Mark Frisse's New Policy Blog

Remedy and Reaction: The Peculiar American Struggle Over Heatlh Care Reform.

2011-09-26T08:45:00.000-07:00

Paul Starr's new book is finally shipping. A master in the study of health care in America, Starr, as the inside cover states, "argues that the United States ensnared itself in a trap through policies that satisfied enough of the public, so enriched the health-care industry, an obscured so much of the true cost as to make the system difficult to change."

The magic of Starr is both in the stories he tells and the manner in which he tells them.

http://yalepress.yale.edu/yupbooks/book.asp?isbn=9780300171099

Budget Lessons From Canada

2011-07-31T05:35:00.000-07:00

In a July 31 New York Times essay, entitled "Debt Problem’s Sure Cure: Economic Growth," Katerine Rampel points out the structural impediments to economic growth that were not as influential during America’s past recoveries. She further points out that of the $12.7 trillion in additional federal debt that was accumulated over the last decade, about a third came from the souring economy. She sides with the camp that argues that Congressional fiscal restraint in 1937 dampened and even reversed whatever recovery Roosevelt’s Keynesian measure had.

The exciting part of her piece follows her discussion with Paulo Moro, author of "Chipping Away at Public Debt: Sources of Failure and Keys to Success in Fiscal Adjustment" (found on Amazon, Google Books, and other sites). Moro, an executive at the International Monetary Fund, cites the 1994 Canadian turn-around. Rather than making decisions under the gun, Canada in 1994 "undertook a comprehensive, McKinsey-style review of all of its federal spending over the course of a year to determine where they were getting value for their money, rather than just doing across-the-board cuts," he said.

So, where it the inquisitive reader going to learn more?

A great summary is to be had in Jocelyn Bourgon’s September 2009 study. It lists some principles applicable to many other smaller projects. Her home base is the Center for International Governance Innovations. Note the two key words: Governance, innovation. See her major points – excerpted below.

Program review: The Government of Canada’s experience eliminating the deficit, 1994-99: a Canadian case study

Jocelyne Bourgon, Center for International Governance Innovations (CIGI)

I have quoted heavily, but the primary document is a "must read" because of its format and wonderful figures.

excerpts:

Learning from the past: 1975 - 1984

Important lessons may be drawn from this period:

No public policy agenda is valid for all time. The stimulus policies that served Canada well in the 1950s and 1960s eroded Canada’s fiscal health in the late 1970s and early 1980s. The challenge for governments is to anticipate emerging trends and adjust public policies to respond to changing circumstances, address emerging needs and seize opportunities. Those governments best able to adjust and adapt stand a better chance of providing their countries with comparative advantages that translate into higher standards of living and a higher quality of life. Governing is a never-ending process of transformation.
Public policy choices matter. In ten years (1975-84), Canada would go from having one of the best to one of the worst fiscal performances among G7 countries. Actions taken today are already part of framing future decisions.
Public policy debate matters. The Canadian experience is a reminder that a strong consensus among opinion leaders does not guarantee the best policy decisions and the best policy outcomes. In fact, the stronger the consensus, the more reason to challenge the status quo and examine different policy choices. Debate elevates public understanding of policy options, and improves the likelihood of sound public policy decisions.
Public policy preferences must be tempered by evidence. This study found no indication that the GoC took account of the actions of other countries. As a result, Canada did not change its policy course for ten years. It draws attention to the importance of sound policy research and evidence-based policy advice.

Learning from the past: 1984 - 1993

Lessons included:

Agenda overload increases the risk of failure. Eliminating a sizable deficit is a major undertaking. Fiscal reform of the scale discussed in this report affects all government departments and agencies, leaving little room for other ambitious reforms.
Public awareness is necessary for citizens to accept the sacrifices demanded of them. The lower the public awareness of the problem, the harder it is to reduce government spending and the longer it takes to implement fiscal reform.
Across the board cuts and freezes that affect programs and services in an undifferentiated way have significant perverse effects. Such cuts erode the quality of public services, reduce the quantity of available services for the same level of taxpayer contribution, and affect morale in the Public Service. Over time, they erode citizens’ confidence in government, in the public sector and in public organizations.
Efficiency measures or ‘doing more with less’ are not viable solutions to eliminate a sizable deficit. They may help with internal reallocations from lower to higher priorities, but there is no substitute for making choices about the relative importance of government programs to eliminate a large deficit. It comes down to repositioning the role of the government within the collective means of citizens.
Acting quickly can help avoid unforeseen circumstances. External factors beyond the control of government can steer it off course. Each failed attempt makes the next one increasingly difficult. Once the process has begun, it is preferable to aim for a balanced budget

She then presents a conceptual framework worthy of study:

Six tests of the Canadian conceptual framework

Does the program or activity continue to serve a public interest?
Is there a legitimate and necessary role for government in this program area or activity?
Is the current role of the federal government appropriate or is the program a candidate for realignment with the provinces?
What activities or programs should, or could, be transferred in whole or in part to the private or voluntary sector?
If the program or activity continues, how could its efficiency be improved?
Is the resultant package of programs and activities affordable within the fiscal restraint? If not, what programs or activities should be abandoned?

She then reports on the results

Program spending (which includes all spending except interest payments on the public debt) declined in absolute terms by over 10 percent between 1994-95 and 1996-9

Half of these reductions were the result of changes to statutory programs, including employment insurance benefit payments to individuals and fiscal transfers to the provinces. Relative to the size of the economy, program spending fell from 18 percent of GDP in 1993-94 to 11 percent in 1999-2000, its lowest level since 1949-50.

She draws some important lessons:

Eliminating a sizable deficit is a societal project not a normal budget exercise. A budget exercise often involves a small number of people working in relative secrecy. The purpose of the exercise is to reconcile fiscal capacity with demands for funding, including funding for new government priorities. Eliminating a sizable deficit involves a realignment of the role of government in society. As such, it requires a more open and inclusive approach, one that engages the whole of government.
Scale is important. Scale makes possible reforms that alone would not be politically feasible. All programs have beneficiaries. Cuts that affect individual programs unleash a strong reaction on the part of those beneficiaries. The scale of Program Review helped to balance single interests with the collective interest. The public judgment about the merit of the approach hinged on the relative fairness of the proposals among regions, groups, income levels, and so forth.
Speed is important. Successful public sector reforms are incrementally implemented over time. However, where a high level of societal consensus has been achieved, it is preferable to move expeditiously. It creates hope at the end of the tunnel.
Prudence is important. Prudence is about protecting the collective journey while avoiding slippage due to unforeseen circumstances. A high degree of prudence was built around Program Review. It was achieved through lower-than-average fiscal hypotheses, the creation of a contingency reserve and the elimination of policy reserves for funding new initiatives.
Luck plays a role, but it does not last forever. During the period of Program Review, there were no major external shocks to throw the exercise off course. Furthermore, the North American Free Trade Agreement created strong external demand for Canadian exports. This, combined with a weak Canadian dollar, replaced domestic demand and facilitated adjustment.
It can be done. The test of a successful reform is whether the desired outcome is accomplished at the lowest possible costs to society while minimizing the unintended consequences. In that perspective, easy cuts and easy targets may be the worst approach since they might not be sustainable; could erode some of the levers needed to meet priority societal needs in the future and cause damage to the public sector institutional capacity to serve. It is possible to lead ambitious reforms and to make choices in a principled and defensible way for citizens and public servants.

One very good read full of important lessons and approaches.

Enclosed are some of the other budget proposals.

CBO: The Long-term Budget Outlook
Obama's budget - an fabulous illustration courtesy of the Hive Group
Federal Budget (2011 & 2011) - Obama and Ryan compared (NYTimes)
Bipartisan Policy Center's Debt Reduction Task Force Report (Dominici and Rivlin)
Dodarow's "30 Steps to Better Government" (Feb. 15, 2011; NYTimes)
Peter Orszag's "How Health Care Can Save or Sink America" in Foreign Affairs.
And, finally, David Brooks' insightful July 14, 2011 NYTime piece entitled: Death and Budgets.

Health Affairs: What I Would Have Cited

2011-03-26T07:03:00.000-07:00

I recently had the great joy of writing a piece for the Health Affairs Blog entitled "Health Information Technology, the Work is Only Beginning."

My posting was accompanied by a great piece by Carol Diamond entitled "The Road Ahead for the New HIT Coordinator."

My posting was a follow-on to a 2009 article entitled "Health Information Technology: One Step at a Time." This piece too, was in an issue with a wonderful article by Carol Diamond and Clay Shirky entitled "Health Information Technology: A Few Years Of Magical Thinking?"

The posting was released on March 25. Imperfect and perhaps more controversial than I had intended, I tried to place ONC's work in an historical context. I was limited to 2000 words. Much of what I wanted to say had to be cut clear to allow for a clearer argument. Christopher Fleming, Health Affair's Social Media Manager and his team were invaluable.

I enclose the full list of citations used in longer and earlier drafts of the piece.

Blumenthal and Leadership

I placed Blumenthal in the context of the leadership types described by Garry Wills in his wonderful book “Certain Trumpets.” I also had citations from speakers at a remarkable workshop David Blumenthal held for ONC staff in the first two months of his tenure there. Watching Dr. Blumenthal and his colleague John Glaser in action was insightful. Before they began their work in earnest, they conducted a critical evaluation both of the issues before them and, more subtly, of the capabilities of the ONC staff.

G. Wills, Certain Trumpets : The Call of Leaders (New York: Simon & Schuster, 1994).
F. Ostroff, "Change Management in Government," Harv Bus Rev 84, no. 5 (2006).
B.N. Tabrizi, Rapid Transformation : A 90-Day Plan for Fast and Effective Change (Boston: Harvard Business School Press, 2007).

Historical Context

I wanted to say a lot more about parallels with Clinton’s health care reform agenda and other related events. Most of this didn’t make the word cut.

H. Johnson and D.S. Broder, The System : The American Way of Politics at the Breaking Point (Boston: Little, Brown, 1997).
P. Starr, "Smart Technology, Stunted Policy: Developing Health Information Networks," Health Aff (Millwood) 16, no. 3 (1997).
Markle Foundation, Lessons from Katrina Health, (New York: Markle Foundation, June 13, 2006).
R.H. Miller and B.S. Miller, "The Santa Barbara County Care Data Exchange: What Happened?," Health Aff (Millwood) 26, no. 5 (2007)

Technology Context

ONC built on what came before. I listed some citations on important but at times overlooked seminal documents. The original Thompson/Brailer article is still a good read. Other works - notably the Commission for Systemic Interoperability's urging for a comprehensive prescription drug history - were prescient. We can learn a great deal by revisiting what has already been done and learning from the successes, the failures, and the ideas forgotten.

