleans now, though, thinking about health is having all the social determinants. How can we understand who is not using the system, who else is in my community how do I find them and get that information into that multidata pair payer base, much looser idea than just who is using the system. We have gone from zero to within 00 but we know we have a long way to go.

We have a lot to do to understand about our cost equation and how we pay for it better but I think I'm really proud of the progress that we've made. Thank you.

George Halvorson

Very impressive. A couple comments by Kaiser Permanente. We are blessed with being a vertically integrated care system, and we have 9 million members. So we have hospitals, clinics, pharmacies, labs, the entire infrastructure of care within Kaiser Permanente, and we take care of an entire population, and we do it for prepayment.

Which means we're not fee driven, we don't have to do pieces of care, and bill for pieces of care. We get a cash flow from the members, and with that cash flow we deliver care. And we care inside that organization

And it basically is a macro model, and until relatively recently when we were forced to do it for external reasons, we didn't even have a price internally for something like a CT scan for an MRI, because there was no internal structure that involved pricing anything.

Everything was based on costs and budgets and appropriate care.

So we have this vertically integrated system, a population we're accountable for, and we concluded quite awhile ago that the very best way of taking advantage of that organizational model and taking care of that population would be to have sufficient data about the people that we're taking care of, so that we knew what the care needs were, we could track care, follow care, track outcomes. So we decided to go electronic, and we made a commitment to have zero paper inside Kaiser Permanente. We wanted to have paperless clinics, paperless hospitals, pharmacies. We wanted all of our imaging to flow electronically, so we wanted to be filmless imaging.

And we set that model up and have been working on it, and we have pretty much achieved that model. We are basically a paperless care system, and our goal is to have all of the information about all of the patients available all of the time to caregivers at the point of care.

So we set that as a goal. All, all, all. As an agenda, and then designed our rollout of our care systems, and our systems around that.

And it's actually a really good model, it works incredibly well. We've managed to follow up on patient care, focused on patient care. We've cut the death rate for stroke by 40 percent, we've cut the number of broken bones by a third, we've basically our HIV patient death rate is half the national average, we've got one of the lowest dengt rates for HIV patients. Because we've put together a total paj of care, care plans, track patients communicate with the patients, and we put together an agenda that uses the data in systematic targeted ways to follow up on care.

We just put a new system in place that goes into the database and identifies -- we call it the outpatient safety net. The outpatient safety net scans through the database to identify whether or not there were pieces of care that maybe we should have delivered, or reminders that we should have sent out or patients not refilling prescriptions that they should have refilled, and created a scan and identified last year across the care system actually two million opportunities to do interventions, to send somebody a notice out to invite somebody to an appointment or follow up care and we can do that because we have the database and because we have the cash flow model we have.

And when we do something like cut the number of broken bones by a third it doesn't hurt us financially, because we're prepaid and we're not based on those admissions. So that actually saves us about $250 million a year in hospital admissions that we don't have, because we don't have broken bones.

For just about anybody else on the planet that would ab lost revenue. So that's a good model. We strongly recommend it, and we believe that we -- we believe to a passion and meaningful use, we really think if you put data on a computer and don't use it in a meaningful way, that's a waste of money. But if you put data on a computer and then actually use it in a meaningful way that's incredibly powerful and important thing to do and patient care is better as a result of that.

So that's one comment. The second comment I'd like to make is as we look into the future what we believe to be true is that the future is going to have care delivered on four care sites. And the four care sites, the first care site is going to be hospitals, hospital equivalents, nursing homes, places where patients are in bed, and are taken care of over time, and in that setting we need the very best and the very safest care.

We need the lowest infection rates best data flow we need those patients to be taken care of, and we think that inpatient setting is going to be taken equipped with increasingly good electronic, technical equipment. That the inpatient setting is going to get better and better relative to monitoring, tracking, follow-up. So we think that's going to be an improving care site.

