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Sunday, February 10, 2013

Cane toads and kudzu

It’s the EHR System, Stupid: Reversing the Law of Unintended Consequences

...We incentivized comprehensive IT adoption, making it easier to bill for every procedure, examination, aspirin, tongue depressor, kind word and gentle (or not) touch without first flipping the American healthcare paradigm on its head, if such a thing is even possible.

According to analysis by the New York Times, hospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier. Overall, the Times says, “hospitals that received government incentives to adopt electronic records showed a 47 percent rise in Medicare payments at higher levels from 2006 to 2010 … compared with a 32 percent rise in hospitals that have not received any government incentives …”

To paraphrase the mantra of Bill Clinton’s successful 1992 presidential campaign: It’s the system, stupid. More specifically, it’s the business model, stupid, the fee-for-service system in which electronic health records are enabling tools.

It’s also the law of unintended consequences. You know … you take action, planning on this but instead you get that.

Like the introduction of cane toads in Australia to kill beetles (they couldn’t jump high enough). Like letting mongooses loose in Hawaii to manage the rat population (they preferred native bird eggs). Like Kudzu, the insatiable vine that’s devouring the South.

According to the authors of the RAND report, the problem is with the incentive structure that encourages more tests and procedures. Well, of course it is. Doctors and administrators have a clinic or hospital to run. They have expensive invoices from Epic and Cerner to pay. They can now track and bill for all this stuff they used to not get paid for. Are we surprised?

And meanwhile, fee-for-service leads us down a contradictory rat hole of massive healthcare costs and lousy public health...

Will the U.S. become a patchwork of regional healthcare organizations? We know that corporate healthcare is gobbling up independent physicians. Are the days of private doctors performing services and getting paid for them coming to an end? Maybe they are. Maybe they should be.

Because what we’ve done in the past has not worked out the way we hoped.

Like cane toads and kudzu...
Interesting stuff. As is this, from THCB:

Fundamentals of Electronic Medical Record Design Part I

Our ancestors began using tools millions of years ago and humanity assumed control of the planet it lives on through a succession of tools ranging from sticks and stones all the way to iPhones and drones. The basic process for discovering or inventing tools hasn’t changed much over the millennia, and it follows two basic patterns. Either an existing artifact is examined for fitness to various purposes until one such purpose is discovered accidentally or through organized efforts, or a problem is identified and a tool is then invented, or located, to solve the problem.

The problem itself could be something that was thought impossible before, such as flying, or a more mundane desire to reduce the effort and expand the capabilities associated with an existing activity, such as moving goods from one place to another. Tools can have limited effects, revolutionize an entire economic sector or can change history, and some tools can have harmful effects that must be balanced with the benefits they offer for the intended task. Tools usually undergo long processes of change, improvement and expansion, and sometimes the evolving tool looks nothing like the original invention. Why are we talking about tools here? Because programmable computers are tools. The computer hardware is like the hammer head and the programming software is like the hammer’s handle (more or less). And EMRs are one such handle.

Let’s imagine that we are software builders and we have a desire to help doctors deliver patient care. And let’s further assume that we, and our prospective customers, examined all the existing tools out there and found them not quite fit for purpose. Let’s also assume that we are not suffering from delusions of grandeur, have the humility to admit that we don’t know how to cure disease and have no interest in global social engineering initiatives. Let’s imagine that we are the misguided founders of a small social business interested in doing well by helping others do good things...

Patient care is a longitudinal activity occurring over varying periods of time, but it is not continuous; instead it is a chain of discrete units of service usually called encounters, which may or may not be dependent on each other. Encounters can be proactive, reactive, physical or virtual. The mechanics of a patient encounter in primary care is very simple. Patient comes in (or not), patient relates problems (if any) to physician, physician formulates diagnosis based on patient narrative, physical examination, diagnostic measurements and finally suggests therapies to resolve, alleviate or prevent suffering from problems. Patient may or may not agree with suggestion. There are three major parts to this process – gathering of information, synthesis of information and relationship building – and each part has a very clear purpose. Note that documenting the events is just a corollary to the main process. Sounds simple? Not quite...

Thus our little project lends itself very well to an agile development model where we can have successive series of small releases that are useful to our users from the get go.  Another look at those general goals reveals that we could benefit from placing some boundaries on the magnitude of our project to avoid the number one pitfall of all software projects – scope creep, or consistently succumbing to the temptation of adding one more little thing. To do that we should look, within our scope of service, at what patient care is not.
  • Patient care is not a synonym for public health.
  • Patient care is not a financial transaction.
  • Patient care is not lifestyle coaching.
  • Patient care is not a commodity (at least until people become a commodity as well).
And just in case we were not specific enough in our definitions, this software is for physicians administering care to an individual patient. We are not designing tools for staff, billers, payers, employers, federal or state agencies, and no, we are not building tools for patients...
Margalit never disappoints. Her blog On Healthcare Technology is a motherlode of sharp and witty thinking.
EHRs: Where will your meaningful use bonus go?
Practices should set expectations early in the process for how the money will be divided and how it will be spent.
By PAMELA LEWIS DOLAN, amednews staff. Posted Feb. 11, 2013.