T.G. Thompson and D.J. Brailer, The Decade of Health Information Technology: Delivering Consumer-Centric and Information-Rich Health Care Framework for Strategic Action, (Washington, DC: Department of Health and Human Services, July 21 2004).
Commission on Systemic Interoperability, "Ending the Document Game," (2005).
C.M. DesRoches et al., "Electronic Health Records in Ambulatory Care -- a National Survey of Physicians," N Engl J Med (2008).
Agency for Healthcare Research and Quality, Findings from the Evaluation of E-Prescribing Pilot Sites (AHRQ Publication No. 07-0047-Ef), April 2007).
L.L. Diminitropoulos, Privacy and Security Solutions for Interoperable Health Information Exchange: Impact Analysis, (Washington: Office of the National Coordinator for Health IT, December 20, 2007).
L.L. Diminitropoulos, Privacy and Security Solutions for Interoperable Health Information Exchange: Nationwide Summary, (Washington: Office of the National Coordinator for Health IT, July 2007).
A.K. Banger et al., Lessons Learned from AHRQ’s State and Regional Demonstrations in Health Information Technology, (Rockville, MD: Agency for Healthcare Research and Quality, May, 2010).
C. Chen et al., "The Kaiser Permanente Electronic Health Record: Transforming and Streamlining Modalities of Care," Health Aff (Millwood) 28, no. 2 (2009).
J.S. Kahn, V. Aulakh, and A. Bosworth, "What It Takes: Characteristics of the Ideal Personal Health Record," Health Affairs 28, no. 2 (2009).

ONC Publications under Blumenthal’s Tenure

David Blumenthal's team were present everywhere communicating, learning, and refining their message. As several people told me over the past two years, even the prose of regulatory documents was well done. As we'd say in where I came from, ONC knows how to write "real good."

D. Blumenthal, "Launching HITECH," New England Journal of Medicine 362, no. 5 (2010).
D. Blumenthal, The Age of Meaningful Use (HIMSS 2011 Address), February 23 2011).
D. Blumenthal and M. Tavenner, "The "Meaningful Use" Regulation for Electronic Health Records," New England Journal of Medicine 363, no. 6 (2010).
M.B. Buntin, S.H. Jain, and D. Blumenthal, "Health Information Technology: Laying the Infrastructure for National Health Reform," Health Aff (Millwood) 29, no. 6 (2010).
Office of the National Coordinator for Health Information Technology, Health It Strategic Framework: Strategic Goals, Principles, Objectives, and Strategies. Version 41, (Washington, May 10, 2010).
Office of the National Coordinator for Health Information Technology, Program Information Notice: Requirements and Recommendations for the State Health Information Exchange Cooperative Agreement Program (Washington: Department of Health and Human Services, July 6, 2010).
M.B. Buntin et al., "The Benefits of Health Information Technology: A Review of the Recent Literature Shows Predominantly Positive Results," Health Aff (Millwood) 30, no. 3 (2011).

Innovation, the “Mythical Man Month” and other Inconvenient Realities

In my posting, I tried to focus attention on the "trailing edge" and the "mainstream." Some things take time. I fear that I am viewed as a cynic. I am the opposite. Any differences I have are not with the goal but with the pace and method. And these differences are very small.

Some initiatives - especially MU Phase 2 and 3 and State HIE - cannot be rushed are fraught with risk. I think of former Tennessee Governor Phil Bredesen's HIMSS 2007 address where he urged the audience to "build version 1.0 first."

It would be so much easier to forge policy if our remarkable entrepreneurial spirit was frozen. In essence, you need only visit Havanna to see what happens then. The roads of Cuba are filled with American cars from the 50s and 60s. Time warp? Yes. Progress? No.

F.P. Brooks, The Mythical Man-Month : Essays on Software Engineering (Reading, Mass.: Addison-Wesley Pub. Co., 1995).
J.P. Kotter, "Why Transformation Efforts Fail," Harv Bus Rev, no. March-April (1995).
B. Toan, "Wrangling Prescription Drug Benefits: A Conversation with Express Scripts' Barrett Toan. Interview by Robert F. Atlas," Health Aff (Millwood) Suppl Web Exclusives (2005).
C.M. Christensen, J.H. Grossman, and J. Hwang, The Innovator's Prescription : A Disruptive Solution for Health Care (New York: McGraw-Hill, 2009).
M.E. Frisse, "Health Information Technology: One Step at a Time," Health Affairs (Millwood) 28, no. 2 (2009).
K.D. Mandl and I.S. Kohane, "No Small Change for the Health Information Economy," New England Journal of Medicine 360, no. 13 (2009).
Presidents Council of Advisors on Science and Technology, Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward, (Washington: Executive Office of the President, December 8, 2010).
NHIN Direct May "Throw Wrench" into States' HIE Plans http://www.healthcareitnews.com/news/nhin-direct-may-throw-wrench-states-hie-plans.(accessed March 14 2011).

Meaningful Use Phases 2 and 3....

2011-03-22T05:28:00.000-07:00

In a March 16 blog posting entitled "Not so Fast," Joseph Conn summarizes the perspectives of those who suggest that MU 2 and 3 goals are simply too agressive.

I expressed my concerns about the challenges of this task shortly after HITECH's passage in a Health Affairs piece called "One Step at a Time."

I ask a rhetorical question. What is there were no Phase 2 and Phase 3 MU criteria, rewards, and penalties? Do we have sufficient momentum and guidance through health reform and quality legislation to "pull" desired goals through rational local responses rather than "push" goals through federal action?

Most everyone agrees with the goals espoused in MU 2 and 3, but many differ as to the pace an method. In light of the maturity and pace of standards development and the imperatives to achieve interoperable functions in anticipation of new reimbursement approaches and care delivery models, is it heretical to suggest that Phase 2 and 3 MU incentives (and penalties) be dropped altogether. One could argue that we will of necessity achieve these aims even without subsequent MU because ONC's great efforts to far have created sufficient momentum to realize a "tipping point."

What does history teach us? Pharmacy claims transactions were mandated through the 1988 Medicare Catastrophic Coverage act. These practices grew and evolved even after repeal of the Act. They simply made too much sense. They were, in essence, a precursor to RxHub and e-prescribing.

Perhaps we've got enough momentum to focus on the goals and not the methods. Perhaps its time to move the conversation out of Washington and back into communities where practitioners and vendors can discuss business and care needs at the local level. It's the same conversation, but it will be "owned" by the stakeholders - something that federal efforts strive for.

So, what happens if the Nation keeps standards and infrastructure development but lets care reimbursement and quality agenda drive innovation and adoption rather than by adding additional stress and complexity through Phase 2 and 3 MU?

Chaos in Medical Practice?

2011-03-04T19:41:00.000-08:00

A timely message:

Medical practice is far behind the plans that have been developed in industry and in many other forms of public service. It will require the most searching study of the facts and the application of these facts in the true spirit of the experimenter if we are to develop conditions that will make it possible for physicians to meet their own problems and for a single illness not to become a prolonged handicap to an individual or to a family….

Perhaps the medical school is not ready yet to insist on a training in economics, government, political science and history, and the relations of medicine thereto; but unless such training and thinking are soon started the present chaos in medical practice will inevitably make for high charges on the sick and an inadequate return to the physician.

Ray Lyman Wilbur, M.D.,
The Relationship of Medical Education to the Cost of Medical Care. Journal of the American Medical Association, April 27, 1929

A Tribute to Darlene Vian

2011-02-09T17:20:00.001-08:00

Tonight I received some very sad news:

From: Brian P. McCune

Sent: Wednesday, February 09, 2011 4:45 PM

To: undisclosed-recipients:

Subject: sad news

Dearest friends and relatives,

I have some very sad news to relate to you. My wife and my life, Darlene Vian, passed away today at 1:55 pm. Fortunately she came home from Stanford Hospital yesterday, so was able to be at Tennyson with her three children and me in her final day. She slept peacefully in her own bed until the end.

To anyone who was a Stanford Medical Informatics student during the period from the early 1980s through this decade, Darlene was a godmother, organizer, social networker, mediator, and invaluable counselor.

When my wife Cathy and my daughter Liz (aged 1) came to Stanford in 1985, Darlene was literally our lifeline. A great mother, Darlene understood the challenges families faced when a parent embarked on an arduous academic schedule. She literally held us all together.

At the same time, she managed the Ted Shortliffe, Larry Fagan, and the many faculty and staff who created such great opportunities for us.

In the past few years, Darlene has suffered from a crippling chronic lung disease. Despite the very real pain and disability, her spirit marched on. She remained - from a distance - a friend and colleague.

Around the world tonight, a lot of prayers are being said and a lot of toasts are being raised to this remarkable woman who gave us so very much. Darlene - never published and never really noticed by the larger world - was in many way the heart and soul of a training program that has produced a generation of remarkable individuals.

You are with us, Darlene. We love you.

2011-01-26T17:14:00.001-08:00

The informatics community has become quite engaged with a discussion surrounding a publication in the Archives of Internal Medicine addressing the impact of EHRs on measurable clinical quality.

Th article, is entitled "Electronic Health Records and Clinical Decision Support Systems: Impact on National Ambulatory Care Quality" and was written by Max J. Romano and Randall S. Stafford. Using the 2005-2007 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey and 20 quality indicators, their study, performed at Stanford, found:

Electronic health records were used in 30% of an estimated 1.1 billion annual US patient visits. Clinical decision support was present in 57% of these EHR visits (17% of all visits). The use of EHRs and CDS was more likely in the West and in multiphysician settings than in solo practices. In only 1 of 20 indicators was quality greater in EHR visits than in non-EHR visits (diet counseling in high-risk adults.....). Among the EHR visits, only 1 of 20 quality indicators showed significantly better performance in visits with CDS compared with EHR visits without CDS (lack of routine electrocardiographic ordering in low-risk patients.....). There were no other significant quality differences.

They concluded:

Our findings indicate no consistent association between EHRs and CDS and better quality. These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality.