We think the second site of care is going to be face-to-face encounters with the patient in the care system, in places where the patient actually goes somewhere to get to the care site. The clinic, the medical office, and we think there's going to be a distribution -- and we think that's going to go to two extremes. One extreme is going to be the mega clinic, the macro clinic, where everything exists, the patients go there and they have one site delivers all care and we're building some of those and we're very happy with them. And the other end of the continuum face-to-face care is going to be the care kiosk, it's going to be the little outpost, the place that sits in the pharmacy or sits in some other care settings or sits in a school or work site, where the patient goes in, has an encounter with maybe a nurse who is connected in an ideal setting upstream with a complete infrastructure of care.

So all the intelligentsia of care is upstream and connected to that patient through the care site, but that care site is going to be very important for a certain number of patients.

So we think that's going to be the second site of care and again that's going to be increasingly supported by really great technology. Computer technology that's getting better every day.

Third site of care, we think this is going to be equally important, is going to be the home. There's a certain number of patients who really need care in their home, will benefit from care in their home, and if we deliver in-home care with the right technology, the right support, the right interaction, the right communications, the right follow-up, we think in-home care is going to replace both of the first two sites of care for many patients, the care is going to be better for those people, it's going to be more proactive, it's going to be -- the interventions are going to be good and the ability right now in the home to have a face-to-face electronic encounter with your doctor or your nurse is getting better every day.

And that whole world of having the home be a site of care, I just heard about this isn't one of us but I just heard about someone who is bringing basically little trailer houses, in the people's back yards and they call them something like grandma -- have you heard of this?


What do they call them grandma sites or something? They're basically bringing them to peoples homes hook willing them up it's a living quarters but it's got great technologies you're doing blood pressure, doing EKGs doing all this on this site, which is in home care, but the future of in home care we think is very, very robust, and it's going to be well equipped

And then the fourth site of care, we believe is going to be the internet. And the internet is going to make the world flat for much care. It's going to be able -- people will be able to get diagnoses over the internet, follow-up care, monitoring of their care, tracking of their care, care plans, care strategies, second opinions.

There's going to be a very rich set of apps that are internet-based apps that will help people, and interestingly, the fourth site of care is going to be a place where a lot of the placement interventions are going to take place, where people are reminded about decisions that need to be active or reminded about decisions to eat well, and that's sort of a place for coaching and nurturing and even some serious counseling, patient-specific.

And the fourth site of care is going to be operating at the level, one level it's going to be very patient -- specific, where it's part of an overall care team, and another level where it's completely disintermediate 88 ing the care system because it's available as was one site very cheap way to purchase for particular pieces of care in a way that's much less expensive than it is at other sites.

So as we look into the future we actually believe that the future of care is going to be supported by technology, in all four sites of care. And that if we do this really well, care will be less expensive, more consistent, and better. Significantly more convenient. And that the care outcomes are going to be better. So we're really optimistic about the future of care, and everything that we're seeing from computerizing the pieces of care and the sites of care that we're working with, causes us to feel like this is the right path. This is the right direction.

And we need to make sure we get this right, because there is no -- there's really no -- I'll end with that, there really is no good alternative to reengineering care. You've got two R words at play. You can either ration care, and there are people who believe this country should end up rationing care, and I think that would be just criminal. And there's the opportunity to reengineer care, make it more affordable. And if we reengineer care more appropriately we can make it more affordable and the rationing question never needs to come up.

So the path that we need to go down, and we need to do it across the country, is the path of reengineering care. So end I'll end with that. 



I just finished Jake Tapper's depressing book "The Outpost."

It's basically another "Restrepo," in print. "The Outpost" chronicles the tragedy of Combat Outpost Keating, which, similar to Outpost Restrepo, was abandoned by the U.S. military after much futile loss of life and limb.
It was madness. 
At Jalalabad Airfield, in eastern Afghanistan in the summer of 2006, a young intelligence analyst named Jacob Whittaker tried with great difficulty to understand exactly what he was hearing. 

The 10th Mountain Division of the United States Army wanted to do what?...

...A small settlement missing from most maps, Urmul was home to fewer than forty families of Nuristanis, or roughly two hundred people, who lived in houses made of wood and rock and mud sealant. The residents were primarily subsistence farmers trying to eke out a living through both crops and livestock, but the U.S. Army knew little more than that about them. 

