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Thursday, February 28, 2013


We may be increasingly obese physically in  the U.S., but federal budget "austerity" may abate that trend, 'eh?

As I post this it's 11 p.m. DC time. One hour to go to the onset of "The Sequester," starring Barack Obama, Harry Reid, Mitch McConnell, and John Boehner.


$11.8 billion out the door to date. An utter coincidence that this got announced today. As will be next week's breathless February numbers release at HIMSS13 (today was the close of the 2012 Attestation period for the laggards; I think I have two on my caseload who didn't make the cut).

Just joking. But, it could happen.


I just want to get to NOLA and back without disruption. 

More to come...

Tuesday, February 26, 2013


Heard a cool NPR segment on the way into the office yesterday. Interview with the author of this book, Jeff Speck.


In any meaningful discussion about American health (and health care), obesity has to be front and center. In the mid-1970s, only about one in ten Americans was obese, which put us where much of Europe is right now. What has happened in the intervening thirty years is astonishing: by 2007, that rate had risen to one in three,  with a second third of the population “clearly overweight.” The childhood obesity rate has almost tripled since 1980 and the rate for adolescents has more than quadrupled. 10 According to the rules of the U.S. military, 25 percent of young men and 40 percent of young women are too fat to enlist.

As recently as 1991, no states had adult obesity rates over 20 percent. By 2007, only one state, Colorado, was under 20 percent. 11 Projecting current trends forward, it would seem that 100 percent of the population will be obese by 2080, a year that my children will probably live to see— but perhaps not if they are obese. 

In terms of actual weight, men are now seventeen pounds heavier than they were in the late 1970s, and women nineteen pounds heavier. This means that, independent of population growth, as a nation we have gained 5.5 billion pounds. The real problem, of course, is not obesity itself, but all the other maladies that obesity causes or makes worse. These include coronary disease, hypertension, a variety of cancers— including colorectal and endometrial— gallstones, and osteoarthritis. Excessive weight now kills more Americans than smoking.

Over the past decade, there has been a series of studies that attribute obesity and its related illnesses directly to the automotive lifestyle and, better yet, to the automotive landscape. One effort found that for every additional five minutes Atlanta-area residents drove each day, they were 3 percent more likely to be obese. Another showed that drivers who switch to public transit drop an average of five pounds. A third, in San Diego, reported that 60 percent of residents in a “low-walkable” neighborhood were overweight, compared to only 35 percent in a “high-walkable” neighborhood. Another Atlanta study found that “the proportion of obese white males declined from 23 percent to 13 percent as neighborhood residential density increased from less than two to more than eight dwellings per acre.” These are careful academic studies that control for age, income, and the other factors that correlate with body mass. 

Finally, a six-year analysis of 100,000 Massachusetts residents found that the lowest body mass index averages were located in Boston and its inner-ring suburbs, while the highest could be found in the “car-dependent” outer ring surrounding Interstate 495. The Boston Globe noted that “health officials suggest these higher rates are due, in part, to a lack of opportunities for everyday recreation and the time-squeezed lifestyle of many residents who have long commutes."

I am wary of confusing causality with correlation, and it would be fair to say that heavier people are probably more likely to prefer driving over walking, and are therefore also more likely to prefer sprawl over urban neighborhoods. It is theoretically possible that, rather than suburbs making people fat, fat people make suburbs. But only a soulless pundit funded by the automotive industry— and there are several— would claim that people are not more likely to be healthy in environments that invite walking. 

You can tell that an idea has reached its tipping point when it makes enemies, and the sprawl-obesity connection finally has. The American Dream Coalition (“ Protecting Freedom, Mobility, and Affordable Homeownership”), a consortium of automotive and sprawl-building interests, has come up with the fairly hilarious concept of the Compactorizer. As celebrated on their website in the (stereotypically effeminate) voice of the fictional Biff Fantastic:
Urban planners and metrosexuals agree that suburbs make you fat! With the Compactorizer, you’ll move out of boring and subtly racist suburban homes and into smallish apartments in high-density transit-oriented developments. Only the Compactorizer uses a patented planning doctrine to create noisy nights, random crimes, and panhandler harassment, triggering the high-stress and abnormal dietary patterns so important for rapid weight loss.
As both an urban planner and a purported metrosexual, I can feel my credibility tanking here. But I have to admit that this piece is funnier than it is offensive and it appropriately pokes fun at an antisuburban snobbery that I probably share. But, ultimately, I have to ask myself: whom do I trust more: the doctors— who have nothing to gain either way— or the sprawl-builders? I’m going with the doctors.

Below: props to my friends at Stratasan.


LOL, not even close.


“We’re looking forward to another turn at HIMSS, because we love technology, but only if it’s moving quickly past staid, broken processes in health care. Our mission at athenahealth is to be caregivers’ most trusted service, helping them do well by doing the right thing, and we don’t get paid unless our clients do—period,” said Jonathan Bush, Chairman and CEO of athenahealth. “Because we have skin in the game, we aim to deliver services that are future-proof. In other words, our services scale based on need, can be managed without heavy IT support and cost, and most importantly, are flexible to adjust to new challenges ensuring they improve with time and will not become obsolete.”
I hope to interview him.


Medical errors, patient safety, etc...

Study: Missed Diagnoses in the Doctor's Office are Leading to Thousands of Deaths
Feb 25, Forbes, David DiSalvo

A new study published in JAMA indicates that primary care doctors are increasingly missing diagnoses at the office, resulting in thousands of deaths and disabilities per year.

Researchers used electronic health records to track 190 diagnostic errors made during primary care visits at one of two healthcare facilities. In each of those cases, the misdiagnosed patient was hospitalized or turned up back at the office or emergency room within two weeks.

Pneumonia, heart failure, kidney failure and cancer each accounted for between five and seven percent of conditions doctors initially diagnosed as something else, according to a report in Reuters Health.

Dr. David Newman-Toker from Johns Hopkins University School of Medicine in Baltimore, who co-wrote a commentary on the new study, told Reuters: “We have every reason to believe that diagnostic errors are a major, major public health problem. You’re really talking about at least 150,000 people per year, deaths or disabilities that are resulting from this problem.”...
From the JAMA piece:
Diagnostic errors are increasingly recognized as an important source of preventable harm in many health care settings. Missed, wrong, and delayed diagnoses have been underappreciated by internal peer review, autopsy reports, and examination of malpractice claims. All of these methodological approaches have limitations. Internal peer review is often challenging because of local hospital politics, physician-vested interest, and sampling error. Autopsy studies may overestimate diagnostic performance when necropsy rates are low, and they often miss nonlethal diagnostic errors. Malpractice claims may capture nonlethal errors; however, they are most often associated with permanent disability or death. Only about 1% of adverse events due to medical negligence result in a claim. Thus, malpractice-based rates of diagnostic errors substantially underrepresent the true impact of these events and are biased toward cases with a clear paper trail (eg, missed cancers evident on radiographic images), in which the burden of legal proof can be met more easily. None of these approaches is well suited to real-time surveillance for errors that might be rectified before harm occurs.