Source: http://archinte.ama-assn.org/cgi/content/full/archinternmed.2010.527

In an insightful accompanying piece, Drs. Clement McDonald and Swapna Abhyankar of the Lister Hill Center at the National Library of Medicine point out many of the reasons for the disconnect between the Annals study and the work that has gone before. They conclude:

Regardless of the differences, we know from multiple randomized controlled trials that well-implemented CDS systems can produce large and important improvements in care processes. What we do not know is whether we can extend these results to a national level. The results of Romano and Stafford's study suggest not. However, we suspect that the EHR and CDS systems in use at the time of their study were immature, did not cover many of the guidelines that the study targeted, and had incomplete patient data; a 2005 survey of Massachusetts physicians supports this concern.

This writer suggests one read the primary study only after reading McDonald and Abhyankar's commentary. Perhaps like this writer, the reader will develop clearer view concerning the hazards of drawing conclusions with the data we have today in a way that is accurate, timely and insightful. More often than not, one fails to make the case early in the game.

Imagine this hypothetical early 20th century article:

"Randomized trial shows that horse-drawn carriages are superior in performance to Henry Ford's new horseless carriage."

No surprise! It takes a long time for even good ideas to become the conventional…and an even longer time to prove the impact of change.

Economists, not surprisingly, have often tried to study the impact of computers and information technology on productivity and social good.

Often quoted in this respect is the MIT economist Robert Solow who in 1987 said:

"You can see the computer age everywhere but in the productivity statistics. "

Context for his quote

Reviewing Cohen and Zysman's "Manufacturing Matters: the Myth of the Post-Industrial Economy" in the July 12, 1987 issue of the New York Times book review, Solow writes of the book:

"The authors state: ' We do not need to show that the new technologies produce a break with past patters of productivity growth....[that] would depend not just on what the technologies represent, but rather on how effectively they are used.'"

In his review, Solow added:

"What this means is that they [Cohen and Zysman], like everyone else, are somewhat embarrassed by the fact that what everyone feels to have been a technological revolution, a drastic change in our productive lives, has been actually accompanied everywhere, including Japan, by a slowing-down of productivity growth, not by a step up. You can see the computer age everywhere but in the productivity statistics. "

source:

Robert Solow: "We'd Better Watch Out."

NY Times Book Review, July 12, 1987, p. 36

My own experience suggests that often people pursue a collective course based on a collective belief grounded in intuition, preliminary findings, and simple common sense. The people I've known with such courage do so knowing that – at the very best – formal validation of large-scale social impact will be realized only years after a great effort has begun. Along the way, one tries to think things through, to stay focused on the important things, and to make incremental progress on the really important aspects and not merely the interesting ones.

But all too often, solid evidence for even the greatest of efforts is to be found only when looking through the rear view mirror.

Physicians and incomes - from Deloitte

2010-09-07T09:37:00.000-07:00

The Deloitte Center for Health Solutions is a great resource. Their Monday morning news updates tend to be concise and informative.

This week's is no exception. Among the topics is a terse summary AMA survey data on physician roles and incomes.

According to Deloitte:

661,400 physicians and surgeons are licensed in the U.S. (2008): 19 percent are employed in hospitals; 53 percent in group practices, 12 percent are solo practitioners and 16 percent work in research/educational roles in larger organizations (Source: AMA)
Of those in patient-care settings, 32 percent practice in primary care; 68 percent in specialties (Sources: AMA, U.S. Bureau of Labor Statistics)
75 percent practice in urban areas; 25 percent in rural (Sources: AMA, U.S. Department of Commerce)
Between 2008 and 2018, the physician workforce will increase 22 percent to 805,500 (Source: U.S. Department of Labor)
Median income for primary care physicians in 2008: $186,044; for specialists $339,738 (Source: Medical Group Management Association) Note: Does not include income from ownership of ancillaries/hospitals

Deloitte also summarizes Merritt-Hawkins' 2010 Inpatient-Outpatient Survey data on the revenue production per employed physician and salary for select specialties:

Neurosurgery: $2,815,650 revenue; $571,000 salary
Cardiology (invasive): $2,240,366 revenue; $475,000 salary
Orthopedic surgery: $2,117,764 revenue; $481,000 salary
General surgery: $2,112,492 revenue; $321,000 salary
Internal medicine: $1,678,341 revenue; $186,000 salary
Family practice: $1,622,832 revenue; $173,000 salary
Hematology/Oncology: $1,485,627 revenue; $335,000 salary
Gastroenterology: $1,450,540 revenue; $393,000 salary
Urology: $1,382,704 revenue; $401,000 salary
OB/GYN: $1,364,131 revenue; $266,000 salary
Cardiology (non-invasive): $1,319,658 revenue; $419,000 salary
Psychiatry: $1,290,104 revenue; $200,000 salary
Pulmonology: $1,204,919 revenue; $293,000 salary
Neurology: $907,317 revenue; $258,000 salary
Pediatrics: $856,154 revenue; $171,000 salary
Ophthalmology: $842,711 revenue; $282,000 salary
Nephrology: $696,888 revenue; $240,000 salary

I find these resources valuable when one wants to to "back of the envelope" calculations.

Controlled Substances Databses

2010-08-12T11:24:00.000-07:00

The Boston.com web site posted a Boston Globe article by Stephen Smith dated August 12, 2010 entitled "State OK’s tool to detect prescription drug abuse."

Full of informative facts, the artilce states that "State health regulators yesterday unanimously approved the new detection system designed to stop “doctor shopping’’ by addicted patients who try to dupe doctors into prescribing narcotics. The practice, specialists said, has fueled a surge in drug-related deaths in Massachusetts, where abuse of painkillers poses a health threat that rivals heroin and other street drugs."

It describes a Kentucky system that is similar in nature and raises the issue of security breaches.
Concerning Massachusetts:: "The state is spending about $1 million to strengthen prescription monitoring and will commit $400,000 annually to maintain the initiative. Health authorities said they expect the state’s health insurance program for the poor will save $2 million a year by spotting abusers.

Managing prescription drug information has been a challenge. Massachusetts' early experience was described by Gottlieb et. al. in a 2005 article entitled: "PERSPECTIVE: Regulatory And Policy Barriers To Effective Clinical Data Exchange: Lessons Learned From MedsInfo-ED."

My states, including my own, have implemented databases of controlled substances, but one wonders.....

If every practitioner is going to have access to e-prescribing software and this software enables review of a comprehensive medication history, then why would any clinician have to resort to a separate database to determine a patter of prescription drug use? Will this not, automatically, realize the alleged benefits of spotting prescription drug users?

If this is the case, then the only rationale for a dedicated database is either that this database is more comprehensive or that the database allows for queries across populations. The former would be difficult to support. The latter in my own mind is the only rational purpose for a dedicated database, and even then, one suspects a contract with the same organizations who prescribe data for individual care could be created a lesser expenditure.

I wrote about such an idea a year ago.

Am I missing something?

Goodman on Innovation

2010-07-26T08:39:00.000-07:00

In a July 26, 2010 Kaiser Health News Posting, entitled "Where Are the Innovators in Health Care Delivery?", John Goodman, President and CEO of National Center for Policy Analysis writes:

There has been an enormous amount of innovation in the medical marketplace regarding the organization and financing of care. And wherever health insurers are paying the bills (almost 90 percent of the market) it has been of two forms: (1) helping the supply side of the market maximize against third-party reimbursement formulas, or (2) helping the third-party payers minimize what they pay out. Of course, these developments have only a tangential relationship to the quality of care patients receive or its efficient delivery.

The tiny sliver of the market (less than 10 percent) where patients pay out of pocket has also been teeming with entrepreneurial activity. In this area, however, the entrepreneurs have been lowering cost and raising quality — what most of us wish would happen everywhere else.

A good read. A good point often made.

Meaningful Use - HIE Disconnect Notes - Part I

2010-07-26T08:21:00.000-07:00

As we progress inexorably towards federally-mandated deadlines, attention has focused on the dependency of Meaningful Use Requirements on the broad range of services and organizations collectively bundled under the term "exchange."

States, NHIN, and the private sector are each addressing overlapping parts of these issues - often from different or even competing perspectives. The disconnect between what can be done and what is required to be done was recently highlighted by changes made to the Meaningful Use Final Rule.

In testimony before the House Ways and Means Committee on July 20, 2010, Dr. David Blumenthal carefully and rationally explained how ONC is addressing the short-term realities and the long-term needs.

According to Rebecca Adams in a Commonwealth Fund posting:

Republicans Wally Herger of California and Sam Johnson of Texas specifically questioned why the rules do not require providers to exchange electronic information in a secure way. Instead, officials would require providers only to test systems to see if they are capable of exchanging information during the first stage of the three-phase initiative.

David Blumenthal, the national coordinator for health information technology, responded that exchange systems are not ready to be deployed in all parts of the country. He said that providers should not be penalized if an exchange clearinghouse that must be used to trade information is not operating in an area or if hospitals and physicians have not set up an agreement on how to securely share data.

"It's not fair to individual physicians who are trying desperately to become meaningful users" of health information technology to require them to securely transmit data if the problems are "something they can't control," said Blumenthal.

He noted that the rule does move forward on exchanging information through such requirements as telling physicians to transmit more than 40 percent of prescriptions electronically.

Most importantly, Blumenthal said, the next two phases of the initiative will have more ambitious goals.

"In 2013, they have to be ready to exchange in a much more robust way," said Blumenthal, adding that the administration is "starting where we think industry is, but putting them on notice that they're going to have to move fairly rapidly."

Source: Rebecca Adams. Ways and Means Members Challenge Administration Officials on Health IT. Washington Health Policy Week in Review - July 26, 2010

Is Consumers Union Right?

2010-07-22T09:23:00.000-07:00

The local newspapers have picked up a report from Consumers Union critical of the cash reserves of some health plans. The report gives surplus figures for the past 8 years. An attempt was made to associate these cash reserves to rate increases, but one suspects that if one does the math, overall health care expenditures are such that cash reserves, no matter how high - would be quickly depleted. More relevant, perhaps, is the relationship of the cash expenditures over time with covered lives, rates, and other factors.

The health plans, in turn, have responded both in terms of accounting at the state level and the higher cash needs in light of health care reform. Who is right? Can one tell now?

