Wiki Doc Resource: "The Living Textbook of Medicine"

This is pretty cool.

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Some low hanging fruit Health IT topical areas:

• Electronic medical record
• Electronic health record
• Medical informatics
• Health information exchange

Be sure to view all of the "See Also" links.

ALSO: hook up with WikiDoc on Twitter.

IN OTHER NEWS

Even though billions of dollars are being invested in electronic health records, the promise of cost savings has not reached its potential due in part to “sluggish adoption of health IT systems” and a U.S. health system that needs to change the way it provides medical care service, researchers at RAND Corp. say in a new analysis...

“We believe that the original promise of health IT can be met if the systems are redesigned to address these flaws by creating more standardized systems that are easier to use, are truly interoperable, and afford patients more access to and control over their health data,” write Rand researchers Arthur Kellermann and Spencer Jones. “Providers must do their part by reengineering care processes to take full advantage of efficiencies offered by health IT, in the context of redesigned payment models that favor value over volume.”...

Yeah. Transparency, interoperability, and workflow redesign. I've been blogging about these issues for going on three years now.

From ModernHealthCare.com:

"The health IT systems that currently dominate the market are not designed to talk to each other," the two claim. Even with large, integrated healthcare delivery systems that are models of healthcare IT adoption and use—the Veterans Affairs Department and Kaiser Permanente—"information stored in those records is essentially useless if the patient seeks out-of-network care," they said. "The lack of interoperability is so stark that it has led some to speculate that major health IT vendors are opposed to interoperability."

Regarding EHRs' ease of use, the authors said user interfaces on different systems should be similar enough that a clinician could move from one system to another "without extensive retraining," just as a driver can hop between rental cars and "drive any vehicle off a rental lot without instruction."

Meanwhile,

Whopping $1.2 billion in EHR payments in December

There was a gold rush in December, and not just at the malls.

The CMS estimates it paid out a record $1.2 billion in December as hospitals, physicians and other professionals filed a flood of claims for Medicare and Medicaid electronic health-record system incentive payments.

"This is our single largest monthly payment by a factor of three," Robert Anthony, a health insurance specialist with the CMS' Office of eHealth Standards and Services, said Tuesday to members of the Health Information Technology Policy Committee.

For the month of December, Medicare paid out $175 million and Medicaid paid $80 million in EHR-use incentives to physicians and other professionals, while Medicare and Medicaid paid $1 billion to hospitals, according to CMS estimates. The December payments pushed the total estimated payouts since the start of the EHR incentive programs, created by the American Recovery and Reinvestment Act of 2009, to $10.3 billion, Anthony said.

The deluge of applications continued in early 2013, with 2,000 eligible professionals filing incentive payment claims on a single day, Jan. 2, the first business day of the new year, Anthony said...

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THE HOLY GRAIL OF HEALTH IT "ALIGNMENT"

From The National Academy for State Health Policy.

"...Leaders recognize HIT as a key building block for the infrastructure of delivery system transformation, to enable far-reaching reforms that are targeted to solve the biggest issues. However, because HIT and delivery system initiatives have not been well aligned historically, leaders face significant challenges in orienting siloed efforts toward a common goal..."

Ya think?

I reached out to the authors (pdf). One replied, graciously. I reciprocated.

apropos of “alignment,” there are as of today a total of 3,873 ONC “Certified” HIT systems (complete and modules) -- 1,473 and 276 outpatient and inpatient “complete” systems respectively. There is no required common schema / data dictionary standard; indeed, schema are still regarded as proprietary – core HIT product RDBMS value feature differentiators. Consequently, cross-system “data mapping” comprises a significant barrier to “ transparency” for “alignment.”

We at the RECs have to sign non-disclosure agreements just to be able to use EMR vendors’ “sandbox/training accounts,” prohibiting us from divulging any “under-the-hood” stuff we learn (and we only have a handful of vendors who even grant us such limited access).

Try to imagine 3,873 AC power wall socket architectures. 3,873 web browser source code schema…

If the point requires further elaboration, consider that a three prong "Meaningful Use Certified" NEMA 5-15 (15 A/125 V grounded Type B) wall outlet would need only faithfully delivery 125 VAC. The physical design specs ("usability?") of the socket receptacle would not be ONC-CHPL criteria. That you might need hundreds to thousands of shapes and sizes of plugs would be your problem. The "information" would be there (electrons under pressure), but its utility would be dependent on the (proprietary) technological capability to port/transport it from source A to destinations B-Z with 100% accuracy and precision.

BTW: Food and Drug Administration Safety and Innovation Act (S. 3187, July 9, 2012)

Will the FDA continue to beg off Health IT regulatory oversight?
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COOL POST I RAN ACROSS

How Healthcare Pros are Using Social Media (Infographic)

by ANDRE BLACKMAN on AUGUST 12, 2012

Ok so I recently folded under pressure from colleagues (or maybe I was really curious) and decided to check out all the fuss around Pinterest. Apparently, it’s the fastest growing social network or something and recently opened up to everyone to get an account. In any case, I came across this infographic that pointed out some trends from a survey that my buddy Ed Bennett conducted – check it out:

JAN 10TH UPDATE

Yes, this is tangential, but, RECs are charged with helping achieve HHS's "Triple Aim" -- better patient experience, improved population health, and reduced cost. Does stuff like this imped such ends?

