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Wednesday, May 14, 2014

We're about to be Bushwhacked

Read an interesting post by athenahealth CEO Jonathan Bush on THCB this morning. Led me to this:

Interesting. I bet it's one long (ghostwritten?) riff on this well-known theme of his (from his THCB post):
...To create a modern, caring and efficient health care economy, we have to create more spaces where entrepreneurs can compete in the marketplace—and not in the corridors of Capitol Hill.

Unlike many entrepreneurs, I had reason to feel comfortable in Washington. Even though I couldn’t call my presidential cousin for help, I had my political name, fancy venture firms behind me, and my equally fancy business degree from Harvard. That gave me the confidence—or hubris—to assume I could get in there and make a difference. I was an outsider with insider status. I’d guess that 90% of businesses that get blown up by government mis-steps, or even prevented from being born, are run by outsiders with outsider status. That is why it’s so hard for an activist government to be effective. It works with known players—while the future should be in the hands of unknown players working to make the household names obsolete.

The government, by regulating industry, actually ends up protecting the incumbents. Here’s how. Let’s say the news comes out that insurance companies are taking advantage of customers in an especially awful way. Because this a service that society views as vital, the government comes in and says, “Whoa, what’s going on in here?” Now the best thing to do at this point would be to make it as easy as possible for new entrants to come into the system and disrupt these guys—clean their clock, kill them, or at the very least force them to change. But instead the government looks to control them. They do this by writing up cumbersome regulations. These discourage newcomers from the market. Many of the best would-be competitors don’t employ a single lobbyist or lawyer. They take one look at a market regulated up the wazoo, and conclude, wisely, that they’re not built to play that game. They’re better off building a new video game or a dating app. So instead of making the bad incumbents vulnerable, the government leaves them fat, lame and stupid—but with formidable lobbying power. Since these companies employ a lot of people, they become untouchable...
From CNBC:
[David] Einhorn, co-founder of Greenlight Capital, called Athenahealth a "bubble" stock that could fall 80 percent or more from its peak share price of more than $204 in March. He also said the company's potential products are being overvalued.

Einhorn has been advising investors to short ATHN.

UPDATE: I emailed athenahealth asking for a comp review copy. They blew me off. No reply. The gall of some pissant small-fry curmudgeon independent blogger.

Just checked; the price of the Kindle edition has already dropped $3, from $14.99 to $11.99. I don't think I'm gonna buy it, even though it's probably pretty well done. Competing priorities for my dollars.

Once we get past the 5-Star effusive "Friends and Family" hagiographic Amazon shill "reviews," we'll see what people actually think.


I used Dragon to transcribe this little excerpt.
In the lumbering healthcare industry that we have come to know in the last half-century, information is a scarce resource. Patients rarely have access to the records. No one can hazard a guess as to what an operation, a medicine, or even a Band-Aid might cost. Keeping this information button and up benefits the incumbents, who thrive within what we might call and ignorance economy. Some, as we’ll see, are still attempting to control their local markets by limiting access to data. It sooner or later, data promises to turn this status quo on its head, ushering in a slew of new digital startups and — most important — delivering vital and timely information to the patients, or customers.

And what will they do with this information? It can be summed up in a single word: shopping. This has to do with making choices. We weigh countless options in the rest of our lives, but not nearly enough of them in healthcare. Shopping, whether it’s driven by an individual, a retail buyer, or a wholesaler, creates the market, and the market responds with choices and innovation. What’s more, in markets driven by shopping, losers figure out how and where to change their fortunes, or they disappear.

We need shopping, I believe, not only to fix healthcare, but also — and I know this may sound strange — to express our own humanity. Think about it. We shop for clothes to express our tastes and personality. We do the same for music and food. Some of us trick out our cars, put them on mega wheels, or hang big, fuzzy dice from the mirror. We express we are with these choices. And yet for the care of our bodies, for some of the most important decisions we make in life, we rely on a handful of menu options and lists drawn up by bureaucrats. What I want is for people to have a dizzying array of options in healthcare, so they can care for themselves and their  loved ones in a way that suits them best, that makes them happy and proud. Some of the choices will be simple, of course, others delightfully convoluted. But in my vision, each of us will fashion the health care we want and deserve. We'll express ourselves.
Go shopping? Where have we heard that before? Right, health care purchases are no different from buying clothing or CDs or cars. We don't want actual health care, we want "choice," via which to make fashion statements?