Follow this link to a pdf of the report

Here are the first few paragraphs

In the last decade, nonprofit Blue Cross and Blue Shield (BCBS) plans have set aside billions of dollars in surplus, even as they raised rates for many customers. Surplus is the excess of a company's assets over liabilities – essentially a health plan's retained profits—which plans hold to protect the company and its policyholders and providers from financial losses. Nonprofit BCBS plans, including community-owned charitable plans and subscriber-owned mutual plans, held more than $32 billion in surplus at the end of 2008.

Those surplus funds are built primarily with consumers' premium dollars, and insurers typically include a targeted contribution to surplus in rate increases. Surplus can be used to moderate premium increases, yet we found that some financially strong BCBS plans with large surpluses have continued to seek double-digit rate increases.

In 2009, BCBS of TN is said to have cash of $1.1b; BCBS of Michigan has $2.5b.

NHIN Exchange and the limitations of governance

2010-07-06T17:28:00.000-07:00

A June 25 posting by Mary Mosquera of Government HealthIT is representative of the challenges facing ONC as they implement HITECH. Despite remarkable execution, one gets the feeling that the complexity of the legislation and the governing process often reduce sincere intentions and intense effort into a Beltway version of "whack-a-mole."

According to Mosquera (and consistent with my experience), "participation in the NHIN Exchange is currently limited to federal health agencies and healthcare organizations that contract with them or are federal grantees." By the HHS General Counsel imply that the current collaboration between Kaiser, SSA, the VA, and a few others cannot be extended because the parties "have no framework for doing that now, and they have no legal authority or mechanism [to extend the NHIN Exchange)," according to David Blumenthal. This is particularly crippling to State HIEs who under Section 3013 of HITECH are supposed to connect to the NHIN. (The entire role of States and 3013 is a far larger matter for discussion).

So, what is going to happen? Does this limitation in some way preclude Kaiser Permanente from connecting to the rest of the world using exactly the same standards? I would think not. Does this limitation somehow prohibit the rest of the Health IT community from connecting with one another following sensible standards? I would think not. (For an understanding of the NHIN standards, nothing is better than Wes Rishels' blog.)

There is a sense among some in ONC (quoted in Mary Mosquera's piece) that governance "won't happen by itself" and that a significant degree of national governance is required to maintain trust. This is no doubt true at some level, but what kind of governance is required and how soon?

Despite significant disagreements between various groups of vendors, real progress has been made. Although there are many points of view, the degree of convergence is fairly impressive. Given that the Federal rule making process does not allow a proposed rule until early 2011 and a final rule in the second or third quarter of 2011, the degree of governance required will be tested in reality. This writer believes people will go a long way toward figuring things out during the rule-making process.

The past year has witnessed an extraordinary degree of critical thinking and collaboration. These Herculean efforts should help realize rapid progress while the rule-making process proceeds. This writer has a belief that if its a good goal, people will find a path and most will follow along similar tracks.

Additional note: Whack-a-Mole may be a trade mark. Apologies for that. This term is not used by ONC, but according to Mosquera, one colloquialism is "pants-on-fire short term issues that we have to deal with." Well said.

Mission Statements

2010-05-06T13:50:00.000-07:00

Working with groups on HIT strategy - particularly state and regional efforts, I am again struck by the value of a clear mission statement. I posted the best piece I know about this on my old policy blog in 2008.

Here is the link to my original posting

My original posting follows:

Participating in the AHIC 2.0 discussions, I am repeatedly reminded of an influential talk and paper delivered by Russ Ackoff several years ago. His advice should be heeded when one is talking of ambitious, sincere, and inclusive "public private partnerships."

I have located a copy of this paper attributed to him on Charles Warner's Web Site. It seems to be the paper I read long ago. I reprint in full. Emphases in bold or italics are mine.

MISSION STATEMENTS
by
Russell Ackoff

Most corporate mission statements are worthless. They consist largely of pious platitudes such as: "We will hold ourselves to the highest standards of professionalism and ethical behavior." They often formulate necessities as objectives; for example, "to achieve sufficient profit." This is like a person saying his mission is to breathe sufficiently.

A mission statement should not commit a firm to what it must do to survive but to what it chooses to do in order to thrive. Nor should it be filled with operationally meaningless superlatives such as biggest, best, optimum, and maximum; for example, one company says it wants to "maximize its growth potential," another "to provide products of the highest quality." How in the world can a company determine whether it has attained growth potential or highest quality?

To test for the appropriateness of an assertion in a mission statement, determine whether it can be disagreed with reasonably. If not, it should be excluded. Can you imagine any company disagreeing with the objective "to provide the best value for the money." If you can't, it's not worth saying.

What characteristics should a mission statement have?

First it should contain a formulation of the firm's objectives that enables progress toward them to be measured. To state objectives that cannot be used to evaluate performance is hypocrisy. Unless the adoption of a mission statement changes the behavior of the firm that makes it, it has no value. The behavior of a Mexican firm was profoundly affected by the following passage from its mission statement:
To create a wholesome, varied, pluralistic, multi-class recreational area incorporating tourist facilities and permanent residences, and to produce locally as much of the goods and services required by the area as possible, so as to improve the standard of living and quality of life of its inhabitants.

Second, a company's mission statement should differentiate it from other companies. It should establish the individuality, if not the uniqueness of the firm. A company that wants only what most other companies want--for example, "to manufacture products in an efficient manner, at costs that help yield adequate profits"--wastes its time in formulating a mission statement. Individuality can be attained in many ways, including that in which a company's business is defined.

Third, a mission statement should define the business that the company wants to be in, not necessarily is in. However diverse its current business, it should try to find a unifying concept that enlarges its view of itself and brings it into focus; for example, a company that produces beverages, snacks, and baked good and operates a variety of dining, recreational, and entertainment facilities identified its business as "increasing the satisfaction people derive from use of their discretionary time." This suggested completely new directions for its diversification and growth. The same was true of a company that said it was in the "sticking" business, enabling objects and materials to stick together.

Fourth, a mission statement should be relevant to all the firm's stakeholders. These include its customers, suppliers, the public, shareholders, and employees. The mission should state how the company intends to serve each of them; for example, one company committed itself "to providing all its employees with adequate and fair compensation, safe working conditions, stable employment, challenging work, opportunities for personal development, and a satisfying quality of work life." It also wanted "to provide those who supply the material used in the business with continuing, if not expanding, sources of business, and with incentives to improve their products and services and their use through research and development."
Most mission statements address only shareholders and managers. Their most serious deficiency is their failure to motivate non-managerial employees. Without their commitment, a company's mission has little chance of being fulfilled, whatever its managers and shareholders do.

Finally, and of greatest importance, a mission statement should be exciting and inspiring. It should motivate all those whose participation in its pursuit is sought; for example, one Latin American company committed itself to being "an active force for economic and social development, fostering economic integration of Latin America and, within each country, collaboration between government, industry, labor and the public." A mission should play the same role in a company that the Holy Grail did in the Crusades. It does not have to appear to be feasible; it only has to be desirable.

"man has been able to grow enthusiastic over his vision of ... unconvincing enterprises. He has put himself to work for the sake of an idea, seeking by magnificent exertions to arrive at the incredible. And in the end he has arrived there. Beyond all doubt it is one of the vital sources of man's power, to be thus able to kindle enthusiasm from the mere glimmer of something improbable, difficult, remote."

If your firm has a mission statement, test it against these five criteria. If it fails to meet any of them, it should be redone.

CMS Updates CLIA Regulations to Accomodate Meaningful Use and HIE

2010-03-05T12:56:00.000-08:00

CMS has released some policy changes designed to facilitate exchange of laboratory information. The response to the HIT Policy Committee, Brookings, and many other groups has been both rapid and impressive.

Follow this link for the pdf document from CMS

The Q&A on page 15 provide the best summary.

One quotation emphasizes the need for consent when a test is requested. It would appear that consent documents that incorporate HIE provisions could be explicitly modified to include these laboratory provisions and from my non-legal perspective, assure data liquidity.

For CLIA purposes, the final report destination for test results is considered to be the authorized person or their designated agent (an agent is an individual or entity legally acting on behalf of the authorized person to receive test results); additional individuals or entity(s) who are responsible for using the test results may also receive test results from the laboratory if they are designated by the authorized person on the test requisition; individuals may be able to receive their test results directly from the laboratory where there is no State law prohibiting it.

To ensure the accurate, timely, confidential, and easily understood reporting of patient test results to the authorized person, their agent (if applicable) and others who are identified as responsible for using the test results on the requisition, a laboratory may contract with another entity to assist in the delivery of patient reports in a manner that complies with all applicable laws, including the CLIA regulatory and statutory requirements.

More explicit discussion of HIE is to be found in the Q&A section

A few thoughts on the Interim Final Rule

2010-01-02T11:19:00.000-08:00

The Interim Final Rule emphasizes the need for more effective communication among care participants with the intent of achieving better clinical outcomes. The Rule implies – rightfully - that the electronic medical record is not primarily a static repository of electronic health information but instead more a means of communication among providers, patients, and other care givers. Hence, the correct model for the EHR is not the traditional paper chart but instead the telephone and the facsimile machine.

The Interim Final Rule emphasizes the direct responsibilities providers have in managing the care information of their patients and in communicating this information to their patients and to other provider in a complete, accurate, and timely manner. The Interim Final Rule hearkens back to the era of Lawrence Weed, who at the University of Vermont in 1969 developed a computer system focused around the problems of patients rather than the transactions necessary for care reimbursement. (Weed would have possibly argued that the primary purpose of an EMR is to "maintain an up-do-date problem list of current and active diagnoses." ) The Rule carries this clinical tradition through almost four decades of research on clinical decision support, e-prescribing, human factors, and outcomes measurement. It deftly integrates and harmonizes years of controversy and dispute over standards and, in doing so, emphasizes the "why" as well as the "how." Undoubtedly, this interim final rule is focused on the well-being of the individual receiving care first and foremost.

Despite years of focused effort on the part of so many, the Interim Final Rule presents many challenges to those who wish to adopt information technology to improve care. Medication management is challenging under any circumstance. There are great discrepancies among the prescription medication list in an EHR, what many claims-based systems report having been dispenses, what retail pharmacy systems report as dispensed, and the intent of the prescriber. When over-the-counter medications, herbals, and other supplements are added, the challenge of maintaining an active medication list and demonstrating the accuracy of such a list is challenging. Reconciling these lists is challenging when one must "electronically complete medication reconciliation of two or more medications lists (compare and merge) into a single medication list that can be electronically displayed in real time."