SBM: The Dr. Oz Red Palm Oil (non-) Miracle

If there is an antithesis to the principles of science-based medicine, it’s probably the Dr. Oz show. In this daytime television parallel universe, anecdotes are evidence. There are no incremental advances in knowledge – only medical miracles. And every episode neatly offers up three or four takeaway health nuggets that more often than not, seem to leave the audience more ill-informed about health and medicine than they were 30 minutes earlier...

If there is a common characteristic of complementary and alternative medicine (CAM) proponents who believe themselves to be scientific, (and I include Dr. Oz in this group), it is that they extrapolate weak clinical evidence into grandiose claims, while cherry picking the most supportive strands of evidence to give the impression of being evidence-based...

If there is one thing that really frustrates me about the Dr. Oz show is that he ignores the boring-but-factual and always hypes the gimmicks. Red palm oil is no exception. It’s foolish and short-sighted to declare red palm oil as healthy or beneficial based on the limited data that exists. The history of dietetics and nutrition is replete with cases of extrapolating preliminary data into supplement and dietary advice, only to see population-level data, and good clinical trials later refute it. ... The impact of red palm oil consumption on your health is likely to be insignificant, compared to the big drivers of health. But none of this matters on the Dr. Oz show. Because just as quickly as this post is published, Oz will have moved on to the next dietary fad, leaving consumers who watch his show more confused than ever about what constitutes good health and nutrition.

"CAM" in the WikiDoc

Sociological and psychological explanations for belief in CAM efficacy
 
There are both social/cultural and psychological reasons:

Social or cultural reasons:

• the low level of scientific literacy among the public at large
• an increase in anti-intellectualism and antiscientific attitudes riding on the coattails of new age mysticism
• vigorous marketing of extravagant claims by the "alternative" medical community
• inadequate media scrutiny and attacking critics
• increasing social malaise (conspiracy theories) and mistrust of traditional authority figures - the antidoctor backlash
• dislike of the delivery methods of scientific biomedicine.

Psychological reasons:

• the placebo effect
• the will to believe
• self-serving biases that help maintain self-esteem and promote harmonious social functioning
• demand characteristics - the obligation to respond in kind when someone does them a good turn
• post hoc, ergo propter hoc fallacy ("after this, therefore because of this"; the basis of most superstitious beliefs)
• psychological distortion, such as confirmation bias and Cognitive dissonance (inability to respond to criticism of alternative medicine in order to reduce one's cognitive dissonance)

UPDATE:

Recognizing that not every meaningful use measure applies to every provider, this fact sheet gives specialty providers tips about how to successfully meet meaningful use measure requirements and navigate the Medicareand Medicaid Electronic Health Record (EHR) Incentive Programs.

Are you facing measures that require data you don’t normally collect as a specialist? While eligible professionals (EPs) can choose measures that apply to their practice, in some cases, data that has been collected by another provider—for example, a referring physician— can be used to fulfill required measures.

Pretty interesting and useful resource. Link here (pdf).

"COST CURVE" UPDATE FROM HHS (pdf)

Summary: Medicare spending per beneficiary grew just 0.4% per capita in fiscal year 2012, continuing a pattern of very low growth in 2010 and 2011. Together with historically low projections of per capita growth from both the Congressional Budget Office and the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary, these statistics show that the Affordable Care Act has helped to set Medicare on a more sustainable path to keep its commitment to seniors and persons with disabilities today and well into the future. The success in reducing the rate of spending growth has been achieved without any reduction in benefits for beneficiaries. To the contrary, Medicare beneficiaries have gained access to additional benefits, such as increased coverage of preventive services and lower cost-sharing for prescription drugs.

OK, HHS eager, early PPACA self-congratulation aside, how much of this is "cost-shifting" rather than "cost increase attenuation"? And, while, per capita is nice, the Baby Boomers are going to dramatically increase the size of the Medicare bene pool, so overall cost is likely to continue upward.

JANUARY 11TH UPDATE

From THCB, Quote of the day:

'...The ACA tries to increase access to health insurance through a bewildering combination of Medicaid expansions, private insurance subsidies, health insurance exchanges, and the infamous health insurance mandate.  It attempts to improve healthcare quality through things such as reimbursement reforms and promotion of electronic medical records.  And it encourages the formation of more efficient healthcare organizations, with inscrutable names like “accountable care organizations” and “medical homes”.'

Yeah.
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More to come...
 

ARCH-IT website launched

Congratulations on the launch.

CURRENT MEMBERS (click here for links)

• HIT Arkansas
• South Florida REC
• Center for the Advancement of Health IT (North/Central Florida)
• North Texas REC
• Wide River TEC (NE)
• Oregon Health Information Technology Extension Center (O-HITEC)
• West Texas Health Information Technology Regional Extension Center (WTxHITREC)
• Illinois Health Information Technology Regional Extension Center (IL-HITREC)
• Wisconsin Health Information Technology Extension Center (WHITEC)
• North Carolina Healthcare Information & Communications Alliance, Inc. (NCHICA)

The Curious Case of the Missing Final Rule

Well, maybe I'll wake up tomorrow, log into FederalRegister.gov, and the HIPAA Omnibus Final Rule will magically appear at long last.