As they do every time they expect to come into extra money, the partners at Acacia Internal Medicine Specialists talked about what to do with a bonus from the meaningful use incentive program.

The three-physician, four-nurse practitioner practice in Phoenix was building a new facility when the incentive program was announced, so by the time the checks arrived, the investments needed to bring the technology infrastructure to meaningful use readiness had already been made. But there was a community room in the new building that the group had envisioned as space for wellness classes. Together, they decided their meaningful use checks would go toward hiring a teacher to conduct weekly tai chi classes. They also made other small technology purchases to improve the existing IT...

Wow. The hardcores at will have a cow.


Next comes the 'Upgrade your account today!' pitch, right?


How is CONNECT 4.0 Different?
CONNECT 4.0 offers more flexibility for users through its modular platform, which allows users to pick and choose which components they want to use in their IT environment.
CONNECT 4.0 also allow users to:
  • Receive higher message volumes – CONNECT 4.0 can support secure health information flows of 1600+ messages per minute.
  • Exchange large files (for the first time) of  up to 1 GB.
  • Run CONNECT on additional application servers such as Glassfish, IBM WebSphere, and Oracle WebLogic to meet unique IT environment needs.
  • Get more comprehensive event and metric data with improved logging capabilities. Since CONNECT is often used as a gateway in concert with other systems like electronic health records, improved logging allows adopters to integrate CONNECT into whole-system monitoring.
  • Determine the state of a transaction across messages to better track and analyze the operations of CONNECT and trading partner gateways.
  • Minimize deployment load by supporting a lightweight gateway, which allows for a smaller server footprint and use of system resources.

A pair of Indiana University researchers has found that a pair of predictive modeling techniques can make significantly better decisions about patients’ treatments than can doctors acting alone. How much better? They claim a better than 50 percent reduction in costs and more than 40 percent better patient outcomes.

The idea behind the research, carried out by Casey Bennett and Kris Hauser, is simple and gets to the core of why so many people care so much about data in the first place: If doctors can consider what’s actually happening and likely to happen instead of relying on intuition, they should be able to make better decisions...
That assertion will certainly generate some serious pushback from the MD-as-Ironman cohort. Maybe we should take a quick jaunt back "down in the Weeds'" though.
In medicine, tools for reliably processing complex information can simplify the ultimate choices presented to consumers by filtering out what is extraneous while presenting individually relevant options and the pros and cons of each. Without a system for accessing that information as needed, patients will continue to rely on the apparent expertise of practitioners. In turn, as Chris Weed has written,   
practitioners might just as well continue to rely on their own creative intuition, experience, and random and informal contacts with other concerned people. Without the routine use of powerful knowledge coupling tools to generate specific linkages of the knowledge base to practical decision-making for unique individuals, scientific medicine affects practice primarily through new procedures and associated technologies, while the application of such procedures and technologies is left to a sort of cottage industry or folk art based on something approaching oral tradition.”
Practitioners need knowledge coupling tools to inform their use of advanced procedures and technologies at two levels. First, in order to determine when an advanced procedure or technology is superior to other options, practitioners and patients need to elicit all relevant options, and the pros and cons of each, for that patient’s specific problem situation. Second, if an advanced procedure or technology is determined to be the superior option, using it effectively may itself require careful information processing. Use of imaging technology, for example, requires taking into account a bewildering array of factors in judging alternative tests, test protocols, test limitations and the significance of test results.  Practitioners thus need information tools to use clinical imaging tools cost-effectively no less than they need the imaging tools themselves to reveal internal organs. In both contexts, ignoring modern technology is unacceptable. [Medicine in Denial, pp 124 - 125]


Telligen Iowa HIT Regional Extension Center Achieves Meaningful Use Milestone
February 12, 2013

In December 2012, the Telligen Iowa HIT Regional Extension Center successfully achieved 100 percent of their Milestone 2 goal – 1,200 providers live on a certified electronic health record with active quality reporting and e-prescribing. Telligen REC now joins the ranks of 13 of the 62 federally designated RECs nationally who’ve reached this goal.

“This achievement will truly benefit patient care, which is the most exciting part. 2012 was a tremendous year for Health IT adoption in Iowa, and we were fortunate to support so many outstanding providers with the technology foundation and workflow redesign that was required,” said Susan Brown, Director of Telligen REC.

According to the HITECH Act of 2009, preferred primary care physicians are required to achieve Meaningful Use of EHRs by 2014. Therefore, the Telligen REC must reach three milestones by February 2014:

  • M1: Signed technical assistance contracts between the Regional Center and provider
  • M2: Documentation of Go-Live status on a certified EHR, with active quality reporting and electronic prescribing
  • M3: Meeting the meaningful use criteria established by the HHS Secretary
The Telligen REC began recruiting PPCPs in February 2010, and achieved their Milestone 1 goal by reaching 100 percent of their recruitment goal in December 2011.
Excellent work. Congratulations, Buckeyes.

More to come shortly...

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