Singh and colleagues are to be congratulated for their substantial body of work developing electronic health record–based “trigger tools” to help overcome shortfalls in traditional approaches to diagnostic error detection. These tools seek to use readily available electronic data to identify patient encounters with a high risk for diagnostic errors to have occurred. The triggers were based on unanticipated readmissions or revisits within 14 days of an initial primary care visit. Triggered visits then were assessed manually for errors. Electronic triggers are relatively easy to measure across visits and likely could be tracked over time as quality metrics. Some triggers might eventually enable us to detect and rectify errors in real time, before harm occurs.

However, even systematically applied trigger tools do not give us a full picture of the burden from diagnostic errors. Singh et al found that roughly 0.1% of all primary care visits were associated with missed opportunities to make an earlier diagnosis and prevent “considerable harm.” This estimate, however, does not include cases in which misdiagnoses did not result in a readmission or a revisit within 14 days (even if the errors eventually caused harm) or cases in which a misdiagnosis occurred but reviewers could not determine whether the diagnosis might reasonably have been made initially. Nevertheless, with more than half a billion primary care visits annually in the United States, if these data from Singh et al are generalizable, at least 50 000 missed diagnostic opportunities occur each year at US primary care visits, most resulting in considerable harm. Combining this figure with autopsy-based estimates of US hospital deaths from diagnostic errors (40 000/y to 80 000/y) and unaccounted nonlethal morbidity from hospital misdiagnoses and acknowledging another half billion visits annually to non–primary care physicians, more than 150 000 patients per year in the United States might have undergone misdiagnosis-related harm.

Why are there so many diagnostic errors? In some sense, the answer is simple: medical diagnosis is extremely difficult. It may not be as difficult as accurately predicting a specific weather forecast 6 months in advance, but it is one of the toughest tasks human minds routinely face. Diagnosing can be messy, and scientific understanding is imperfect. Decisions must be made with limited time and information under conditions of uncertainty, often with inadequate experience or expertise in diagnosing a given symptom or disease. Consistent patient follow-up with feedback on diagnostic performance is usually lacking or biased away from detecting diagnostic errors, creating a serious barrier to ongoing skills improvement...
One of their proposed remedies will surely be red meat for the anti-HIT crowd.
  • mandatory, structured recording and coding of presenting symptoms, rather than simply diagnoses, in our electronic health record systems. This step alone, if consistently performed, would radically transform our ability to track and reduce diagnostic errors.
Interesting. From AHIMA:
How to Code Symptoms and Definitive Diagnoses
by Sue Prophet, RHIA, CCS 
Determining when a symptom, definitive diagnosis, or both should be coded can be challenging for coding professionals. This challenge is complicated by the varying rules regarding the coding of symptoms versus definitive diagnoses, according to the type of encounter and the particular service rendered. In an era of increased focus on fraud/abuse and regulatory compliance, it is especially important for coding professionals to understand and properly apply official coding rules and guidelines. This article will explore the various guidelines affecting symptom and definitive diagnosis coding and what guidelines to apply...
A good read, but nothing much beyond dx coding which takes into account symptoms.

Below, an old school SOAP note example:


Coding Symptoms, Signs and Ill-Defined Conditions Under ICD-10-CM
Written by Michael Calahan, PA, MBA, Monday, July 25, 2011

In preparation for conversion from ICD-9-CM to ICD-10-CM diagnosis coding, and in anticipation of the new coding system’s implementation (effective Oct. 1, 2013), providers will need to take stock of their coding patterns as well as review their internal charge capture tools (i.e. the practice superbill) to see which frequently reported ICD-9 codes they immediately will want to research within ICD-10.  Becoming familiar with the updated codes will be a pivotal step in this transition. One of the coding patterns that should be scrutinized is the frequency with which unspecified and “not otherwise specified” (NOS) codes currently are assigned appropriately. Often, as explained below, unspecified and/or NOS codes are the only options for diagnosis coding at certain levels of patient study and care.

Many of these codes, though certainly not all, are found in the ICD-9-CM chapter dedicated specifically to unconfirmed diagnoses and similar conditions; this chapter aptly is named “Symptoms, Signs and Ill-Defined Conditions.” A quick glance at the practice encounter form may be telling in this regard. Often superbills are packed with nonspecific codes to help facilitate quick, at-a-glance coding by providers on the run instead of having certified coders assign diagnosis codes from detailed, well-written medical record documentation. The latter obviously is preferred – and even mandatory, in many instances – to establish medical necessity and obtain appropriate reimbursement for services rendered.

That said, unspecified and nonspecific coding scenarios are actually commonplace in general practice, family practice and internal medicine, among other primary care specialties in which the level of evaluation and assessment may be more limited until a patient has been sent to specialists for further work-up, evaluation and treatment. Which unspecified and nonspecific codes are available for use promises to change slightly under ICD-10, however. In fact, the ICD-9-CM chapter now housing most of these codes, Chapter 16 covering “Symptoms, Signs and Ill-Defined Conditions” (code series 780 – 799), has many organizational changes under the new ICD-10-CM format, now falling under Chapter 18 and renamed “Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified” (code series R00-R99).

Some of the codes that previously were found in body system chapters are now in this particular ICD-10-CM chapter, and the reverse is true for some ICD-9 codes that once were located in the symptoms/signs chapter and now will be located in specific ICD-10 body system chapters. For example, in ICD-9-CM “hematuria, unspecified” currently is coded to 599.70 in Chapter 10, “Diseases of the Genitourinary System” (code series 580 – 629), but in ICD-10-CM this has been moved to Chapter 18 and is included under symptoms/signs of the GU system (being coded to R31.9). Likewise, conditions such as “systemic inflammatory response syndrome” (SIRS), “severe sepsis” and “septic shock” currently found in ICD-9-CM Chapter 17, “Injury and Poisoning” (code series 800 – 999) are located in Chapter 18 under general symptoms/signs in code series R65 in ICD-10-CM – specifically, R65.10, “SIRS of non-infectious origin without acute organ dysfunction.”

Conversely (and curiously), ICD-9-CM code 785.4, representing “Gangrene NOS,” which currently is located in Chapter 16 for symptoms/signs is to be found under code I96 (eye-96) in the specific body system Chapter 9, “Diseases of the Circulatory System” (code series I00 – I99) in ICD-10-CM.

The preamble for Chapter 18, “Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified” in the new ICD-10 coding system remains much the same as it was in ICD-9, specifying that the codes found within this range include “(a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated; (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined; (c) provisional diagnosis in a patient who failed to return for further investigation or care; (d) cases referred elsewhere for investigation or treatment before the diagnosis was made; (e) cases in which a more precise diagnosis was not available for any other reason; (f) certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right.”...

More to come...

Saturday, February 23, 2013

Countdown to HIMSS13 in NOLA

WASHINGTON [Los Angeles Times] — The Obama administration issued a travel advisory Friday: Because of a budget standoff in Washington, flights will be delayed.

That was the message Transportation Secretary Ray LaHood delivered at the daily White House briefing as he outlined the impact that across-the-board budget cuts would have on air travel, a drumbeat he acknowledged was aimed by the administration at Republicans in Congress.

"I would describe my presence here with one word — Republican," LaHood said of the White House. "They're hoping that maybe I can influence some of the people in my own party."

LaHood described a nettlesome set of potential problems if, as scheduled, $600 million is eliminated from the Federal Aviation Administration's budget this year as part of the so-called sequester cuts set to kick in March 1...
Lovely to be pawns in all of this, ja?