Equally daunting is the essential task of communicating in a meaningful way assertions of medication allergy lists and the context in which these assertions were made.Clinicians understand the difference between life-threatening allergic reactions and side-effects of common medications often reported as "allergies." Turning these lists into credible and actionable documents will take some time.

The emphasis on children is heartening in that immunizations and growth charts are essential. Under the Interim Final Rule, critical issues supporting child health are being addressed.

Among the most powerful “game changers” in the Interim Final Rule may be the requirement that care-givers “provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) within 96 hours of the information being available to the eligible professional."

This is transparency on steroids. Given the emphasis on claims, practitioners should expect significant consumer reaction when - like the famous "e-Patient Dave" incident at Beth Israel in Boston - individuals fail to see a correspondence between administrative data and their real problems. Moving beyond claims data to active problems will be key to meaningful dialogue among providers and patients.

One significant challenge will be in auditing and acting on various aspects of these implementations. Drug interaction alerts – infamous for their "alert fatigue" potential - must be monitored. Providers are to "automatically and electronically track, record, and generate reports on the number of alerts responded to by a user."

We have learned the hard way that, thoughtlessly implemented, alerts create discord. Reports on responses to a poorly-implemented alerting system may reflect more on the inadequacy of the implementation than on the motives of the clinician. This provision will place great pressure on those who implement and maintain EHR systems.

Another challenge will be in the management of population data. The requirements require that a user can "electronically select, sort, retrieve, and output a list of patients and patients’ clinical information, based on user- defined demographic data, medication list, and specific conditions." Along a similar vein, the systems must be able to "calculate and electronically display quality measure results as specified by CMS or states." These were expected, but will be a challenge. In addition, since patients are seen by multiple providers, the supplier of the "definitive" aggregation resource will be a matter of controversy. Both at the provider and aggreggator level, the technical challenges will be formidable, and the results will have important implications to care measurement and ultimately reimbursement.

In all, one could not have asked for more from a concerted Federal effort working in collaboration with the private sector under incredible legislatively-induced time compression. The Interim Final Rule is demanding, it is precise, and it is artfully crafted.Responding to these requirements will not be easy, but the public will benefit greatly.

Mark's Links:

Mark's working copy of the standards Interim Final Rule

Health Care Legislation: Possible Macro Trends

2009-09-26T10:47:00.000-07:00

It is very difficult to gauge the ultimate outcome of proposed health care legislation, but several common themes do allow one to make educated guesses on trends.

The trends:

A shift from plan exclusion of pre-existing illness to controlling expenditures of covered members
Rising health care costs
More dialogue between payer intermediaries and decisions at the point of care
More capitation and risk relationships with providers
More dynamic provider networks based on a variant of social networks and preferences
A shift in the delivery of health care services from physician-based practices to networks of clinicians with varying skills practicing in a wider range of accessible settings
A shift in "ROI" from short-term return to long-term value
A shifting responsibility from intermediaries to individuals
Administrative simplification
Pricing and quality transparency

Trend: A shift from plan exclusion of pre-existing illness to controlling expenditures of covered members

It appears that in far fewer cases will health plans be allowed to exclude from participation those with pre-existing conditions. This is heartening to those of us who have family members with such conditions. What will be the consequences of this? In a September 22, 2006 NY Times Op-Ed article (subscription required), Paul Krugman cites a September 17 Lisa Girion article in Los Angeles Times article entitled "Sick but Insured? Think Again" and, carrying that theme, argues that the current incentive structures pit parties against the best medical interests of the individual. He states "cruelty and injustice are the inevitable result of the current rules of the game."

Krugman makes the following claims without reference:

Between 2000 and 2005, the number of Americans with private health insurance coverage fell by 1 percent. But over the same period, employment at health insurance companies rose a remarkable 32 percent.

These positions will be eliminated or transformed into efforts that apply actuarial skills to care management. Health plans and providers will both be forced by cost pressures to exert more influence within a specific care episode and across providers and episodes of care.
Debate will grow over "minimal benefits package." What are the "basic" health care services that will be required from all payers? Publications from the Cato Institute are but one example of the dilemma faced by those who seek to define a "minimal benefits package." Glen Whitman summarizes the challenge:

If you're going to mandate something, you have to define it. Under an individual mandate, legislators and bureaucrats will need to specify a minimum benefits package that a policy must cover in order to qualify. It's not plausible to believe this package can be defined in an apolitical way. Each medical specialty, from oncology to acupuncture, will pressure the legislature to include their services in the package. And as the benefits package grows, so will the premiums.

Limiting the mandate's scope with vacuous phrases like "basic health care products and services" will not solve the problem, because what is basic to some is crucial to others. Does contraception constitute basic health care? How about psychotherapy? Dental care? Chiropractic? The phrase "medically necessary" is just as problematic, because there is no objective definition of necessity. And even if there were, it wouldn't matter, because the content of the law will be determined by the legislative process. The "basic" package might initially be minimal, but over time it will succumb to the same special-interest lobbying that affects every other area of public policy. If psychotherapy is not initially included in the package, eventually it will be, once the psychotherapists' lobby has its way. And likewise for contraception, dental care, chiropractic, acupuncture, in vitro fertilization, hair transplants, ad infinitum.

Trend: Rising health care costs

Health care costs in general are expected to increase. One could elaborate at length on this, but it seems redundant.

Trend: More dialogue between payer intermediaries and decisions at the point of care

Since intermediaries cannot exclude the sick and costs will continue to rise, an increasing emphasis on cost controls through real-time dialogue seems inevitable. EMR technology "clinical decision support" will include dialogue with intermediaries on test ordering behavior. Much as formulary requirements and prior-authorization are drivers for prescription writing, similar metrics will be applied to the use of diagnostic testing and procedures. (Think of "prior authorization" on steroids). Technology makes this possible. Those who don't adopt will see claims denied post hoc for lack of authorization or assertions that a test was unnecessary or redundant.
Consider the following example: a practitioner encounters a new patient with anemia and chronic abdominal pain. A CT scan is ordered. The practitioner does not know that the patient received an abdominal MRI scan from a neighboring institution only a week before. Those responsible for payment have a justifiable claim in asking "wasn't that abdominal MRI scan informative enough?" and "shouldn't you have made greater efforts to obtain a report or review the study (through a health information exchange or by other means) before ordering the CT scan? Payers will have one of two broad approaches: they can either encourage the use of health information exchanges so that the provider is aware of the other test and argues for the new test, or they can post hoc deny payment for the second test. Both will happen. Certainly this pressure should promote health information exchange in one form or another.

Trend: More capitation and risk relationships with providers

An inability to control costs through exclusion of pre-existing conditions will lead to a growth in service agreements between plan intermediaries and providers or coalitions. Provider coalitions - whether capitated or not - will have to increase their investments in information technology that helps them understand the quality and cost of care across providers. The focus will be on the longitudinal care of an individual rather than the service delivered for any one discrete event.

Trend: More dynamic provider networks based on a variant of social networks and preferences

Since care will be more patient-centered, collaboration technologies more available, and (I argue) administrative mechanisms more uniform, one can imagine an evolution from static provider networks to more dynamic relationships based on community preferences and patient needs. Technology in the form of some business-related "social network" allows more dynamic relationships between buyers and sellers. One may see an evolution of the notion of competition from competition among static provider networks to more dynamic and fluid competition aimed at increasing quality and cost metrics for populations.
Consider a population of diabetics. Health plans and providers will not doubt continue managing many individuals through static care delivery networks contracted to deliver services at certain fees of capitation levels. At the same time, they (and consumers) may also begin exploring "bids" from coalitions that coordinate care for specific individuals or groups at a pre-arranged price. These coalitions may be more dynamic and individual than the more static relationships. Two diabetics under the same employer coverage may have different networks of care that deliver agreed-upon services at a given price. Both networks create contracts dynamically under a set of business rules set by the payer. I admit, this is not only speculative, but as some of my colleagues state: "I don't understand what you are talking about."

Trend: A shift in the delivery of health care services from physician-based practices to networks of clinicians with varying skills practicing in a wider range of accessible settings

The experiences of states with expanded coverage has shown that the traditional primary care based physician model is insufficient to meet demand. Accordingly, pharmacists, nurse practitioners, and many other health care professionals and individuals will play an expanded role in care delivery delivered through networks sharing clinical and administrative data. Settings will also change. Retail services - including pharmacies and retail clinics delivering a limited set of services - will complement a broader range of clinical services offered in traditional settings. Care coordination services enabled by health care technology will be essential for effective and efficient care delivery.

Trend: A shift in "ROI" from short-term return to long-term value

An elimination of pre-existing illness barriers will eliminate the current illogical tendency to withhold short-term expenses (e.g., medication expenses) at the expense of long term costs towards the realization that within communities, shifting of consumers from one plan intermediary to another is a zero-sum game. All benefit if health care issues are addressed immediately. But this notion is at risk because of lower adherence due to consumer price sensitivity and short term incentives to optimize local costs despite legislative change. If government is a safety net, one can imagine scenarios in which care is limited because long-term sequelae will be paid for by "the government." Hypertensives, for example, need control, but if their control is poor and they ultimately require dialysis, intermediaries are off the hook and Medicare (i.e. all of us) pays dearly for earlier inattention.
The reaction of my colleagues to this point is summarized by the statement "I don't think so." I admit that the change will be gradual, but adherence programs and wellness programs suggest such a trend is occurring, albeit slowly.

Trend: A shifting responsibility from intermediaries to individuals

Health care costs will not be reined in until the individual has a better sense of what they are getting for what portion they pay. Until "everyone pays something," the moral dilemma argument is sound. Individual payment of at least a fraction of a known total cost seems essential. Regina Herzlinger's views on consumer-focused health care seem very applicable.

Trend: Administrative simplification

Plans have "differentiated" on the basis of minor differences in procedures and plans. For example, this writer believes the number of formularies in the United States is in excess of 3,500 and the number of prior authorization variants for some drugs and procedures range in the hundereds. (Any better data would be greatly appreciated!). The unnecessary complexity of this number of formularies or prior authorization rules has been passed on to the larger "system." As margins in plan intermediaries are squeezed and greater cost-related administrative dialogues engage providers, a more simple, uniform approach will be a technical and business necessity.
This claim is also met with skepticism, but I believe the simplification and ad hoc standardization we've seen evolve in other industries is inevitable to maintain margins. Time will tell.