Hunton and Williams' Head of Global Privacy and Data Security Practice Lisa Sotto, Esq gave a nice recent interview here on the topic. One factor she speculated might be a cause of the delay would be understaffing at OMB -- i.e., backlog.

I'm not buyin' that, in the wake of the deluge of FRs announced post-election. Moreover, while I could see why the administration might want to keep it off the lame duck session "fiscal cliff" radar, what's the excuse now? Keeping it away from the bogus "debt ceiling" carnival that will ramp up and conclude by March 1st?

The other rumor is that the NPRM is undergoing significant revision, hence the delay.

Be nice if they'd wrap it up. A lot of entities are on hold regarding various HIPAA related P&P updates that may be required by the Omnibus.

THIS IS PRETTY INTERESTING

Health Information Industry Code of Conduct

Proposed: To achieve the universally supported objectives of systemic cost reduction and quality improvements, members of the health information industry should agree to maintain, uphold and abide by a uniform set of high standards related to data portability, patient safety, freedom of choice, and meaningful, ethical use by health care providers of health information technology (HIT).

Resolved: The signatories hereto, representing innovative, forward-thinking members of the health information industry, agree that they and their respective companies will adhere to each of the provisions of the following Code of Conduct:

1. Empowering Data Portability and Provider Choice

In the event that any client opts to change to the electronic health record (EHR) of another signatory, we will, at our own expense, facilitate the intact transfer to the latter’s EHR of all of the provider’s clinical data.

2. Building a True Nationwide Information Backbone

We will build, maintain, and curate reliable interfaces on behalf of any qualified healthcare provider that requests one.

3. Protecting Patients

We commit to public reporting of adverse patient safety event information. Within one year of signing, we will affiliate with a Patient Safety Organization (PSO), report all patient safety-related events to that PSO, and work proactively with clients to identify and resolve the causes of any such issues.

4. Preventing Fraud

We will actively monitor, and report to clients, changes in provider billing patterns that could indicate up-coding or fraud.

5. Driving Meaningful Use

We will adjust reporting to accommodate government quality reporting programs, at no incremental cost to clients...

 Pretty good. How about...

6. Fundamental Transparency

All vendors shall publish their RDBMS schema / data dictionaries.

I can dream.

MONDAY MORNING UPDATE, 7 A.M. PST

No HIPAA Omnibus Final Rule today. In general, It's been a slow news period of late in Health IT, Lost of articles citing other articles citing yet other articles, etc.A relative dearth of really new topics.

TUESDAY MORNING UPDATE

No HIPAA Omnibus Final Rule. In other news:

CMS: Meaningful use incentives estimated to exceed $10 billion
Kyle Murphy, PhD, January 8, 2013
Early estimates for meaningful use payouts in December 2012 are slated to push the total amount of payments north of $10 billion. During the monthly meeting of the Health IT Policy Committee, which takes place today in Washington, DC, Rob Anthony of the Centers for Medicare & Medicare Services is scheduled to present the update for the EHR Incentive Programs with final figures for November 2012 as well as estimates for last month. With the estimates for December 2012 included, the amount of payments made through the EHR Incentive Incentives is close to $10.32 billion (YTD)...

Once everyone has finished attesting for 2012, (EPs have until Feb 28th) there will be a large December spike.

Also noteworthy:

One might reflect on how timid our “meaningful use” requirements truly are on the cusp of 2013 in light of this headline from the Wall Street Journal in 1959: “Electronic Medicine: Scientists Press Work on Advanced Machines to Aid Medical Care. They See Automatic Nurses Watching Sick, Computers Helping Diagnose Illnesses.”

From The Man Who Brought Computers Into Medicine by Michael Millenson
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More to come...

A 2013 Happy New Year to the HIT sector

May you all thrive and continue your good works.
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NOON PDT UPDATE

Congress is "working" today. It is now reported that the Senate as passed H.R. 8 and sent it back over to the House. Among other things, this double-spaced 157 page draft proposes to 

• make permanent the bulk of the Bush tax cuts; 
• extended the ag price support program for another year (the "Dairy Cliff" thing);
• again kick the Medicare SGR can down the road for another year;
• extend unemployment benefits for another year;
• kick the "automatic sequester" problem down the sidewalk for two months (which assures us of a "deficit ceiling" circus in late February);
• and, it says nothing about recission of Meaningful Use incentive funds (an issue sure to be raised again in less than two months per the "sequester" wrangle.

 I will be following developments. I guess, for now, I'll still have a job in the morning.

3 P.M. PDT UPDATE

WASHINGTON [Wall St. Journal] —House Democrats on Tuesday pressed for a vote on a bipartisan plan to avert year-end tax increases and spending cuts known as the fiscal cliff, as conservatives in the Republican-controlled House resisted the proposal.

The deal met opposition from House Majority Leader Eric Cantor (R., Va.) and many House Republicans because it didn't do more to reduce federal spending—returning to a central disagreement between the parties for the past two years.