HIMSS library stocked with must-reads
NEW ORLEANS | February 22, 2013

Knowledge is the best tool for IT professionals hoping to weather the turbulence of healthcare initiatives. And as a vital part of its role as the industry’s chief information resource, HIMSS has produced some of the most essential reading materials to address these vital topics.

Written by some of healthcare’s brightest minds, the HIMSS 2013 library lineup addresses some of the key issues facing healthcare IT professionals today, such as accountable care organizations, patient privacy and security, interoperability and data warehousing. Most selections are available in print and electronic editions...

Medicare Officials Raise Issue of Fraud as Greater Use of Electronic Health Records Increases the Number of Claims Upcoded to More Complex CPT Codes

Could increased use of electronic health records (EHR) systems be causing more hospitals and physicians to commit fraud because of upcoding? That’s the assertion of certain federal health officials. They attribute the increased proportion of Medicare claims for more complex and more expensive services by some providers to be, in some part, acts of fraud.

Most pathologists and clinical laboratory managers will notice the irony in these allegations that providers are upcoding services to Medicare patients in fraudulent ways. After all, the federal government is currently paying billions of dollars in financial incentives to encourage providers to implement and use certified EHR systems with the goal of lowering healthcare costs, while improving patient outcomes.

OIG Audit Findings Are Source of Fraud Allegations
Insinuations of provider fraud came after the public learned of findings of an audit done by Health and Human Services’ Office of Inspector General (OIG). The OIG determined that payments for more complex Level 5 E/M services increased by 21% between 2001 and 2010. During that same period, payments for medium-complexity patient services decreased by 11%...

The excellent Skeptical Scalpel Blog ran a good post on this issue back in December.
Electronic medical records: Documentation of care and upcoding
Wednesday, December 19, 2012
Electronic medical records make documentation easier and that may be a problem.

There are many interesting unintended consequences of electronic medical records (EMRs). I was reminded of this by a recent blog I wrote about what interns really do when they are on call. According to a study from a VA hospital using trained time-motion observers, interns spend 40% of their time on a computer and only 12% of their time taking care of patients. This meshes well with other reports noting that doctors are staring at screens instead of talking to patients.

Here’s the problem. The system actually rewards extensive documentation which may result in less patient contact. The saying “If you didn’t document it, you didn’t do it” has morphed into “Document it, and you can use a higher billing code.”

Here are some CPT billing codes for hospital visits.

99221 Initial Hospital Care, Physician spends 30 minutes at the bedside
99222 Initial Hospital Care, Physician spends 50 minutes at the bedside
99223 Initial Hospital Care, Physician spends 70 minutes at the bedside

Sources tell me that they know of physicians who never bill for less than 99223 or 70 minutes for a history and physical (H&P) examination. In order to do this the doctor must document such things as having reviewed at least 10 different systems (e.g., respiratory, GI, musculoskeletal etc.). This is easy to document without having actually done it. The EMR may have popup windows with lists of systems and symptoms that can be checked off as reviewed...

Now that it is so easy to write a very detailed H&P, it must be tempting to bill every encounter at the maximum level. However, this may come back to bite those who try it. Medicare has been known to audit hospital charts and office records. They have profiles of what the distribution of the various levels of care should be.

Also, there are only so many hours in a day. Let’s say you are working a 12-hour shift and bill for eight 75 minute H&Ps and ten 25 minute subsequent visits. That’s 600 + 250 = 850 minutes or over 14 hours. If you are audited, you will have some explaining to do...
I keep saying it: an EHR audit trail log is a workflow log, insofar as it must (by §170.210) date/time stamp the creation, viewing, updating, transmitting, or deletion of ePHI ("electronic Protected Health Information"). From those data we can elicit a chronology of the flow of user-PHI, which, when coupled with a thorough examination and intersplicing of of the concomitant physical tasks during work hours, comprises a complete workflow record.

I could wreak forensic havoc in a lot of HIT audit logs.


Bitter Pill: Why Medical Bills Are Killing Us
By Steven Brill, Feb. 20, 2013

...Although it is officially a nonprofit unit of the University of Texas, MD Anderson has revenue that exceeds the cost of the world-class care it provides by so much that its operating profit for the fiscal year 2010, the most recent annual report it filed with the U.S. Department of Health and Human Services, was $531 million. That’s a profit margin of 26% on revenue of $2.05 billion, an astounding result for such a service-intensive enterprise.

The president of MD Anderson is paid like someone running a prosperous business. Ronald DePinho’s total compensation last year was $1,845,000. That does not count outside earnings derived from a much publicized waiver he received from the university that, according to the Houston Chronicle, allows him to maintain unspecified “financial ties with his three principal pharmaceutical companies.”

DePinho’s salary is nearly triple the $674,350 paid to William Powers Jr., the president of the entire University of Texas system, of which MD Anderson is a part. This pay structure is emblematic of American medical economics and is reflected on campuses across the U.S., where the president of a hospital or hospital system associated with a university — whether it’s Texas, Stanford, Duke or Yale — is invariably paid much more than the person in charge of the university.

I got the idea for this article when I was visiting Rice University last year. As I was leaving the campus, which is just outside the central business district of Houston, I noticed a group of glass skyscrapers about a mile away lighting up the evening sky. The scene looked like Dubai. I was looking at the Texas Medical Center, a nearly 1,300-acre, 280-building complex of hospitals and related medical facilities, of which MD Anderson is the lead brand name. Medicine had obviously become a huge business. In fact, of Houston’s top 10 employers, five are hospitals, including MD Anderson with 19,000 employees; three, led by ExxonMobil with 14,000 employees, are energy companies. How did that happen, I wondered. Where’s all that money coming from? And where is it going? I have spent the past seven months trying to find out by analyzing a variety of bills from hospitals like MD Anderson, doctors, drug companies and every other player in the American health care ecosystem.

When you look behind the bills that Sean Recchi and other patients receive, you see nothing rational — no rhyme or reason — about the costs they faced in a marketplace they enter through no choice of their own. The only constant is the sticker shock for the patients who are asked to pay.

Yet those who work in the health care industry and those who argue over health care policy seem inured to the shock. When we debate health care policy, we seem to jump right to the issue of who should pay the bills, blowing past what should be the first question: Why exactly are the bills so high?

What are the reasons, good or bad, that cancer means a half-million- or million-dollar tab? Why should a trip to the emergency room for chest pains that turn out to be indigestion bring a bill that can exceed the cost of a semester of college? What makes a single dose of even the most wonderful wonder drug cost thousands of dollars? Why does simple lab work done during a few days in a hospital cost more than a car? And what is so different about the medical ecosystem that causes technology advances to drive bills up instead of down?

Recchi’s bill and six others examined line by line for this article offer a closeup window into what happens when powerless buyers — whether they are people like Recchi or big health-insurance companies — meet sellers in what is the ultimate seller’s market.

The result is a uniquely American gold rush for those who provide everything from wonder drugs to canes to high-tech implants to CT scans to hospital bill-coding and collection services. In hundreds of small and midsize cities across the country — from Stamford, Conn., to Marlton, N.J., to Oklahoma City — the American health care market has transformed tax-exempt “nonprofit” hospitals into the towns’ most profitable businesses and largest employers, often presided over by the regions’ most richly compensated executives. And in our largest cities, the system offers lavish paychecks even to midlevel hospital managers, like the 14 administrators at New York City’s Memorial Sloan-Kettering Cancer Center who are paid over $500,000 a year, including six who make over $1 million...
If you care about anything beyond your own job in health IT, you should closely read and re-read this long article. Draw your own conclusions, but draw them with due consideration. I've been involved with the health care field for 20 years now -- professionally, academically, as a next-of-kin caregiver, and now as a Medicare bene.