Trend: Pricing and quality transparency

Pricing and quality transparency - cornerstones on the last Administration, will become central as a by-product of health care reform because of the pricing pressures and care decisions that individuals and the public will be forced to make. "Rationing" will take place at the level of individual consumer decisions as well as at the level of plan intermediaries, states, and the federal government. Such "rationing" takes place now and can only be more dominant as price pressures grow. It might be "invisible" to the public rhetoric, but it will be there. The only way out of this is to make prices and value more transparent to all. Administrative simplification and greater consumer involvement will accelerate this trend (at present, it is very difficult to know exactly what the full cost of a retail prescription is, for example).

Budget Deficits

2009-06-11T05:51:00.000-07:00

If one accepts the findings of David Leonhardt's June 9, 2009 New York Times analysis, the stimulus package and the proposed Obama initiatives in energy, health care, and education, at face value contribute only 10% to our future sea of red ink. But 10% is a huge number. In business, smaller percentages make the difference between prosperity and failure.

adapted from: David Leonhardt. Economic Scene: America’s Sea of Red Ink Was Years in the Making. New York Times. June 9, 2009.

The central issue may be the extent to which policies contribute to the "business cycle." This is the overall economy - jobs, productivity, markets, and the other factors that lead to social prosperity.

Perhaps its not the proposals per se. It's hard to argue against better education, health care, and energy policy. Perhaps instead its just the very real argument about how current policies will influence not only the well-being of Americans but our collective future economic prosperity.

e-Patient Dave

2009-04-18T13:33:00.001-07:00

"....I didn't highlight a lot of administrative data. Administrative data, it is true, what we have today, but one caveat for you. You read the Boston Globe, and you will see that I have had some fun over the last two weeks investigating the nature of administrative data."
John Halmka, NCHVS, April 28, 2009

A remarkable series of public postings and articles demonstrates how people are getting the bugs out of systems. It all surrounds a self-identified cancer survivor named Dave deBronkart who is fairly unique:

He is cared for by Danny Sands, an informatics leader practicing at Beth Israel and also employed by Cisco
His care is provided at Beth Israel Deaconess; the inaccuracies were in transferring claims data from B.I. to Google Health. The CIO of Beth Israel is John Halamka, a national authority on health IT and an advisor to Google Health.

One would think: "If there is anyplace where things should not go wrong, this would be it." Not so. (But this writer points out that there were no adverse medical events and that the system responded very quickly to the issues).

The series begins with an April 1 posting on ePatients.net. Mr deBronkart found numerous innacuracies in his Google personal health record, primarily because the record contained a wide array of medical claims. (Read this long posting and ask again what the risks are of using medical claims as a medical record "proxy.")

Follow this link to the posting

This in turn was picked up by the Boston Globe.

Follow this link to the Globe article

John Halamka gave a very thoughtful answer to the concerns in his blog.

Follow this link to Halamka's posting on April 17

On April 18, e-patient Dave was able say that the Boston Globe published an article saying Beth Israel had discontinued transferring claims data to Google Health.

Bottom line:

Claims data do not correspond to clinical situations; one should view claims-based clincial systems with suspicion
The Internet seems to be a great way to raise awareness and bring about positive quality control.

Joe Bugajski: The Data Model That Nearly Killed Me - what does this mean for "meaningful use"?

2009-04-18T06:23:00.000-07:00

Danny Sands posted to Facebook a link to a blog posting (March 17) at Syleum.com written by Joe Bugasjski and entitled "The Data Model That Nearly Killed Me."

Follow this link to the blog posting

The posting provides a very human and disturbing set of circumstances depicting one view of how things can go wrong when an information technology professional becomes ill. Although the posting addresses the "data model," within the story are examples of flawed processes, internal communication, inadequate hand-offs, and, arguably, poor communication among the patient, and the many providers who tried to help. One could argue that the right term here is "system model" where the system routinely has access to medications, allergies, laboratory tests, and other core information.

Echoing the spirit of the National Resource Center Report, Bugasjki states that "The root cause of these problems is the failure by information technology (IT) system architects to correctly capture business requirements. There also is evidence that no one ever produced a reliable conceptual data model."

He lists a number of observations - copied verbatim from his posting (but the graphics and the narrative are essential to understand his position; please read his full posting).

Incoherent database design isolates patient information from one department to the next and from one organization to the next. This wastes time and increases errors because medical personnel must enter patient information into a unique view of the system that corresponded to user identity and department - this prevents one medical professional from seeing patient information input by another medical professional.
Patient information is easily lost inside the electronic records system
Hard copy patient information becomes dissociated with the electronic record
A healthcare professional’s work pattern is not reflected in either the system design or data model - people spent considerable time searching and data reentry
No master data management (MDM) in evidence - Production of a consistent record of me as a patient required the ICU nurse to copy data from multiple database views into the in-patient record
Admitted in-patient records are treated differently by the system than out-patient or ER record only patients - no information about my medical history gathered during a prior visit to ER was available to my doctors or nurses.
Nurses and doctors do not have ready access to listings of pharmaceuticals which wasted much time while they searched for information about my daily medications - lists of medications in the system are limited to those at the hospital pharmacy.
No support existed for recording allergies differently than to ambient source and foods - Lists of allergies were not in drop down menus although these are well known by allergists and drug companies.

What Bugajski has experienced is the absence of a patient-focused care delivery system. He's shown yet another example of what happens when data are not "liquid" and available easily and securely across his many sites of care. A few elements - providers, medications, allergies, could - if made uniformly available ease the complexity and "data loss" he cites through complex system designs.

I would argue that his story is just a sampling of what needs to be done and that some simple priorities, "data utilities," and work flow patterns could ease the risk dramatically. Not everything has to be done to avoid errors and delays; if just some of the important tasks were routine and data were available, a significant majority of these concerns could be addressed because health care professionals would have far more time to think about care and less trying to understand what all has gone on.

From reading the story, it appears that he sought care at very solid institutions but that the system as a whole failed him.

Addressing simple things in a systematic way could do much to address the problem. Meeting the foundational data needs of this individual would, in my opinion, constitute "meaningful use."

Update on the MidSouth eHealth Alliance - Memphis Health Information Exchange

2009-04-17T08:39:00.001-07:00

While national experts urge "implement now" and press releases announce early award of non-profit status, some established exchanges - Memphis included - are wondering what the big deal is about.

In May, the Memphis health information exchange funded through AHRQ and the State of Tennessee will have been in operation for three years. The Exchange is governed through data-sharing agreements based on Markle and, through the Vanderbilt Regional Informatics, have supported efforts by organizations in thirty states. The system includes all major hospitals, all consenting patients, and is used hundreds of times a day in 14 emergency departments and 14 ambulatory clinics. The major value has been in a demonstrable reduction in duplicate radiology tests and significant impact on transitions from hospitals to safety net clinics and value to hospitalists seeing newly hospitalized patients. The model is generalized and will be extended to other regions.

Follow this link to some screen shots (demonstration data)

To us, "health information exchange" is a verb more than a noun. Our project and organizations are viewed as interim measures to build trust among providers and the public to create a secure, simple, inexpensive approach to patient-centered care. Our mantra is not "make our project sustainable" but instead "find a way to make sure that every consenting Tennessean has access to their care information whenver - and wherever - it is needed for clinical care."

To us, such a reality will be inevitable whether achieved through our approach, PHRs, or some nascent combination of policies and technologies. This writer remembers speaking of "hypertext" in 1986 and saying that in the future, people won't believe you had to go to libraries to read books and newspapers. Audiences were skeptical. Looking forward a few years, few will believe that personal health information wasn't "liquid" and available in a secure and trusted way where it is needed. Can one really envision a health care system without such data liquidity?

Returning to the Memphis Exchange, the coverage is extensive. As of April, 2009, salient metrics include:

Total number of encounter records: 4,704,000
Total # of patients: 1,284,000
Total # of patients with clinical data: 1,018,000

Estimates of monthly volume include:
Monthly Encounter Data: 140,000
Monthly ICD-9 admission codes (Chief complaints): 34,000
Monthly labs: 2,400,000
Monthly microbiology reports: 26,000
Monthly chest x-ray reports: 35,000

Operational costs are under $3 million per year. That's less than $3 annually per person. Administrative claims data are available to some degree, but are considered by users largely irrelevant when they have access to labs, dictated reports, and other real clinical data.

But is this enough? It's not clear. The entire health care system has one primary sustainability strategy: get the health care dollars of the public first and hold on to as many of them as possible.

Is the not the absolute volume that counts, but instead the coverage for specific individuals and populations. Health care will be improved not so much by having 10% of the data of everyone as it will be when the Exchange supports care by making availble 90% of the important clinical information for specific individuals and groups. Hence a broad push into ambulatory arenas.

Governor Phil Bredesen spoke of "building version 1.0" when addressing HIMSS in 2007. That's what we are trying to do. Heavily influenced by Clayton Christensen and other innovation thought-leaders, we strive to build something simple that provides a low barrier to entry and incremental evolution as a "disruptive" approach to health care IT. We believe the standards are by and large sufficient, that value can be derived from semi-structured data, that systems can be inexpensive, and that, by and large, things are really pretty good if organizations would only focus on collaboration. Memphis isn't a final answer, but it has provided us with some insights into what it takes to improve care.

Follow this link for a draft pdf document with additional historical details

States or Regions?

2009-03-31T17:14:00.000-07:00

Current legislative language offers some choices between state and regional efforts. This is a sensible thing for the usual reasons:

Change always has a strong local component
Some regions span multiple state boundaries
States, on the other hand, have financial and legislative frameworks regions do not.
Medicaid is a primary driver for health care and is a state-level effort leveraged by federal FMAP funds

As financing models for health information exchange (the verb) evolve, it will be important to understand the tensions between regional and state effort and to learn from them. Every state (almost) has boundaries: rural vs. urban; east vs. west; up-state vs. down-state and within every state there is significant heterogeneity in cultural, policy, and technical readiness to accelerate efforts.

California - always a leader - is one state where such differences are playing out. Several blog postings and testimonies serve as a starting-point for understanding California efforts from afar.