From the Amazon blurb on another of my favorite books, The Paradox of Choice: Why More Is Less:
Whether we're buying a pair of jeans, ordering a cup of coffee, selecting a long-distance carrier, applying to college, choosing a doctor, or setting up a 401(k), everyday decisions -- both big and small -- have become increasingly complex due to the overwhelming abundance of choice with which we are presented.

As Americans, we assume that more choice means better options and greater satisfaction. But beware of excessive choice: choice overload can make you question the decisions you make before you even make them, it can set you up for unrealistically high expectations, and it can make you blame yourself for any and all failures. In the long run, this can lead to decision-making paralysis, anxiety, and perpetual stress. And, in a culture that tells us that there is no excuse for falling short of perfection when your options are limitless, too much choice can lead to clinical depression.

In The Paradox of Choice, Barry Schwartz explains at what point choice -- the hallmark of individual freedom and self-determination that we so cherish -- becomes detrimental to our psychological and emotional well-being. In accessible, engaging, and anecdotal prose, Schwartz shows how the dramatic explosion in choice -- from the mundane to the profound challenges of balancing career, family, and individual needs -- has paradoxically become a problem instead of a solution. Schwartz also shows how our obsession with choice encourages us to seek that which makes us feel worse.

By synthesizing current research in the social sciences, Schwartz makes the counter intuitive case that eliminating choices can greatly reduce the stress, anxiety, and busyness of our lives. He offers eleven practical steps on how to limit choices to a manageable number, have the discipline to focus on those that are important and ignore the rest, and ultimately derive greater satisfaction from the choices you have to make.

BTW: Got my hardcopy of the ThedaCare Center book "Beyond Heroes" yesterday. Started on it in earnest last night.

Just downloaded this as well:

The Scientific American eBooks are excellent, and inexpensive. I have a bunch of them.

Stay tuned...


How Meaningful Is Meaningful Use?
The government's Meaningful Use program mandating electronic health records is out of touch with reality. EHRs bog down process and can even worsen care. Despite the existence of a government program called Meaningful Use, as a doctor I have yet to see a meaningful, positive impact on care from electronic health record (EHR) systems.

Regulators pushing for better and more cost effective medicine have decided that electronic technology, which has revolutionized many industries, is the solution needed to revolutionize medicine. We have been told that EHRs will make us better doctors, and they will make patients more responsible and engaged in their care. They go so far as to claim that EHRs will save doctors and hospitals time, that they will provide better coordination of care and save lives. While I can envision a world where this could be true, those of us living in the real world struggle with the disconnect between what is touted and what we experience every day.

It is true that some studies have shown specific benefits on selectedmeasures when EHRs are used. Unfortunately, this is not true in all studies. Some studies have failed to show improvement of any kind when an EHR system is implemented. Some show an increase in adverse outcomes, including death. The EHR is not a proven technology. It is an experiment, and hospitals and clinics are beta testing new ways of doing things every day. The en masse adoption of EHRs into hospitals is akin to forcing car makers to make all vehicles from a new plastic that theoretically could make them safer without having shown that it really works.

High expectations for a new technology are typical, but pushing adoption of a technology that hasn't proven itself yet is inappropriate and flawed. Many haven't seen improvement in care coordination, efficiency, or patient engagement. In fact, some think things are worse with EHR. Patients now have to compete with computers to get their provider's full attention. Good documentation can take more time to input, and coordination of care still requires highly motivated teams. It is not clear if the EHR is more effective that a cohesive team with a spreadsheet. Additionally, health information exchanges are years away from truly interconnecting institutions and are not adding proven benefit to many.

Part of the problem is the menagerie of disconnected proprietary systems, all trying to solve problems in their own way. They don't speak to each other. Many are plagued with poor design and poor usability. These problems can be solved, but they should have been solved before we bought the software, not after.

In an effort to push EHR adoption and use, the Center for Medicare and Medicaid Services (CMS) has created the Meaningful Use (MU) incentive program, which defines what people should be doing with their EHR and pays them for doing it. The CMS has also instituted penalties for those who would remain on the sidelines. MU Stage 2 is ongoing, with the goals of increasing use of health information exchanges and patient engagement by enabling patients to access and transmit their own data. It also requires more intense use of EHR by physicians who must order tests, e-prescribe more consistently, look at labs in an electronic format, and keep everything safe from hackers.