Things have not clarified for me.

Niacin is available at Walgreen's (or your supermarket) for 3 to 5 cents per 500 mg tablet. $24 per tablet in the hospital is an average 600% markup.

I would put people in jail for doing this. Particularly those pulling down 7-8 figure annual comp packages.

Read the Brill article.


Health Technology’s ‘Essential Critic’ Warns Of Medical Mistakes
By Jay Hancock KHN Staff Writer FEB 18, 2013
Produced in collaboration with the Philadelphia Enquirer

Computer mistakes like the one that produced incorrect prescriptions for thousands of Rhode Island patients are probably far more common and dangerous than the Obama administration wants you to believe, says Drexel University’s Dr. Scot Silverstein.

Flawed software at Lifespan hospital group printed orders for low-dose, short-acting pills when patients should have been taking stronger, time-release ones, the Providence-based system disclosed in 2011. Lifespan says nobody was harmed.

But Silverstein, a physician and adjunct professor of healthcare informatics who is making a name for himself as a strident critic of electronic health records, says the Lifespan breakdown is part of a much larger problem.

“We’re in the midst of a mania right now” as traditional patient charts are switched to computers, he said in an interview in his Lansdale home. “We know it causes harm, and we don’t even know the level of magnitude. That statement alone should be the basis for the greatest of caution and slowing down.”
Use of electronic medical records is speeding up, thanks to $10-billion-and-counting in bounties the federal government is paying to caregivers who adopt them. The consensus among government officials and researchers is that computers will cut mistakes and promote efficiency. So some 4,000 hospitals have or are installing digital records, the Department of Health and Human Services said last month.

Seventy percent of doctors surveyed in September  by research firm CapSite said they had switched to digital data.

But the notion that electronic charts prevent more mistakes than they cause just isn’t proven, Silverstein says. Government doesn’t require caregivers to report problems, he points out, so many computer-induced mistakes may never surface.

He doesn’t discount the potential of digital records to eliminate duplicate scans and alert doctors to drug interactions and unsuspected dangers.

But the rush to implementation has produced badly designed products that may be more likely to confound doctors than enlighten them, he says. Electronic health records, Silverstein believes, should be rigorously tested under government supervision before being launched into life-and-death situations, much like medical hardware or airplanes.

Silverstein “is an essential critic of the field,” said Dr. George Lundberg, editor at large for MedPage Today and former editor of the Journal of the American Medical Association. “It’s too easy for those of us in medicine to get excessively enthusiastic about things that look like they’re going to work out really well. Sometimes we go too far and don’t see the downside of things.”

A growing collection of evidence suggests that poorly designed software can obscure clinical data, generate incorrect treatment orders and cause other problems. Cases include the Lifespan glitch; a data-entry error that led to the 2010 death of a baby at Advocate Lutheran General Hospital in Illinois; and computers at Trinity Health System, a major Midwest chain, that logged doctors’ orders on the wrong patients’ charts.

Computer mistakes voluntarily reported to the Food and Drug Administration include those that researchers said were linked to 44 injuries and six deaths at unidentified institutions. Those problems included tiny fonts causing caregivers to click on the wrong medication; flipped images that led a surgeon to operate on the wrong side of a patient’s head; and lost or misdated test results that caused unnecessary surgery or delayed treatment.

The FDA’s Dr. Jeffrey Shuren has said that such cases “likely reflect a small percentage of the actual events that do occur.”

At conferences and working from home on the Health Care Renewal blog, Silverstein chronicles digital failures and criticizes hospitals in the same dogged way that he applied himself to building the 1970s-era Heathkit computers he still keeps in his home, say people who know him.

“His message has been consistent: [health IT]provides far less benefit than is claimed by its proponents and opens new — sometimes potent — routes to failure,” said Dr. Richard I. Cook, a medical error expert at the University of Chicago who sat on a panel examining electronic record safety at the authoritative Institute of Medicine. “No one wants him to be visible. But his message and tone have not wavered.”

The HIMSS Electronic Health Record Association, an industry group, declined to comment on Silverstein. A spokesman for the HHS’s Office of the National Coordinator for Health Information Technology, the administration’s proponent of digital records, said: “It’s important to listen to all the voices” in the discussion of the subject.

Trained as an internist and in medical info-tech as a Yale postdoc, Silverstein, 55, served as Merck’s director of scientific information in the early 2000s and then as a full-time Drexel professor, shifting in recent years to part-time teaching and working on medical liability cases for plaintiff attorneys. His insistent warnings about digital health risks over more than a decade have effectively barred him from a lucrative career at a hospital or software vendor.
Scot Silverstein, one of the most ardent critics of electronic medical records, works on an antique computer. A growing collection of evidence suggests poorly designed medical software can obscure clinical data, generate incorrect treatment orders, and cause other problems. (Photo by Ron Tarver/Philadelphia Inquirer)
“I’m sure Scot would be better off by keeping his mouth shut and getting a job with a hospital that’s just put in a big effing system,” said Matthew Holt, a Silverstein critic and co-chairman of Health 2.0, which organizes health technology conferences.

Many say he comes on too strong. Even admirers cringed when he began blogging about the 2011 death of his mother, which he blames in a lawsuit on a computer error that allegedly caused Abington Memorial Hospital to overlook a key medication. (Both he and the hospital said they couldn’t comment on a pending suit.) Personalizing his campaign, some thought, made him seem less objective.

“His refusal to temper his message makes it sometimes difficult to hear,” said Ross Koppel, a University of Pennsylvania sociologist and digital health record skeptic.

But Silverstein says his position today is the same as it has always been. He believes in the potential power of electronic records for good, he says. But any doctor who feels bound by the Hippocratic oath’s injunction to “first, do no harm,” he adds, should balk at what’s going on.

“Patients are being harmed and killed as a result of disruptions to care caused by bad health IT,” he said. “I’m skeptical of the manner and pace [of implementation], not of the technology itself…. My only bias is against bad medicine. And my bias is against people with complacent attitudes about bad medicine.”
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I've corresponded with Dr. Silverstein a bit. Dude is hardcore. A stickler for facts and logic.

Where they favor his case, to a degree, though. An affliction regarding which we all have to be careful of.


From The Health Care Blog:
...Unfortunately, the increasing popularity of EMR caused increased focus from the government. PQRI, NCQA, HIPAA, and CCHIT all took focus of our vendor from clinical development, instead focusing on regulatory requirements. When the HITECH act passed I was still (delusionally) optimistic that the focus would eventually turn to patient care. But the last update I saw on the product I bought in 1996 showed the truth: the product was certified for “meaningful use,” but it was bad. Really bad. We even nicknamed it “Vista.” Previously simple tasks were difficult, and data was harder to use, and was not moving at all toward better patient care.