Republicans said they may try to change a deal that cleared the Senate in an 89-8 vote in the early hours of the new year. The Senate agreement would boost income-tax rates for the first time in 20 years, maintain unemployment benefits and delay spending cuts that were part of the fiscal cliff...

Maybe I'll still have a job in the morning.

LOL.

5:30 P.M. PDT UPDATE

Patient compliance is important.

From Forbes, by way of THCB: HIT, THE ROAD AHEAD

Turning Information Into Impact: Digital Health's Long Road Ahead

By DAVID SHAYWITZ, MD AND TORY WOLFF

A leading scientist once claimed that, with the relevant data and a large enough computer, he could “compute the organism” – meaning completely describe its anatomy, physiology, and behavior. Another legendary researcher asserted that, following capture of the relevant data, “we will know what it is to be human.” The breathless excitement of Sydney Brenner and Walter Gilbert —voiced more than a decade ago and captured by the skeptical Harvard geneticist Richard Lewontin [1]– was sparked by the sequencing of the human genome. Its echoes can be heard in the bold promises made for digital health today.

The human genome project, while an extraordinary technological accomplishment, has not translated easily into improved medicine nor unleashed a torrent of new cures. Perhaps the most successful “genomics” company, Millennium Pharmaceuticals, achieved lasting success not by virtue of the molecular cures they organically discovered, but by the more traditional pipeline they shrewdly acquired (notably via the purchase of LeukoSite, which ultimately yielded Campath and Velcade).

The enduring lesson of the genomics frenzy was succinctly captured by Brown and Goldstein, when they observed, “a gene sequence is not a drug.”

Flash forward to today: technologists, investors, providers, and policy makers all exalt the potential of digital health [2]. Like genomics, the big idea – or leap of faith — is that through the more complete collection and analysis of data, we’ll be able to essentially “compute” healthcare – to the point, some envision, where computers will become the care providers, and doctors will at best be customer service personnel, like the attendants at PepBoys, interfacing with libraries of software driven algorithms.

A measure of humility is in order. Just as a gene sequence is not a drug, information is not a cure. Getting there will take patience, persistence, money and aligned interests. The most successful innovators in digital health will see the promise of the technology, but also accept, embrace, and ideally leverage the ambiguity of disease, the variability of patients, and the complexities of clinical care.

We’ll also need to incorporate four key lessons of the genetics experience: 

• Don’t confuse data with insight: it can be difficult to extract robust, clinically-relevant conclusions from reams of data; 
• Don’t confuse insight with value: many solid scientific findings, while interesting, do little to inform existing practice or significantly improve today’s outcomes; 
• Don’t overestimate your ability to forecast from data: even the best data often afford only limited insight into health outcomes; a lot may depend upon chance or other factors; 
• Don’t underestimate the implementation challenges: leveraging data successfully requires a care delivery system prepared to embrace new methodologies, requiring significant investment of time and capital, and the alignment of economic interests. 

Digital health will ultimately revolutionize medicine, but it will get there through a series of evolutionary phases. These won’t be tidily sequential – some disease areas and some delivery systems may offer more fertile ground initially and see early successes.

But for the healthcare experienced by the vast majority of providers and patients and influencing a meaningful share of the dollars spent, the process will take much longer. Ten to fifteen year adoption cycles are typical (even rapid) in healthcare, and digital health is well advanced in only one domain (digital capture of data in today’s workflows through electronic medical records [EMRs] and digital diagnostics) of the many required for far-reaching impact...

Excellent article. Read the entire piece.

Concluding Thoughts

While we believe deeply in the promise of digital health, our optimism is tempered: human health is complex, our understanding is incomplete, and change – for both individuals and systems – is very, very hard.   While media reports often focus on exceptional examples of early adopters, we would be foolish to use these to calibrate our expectations (a specific example of a more general publication bias).

We are likely to discover that even if we could acquire all the data we could imagine, there are fundamental limits on what this might reveal.  It’s unlikely we’ll ever be able to “compute the whole organism.”

Even so – and with humbled mien — we should push digital health technologies hard, and leverage the resulting data as best we can to improve the human condition.

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JAN 2 FISCAL CLIFF UPDATE

The House passed H.R. 8: 11:01:15 P.M., H.R. 8: On motion that the House agree to the Senate amendments Agreed to by recorded vote: 257 - 167 (Roll no. 659).

The SGR "Doc Fix"

Kick this one again down the road for another year.

No HIPAA Omnibus Final Rule yet, btw. Like, c'mon.

Well, H.R. 8 didn't cut any Meaningful Use money, so it's back off to work. MU incentive funds will likely again be in the crosshairs during the upcoming "Debt Ceiling" wrangle in mid- late February.

