Search the KHIT Blog

Sunday, April 28, 2013

The fundamental problem facing health care policy

 Props to WaPo's Ezra Klein:
The graph [below] shows the U.S. death rate for infectious diseases between 1900 and 1996. The line starts all the way at the top. In 1900, 800 of every 100,000 Americans died from infectious diseases. The top killers were pneumonia, tuberculosis and diarrhea. But the line quickly begins falling. By 1920, fewer than 400 of every 100,000 Americans died from infectious diseases. By 1940, it was less than 200. By 1960, it’s below 100. When’s the last time you heard of an American dying from diarrhea?

“For all the millennia before this in human history" [Ken Coburn says] "it was all about tuberculosis and diarrheal diseases and all the other infectious disease. The idea that anybody lived long enough to be confronting chronic diseases is a new invention. Average life expectancy was 45 years old at the turn of the century. You didn’t have 85-year-olds with chronic diseases.”

With chronic illnesses like diabetes and heart disease you don’t get better, or at least not quickly. They don’t require cures so much as management. Their existence is often proof of medicine’s successes. Three decades ago, cancer typically killed you. Today, many cancers can be fought off for years or even indefinitely. The same is true for AIDS, and acute heart failure and so much else. This, to Coburn, is the core truth, and core problem, of today’s medical system: Its successes have changed the problems, but the health-care system hasn’t kept up.
There you have it.


3rd Annual AJMC HIT Special Issue

It has been 4 years since Congress and the Obama Administration authorized as much as $27 billion in new funding under the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act of 2009 to support the meaningful use of health information technology (HIT). Since that time, there has been a dramatic growth of interest in the potential for HIT to improve health and healthcare delivery.
To continue to help facilitate this growing interest, The American Journal of Managed Care (AJMC) is publishing its 3rd Annual HIT special issue that will feature scholarly articles and perspectives from policymakers, payers, providers, pharmaceutical companies, health IT vendors, and health services researchers with the goal of improving efficiency and outcomes in implementing HIT. The Editors seek original research papers and informed commentary on HIT and its impact on the following topics:
  • Medical Care (general and special populations)
  • Healthcare Costs
  • Comparative Effectiveness Research
  • Reimbursement
  • Health System Strategy
  • Healthcare Delivery
All papers will undergo the Journal's customary rigorous peer-review process. Due to space constraints, please limit the text to 2500 words (excluding references) and the graphic elements to a combined total of 3 figures/tables. Final decisions regarding ultimate acceptance and inclusion in this special issue rest solely with the Editors. Papers submitted before May 3, 2013, will have the best chance for consideration in this special issue. High-quality papers not selected for this special issue may be considered for one of the regular, monthly issues of the Journal.

Please submit all manuscripts through AJMC’s online submission system at If you have questions or want to speak to an Editor, please e-mail
Feds Demand Answers From Nevada Psychiatric Hospital Accused Of Busing Patients Out Of State

CARSON CITY, Nev. -- The federal agency that oversees Medicaid and Medicare compliance has put Nevada on notice of "serious deficiencies" at a Las Vegas psychiatric hospital following reports of patients being improperly discharged.

A letter Thursday from the Centers for Medicare and Medicaid Services, first reported by The Sacramento Bee and obtained Friday by The Associated Press, gave Nevada 10 days to correct problems in its mental health discharge policies at Rawson-Neal Psychiatric Hospital or risk the loss of federal funding, potentially tens of millions of dollars.

The move follows an investigation launched by the Bee after James F. Brown, a patient at Rawson-Neal, was put on a bus alone in February and sent on a 15-hour trip to Sacramento, Calif., where he knew no one. Brown suffers from schizophrenia and depression.

The newspaper then reviewed bus ticket receipts dating to 2008 and found the hospital, part of the Southern Nevada Ault [sic] Mental Health Services, had transported about 1,500 patients to other states. Roughly 500 went to California.

Last year alone, Rawson-Neal bused out patients at a pace of more than one per day, shipping nearly 400 patients to a total of 176 cities and 45 states across the country, the Bee reported.

City attorneys in Los Angeles and San Francisco this month launched their own criminal investigations into whether Nevada engaged in "patient dumping."
This bears watching, being in my service areas. My former Sup Erick Maddox might have some views on this, coming to HealthInsight from Behavioral Health.


Canada Health Infoway (Infoway) commissioned PwC to conduct a Benefits Evaluation Study (“the Study”) to determine the current and emerging effects of implementing Electronic Medical Records (EMRs) in community- based practices in Canada. Within scope for this Study was an assessment of the effects of EMR use by family physicians and specialists (medical or surgical) who work in private offices or clinics, community clinics and community health centres, and free-standing walk- in clinics. 