My inability to accept mediocre care (and my obnoxious obsession with improving it, from my partners’ perspective) eventually drove me from the world of meaningful use and E/M coding to my current home: a practice that accepts only monthly payments between $30 and $60 a month in exchange for an undiluted attention to patient care. Without the overhead caused by the ridiculous complexity of our payment system, I can finally realize my dream of showing the world what good care actually looks like.

But here’s the hitch: EMR has never left the world of note generation. Yes, it does submit data so the doctor can get the check for (ironically) achieving “meaningful use,” but that data is still very hard to actually use to improve care. My attempts at using other EMR products to accomplish my goal have proven to me once and for all that to truly give good care I’d have to abandon EMR as I knew it. I’ve got to look beyond EMR to something better, more focused on the patient and less on the payment. But it’s really been a hard search. I know what I want to do, but the road to that goal is not yet evident...

More to come...

Tuesday, February 19, 2013


Is an EHR backlash brewing?
February 19, 2013, Tom Sullivan, Editor

There’s a new hashtag in the Twitterverse: #EHRbacklash.

Reasonably easily traced to Feb. 3, when it was typed by Bob Brown, vice president of professional services for HIE consultancy Mosaica Partners, the hashtag was inspired by a Twitter conversation Brown had with Harold Smith III.

“He coined the term,” Brown said. “I coined the hashtag.”

#EHRbacklash was born as EHRs, vendors, and the meaningful use incentive program are under perhaps as much fire as they’ve faced yet.

On Tuesday, in fact, Black Book Rankings managing partner Doug Brown essentially struck at all three by saying that “meaningful use incentives created an artificial market for dozens of immature EHR products,” a scenario that may trigger “the year of the great EHR switch,” in 2013. Black Book reported data to back up that assertion: 31 percent of the 17,000 active EHR users the firm surveyed indicated they were "dissatisfied enough" with their EHR to consider making a switch.

A day earlier, the American Medical Association (AMA) wrote in an editorial that CMS “would do well to take a breather,” given that even though Stage 1 is not completed, CMS is already leading the industry to Stages 2 and 3.

“Outside help should be enlisted to review how the meaningful use program has gone so far,” AMA’s editorial noted. “Then, substantive change can be made to requirements so meaningful use of EHRs really does mean better and more efficient care, and not just lots of meaningless data entry and technological frustration.”

Last week, Edmund Billings, MD, chief medical officer for Medsphere Systems, wrote that HIT vendors are engaged in “prolonged foot-dragging on interoperability and even basic data interfacing,” despite the availability of technical interfaces and open standards. “Yes healthcare IT is their business, but interoperability is not in their nature.”...
Yeah. My quickie Photoshop contribution to the dustup.

Let's be clear. It's not an "EHR backlash" per se, it's "Meaningful Use Stage 3" pushback.


And, what do I find...?

Not online just yet. Stay tuned...

2/21 UPDATE: The article has been posted online. Well worth your time.
When we think of breakthroughs in medicine, we conjure up images of new drugs or new surgeries. When we think of changes to the health-care system, byzantine legislation comes to mind. But according to a growing number of observers, the next big thing to hit medical care will be new ways of accumulating, processing, and applying data—revolutionizing medical care the same way Billy Beane and his minions turned baseball into “moneyball.” Many of the people who think this way—entrepreneurs from Silicon Valley, young researchers from prestigious health systems and universities, and salespeople of every possible variety—spoke at the conference in Las Vegas, proselytizing to the tens of thousands of physicians and administrators in attendance. They say a range of innovations, from new software to new devices, will transform the way all of us interact with the health-care system—making it easier for us to stay healthy and, when we do get sick, making it easier for medical professionals to treat us. They also imagine the transformation reverberating through the rest of the economy, in ways that may be even more revolutionary.

Health care already represents one-sixth of America’s gross domestic product. And that share is growing, placing an ever-larger strain on paychecks, corporate profits, and government resources. Figuring out how to manage this cost growth—how to meet the aging population’s medical needs without bankrupting the country—has become the central economic-policy challenge of our time. These technology enthusiasts think they can succeed where generations of politicians, business leaders, and medical professionals have failed.

Specifically, they imagine the application of data as a “disruptive” force, upending health care in the same way it has upended almost every other part of the economy—changing not just how medicine is practiced but who is practicing it. In Silicon Valley and other centers of innovation, investors and engineers talk casually about machines’ taking the place of doctors, serving as diagnosticians and even surgeons—doing the same work, with better results, for a lot less money. The idea, they say, is no more fanciful than the notion of self-driving cars, experimental versions of which are already cruising California streets. “A world mostly without doctors (at least average ones) is not only reasonable, but also more likely than not,” wrote Vinod Khosla, a venture capitalist and co-founder of Sun Microsystems, in a 2012 TechCrunch article titled “Do We Need Doctors or Algorithms?” He even put a number on his prediction: someday, he said, computers and robots would replace four out of five physicians in the United States.

Statements like that provoke skepticism, derision, and anger—and not only from hidebound doctors who curse every time they have to turn on a computer. Bijan Salehizadeh, a trained physician and a venture capitalist, responded to reports of Khosla’s premonition and similar predictions with a tweet: “Getting nauseated reading the anti-doctor rantings of the silicon valley tech crowd.” Physicians, after all, do more than process data. They attend at patients’ bedsides and counsel families. They grasp nuance and learn to master uncertainty. For their part, the innovators at IBM make a point of presenting Watson as a tool that can help health-care professionals, rather than replace them. Think Dr. McCoy using his tricorder to diagnose a phaser injury on Star Trek, not the droid fitting Luke Skywalker with a robotic hand in Star Wars. To most experts, that’s a more realistic picture of what medicine will look like, at least for the foreseeable future...

Professional groups see lack of evidence in meaningful use criteria
Ed Burns, News Writer - Published: 20 Feb 2013

As the Health IT Policy Committee continues to develop the stage 3 meaningful use criteria, providers are questioning the evidence policymakers are using to justify the new regulations.

The November 2012 request for comment on draft stage 3 recommendations, issued by the Health IT Policy Committee (HITPC) and convened by the Office of the National Coordinator for Health IT (ONC) to devise meaningful use policy suggestions, "doesn't have a discussion that would review the literature on these items and provide evidence from pilot studies or discuss the cost versus the benefit," said Chantal Worzala, director of policy at the American Hospital Association (AHA). "It simply says, 'We think we should do this next,' and we think that's a problem."

Worzala said this kind of approach to rulemaking is an issue because it could represent a missed opportunity for the health care system, and could even create risks to patient safety. She said the majority of health care professionals recognize that IT tools, such as electronic health records, have the potential to greatly improve care quality. However, providers need to know for sure that the systems they implement have been proven to produce these benefits.

Furthermore, implementing unproven technology could lead to unintended consequences, Worzala said. For example, certain meaningful use criteria require physicians to use their electronic health record (EHR) systems to maintain up-to-date medication lists and use decision support systems to determine medication doses. However, some providers have already seen these systems provide dangerous recommendations, jeopardizing patient safety...
And, from the NY Times:
A Digital Shift on Health Data Swells Profits in an Industry
Julie Creswell

It was a tantalizing pitch: come get a piece of a $19 billion government “giveaway.”

The approach came in 2009, in a presentation to doctors by Allscripts Healthcare Solutions of Chicago, a well-connected player in the lucrative business of digital medical records. That February, after years of behind-the-scenes lobbying by Allscripts and others, legislation to promote the use of electronic records was signed into law as part of President Obama’s economic stimulus bill. The rewards, Allscripts suggested, were at hand.