BACK TO PROCESS IMPROVEMENT:
LEAN STRATEGY AT VIRGINIA MASON MEDICAL CENTER

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DR. OZ CRITICIZED OVER AT SBM

Dr. Oz Doubles Down on Green Coffee Bean with a Made-for-TV Clinical TrialPublished by Scott Gavura under Clinical Trials,Herbs & Supplements,Medical Ethics

“One of the most important discoveries I believe we’ve made that will help you burn fat – green coffee been extract” – Dr. Oz, September 10, 2012, Episode “The Fat Burner that Works”

Dr. Mehmet Oz may be biggest purveyor of health pseudoscience on television today. How he came to earn this title is a bit baffling, if you look at his history. Oz is a bona fide heart surgeon,  (still operating 100 times per year), an academic, and a research scientist, with 300+ or 400+ (depending on the source) publications to his name. It’s an impressive CV, even before the television fame. He gained widespread recognition as the resident “health expert” on Oprah, and went on to launch his own show in 2009. Today “The Dr. Oz Show” is a worldwide hit, with distribution in 118 countries, a massive pulpit from which he offers daily health advice to over 3 million viewers in the USA alone. For proof of his power to motivate, just look at the “Transformation Nation Million Dollar You” program he launched in 2011, enrolling an amazing 1.25 million participants. Regrettably, what Oz chooses to do with this platform is often disappointing.  While he can offer some sensible, pragmatic health advice, his show’s content seems more focused on TV ratings than medical accuracy, and it’s a regular venue for questionable health advice (his own, or provided by guests) and poorly substantiated “quick fixes” for health issues. (And I won’t even touch Oz’s guests like psychic mediums.) One need only look at the number of times the term “miracle” is used on the show as a marker of the undeserved hyperbole. Just this week, Julia Belluz and Stephen J Hoffman, writing in Slate, itemized some of the dubious advice that Oz has offered on his show, with a reality check against what the scientific evidence says. It’s not pretty...

My SBM comment:

#BobbyG on 03 Jan 2013 at 7:17 am PST

“Also this will never reach the eyes and ears of Oz viewers sadly”

I wouldn’t give up that easily. I just tweeted him, with relevant hashtags. He has almost 2.5 million Twitter followers. This will get SOMEONE’S attention. I exhort everyone to do likewise.
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@DrOz SBM takes issue with you here. http://www.sciencebasedmedicine.org/index.php/dr-oz-doubles-down-on-green-coffee-bean-with-a-made-for-tv-clinical-trial/ #OzTip #TheDrOzShow #OzResolution #OzQuestion I will cite this on my REC blog.
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I also posted it on his Facebook page: https://www.facebook.com/droz

It’s not about attacking HIM, it’s about defending the scientific method.

UPDATE NOTES ON "THE COST CURVE"

Heath IT is supposed to help "bend the cost curve" downward, recall? I graphed these data from a CMS NHE projection (pdf). $39 trillion across a decade? (Yeah, it's aggregate estimated cost by year, not per capita, and thus is not adjusted for population growth. I'm sure it takes into account a greying population, though).

Below, an interesting graphic I found on Forbes.

Look at the U.S. "hockey stick" curve (red). Notice that in the 50-60 year old segment is wear the wear and tear of aging starts to show up (and is reflected in UTIL). What jumps out at me is the consequence of the way we in the U.S. frame health care "coverage" -- in mostly annual enrollment, the upshot being that in any one year, 5% of patient consume 50% of health care, half the population spends nil, and the remaining 45% is somewhere in between, heading inexorably toward the high UTIL 5%. If half of the population is getting off cheaply at any one time, coming to political consensus on a more cost-effective payment paradigm is made significantly more difficult.

While UTIL is to a degree an inevitable result of aging, framing "coverage" as that of spanning a lifetime dramatically mitigates the uptick. This is not theory; these are data.

But, hey, that sort of reform would be "Socialist."

Below: it's lonely out there on the right. Ruinously so.

These data were posted on Forbes, no less, not on CommiesWhoHateAmerica.net.
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More to come... 

From the REC Blog, adieu 2012

I'll be working on New Year's Eve day, just in case I have to assist some 2012 Attestation stragglers who want to close it out (I had four docs attest on Friday). Notwithstanding that EPs have until the end of February 2013 to do their 2012 MU Attestations, ONC is leaning on RECs to get 'em done before CoB 12/31/2012 -- to help make them look good on the Hill.

Like it's gonna matter.

That aside, I've been exhorting my own caseload to get it done the sooner the better. You just cannot know what may fall out of this down-to-the-wire Fiscal Cliff circus in DC.

A BIT OF ANTI-HIT CARPING FUN

Saw this today on a blog:

All patients will suffer as the funds go to pay for HIT devices that have no proof of efficacy or safety, while medicine can not be afforded or covered, and sick patients get sent to pasture at commercial nursing homes and LTACS. What has become of the way this country treats its sick and defenseless?

The commenter was, of course, untraceable (no link in the screen name).

Let me help you out. From Healthcare Informatics:

Report: Health IT Spending to Exceed $69 Billion over Six-Year Period

Providers, payers, and physician groups will be spending over $69 billion on healthcare related IT and telecommunications services over the next six years, according to a market research study released by the Mountain Lakes, N.J.-based Insight Research Corporation. The report says that spending by the US healthcare industry on telecommunications services will grow at a compounded rate of 9.7 percent over the forecast period, increasing from $9.1 billion in 2012 to $14.4 billion in 2017. as the number of healthcare locations expands by 16 percent and the healthcare employment rate increases 2.5 times faster than the total national employment rate...