There are differences of opinions here, different models, different versions of success and failure, and different views on how technologies should be governed. The California eHealth Collaborative is new but represents the common collaboration among a number of accomplished efforts. CalRHIO is a more long-standing effort to coordinate these same efforts from a top-down perspective.

What is more important, perhaps, than favoring one view over another is to recognize that different views exist and that the right outcome is not clear. Clearly the balance is important.

Time to dust of your copy of the Federalist Papers. Because of the pace of economic stimulus and sense of urgency, these controversies are coming to your state soon. Hopefully, we will all learn from one another.

Physician EMR Adoption and Attitudes; and What Will Dr. Blumethal Do?

2009-03-26T03:31:00.000-07:00

Several recent publications describe once again the large "practice variation" in EMR adoption at least as seen through the eyes of surveys. A brief overview of ARRA written by David Blumenthal provides some hints as to the direction of policy.

see:

Jha surveyed all acute care hospitals as part of an American Hospital Association annual survey. They received responses from approximately 3,000 (63%) of hospitals surveyed. The found very low rates of comprehensive use.

Carol Weimar of American College of Physician Executives has a piece that provides data on approximately 1000 respondents suggesting the "love/hate" relationship with the EMR. Quotations from the report include:

“I feel like I hit a cliff head on and have been dragging myself to the top.” “But after 10 months, I can see the promised land.”
“It’s expensive, difficult and essential. We would never go back. The trick is using the technology to improve the process. We’re still and will always be working on that.”
“It was painful to implement, but I wouldn't go back to the way it was. Access to information is much faster and better, communication with patients has improved, but there has been some degradation of the office visit documentation.”
[Adopting electronic medical records has been “the worst aspect of my 25 years in medicine. It has ruined doctor productivity, produced lower quality care and encouraged notes that are false to the point of fraud.”
“The biggest issue is not necessarily the physician resistance—it is the administrative resistance to admitting that these are not just IT projects. They are clinical projects, just as any other process change in clinical care would be viewed.”
“There has been little attempt to train physicians so they can use the system well. The interface between the physician and software program is cumbersome. Rather than interface the main system with a documentation system that has a proven record in emergency departments, they are using a system that the docs don’t like. Pound foolish!”
“Don’t underestimate your partners’ anxiety in changing their comfortable ways of getting through the day. Promises of efficiency only come after hours of suffering. ‘It ain’t easy, but who said it should be simple?’”

In the same March 25 web publication issue, David Blumenthal, newly appointed National Coordinator, has a review of ARRA. Some comments in his piece (he also provided oversight for the Jha survey) are perhaps indicative of future trends.

First, he recognizes the "tight schedule" the requires the infrastructure to support HIT adoption to be in place "well before 2011 if physicians and hospitals are to be prepared to benefit from the most generous Medicare and Medicaid bonuses." He rightfully states that "it takes time to develop and implement innovative federal programs, and it will take even more time to create the local institutions needed to support HIT implementation." This writer is concerned that the tight timeline may actually lead to the implementation of products in some settings that either do not meet needs or, in simplifying the complex fragmented health care payment system, actually make substantive health care reform more difficult.

Second, Blumenthal focuses on the two critical terms that will define so much: "certified EHR" and "meaningful use." With respect to CCHIT, he states that "many certified EHRs are neither user-friendly nor designed to meet HITECH's ambitious goal of improving quality and efficiency in the health care system. Tightening the certification process is a critical early challenge for ONCHIT." He further states that effective use will require physicians to take "advantage of embedded clinical decision supports that help physicians take better care of their patients. By tying Medicare and Medicaid financial incentives to 'meaningful use,"'Congress has given the administration an important tool for motivating providers to take full advantage of EHRs, but if the requirements are set too high, many physicians and hospitals may rebel — petitioning Congress to change the law or just resigning themselves to forgoing incentives and accepting penalties.

Third, he realizes that the full potential of EHRs will be realized only through a dramatic change in "the health care system's overall payment incentives so that providers benefit from improving the quality and efficiency of the services they provide."

These are formidable challenges. At present the carriage seems before the horse. Incentives are provided to automate a health care system whose characteristics are not well defined. Given the tight frame, this suggests only incremental changes with an increased reliance on our current means of measuring quality and receiving compensation through administrative claims. The most likely outcome of this process will not be the "disruptive innovation" Clayton Christensen and others believe is necessary but rather a refinement of the status quo. But with the rise of alternative vehicles for care like on-site clinics, alternative care providers, inexpensive generic drugs, and self-pay programs, disruptive change may happen despite the federal government rather than because of it.

ONC and the federal government face a formidable challenge and the true nature of this challenge is recognized. But the focus of past work has been primarily focused on physicians and hospitals and the emphasis has been on CPOE and clinical decision support. Little mention is made of the pressing need to create an infrastructure of laboratory, pharmacy, and other information required to enable person-centered care. Indeed, many from Harvard have published or stated publicly a great skepticism about the health information field. A closer examination of what has - and has not - taken place in Massachussetts is in order.

The skills of the individuals involved (including publications that John Glaser may join ONC as a consultant for some period), give great reason for optimism, but the outcome is far from assured. This challange and time frame is critical. Without success, we have simply automated a health care delivery system that we know needs improvement.

Mandl and Kohane on Health Care Information Technology

2009-03-25T04:29:00.001-07:00

In a March 26, 2009 article in the New England Journal of Medicine entitled "No Small Change for the Health Information Economy, Kenneth D. Mandl and Isaac S. Kohane emphasize that interoperability is not sufficient to achieve the results we need. What is required, they say, is "flexible information infrastructure that facilitates innovation in wellness, health care, and public health." Such flexibility is critical. If we are to provide massive incentives to implement health care technologies, do we want systems that merely preserve and actually strengthen our fragmented system or do we instead what systems that "function under new policies and in the service of new health care delivery mechanisms." Do we want to apply to the systems we use a certification process that is of necessity complex and slow so that by the time of certification are already "legacy" or do we want to create processes that "incorporate emerging information technologies on an ongoing basis?"

To achieve the aims of a "learning healthcare system" promulgated by the Institute of Medicine and others, such technologies must not just be interoperable, they must be composed of components that can be substituted one for another. They use as an exemplar the components of our ATM banking technology systems. The Apple iPhone with its myriad applications, is cited as another case. (As yet a another example - not the authors, - personal computer users can substitute one web browser for another, one news feed for another. What is important is that the functions of each component are provided reliably, not that the entire package is somehow certified).

What types of components can be substituted? The authors have a table of categories worth further study and examination. Each category is defined by its purpose. In their view, the "proposed platform would allow a clinical practice or hospital to select the combination of applications that are most useful for the local environment. As alternative applications are developed by competitors, the existing ones may be substituted, or new ones added." Examples cited are:

Medication management
Documentation
Panel management
Quality improvement
Administration
Communication
Public health reporting
Research
Decision support
Data acquisition (subscription)

Each category has many examples. Readers are urged to study this table carefully and to refine it.
These two authors create a structure that supports a stable "platform" upon which interoperable and substitutable components can be added. They claim that health care software must be

interoperable
secure
promote data liquidity by reducing "impediments to the transfer of data"
modular to ease susbsitutability of specific applications
limited in scope when need be (every system must not do everything just as "a customer cannot apply for a mortgage at an ATM.)
based on open standards
robust through diversity that allows choice and "natural selection...driven by successful, real-world innovations."

They join the growing chorus of leaders who argue that certifiying the entire package slows innovation and is doomed to a view of the world through the rear-view mirror. Functional requirements will change and should be not confused with certification. How functional requirements are met is the subject of the type of assurances that certification can provide for subsitutable components.

Their view - one this writer and many others share - required DHHS to take immediate action through regulation, incentives, and critical evaluation of results. The current approach, many argue, is to focused on static products and outcomes measured through the imperfect prism of claims data. As the authors state, one "positive step would be to reduce demands for excessive documentation to support billing and medicolegal defense, so that valuable data-entry efforts could serve nobler goals." DHHS could also introduce greater transparency into its evaluation processes. DHHS should draw on the experience of other fields. The authors cite the Stead and Lin National Academies report as one example.

One hopes informed and influential people will read this article, reflect on its common-sense approach, and stop the sincere but misguided proliferation of certification efforts and quality metrics that root us in the past and potentially making matters worse.

One also hopes that the same rigor encouraged of clinicians will be applied to other actors in the health care delivery industry. As a global metric of performance, should we consider thousands of formularies already prevalent in the US as a good thing? Where is the evidence for this? Where is the business purpose? Similarly, the wide variations in authorizations and processes administrative entities require. Why do they have to be so different? What is the global rationale of unnecessary complexity? How does this allow for meaningful differences in services that count?

We face great opportunity. ARRA requires decisions. The right ones - along the lines of Mandl and Kohane - will make an enormous positive impact. The wrong ones - including much of the status quo - will doom us to a static world that is inefficient and unresponsive to the tsunami of need our society faces as we age.

Ruth Marcus: Five Hard Pieces of Health Reform

2009-03-22T12:24:00.000-07:00

In a March 22, 2009 Washington Post op-ed piece, entitled "Crunch Time for Health Care Reform," the columnist Ruth Marcus raises five questions that must be answered. Elaborations on her questions as well as some of her options, are worth a read.

Follow this link to her article

The questions are:

Piece One: Should there be a public insurance option?
Piece Two: How to pay for the program?
Piece Three: Should individuals be required to purchase insurance?
Piece Four: What mechanism should there be to control costs?
Piece Five: How much muscle should Democrats use to get health-care reform done?

Do Other Countries Have the Answer

2009-03-22T12:10:00.000-07:00

John Goodman, a proponent of health savings accounts and prolific author, writes (March 19) in the Health Affairs blog about a paper he wrote with Linda Gorman, Devon Herrick, and Robert Sade. Entitled "Health Care Reform: Do Other Countries Have the Answers?," the paper, according to Goodman's posting, focuses on eight questions:

Does the United States spend too much on health care?
Are U.S. outcomes no better and in some respects worse than those of other nations?
Is the large number of uninsured in the U.S. a crisis?
Does lack of health insurance cause premature death?
Are medical bills causing bankruptcy?
Are administrative costs higher for private insurance than public insurance?
Are low-income families more disadvantaged in the U.S. system?
Can the free market work in health care?

The Health Affairs blog also has some rather interesting rebuttals and refutations by critics.