Adoption of EMRs by primary care physicians in Canada has more than doubled between 2006 and 2012 from 23% to 56% (Commonwealth Fund Survey, 2012). The adoption of EMRs by community-based specialists has also increased from 28% of physicians in 2007 to 41% in 2010 (National Physician Survey, 2010). This increase in adoption has been supported to a large extent through investments by the provinces and territories in EMR programs, physician practices, and Infoway. As expected, there is variability in EMR adoption across the country, and those jurisdictions with defined EMR programs have experienced the most significant gains. Despite these gains, the use of EMRs in primary care in Canada lags behind that of many other countries – Australia, New Zealand, the United Kingdom and the Netherlands all report use of EMRs by over 90% of their primary care physicians...
3.3 Advanced use of EMRs can improve health outcomes and patient safety through preventive care and chronic disease management.
The costs of managing chronic diseases currently account for 58% of all health care spending in Canada and are estimated at $68 billion annually and growing; in addition, the indirect costs associated with income and productivity loss are estimated at $122 billion, or double the costs of managing chronic diseases (Public Health Agency of Canada, 2011). As such, with advanced use of EMRs (i.e., use of a broader range of available functionalities) there is a significant opportunity to support improved CDM and preventive care and potentially reduce the associated costs to the health care system. However, self- reported survey responses revealed that only 3% –18% of primary care physicians in Canada were estimated to effectively use EMRs for this purpose...
This Study has demonstrated some of the benefits that have been realized with the implementation of EMRs in community- based care practices. In practices demonstrating advanced EMR use, further emerging benefits at the practice and health system level are being realized. The evidence indicates that there is a compelling reason to continue to advance EMR adoption and maturity of use across Canada. 

With the implementation of a number of focused recommendations and with the ongoing engagement and involvement of clinicians, the potential for wide ranging and transformative benefits can be further realized by providers, patients and the health care system as a whole...
Interesting paper. Pretty much the findings we'd expect. Their summary recommendations:

Meanwhile, back stateside, Monday, April 29, 2013

Doctors are increasingly dissatisfied with EHRs 
by Ken Terry, iHealthBeat Contributing Reporter 
Recent studies point to significant and growing problems with the usability of electronic health record systems and their effect on physician productivity. Some of these issues appear to be related to the addition of extra features to meet the meaningful use requirements, such as quality reporting and patient portals. Many physicians also have trouble documenting patient encounters in EHR drop-down boxes, which is an example of the poor usability of user interfaces. Moreover, current EHRs do not fit clinical workflow well, and practices have had to develop numerous workarounds to get their daily tasks accomplished. 
Software design is not to blame for all of these problems. Inadequate training and poor preparation for switching from paper to electronic records are also factors, experts say. The rapid adoption of EHRs in response to the government's EHR incentive program has exacerbated these pain points, as doctors scramble up the steep learning curve to EHR mastery. Nevertheless, even many physicians who are experienced EHR users are dissatisfied with their systems...
The sharp increase in the percentage of physicians who did not find that EHRs had reduced their workload, and the equally marked rise in those who had not seen their productivity return to the level they had achieved before adopting EHRs. 
Cindy Dunn, a senior consultant with MGMA Consulting, is not surprised by these results. Many physicians feel they were sold a bill of goods, she said, because they were told that "the EHR was supposed to make it faster and easier for me and my patients, and it doesn't."
Computer-generated visit notes are often voluminous and difficult to read, and it's much harder to enter data in EHR templates than to simply dictate the note, she pointed out. 
Moreover, if a doctor misses a step, somebody is looking over his shoulder and will tell him to correct it.
Physicians are waiting for a "Star Trek computer" that will be able to parse their dictation and enter discrete data into the system automatically, she said. That's what natural language processing is supposed to do, but it's still not there yet. 
Both Dunn and Brookstone said physicians and practice staff need better training on how to use EHRs. Today, many physicians receive three days of training or less, or perhaps none at all. 
"Practices need realistic training to make these systems work," Dunn said. "They need somebody who understands the workflow and can work with the docs."...
These complaints are nothing new. Not a whole lot being done thus far systematically to mitigate the problems. And, just as the RECs are maturing enough to be able to help address these issues more effectively, we kill the REC program.

What tablets can teach us about EHR usability
If you have followed my blog posts, you realize that I don't think much of EHR certification as currently implemented. The criteria reflect the best that a national committee can do without excluding the products offered by the committee members. The criteria also use terms that may be understandable in broad terms, but which are never precisely defined and present a bizarre mix of the nit-picky and the nebulous. They are simultaneously over-specified and under-specified. 
After griping about computer systems for 30 years, regulators have finally gotten one message — usability is a problem. Their response was predictable: Regulate it. National Coordinator of Health IT Farzad Mostashari recently raised the possibility that the Health IT Policy Committee would recommend usability certification. "If you score 71 [on a usability test], you [would] have permission to market EHRs in this country, and if you score 70, you [would] not." He says he’d be surprised if they do. Many of us were also surprised by “meaningful use,” but not Mostashari. (Next, we will need permission to think!)...

Interesting doc. Read on.

More to come...