But today, as doctors and hospitals struggle to make new records systems work, the clear winners are big companies like Allscripts that lobbied for that legislation and pushed aside smaller competitors.

While proponents say new record-keeping technologies will one day reduce costs and improve care, profits and sales are soaring now across the records industry. At Allscripts, annual sales have more than doubled from $548 million in 2009 to an estimated $1.44 billion last year, partly reflecting daring acquisitions made on the bet that the legislation would be a boon for the industry. At the Cerner Corporation of Kansas City, Mo., sales rose 60 percent during that period. With money pouring in, top executives are enjoying Wall Street-style paydays.

None of that would have happened without the health records legislation that was included in the 2009 economic stimulus bill — and the lobbying that helped produce it. Along the way, the records industry made hundreds of thousands of dollars of political contributions to both Democrats and Republicans. In some cases, the ties went deeper. Glen E. Tullman, until recently the chief executive of Allscripts, was health technology adviser to the 2008 Obama campaign. As C.E.O. of Allscripts, he visited the White House no fewer than seven times after President Obama took office in 2009, according to White House records.

Mr. Tullman, who left Allscripts late last year after a boardroom power struggle, characterized his activities in Washington as an attempt to educate lawmakers and the administration.

“We really haven’t done any lobbying,” Mr. Tullman said in an interview. “I think it’s very common with every administration that when they want to talk about the automotive industry, they convene automotive executives, and when they want to talk about the Internet, they convene Internet executives.”...

Executives at smaller records companies say the legislation cemented the established companies’ leading positions in the field, making it difficult for others to break into the business and innovate. Until the 2009 legislation, growth at the leading records firms was steady; since then, it has been explosive. Annual sales growth at Cerner, for instance, has doubled to 20 percent from 10 percent.

“We called it the Sunny von Bülow bill. These companies that should have been dead were being put on machines and kept alive for another few years,” said Jonathan Bush, co-founder of the cloud-based firm Athenahealth and a first cousin to former President George W. Bush. “The biggest players drew this incredible huddle around the rule-makers and the rules are ridiculously favorable to these companies and ridiculously unfavorable to society.”...

The records systems sold by the biggest vendors have their fans, who argue that, among other things, the systems ease prescribing medications electronically. But these systems also have many critics, who contend that they can be difficult to use, cannot share patient information with other systems and are sometimes adding hours to the time physicians spend documenting patient care.
“On a really good day, you might be able to call the system mediocre, but most of the time, it’s lousy,” said Michael Callaham, the chairman of the department of emergency medicine at the University of California, San Francisco Medical Center, which eight months ago turned on its $160 million digital records system from Epic. Michael Blum, the hospital’s chief medical information officer, said a majority of doctors there like the Epic system.

Whatever the case, the legislation has been a windfall to top executives at the leading health records companies. Neal L. Patterson, who grew up on a farm near Manchester, Okla., population 100, co-founded Cerner in 1979. As Cerner’s sales have soared in recent years, so have Mr. Patterson’s fortunes. From 2007 to 2011, he received more than $21 million in total compensation, according to the executive compensation research firm Equilar, and his stake in the company is worth $1 billion.
In recent years, Mr. Patterson and his wife, Jeanne Lillig-Patterson, who ran as a Republican for Congress in 2004, have emerged as social and business leaders in the Kansas City, Mo., area. Mr. Patterson is also co-owner of a real estate development firm whose ventures include a 1,200-acre community near Kansas City called the Village of Loch Lloyd, featuring a Tom Watson-designed golf course.
Think about that, doc, when you're coding for a measly 99123 encounter.

12% of Docs Meet Meaningful Use Rules
By David Pittman, Washington Correspondent,
MedPage Today
Published: February 20, 2013
Just over 12% of about 509,000 eligible physicians said they met requirements for meaningful use incentives for electronic health records (EHRs), early study results show.

Less than 10% of specialists and 17.8% of primary care providers attested to enough meaningful use to receive incentive payments through Medicare and Medicaid as of May 2012, according to a letter published in the Feb. 21 issue of the New England Journal of Medicine.

"Although these data suggest rapid growth in the number of providers achieving meaningful use, this pace must accelerate for most eligible professionals to avoid penalties in 2015," Adam Wright, PhD, of Brigham and Women's Hospital in Boston, and colleagues wrote...

"Successive stages of meaningful use increase in difficulty, and it is not yet clear how many eligible professionals will successfully attest in these later stages," the authors said. "The downstream effects of meaningful use on quality, safety, and efficiency are not yet known, and further increases in EHR adoption, functionality for clinical decision support systems, and research are needed to ensure the effectiveness of the meaningful use program."...
Wright's work also found attestation rates vary greatly from state to state. While the median was 7.7%, use varied from 1.9% in Alaska to 24.2% in North Dakota. Primary care providers comprised 44% of all attestations.

Physicians used EHRs from a total of 310 different vendors, with the top five vendors accounting for 58.5% of physicians who met Stage 1 requirements. The top 15 vendors accounted for 80.1% of attestations.

Physicians have complained that using EHRs slows their work flow and reduces productivity.
"Successive stages of meaningful use increase in difficulty, and it is not yet clear how many eligible professionals will successfully attest in these later stages"

Nonetheless, ONC is prepared to allow the RECs to quietly exit the stage, notwithstanding that data indicate that EPs working with RECs are more than twice as likely to make it to Attestation relative to EPs who go it alone.


Re: @FarzadsBowTie

Farzad, I was wearing a bow tie 39 years ago.

CODA: piling on.



Dallas / Fort Worth Healthcare Daily.
I have watched this news get repeatedly and uncritically reposted this week. The total number and percentages of Meaningful Use Attestations “to date” will look DRAMATICALLY different once all of CY 2012 is accounted for (there was a huge Q4 eligibility spike, which is still being attested through next Thursday). Everyone involved with the program knows that things really picked up steam in the second half of 2012 — outside the scope of this analysis.

This story does not add much value. It’s clearly implying that the program is failing.
But, wait, there's more...
Electronic medical records probed for over-billing
Critics question credibility of federal panel charged with investigating

The Obama administration is forging ahead with a multi-billion dollar plan to shift from paper to electronic medical records, despite continuing concerns the program may be prompting some doctors and hospitals to improperly bill higher fees to Medicare. An investigation into those billing questions — which convened a hearing Wednesday — has yet to produce much in the way of results, and critics are questioning the seriousness of the efforts. 

Some digital records software marketed to medical professionals may be encouraging use of elevated billing codes that pay fatter fees, according to the nation’s top health information technology official. That could undermine cost savings the government expects to achieve by adopting the digital systems.

“There is a lot we don’t know about that,” Farzad Mostashari, the National Coordinator for Health Information Technology, said Wednesday at a hearing of policy experts studying the billing issue. “We don’t know if the shift (in higher billing) reflects appropriate coding or inappropriate coding.” He added: “We don’t know if this leads to an increase in costs … or has other impacts.”...

Donald W. Simborg, a California physician who participated in two government groups that studied the billing fraud issue, said on Wednesday that Mostashari’s review relies too heavily on panel members with close ties to the burgeoning health information technology industry. He questioned its effectiveness in determining if the digital equipment contributes to Medicare billing fraud.