On the surface, these seem laudable. Yet the technology remains cumbersome and disconnected, making many of these tasks difficult at best. Some tasks require someone else to act -- the patient or the health IT vendor. Even with a certified product, meeting MU Stage 2 requires overcoming some major hurdles. It is not clear that any of these things are improving care or saving time, money, and lives, as claimed by the CMS...
I am all for advancement, but trying to push a technology that is not mature nor the best one to solve the problems at hand is ill-conceived and foolish. Many of the current EHR systems are simply inadequate. Continuing to put energy into making these systems do tasks they can't isn't helping anyone. We are wasting time and resources trying to fit a round peg in a square hole. MU is pushing adoption of technology, but it is not improving the technology. It is simply making people use systems they wouldn't use without incentives.

Our institution is striving to meet MU Stage 2. I am not sure if we will be able to. Our push to meet the required metric for patient engagement is not going well. Perhaps we are doing it wrong, or we have a lot of apathetic patients. Additionally, getting staff to go out of their way to use a very time-consuming CPOE process is more than challenging. Using CPOE makes it harder to look back and see what the current orders are. In order to care for patients, we have to keep separate notes outside of the EHR, creating more than twice the work as doing it on paper. Consultants can't figure out what is going on without talking to the other providers in person. This adds to the challenge of providing good care. If an EHR fails to achieve its No. 1 objective -- being a well-organized repository of information that is pertinent to a patient -- it is of little value, even if it can meet MU.

EHRs need to be measured by usability and functionality, not whether they can achieve Meaningful Use metrics. Right now, we need to be focused on usability. Certifications mean nothing when a product doubles or triples the workload. Our EHR is a roadblock to providing well coordinated, evidence-based, efficient, and compassionate care. MU might have merit, but it is taking the focus off the bigger issue of usability.

We shouldn't be pushing for universal measures until they can be met -- and until we have evidence that they are truly beneficial.


David M. Denton is a board-certified pediatrician and member of the American Academy of Pediatrics. He is a partner of the Pocatello Children's Clinic in Pocatello, Idaho, and is affiliated with Portneuf Medical Center where he currently serves as the medical staff
Link to full article here.
AMA Wants Major Overhaul of Meaningful Use

Warning that many physicians will not be able to advance to Stage 3 of the electronic health records meaningful use program, the American Medical Association is suggesting radical changes to all three stages.

Absent significant changes, more physicians--already struggling with the first two stages--will drop out of the program or be unable to move to Stage 3, the association contends in a letter to Centers for Medicare and Medicaid Services Administrator Marilyn Tavenner and National Coordinator for Health IT Karen DeSalvo, M.D...
AMA sharply criticized a HIT Policy Committee certification workgroup last week for being "unwilling to make a recommendation on making the overall program more manageable for physicians." Mari Savickis, AMA's assistant director for federal affairs, told the workgroup about 40 percent of eligible professionals have never participated in the meaningful use program and, of the 60 percent that have, 20 percent have dropped out. "The way to keep physicians from dropping out today or keeping them from making a decision to not participate is to make the program criteria more flexible," said Savickis.
Fear and loathing in meaningful use
'I cannot stress this enough: It is fear that drives this process – fear of audit, fear of penalty.'

When it comes to the topic of meaningful use, Colin Banas, MD, is driven by fear. And he's far from being the only one.

The chief medical information officer at the Virginia Commonwealth University Medical Center's concern is the potential to fail meaningful use requirements because VCU sometimes tailors a vendor's certified product in order to make it more usable.

Whereas such customization is a common practice in the world of enterprise software, in the realm of electronic health records it has become the veritable equivalent of stepping into a rather cloudy area wherein it is very hard to discern whether they’ve gone so far that an auditor might say VCU did not achieve meaningful use.

What's more, Banas said that it would be impossible to estimate the resources VCU has used to readjust clinical workflows and codes to follow the letter of the law, when it was already clearly following the intent of the measure.

"I cannot stress this enough: It is fear that drives this process – fear of audit, fear of penalty," Banas said, "and fear of vendor abandonment should a client choose to forge a different path."...
Man! Where's the love?

Read the full AMA letter here (pdf).

John Halamka: 80% of providers won't meet MU Stage 2 deadline
May 15, 2014 | By Susan D. Hall

Reiterating his belief that the federal mandates for the healthcare industry are "too much, too soon," Beth Israel Deaconess Medical Center CIO John Halamka predicted that 80 percent of hospitals will fail to successfully attest to Meaningful Use Stage 2 within the allotted time.

He told those attending the iHT2 Health IT Summit in Boston this week that he expects many provider organizations to opt out of the program, according to Healthcare Informatics...

More to come...

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