Big dough, no doubt. Let's round up to an E-Z "$70 billion" and mull over some context.

From CMS, regarding estimates of annual "NHE" (National Health Expenditures, in billions, table on page 6):

• 2012:  $2,809.0
• 2013:  $2,915.5
• 2014:  $3,130.2
• 2015:  $3,307.6
• 2016:  $3,514.4
• 2017:  $3,723.3

~$19.4 trillion. Now, there's some big dough. OK, $70 billion of HIT divided by $19.4 trillion of NHE is...

0.361%

That's not a typo. ~ a third of one percent (if you want to go all "zero degrees of freedom" pedantic, subtract the $70 billion from the denominator to make the two a ratio comparison -- barely moves the needle).

None of this unreflective fellow's lament even begins to consider "netting out," either, i.e., unless you're advocating eliminating medical recordkeeping entirely, the net cost of migrating from paper charts to digital HIT (difficult as the ROI calculations may be in individual scenarios), is vanishingly small.

I took one last shot at this guy on his "safety" and "efficacy" assertions:

As to perfect “proof,” I guess we should all yet be riding around in oxcarts and on donkeys, given the bloody history of incremental alternative transportation safety improvements. We won’t even try to “net out” the relative antecedent safety record of Flintstone Travel.

There is indeed much that is materially lacking in the way we administer health care. Health IT is not a big part of the problem. And, better Health IT will be a significant component of any “solutions.”

Gotta love it.

BACK  TO OUR DC DRAMA...

Countdown

Monday morning update:
NO HIPAA OMNIBUS FINAL RULE THIS YEAR

29 Rules issues today. HIPAA is not among them. Oh, well.

At least...

Oh, wait...

I know we're all busy, but I've posted 54 blog posts -- all in my spare time -- in the 193 days since I announced the public "launch" of ARCH-IT.

DR. NOVELLA'S LATEST

Nutrigenomics – Personalized Pseudoscience
Published by Steven Novella under Science and Medicine

I wrote last week about the problem of stem-cell quackery throughout the world, mostly in poorly regulated countries but with the purpose of attracting international customers. Stem cells are real, and the science of developing medical applications of stem cells is both real and promising, but these stem cell clinics are making claims that are years or decades ahead of the science. They are capitalizing on stem cell hype as a marketing ploy to those who are more desperate than scientifically savvy.

I was asked to comment on yet another example of the same phenomenon – nutrigenomics. That’s a very impressive-sounding name, just like a real science, but as always the devil is in the details. The claim is that by analyzing one’s genes a personalized regimen of specific nutrients can be developed to help their gene’s function at optimal efficiency. One website that promises, “Genetics Based Integrative Medicine” contain this statement:

Nutrigenomics seeks to unravel these medical mysteries by providing personalized genetics-based treatment. Even so, it will take decades to confirm what we already understand; that replacing specific nutrients and/or chemicals in existing pathways allows more efficient gene expression, particularly with genetic vulnerabilities and mutations.

The money-quote is the phrase, “it will take decades to confirm what we already understand.” This is the essence of pseudoscience – using science to confirm what one already “knows.” This has it backwards, of course. Science is not use to “confirm” but to determine if a hypothesis is true or not...

(Read on)

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Science-based medicine:
DR. GORSKI'S LAST POST OF THE YEAR

Closing out 2012 with a bit of fun: Do you want some quantum with that pseudoscience?
Published by David Gorski under Basic Science,Health Fraud, Humor

...Among the favorite real science term that quacks love to appropriate is “quantum.” I blame Deepak Chopra. Although I highly doubt he was the first promoter of alternative medicine and various New Age thought to use and abuse the term “quantum” as a seemingly scientific justification of what in reality is nothing more than ancient mystical thinking gussied up with a quantum overcoat to hide its lack of science, Chopra has arguably done the most to popularize the term among the science-challenged set. In Chopra’s world, the word “quantum” functions like a magical talisman that explains™ everything because in the quantum world anything can happen. Actually, I should clarify. While it’s true that many bizarre and wondrous things can be explained through quantum theory (such as quantum entanglement), it is not, as Chopra and his many imitators would have you believe, a “get out of jail free” card for any magical thinking you can imagine, and quantum effects do not work the way people like Chopra (say, Lionel Milgrom, who seems to think that homeopathy works through quantum entanglement between practitioner, remedy, and patient) would like you to think...

Yeah... Read on.
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More to come...

December 22nd updates

Been difficult to even think about blogging this week in the wake of Newtown CT. But, here goes. First,

 The harrowing evacuation of hundreds of patients made headlines nationwide. The disruption of regular medical care for tens of thousands of outpatients was a clinical nightmare that is finally easing. And the education of hundreds of medical students and residents is being patched back together.

All academic medical centers, however, rest on a tripod — patient care, education andresearch.The effect of the hurricane on the third leg of that tripod — research — has gotten the least attention, partly because rescuing cell cultures just isn’t as dramatic as carrying an I.C.U. patient on a ventilator down flights of stairs in the dark.

But, of course, there is an incontrovertible link between those cell cultures and that patient. For every medication that a patient takes, someone researched the basic chemistry of the drug, someone designed the clinical trial to test its efficacy, and of course a volunteer stepped forward to be the first to take the pill.