Coalition forces likewise had next to no intelligence about the enemy in Nuristan— its numbers, its location, its intentions, or, most important, its capabilities— which was one of the reasons the brass was pushing to build a base there. This was the essential difficulty of the task at hand: the higher-ups in the U.S. Army needed to know about the enemy in this unexplored province, so in order to learn as much as they could, they were going to stick a small group of troops in its midst. For all Lockner knew when he flew over Urmul to reconnoiter, the hamlet might have been Osama bin Laden’s secret compound. 

“They’re going to build another outpost,” Lockner told Whittaker and Ives back at Jalalabad Airfield. “So I need you to take this terrain analysis I started, finish it, and make it pretty so I can brief it in the morning."...

"...there’s no good road to get to it— they’re still building that,” Lockner volunteered. 

The Army had been coordinating efforts to build up the vulnerable and narrow path from Naray to Kamdesh, but rain, steep cliffs, insurgent threats, and high turnover rates among local construction workers had led to frequent delays. The road, often running along the edge of a cliff that spilled into the Landay-Sin River, was a mere thirteen feet wide at its widest, and in some spots only half that— narrower than many military vehicles. A soldier could be killed just driving on that road, without ever coming into contact with a single enemy fighter. “And it’s an eternity away by helicopter if something goes wrong,”

Whittaker said. “Yup,” agreed Lockner. “Sir, this is a really bad idea,” said Whittaker. “A. Really. Bad. Idea. Anyone we drop off there is going to die.” As he said it, he thought he saw Lockner’s eyes glaze over...
I don't think we've learned much since Vietnam.

Next up and in process.

When I told my friends I was going to write this book, many of them warned me, “Your colleagues will hate you.” But what happened was just the opposite. Doctor after doctor who read my manuscript told me that this story needs to be told. At the center of this debate is a fast-growing movement of doctors pushing to make medicine less corporate and more personal. They refuse to keep secrets and they insist on being transparent about every option, risk, and mistake. The movement has no leader and no formal membership. But ours is a cause many health care professionals are as passionate about as the practice of medicine itself...

As a busy doctor, I have watched patients increasingly fed up with a fragmented health care system littered with perverse incentives. It’s an industry that does not abide by the same principles of accountability for performance that govern other industries. Instead, our health care system leaves its customers walking in blind. All while simply rewarding doctors for doing more.

...Despite strong evidence that medical procedures should start with checklists, like those that pilots use before flying planes, most doctors did not use them, and to this day many still don’t. Similarly, some notable hospitals choose not Despite strong evidence that medical procedures should start with checklists, like those that pilots use before flying planes, most doctors did not use them, and to this day many still don’t. Similarly, some notable hospitals choose not to staff their intensive care unit (ICU) at night with a doctor. Even more hazardous, a hospital can be well aware of its consistently high complication rate for a service it provides, yet have little or no incentive to do anything about it, leaving the public in the dark about its “danger zones.” Without publicly available metrics of a hospital’s outcomes, how can Americans choose where to go? The only thing most people have to compare is parking

Medicine is competitive, but it is competing over all the wrong things. In the past few years, experts who gauge the quality of medical care have formalized fair and simple ways to measure how well patients do at individual hospitals. These statistics are telling; they identify the good and the bad outliers within a town or city. If you had access to this data, you’d know just where to find the best care in your area. 

So why can’t you get this information? Because Herculean efforts are made to make sure you can’t. I was amazed when I first learned this. But then it hit me: A hospital is no longer the community pillar I knew growing up, with its altruistic mission guiding its decisions. Hospitals have merged and transformed into giant corporations with little accountability— and they like it that way. Patients are encouraged to think that the health care system is a well-oiled machine, competent and all-wise. It’s not. It’s actually more like the Wild West.
This is an interesting read. Dr. Makary is certainly no flake.


"...Our users give us top marks time and time again for our easy-to-use features and our dedicated support—and 'free' just makes a great thing even better," said Ryan Howard, CEO of Practice Fusion. "We've created the nation's largest doctor-patient community thanks to the hard work of our amazing team and the engagement of our users, who regularly provide us the insight and feedback we need to bring them the best product possible."
I only have two REC clients on Practice Fusion. They both like it.

More to come...

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