Thursday, April 25, 2013


I read and reviewed Dr. Sweet's fine book a year ago, and have subsequently corresponded with this delightful, wonderful physician and author. I cannot wait to meet her.


I think we already knew this, but it was posted by CMS today. If you're an EP eligible for maximum Stage 1, Year 1 payment in 2013, your $15,000 incentive potential has now been reduced by $300 (2% sequestration reduction). It will take new overriding legislation to undo the sequester law.


Missed our connecting flight. Our flight from SFO was late. Then, to get to our connector gate, we had to exit Security and go back through. TSA found my scurrilous 6 oz bottle of water down in my camera bag as it went through the scanner. I got pulled aside for The Schtick.

No problem. The office is now wherever I am. All pretty much wireless. Even use my iPhone as a WiFi "hotspot" to connect online when I have to. I'll just make use of my time while awaiting a later flight.

From InformationWeek HealthCare:

Interoperability Depends On EHR Vendors: AHA
Ken Terry, April 26, 2013 08:56 AM
The American Hospital Association (AHA) does not want the federal government to impose more regulations on healthcare providers to encourage health information exchange.
It would, however, like the government to demand more from electronic health record (EHR) vendors to advance interoperability at several different levels, according to an AHA letter to the Office of the National Coordinator of Health IT (ONC). The AHA sent the letter in response to the ONC's request for information (RFI) on how to increase interoperability...

The Money Shot, I guess...

Glossing over the core problem. They continue:
Electronic information exchange is one tool among many that providers use to achieve the goals of improved health and the best possible health care. Payment policy should incentivize those end goals, not specific means to achieve them. New payment mechanisms such as value-based purchasing, accountable care organizations (ACOs) and bundled payment models incentivize better care coordination and reduced fragmentation of care. The AHA supports these new payment and delivery models, and hospitals around the country are engaged in their implementation. We do not believe it is productive to add specific information exchange requirements to these projects, as the mechanisms of exchange may vary by project, and the specification of requirements could result in unintended consequences, including limiting innovation and posing a reporting burden. 
A key principle behind these new payment and delivery models is to incentivize the right outcomes, while allowing flexibility in determining how they are achieved. These new models are encouraging the movement of data from individual silos that support individual transactions and clinical encounters toward integration of information to support collaboration among a health care team, while allowing local considerations to shape the care delivery approaches taken...

"Payment policy should incentivize those end goals, not specific means to achieve them."

I could not disagree more with the latter part of that sentence. Moreover, one precisely needs means that comprise the mechanics of "incentives." Absent "means," incentives are nothing but empty platitudes, a nullity. Now, none of that observation argues inexorably in favor of government regulation, but regulation of some sort there must be. And, given that government is by far the single largest payer, the "payment policy" of government should explicate the "means" (standards) that produce the "goals."

Is it really that difficult to grasp?

The AHA letter continues, with the customary Motherhood-and-Apple Pie, Continue-to-Miss-The-Point red herrings.

The AHA urges ONC to focus on removing the barriers to data exchange and sharing best practices in order to support the acceleration of the payment and service delivery redesign initiatives currently underway...

Fine. I got your "removing the barriers" right here.


One. Then stand back and watch the Market Work Its Magic in terms of features, functionality, and usability. Let a Thousand RDBMS Schema and Workflow Logic Paths Bloom. Let a Thousand Certified Health IT Systems compete to survive. You need not specify by federal regulation any additional substantive "regulation" of the "means" for achieving the ends that we all agree are desirable and necessary. There are, after all, only three fundamental data types at issue: text (structured, e.g., ICD9, and unstructured, e,g., open-ended SOAP note narrative), numbers (integer and floating-point decimal), and images. All things above that are mere "representations" of the basic data (e.g., text lengths, datetime formats, logical, .tiffs, .jpegs etc). You can't tell me that a world that can live with, e.g., 10,000 ICD-9 codes (going up soon by a factor of 5 or so with the migration to ICD-10) would melt into a puddle on the floor at the prospect of a standard data dictionary comprised of perhaps a similar number of metadata-standardized data elements spanning the gamut of administrative and clinical data definitions cutting across ambulatory and inpatient settings and the numerous medical specialties. We're probably already a good bit of the way there given the certain overlap across systems, just not in any organized fashion. 

Think about it.

Why don't we do this? Well, no one wants to have to "re-map" their myriad proprietary RDBMS schema to link back to a single data hub dictionary standard. And, apparently the IT industry doesn't come equipped with any lessons-learned rear view mirrors.

That's pretty understandable, I have to admit. In the parlance, it goes to opaque data silos, “vendor lock,” etc. But, such is fundamentally anathema to efficient and accurate data interchange (the "interoperability" misnomer).

Yet, the alternative to a data dictionary standard is our old-news, frustratingly entrenched, Clunkitude-on-Steroids Nibble-Endlessly-Around-the-Edges Outside-In workaround -- albeit one that keeps armies of Health IT geeks employed starting and putting out fires.

Money better spent on actual clinical care.

More to come...