Simborg likened the situation to “asking the NRA to investigate gun violence.” Simborg noted that the policy committee consists of strong supporters of electronic health records “who could hardly provide an unbiased and objective view on this.”...


More to come...

Sunday, February 17, 2013

"Interoperability" - soon to be the #1 cliche of the 2010's HIT decade?

Below a Word Cloud I ran using the ONC blog RSS feed as grist.

"Interoperability" looks, informally, to be about #6.
1. data
2. health
3. information
4. standards (3 and 4 may be pretty much a tie)
6. interoperability
Rounding out the Top Ten, hmmm...
 7. use
 8. may
 9. EHR
10. exchange
I have a bit of a pedantic streak that surely elicits a bit of eye-rolling here and there. Nonetheless, I beg to pick a nit or two here.

I will commence by citing an interesting TCHB article:
Is Interoperability Possible in HIT? And if it Is, Do We Even Want it?

Anyone who understands the importance of continuity of care knows that health information exchange is essential. How are we supposed to cut waste and duplication from the healthcare system and truly focus on patient welfare if doctor B has no idea what tests doctor A conducted, or what the results were?

The predominant proprietary HIT vendors know this, yet have engaged in prolonged foot-dragging on interoperability and even basic data interfacing. Yes healthcare IT is their business, but interoperability is not in their nature.

As we’ve seen before, the problem is with the business model.

The proprietary business model makes the vendor the single source of HIT for hospital clients. Complexity and dependence are baked into both solutions and client relationships, creating a “vendor lock” scenario in which changing systems seems almost inconceivable...

[W]hile the commitment to data exchange is progress, we are still just talking about exchanging data, not true interoperability. Let’s look at a couple of definitions.

From the Institute of Electrical and Electronics Engineers (IEEE) Glossary definition on Wikipedia:

The ability of two or more systems or components to exchange information and to use the information that has been exchanged.
So narrowly tailored, this concept might be better defined as “interface-ability” or simply data exchange. And it completely lacks context, which matters a lot to those of us in health IT. There is no mention of the technical challenge and costs. There is no concept of separate systems operating together, which is requisite. And there is no mention of the alternatives.

Compare that with another interoperability definition found on Wikipedia:

Interoperability is a property of a product or system, whose interfaces are completely understood, to work with other products or systems, present or future, without any restricted access or implementation.
This definition, much closer to genuine interoperability, is arguably what Kenneth Mandl and Isaac Kohane of Harvard Medical School had in mind in 2011 when they published “Escaping the EHR Trap – The Future of Health IT” in the New England Journal of Medicine:
“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…”
None of which is exactly news (if just a tad inaqequate). Margin is, after all, significantly a function of opacity. How could it be otherwise? "Efficient Markets Hypothesis" and all that -- otherwise revered in the irony-free zone of Free Marketistan.

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

For insurers in particular, this strategic conundrum over HIT is a redux of the broader managed care conundrum about prevention,which is essentially the prisoners’ dilemma at the heart of game theory. The prisoners’ dilemma always results in an unfortunate ending: All actors in the game would be rewarded if they cooperated and did the right thing by each other. But none will do the right thing without assurance that the other players will all follow, and so they each do exactly the wrong thing, limiting their own downside and thus creating a suboptimal outcome for all. The best way for a health insurer to use HIT to cope with the prisoners’ dilemma is to design a proprietary system that makes it easy for healthy members to sign up; difficult for sick members who need good information to find it and thus remain satisfied with their plan; and even more difficult for everyone outside the insurer’s own organization (that is, everyone looking to get paid) to navigate it. The worst way to cope with the prisoners’ dilemma is to provide an open, interoperable system that works equally well for all members and can exchange data with all other health insurers.
Dot-Gov: Market Failure And The Creation Of A National Health Information Technology System, JD Kleinke, Health Affairs, 2005 (pdf)
 As  spot-on and timely today as it was seven years ago.


Emphasis on the second part. What's so difficult to understand? Dr. Billings has it right in his foregoing observation "...narrowly tailored, this concept might be better defined as “interface-ability” or simply data exchange."

Indeed, and for that all you need are reciprocal "data maps" -- aligned bi-directional data dictionaries that enable data to find unaltered repose and subsequent use in the mutually push-pull source-recipient HIT systems (and, here, to be sure, I assume a transport standard such as HL7) .

That is a far cry from that which the term "interoperability" infers, i.e., where Dr. Bobby here in Vegas, running Amazing Charts could "operate" Dr. Kirsten's eClinicalWorks EHR in Boston -- and vice versa -- via our respective GUI interfaces.

In other words, "integration" versus "interface."

What would be the point of such "integration"? What would be the point of having two or more such functionally commoditized systems were that to be the case? Product differentiation, after all, is the entire point of a commercial for-profit market, through which the "best" products arguably emerge out of the fires of competition, giving the customers the best deals.

What would we be left with? Merely differences in cosmetics (GUI presentation)? Nominal workflow "usability"? What would be the drivers of "sustainability" for the respective vendors?

Dr. Billing summarizes his take:
Mandle and Kohane describe an interoperability that goes beyond mere interfaces and data exchange. Indeed, the fulcrum of this advanced interoperability is open application programming interfaces (APIs), which enable applications to quickly, easily and affordably integrate with the core EHR. Think of all those iPhone apps in the iTunes store and then recall that Apple doesn’t even make open systems.
Right now open APIs are most frequently associated with the Web and work being done by companies like Facebook, Google, Salesforce and LinkedIn, which might seem irrelevant but is anything but. True interoperability in healthcare will result from tightly secured Web-based applications that enable a circle of accountable clinicians to work together with optimal patient health—not a billable test or procedure—as the ultimate goal. Does that sound like something simple data exchange can accomplish?
Policy and industry dynamics are moving toward data exchange, which is merely a precursor to a new healthcare business model and a safer health system with lower costs and better quality. As the paradigm shifts, we will follow other industries and move from interfaces to interoperability and real collaborative care. And we’ll recognize that open APIs eliminate the obstacles to interoperability that stifle competition and innovation.
Well, that's interesting. I've long been one advocating "Change The Payment Paradigm," but I don't underestimate the difficulty of doing so, shiny new nascent ACOs notwithstanding.

For example, the FFS "payment paradigm" is ostensibly not an issue in Single Payer UK. Nonetheless, check out a couple of very recent articles from across the Pond.
The first recounts a dust-up regarding Medicity.
15 February 2013

The Rotherham NHS Foundation Trust has been found in significant breach of its terms of authorisation by Monitor, with its electronic patient record implementation identified as a key issue.

The trust this month admitted it was facing "persistant serious issues" with the deployment of its Meditech EPR including "clinician and staff acceptance and usability".

It has stopped all go-lives of the system and has hired an external consultant, Larry Blevins, to conduct an immediate review of the system.

A statement from Monitor said The Rotherham had significantly underperformed on its financial plans leading to concerns about the way it was governed.

Key concerns included the trust’s failure to successfully implement a new EPR which led to problems booking patient appointments and loss of income.

A letter from Monitor to The Rotherham says: “The trust has not managed EPR implementation in an effective way and significant operational and financial risks will remain until the trust has a robust and operationally effective EPR system."...
The second goes to travails with Cerner Millenium.
12 February 2013

Eight months on from its go-live with Cerner Millennium, Royal Berkshire NHS Foundation Trust is still struggling to reach a “full business as usual model.”