Scientific research has engineered the impressive advancements of medical treatment, and every patient is a beneficiary.

When the hospitals were hit by Hurricane Sandy, hundreds of experiments were obliterated by the loss of power. Precious biological samples carefully frozen over years were destroyed. Temperature-sensitive reagents and equipment were ruined. Medications and records for patients in clinical trials were rendered inaccessible. And sadly, many laboratory mice and rats perished (though 600 cages of animals were rescued during the night by staff members who used crowbars on inaccessible doors and carried the cages out through holes cut in the ceiling).

...scientists can’t just walk in to a new space with a lab coat and a notebook; they need centrifuges, deep-freezes, lab animals, electron microscopes, incubators, autoclaves, gamma counters, PET scanners. They come with graduate students, lab techs, post-docs and collaborating investigators. For clinical researchers, there are also the patients enrolled in their clinical trials, with their medications and voluminous records...

...researchers felt a sense of loss, not just in time, money, momentum, samples and grants, but of a part of their lives. Some senior scientists lost decades of archived samples. Others lost irreplaceable mice with genetic mutations for studying how coronary plaques resolve, the role of inflammation in lymphoma and the development of neural networks. At the other end of the spectrum were post-docs whose nascent careers were suddenly up in the air. Some were in tears.

The logistical efforts to relocate and reignite such a vast research enterprise are staggeringly complicated. But the administration has cataloged each person’s research needs to match them with available space elsewhere, and hundreds of researchers have successfully rekindled their investigations despite the prodigious challenges.

For many patients, the thrum of research within a medical center is invisible. But it is an integral — and very human — part of a hospital. When a hurricane disrupts research, it is a loss that resonates well beyond the laboratories.

Danielle Ofri, an associate professor at New York University School of Medicine, is the editor of the Bellevue Literary Review and the author, most recently, of “Medicine in Translation: Journeys With My Patients.”

Wow. This falls under "Risk Assessment / Disaster Recovery / Business Continuity," does it not? I have to confess, I don't have a clue as to the standardization, security, and calamity response aspects of clinical research data systems (can you say "heterogeneity"?). But, I will certainly get one, ASAP. Will likely find a lot of spreadsheets and custom internal database apps written by IT departments specifically for what the PIs want.

HIT across the past decade seems to have been overwhelmingly focused, necessarily, on a mix of its antecedent revenue cycle management priority (billing -- more about that shortly) and, more recently, mid-office functionality -- the care delivery "clinical data" EHR piece. The big obsession going forward from this period will be on HIE, Health Information Exchange.

But, how about, well, "CRIT"?

Ceritified, secure, cloud-based, scalable, end-user configurable?

And relatively disaster-proof.

It would seem to me that entities such as the SAS Institute could be all over this. Not to mention the Open Source movement.
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THE SKEPTICAL SCALPEL ON "UPCODING"

...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've been around Medicare work on and off for nearly 20 years. During my first tenure with HealthInsight back in the early 1990's, "upcoding" was a frequent topic of conversation. The term had a slightly negative connotation. Experienced and adroit coders were astute in the fine art of spinning claims codes in ways that at once maximized the revenue and minimized the potential for audit red flags.

Then, during the mid-2000's, under the 8th and 9th Scope QIO contracts and its REC-precursor "DOQ-IT" initiative, EMR-programmed "upcoding" was spun as a legitimate tool for increasing revenue "on the up and up."

I recall thinking at the time "there will be pushback on this eventually."

That time is here (and it's been in the news lately).

Every system now has to have an always-on HIPAA-compliant audit log database within its RDBMS schema. e.g.,

Below, from the HHS OCR Audit Protocol:

Technical Safeguards

Access Control. A covered entity must implement technical policies and procedures that allow only authorized persons to access electronic protected health information (e-PHI).

Audit Controls. A covered entity must implement hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contain or use e-PHI.

Integrity Controls. A covered entity must implement policies and procedures to ensure that e-PHI is not improperly altered or destroyed. Electronic measures must be put in place to confirm that e-PHI has not been improperly altered or destroyed.

Transmission Security. A covered entity must implement technical security measures that guard against unauthorized access to e-PHI that is being transmitted over an electronic network.

I've said it before, I'll say it again. The audit log is a "workflow record." Any data miner worth her salt can determine who did what to which patient's protected health information, when -- right down to the second. Couple that with savvy claims analysts, well, goes to Skeptical Scalpel's point.

I would not be trying to game the chart in pursuit of the upcoded claim anymore.
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MEANINGFUL U$E UPDATE

Yet another unscheduled CMS announcement, just in time for our year's-end lame duck Fiscal Cliff Follies. $9.322 billion paid to date? What's not to love?

PERSONAL BLOG "MILESTONE"

Broke 100k. Nice. Not why I do this, but nice nonetheless.

2014 CEHRT FINAL TEST REGULATION

ClinicMonkeyEHR

CART, MEET HORSE

Well, better late than never (pdf). Now that we've issued the 2014 Certification standards, let's study HIT safety some more.

Over a decade ago, the Institute of Medicine’s (IOM’s) report To Err is Human raised an alarm about the failure of healthcare to recognize and reduce the large number of avoidable medical errors harming patients. Health information technology (health IT), in particular electronic health records (EHRs) and health information exchange, create the potential to reduce medical errors. This potential is part of the reason for the creation of the Office of the National Coordinator for Health Information Technology (ONC), first by executive order in 2004 and then through the Health Information Technology for Economic and Clinical Health (HITECH) Act — passed as part of the American Recovery and Reinvestment Act of 2009. In addition to creating ONC, the HITECH Act also provided economic incentives for eligible providers to adopt and meaningfully use certified EHR technology.

The premise of these initiatives is that health IT, when fully integrated into health care delivery organizations, facilitates potentially enormous improvements in health care quality and safety as compared to paper records...

Just as health IT can create new opportunities to improve patient care and safety, it can also create new potentials for harm. For example, poor user interface design or unclear information displays can contribute to clinicians ordering medications not appropriate for their patients’ condition. Health IT will only fulfill its enormous potential to improve patient safety if the risks associated with its use are identified, if there is a coordinated effort to mitigate those risks, and if it is used to make care safer...
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EXCELLENT PAPER FROM CHCF

The California Health Care Foundation does consistently excellent work (pdf). to wit:

THE HEALTH INFORMATION TECHNOLOGY for Economic and Clinical Health (HITECH) Act, part of the 2009 American Recovery and Reinvestment Act (ARRA), set high expectations that federal investment in health information technology (HIT) would significantly improve health care delivery. Now, more than three years later, the high hopes that accompanied HITECH’s passage have given way to more sober realities.

On one hand, marked progress on the adoption of electronic health records (EHRs) among California’s providers has taken place. For example, 40% of office-based physicians in 2011 had a basic EHR, up from 21.8% in 2010. On the other hand, there is room for progress toward widespread use of electronic health information to improve the quality and efficiency of health care delivery.

This report examines HITECH’s history and impact in California and details how HITECH funds have been spent so far. It describes how market drivers and health reform policy have affected the health care environment and given cause for greater alignment among programs to support payment and delivery system redesign. The report was informed by an analysis of publicly available data and through interviews with industry leaders.

Specifically, the report looks at the three largest federally funded programs in California: the Medi-Cal EHR Incentive Program, regional extension centers (RECs), and health information exchange (HIE). It also looks at the state’s progress on telehealth, which was supported through a separate ARRA funding stream, because of its potential to improve health care delivery by expanding access to care and increasing efficiency...

A bracing read, at once candid and diplomatic.

Regarding RECs broadly, a couple of snips:

No federally funded technical support beyond Stage 1. 
Despite the federal government’s goal of getting 100,000 providers nationally to adopt and meaningfully use EHRs and providing implementation assistance to support them, ONC does not provide funding to help providers reach Stages 2 and 3 of meaningful use. This gap in technical assistance may challenge many providers as they attempt to meet increasingly difficult meaningful use requirements.

Develop sustainability plans. 
When considering REC program sustainability, it is helpful to understand the model upon which the program is based. The REC concept was inspired by the US Agricultural Cooperative Extension Program created to help farmers increase acreage and address labor shortages during World War I. The agricultural extension program still exists today, but its programs have shifted as community needs have changed over the decades. Similarly, RECs should be flexible to the changing needs of providers as they optimize their use of EHRs.

To build a long-term plan, RECs must be able to demonstrate the value of the technical assistance that they provide. Until they do, questions will remain as to whether it is worth expanding funding to RECs...

[1] I really tire of the Ag Extension analogy, and, [2] color me dubious on "sustainability." How many Ag Extensions were private market-sustainable after four years?

I see "consolidation" among and "talent flight" from RECs.

Point of accuracy: We're only funded for Stage 1 Year 1. One and Done, baby.

Lots more great stuff in the CHCF report. Check it out.

DECEMBER 28th UPDATE

Federal Register: no HIPAA Omnibus Final Rule yet.

But, nice to know that the Feds are hard at work promulgating vital stuff like this:

Marketing Order Regulating the Handling of Spearmint Oil Produced in the Far West; Revision of the Salable Quantity and Allotment Percentage for Class 1 (Scotch) and Class 3 (Native) Spearmint Oil for the 2012-2013 Marketing Year

This rule revises the quantity of Class 1 (Scotch) and Class 3 (Native) spearmint oil that handlers may purchase from, or handle on behalf of, producers during the 2012-2013 marketing year under the Far West spearmint oil marketing order. This rule increases the Scotch spearmint oil salable quantity from 782,413 pounds to 2,622,115 pounds, and the allotment percentage from 38 percent to 128 percent. In addition, this rule increases the Native spearmint oil salable quantity from 1,162,473 pounds to 1,348,270 pounds, and the allotment percentage from 50 percent to 58 percent. The marketing order regulates the handling of spearmint oil produced in the Far West and is administered locally by the Spearmint Oil Administrative Committee (Committee). The Committee recommended this rule for the purpose of maintaining orderly marketing conditions in the Far West spearmint oil market.

Okeee-dokeee...

BTW

Countdown

More to come...