The trust continues to experience problems with appointment booking and reporting and expects to spend a further £6.2m this year on implementing the system; against a budget of £2.5m.

Not what was hoped five years ago

The situation is a far cry from what the trust hoped to achieve when it quit the National Programme for IT in the NHS in 2008.

In mid-2009, it signed with the University of Pittsburgh Medical Centre, which had done a deal to implement Millennium across Newcastle, to implement the US system in Reading.

The plan was to get theelectronic patient recordsystem live between July and September 2011. But the trust did not go-live until June last year, more than 1,000 days after project start-up.

By this time, UMPC was nowhere in sight, and there were reports that the project had been dogged by problems with poor project management and an over-reliance on contractors...
Read the comments too. They're as good as the articles.Very cool publication. I will add them to my ongoing "must-read" list.


The late CBS News commentator Edwin Newman wrote some delightful books on language and its misuse back in the mid-1970s. I have them. They are treasures to me.

Short take? Sloppy use of language leads to sloppy thinking (and, of course, surely the converse).

Which leads to all manner of sloppy policy, IMO.

Which, I guess, was the notion which begat this rant.

When I read stuff like "Numerous Interoperability Strategies Accommodating The Breadth of Standards Deployment..." my BS detector goes loudly and irritatingly off.
  • As we have seen, HIT "interoperability" is a chimera. Settle for "exchange";
  • "Strategies"? You mean "tactics," really;
  • "The Breadth of Standards"? At some point, the proliferation of "standards" means that none effectively exist. For Health IT data exchange, you really only need one. Not that it will be perfect out of the box. Not that it will encompass every stray, tangential data item of perceived utility to someone. Not that it will mollify everyone. Not that it will be static. But, you don't need a "proliferation." It just becomes a busywork industry.
NEMA 5-15 std outlet
Imagine a nation standardized to 120 VAC power but with 3,965 "Certified" sizes and shapes of electricity "interoperability" portals.

Just Google "data types." There aren't that many. Is it any more difficult than "code sets"?

If the state of U.S. medical technology is one of our great national treasures, then the state of U.S. HIT is one of our great national disgraces. We spend $1.6 trillion a year on health care—far more than we do on personal financial services—and yet we have a twenty-first-century financial information infrastructure and a nineteenth-century health information infrastructure. Given what is at stake, health care should be the most IT-enabled of all our industries, not one of the least. Nonetheless, the “technologies” used to collect, manage, and distribute most of our medical information remain the pen, paper, telephone,fax, and Post-It note. Meanwhile, thousands of small organizations chew around the edges of the problem, spending hundreds of millions of dollars per year on proprietary clinical IT products that barely work and do not talk to each other. Health care organizations do not relish the problem, most vilify it, many are spending vast sums on proprietary products that do not coalesce into a systemwide solution, and the investment community has poured nearly a half-trillion dollars into failed HIT ventures that once claimed to be that solution. Nonetheless, no single health care organization or HIT venture has attained anything close to the critical mass necessary to effect such a fix. This is the textbook definition of a market failure...
All but the most zealous free-market ideologues recognize that some markets simply do not work. Indeed, reasoned free-market champions often deconstruct specific market failures to elucidate normal market functioning. The most obvious examples of such failures (such as public transit and the arts) are subsidized by society at large because such subsidies yield benefits to the public that outweigh their costs. Economists refer to these net benefits as “positive externalities,” defined as effects that cannot be captured through the economic equation of direct cost and benefit. The positive externalities of an HIT system approaching the functionality of our consumer finance IT system include reduction of medical errors like the one that killed Joe Wilson; elimination of tens of thousands of redundant and expensive tests, procedures, and medications, many of which are not only wasteful but harmful; and the coordination and consistency of medical care in ways only promised by the theoretical version of managed care. These public health benefits are well beyond the reach of a health care system characterized by the complexities of medicine and conflicts of multiple parties working at economic cross-purposes. They are trapped outside the economic equation, positive externalities of a stubbornly fee-for-service health care system that inadvertently rewards inefficiency, redundancy, excessive treatment, and rework.
Again: Dot-Gov: Market Failure And The Creation Of A National Health Information Technology System, JD Kleinke, Health Affairs, 2005 (pdf)


My friend the uber-blogger John Lynn has some worthy thoughts.

Interoperability Needs Action, Not Talk – #HIMSS13 Blog Carnival

When you talk to people outside of healthcare about the value of healthcare IT, you will often get a response that healthcare IT is fantastic because it makes it so easy for medical data to be shared with who needs the data when they need it. Those of us in healthcare IT know that this is far from the reality of what’s possible with healthcare data today. This is really unfortunate, because the promise of technology in healthcare is to make the movement of data possible. We’re currently missing out on the benefits of this promise.

I don’t know about the rest of you, but I’m sick and tired of hearing the excuses for why healthcare data can’t be shared. We’ve heard them all: privacy, security, data governance, payment model, etc etc etc. Yet we go to the HIMSS Interoperability Showcase and see that the technology to start sharing data is there, but what seems to be missing is the willpower to push the data sharing through despite the challenges and naysayers...
See you in NOLA, John.

Fast could lead to furious over EHR meaningful use
CMS’ schedule for physicians to show electronic health record proficiency is too ambitious given system limitations and issues that haven’t been addressed from stage 1.
Editorial. Posted Feb. 18, 2013.
The first stage of the federal meaningful use program, covering physician adoption of electronic health records, has not been completed. Yet already the Centers for Medicare & Medicaid Services not only is rolling out proposals for the second stage but also is talking about what is going to be in the third and final stage of the program.
While meaningful use certainly has encouraged physicians to adopt EHRs, to some extent stage 2 and most definitely stage 3 demand physicians to reach standards that are nearly impossible to meet in full. And yet, at stage 3, doctors will have to be at 100% compliance in some measures to meet the standards. The program requires doctors to buy potentially expensive technology that they then must configure and adapt to meaningful use requirements. This is even though those systems might not be right for their practice and aren’t capable of doing the things that CMS requires of doctors. On top of that, all of this must be done in the next three years.
That is an ambitious schedule not required by law but by regulators at CMS. The agency would do well to take a breather. Outside help should be enlisted to review how the meaningful use program has gone so far. Then, substantive change can be made to requirements so meaningful use of EHRs really does mean better and more efficient care, and not just lots of meaningless data entry and technological frustration...
Before CMS talks further about stage 3, whose requirements are in a preliminary phase, it should address these concerns to make sure that physicians have access to systems that truly are meaningful to improving care. Physicians shouldn’t be required to meet mandates on exchanging information when systems aren’t capable of doing it. Doctors should be able to opt out of meaningful use measures that don’t apply to what they do. Additional measures for meaningful use should be held off so vendors can fix the problems current systems have.Before implementing stage 2 (which starts in 2014) and stage 3, CMS should have an independent evaluation conducted of stage 1 and share those results with the public so everyone can learn what went wrong, what went right and what is the best course going forward.
That all takes time, but the meaningful use schedule would be better for it. It would help to ensure that EHRs reach their best potential, not become one more rightfully resented bureaucratic hassle.


More to come...