Follow this link to Goodman's Health Affairs posting

Follow this link to the National Center for Health Policy Analysis report

Goodman also cites the work of Professor Paul Atlas of Stanford and the Hoover Institution.

Follow this link to a brief piece by Professor Atlas

David Blumenthal: A Bibliography

2009-03-20T13:28:00.000-07:00

Dr. David Blumenthal's return to the federal arena brings strong policy experience into the tasks required of ARRA. At Harvard, Dr. Blumenthal was part of a diverse group who effected change. Among this group also were John Glaser, Ken Mandl, David Blumenthal, Isaac Kohane, John Halamka, and countless others. Innovation happened both within discrete training programs and across institutions through inter-faculty groups. On the national level, Dr. Blumenthal has been involved in policy areas for several decades. His primary journal publications range across a wide array of topics. As a careful student of many health care reform efforts locally and nationally and as a serious thinker, his recent appointment is welcome.

Studying his work is like reading a text book. Enclosed are several links that give one an idea of the scope of skills he brings to ONC.

Blumenthal, David, The Federal Role in Promoting Health Information Technology, The Commonwealth Fund, 2009, January 26. http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=792771
Goldstein, M. M. and D. Blumenthal, Building an Information Technology Infrastructure, J Law Med Ethics 36, no. 4 (2008): 709-715, 609. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=19093995
DesRoches, C. M., E. G. Campbell, S. R. Rao, K. Donelan, T. G. Ferris, A. Jha, R. Kaushal, D. E. Levy, S. Rosenbaum, A. E. Shields and D. Blumenthal, Electronic Health Records in Ambulatory Care--a National Survey of Physicians, N Engl J Med 359, no. 1 (2008): 50-60. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=18565855
Blumenthal, David, David Cutler and Jeffrey Liebman, Memo on the Obama Campaign Health Proposal (Source: Ny Times), 2008, Summer, 2008.http://www.nytimes.com/packages/pdf/politics/finalcostsmemo.pdf?scp=1&sq=cutler%20obama&st=cse
Garson, A., Jr. and D. Blumenthal, State-Federal Partnerships for Access to Care: An End and a Means, Jama 297, no. 10 (2007): 1112-1115.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=17356032
Blumenthal, D. and J. P. Glaser, Information Technology Comes to Medicine, N Engl J Med 356, no. 24 (2007): 2527-2534.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=17568035
Blumenthal, D., Employer-Sponsored Health Insurance in the United States--Origins and Implications, N Engl J Med 355, no. 1 (2006): 82-88.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16823002
Blumenthal, D., Employer-Sponsored Insurance--Riding the Health Care Tiger, N Engl J Med 355, no. 2 (2006): 195-202.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16837686
Blumenthal, D., Employer-Sponsored Health Insurance in the United States--Origins and Implications, N Engl J Med 355, no. 1 (2006): 82-88.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16823002
Blumenthal, D., Employer-Sponsored Insurance--Riding the Health Care Tiger, N Engl J Med 355, no. 2 (2006): 195-202.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16837686
Kaushal, R., D. Blumenthal, E. G. Poon, A. K. Jha, C. Franz, B. Middleton, J. Glaser, G. Kuperman, M. Christino, R. Fernandopulle, J. P. Newhouse and D. W. Bates, The Costs of a National Health Information Network, Ann Intern Med 143, no. 3 (2005): 165-173.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16061914
Kaushal, R., D. W. Bates, E. G. Poon, A. K. Jha and D. Blumenthal, Functional Gaps in Attaining a National Health Information Network, Health Aff (Millwood) 24, no. 5 (2005): 1281-1289.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16162574
Blumenthal, David, Marilyn Moon and Mark Warshawsky, Long-Term Care and Medicare Policy: Can We Improve the Continuity of Care?, Brookings Institution, 2003, http://books.google.com/books?id=8I9AcBHQBR8C
Blumenthal, D., Doctors in a Wired World: Can Professionalism Survive Connectivity?, Milbank Q 80, no. 3 (2002): 525-546, iv.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12233248
Blumenthal, D., Health Care Reform at the Close of the 20th Century, N Engl J Med 340, no. 24 (1999): 1916-1920.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=10369858
Blumenthal, D., The Future of Quality Measurement and Management in a Transforming Health Care System, Jama 278, no. 19 (1997): 1622-1625.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9370511
Blumenthal, D. and A. M. Epstein, Quality of Health Care. Part 6: The Role of Physicians in the Future of Quality Management, N Engl J Med 335, no. 17 (1996): 1328-1331.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8857015
Blumenthal, D., Part 1: Quality of Care--What Is It?, N Engl J Med 335, no. 12 (1996): 891-894.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8778612
Blumenthal, D., Health Care Reform--Past and Future, N Engl J Med 332, no. 7 (1995): 465-468.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=7824020
Blumenthal, D., Federal Policy toward Health Care Technology: The Case of the National Center, Milbank Mem Fund Q Health Soc 61, no. 4 (1983): 584-613.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=6557372

Disrupt and Prosper?

2009-03-11T18:55:00.001-07:00

At a fascinating meeting today, I again heard physicians express concern that the HITECH EHR programs could lead to inappropriate intrusion by third parties. Third parties like health plans and PBMs could play a vital and very positive role if they are consumer-focused, transparent, and consistent with the President's principles of portability and non-exclusion. And I think they will play that role.

But reconciliation will be hard. Consider the rhetoric of managed care trade publications.

For example, the January, 2009 issue of Managed Care Magazine has an article by Steven Wunker and David Duncan of Innosight, an innovative Boston consulting firm.

Entitled "Health Plans: Disrupt and Prosper," the article claims:

"if they can adapt, payers will have far more power than fragmented physicians, other providers, employers, and patients to shape the new environment."

Quoting further:

A vast expansion of EMRS, as proposed by President-elect Obama as part of the fiscal stimulus, would have profound implications on the business models of payers. Widespread use of EMR technology would enable payers to exert much more realtime power over clinical decisions, much as the National Health Service is able to conform medical practice in the United Kingdom to accepted standards to a far-greater degree than in the Unites States. Payers could adjudicate more claims at the point of care, reducing conflict with physicians. They could implement pay-for-performance criteria more effectively than at present, and they could steer patients to physicians with the best treatment records. Physician practice groups could fracture, as government support for EMR implementation and interoperability would remove a large incentive for consolidation. Payers could become powerful coordinators of care.

If taken out of context, one could interpret these words as an argument for a consolidated power play by health plans. They are not arguing this. Rather, they are arguing that plans as well must "separate out business models" and pursue a disruptive process to "disentangle" activities into distinct providers and delivery models. Similar, they argue for integrating strongly with physicians as partners. They apply the work of Clayton Christensen and others in extremely constructive ways. But it is possible to exert power through HIT without reforming the business models of either health plans or health care delivery organizations. That is the matter of concern.

There is a obvious point here: Health care technology is a necessary prerequisite for reform. But the nature of this reform, and the power distribution among consumers, providers, and intermediaries is far from resolved. HIT can create a new and very positive relationships, or it can merely embed the status quo in technology concrete. Since all sides of the debate argue that the status quo is untenable, Congress must act.

Think of the HITECH milestones as a ticking "doomsday clock." Every day with out health care reform clarity is a day closer to an outcome few desire.

Health Affairs Policy Briefing, Washington, March 10

2009-03-10T12:03:00.000-07:00

The journal Health Affairs held a briefing introducing their March issue featuring health care information technology.

The speaker agenda included:

Pioneering Initiatives

Louise Liang, Kaiser Permanente
Farzad Mostashari, New York City
James Walker, Geisinger Health System

Industry Perspectives

Peter Neupert, Microsoft Health Solutions Group
Colin Evans, Dossia Consortium
Alfred Spector, Google Inc.
Neal Patterson, Cerner Corporation

Health IT and Privacy

Deven McGRaw, Center for Democracy and Technology
Linda Dimitropoulos, RTI International (unable to attend)
Deborah Peel, Patient Privacy Rights Foundation

A Public Policy Discussion on Health IT After HITECH

Robert Kolodner, Office of the National Coordinator for Health Informaiton Technology
Mark Smith, California HealthCare Foundation
Carol Diamond, the Markle Foundation
Jon White, Agency for Healthcare Research and Quality

The meeting was well-attended. Indeed, there was overflow and for some time, people were sitting in an adjacent room staring at a blank wall waiting for the wall panel to open to the broader room.

There was consensus on decoupling data, consumer-focused medicine, and privacy. Farzad Mostashari described how implementing his system did not make life easier all of the time, often took more effort and time from practitioners, and did not always make them happy. Jim Walker gave a nice overview of how Geisinger is now working across their traditional organizational boundary and fostering medical homes among individuals who do not have strong relationships with Geisinger.

Colin Evans, when speaking of privacy, said of Washington DC that "nobody minds the answer to a question as long as you ask the wrong question." He says the right question - not answered - is how to get information to consumers. Spector from Google and Neupert from Microsoft both gave a similar perspective. Neal Patterson provoked asking why we did not have a national patient identifier and why we tolerated the financial chaos and transaction confusion of our current system. In discussions, Alfred Spector spoke in greater detail about the tension between innovation/risk-taking and the top down plan approach.

Deven McGraw said that "privacy is the enabler, not the obstacle." She cites that 1 in 6 people exhibit privacy-protecting behavior. She said that work needs to be done, including re-examination of "health care operations" and when personally identified data are really needed. She is concerned about protection for information in personal health records - particularly when they are not HIPAA covered entities. Consent is critical but not sufficient; one needs an enforceable floor of protections; she raises uses that may be absolutely prohibited (e.g., genetic non-discrimination); she raises a common concern about "downstream" use. She wants to make sure applications are somehow addressed. she did not raise the "transitive trust" raised by others.

In a talk entitled "Privacy after ARRA," Deborah Peel spoke of her background in Freudian analysis and the critical role privacy paid in the treatment of her patients. She is optimistic about the role technology can provide in assuring privacy. Her primary concern is on the impact breaches have on denying jobs, credit, insurance, education, and other opportunities. What ARRA did (Peel):

No definition of privacy
Right of consent not restored

ARRA: new Rights

Ban on sales of PHI
Segmentation (the right to segment sensitive information)
Audit trails x 3 years
Breach notice
Encryption
Right to restrict disclosure of PHR if payment and HCO are paid out of pocket
Preservation of the therapist-patient relationship

Peel argues for a "single source" for consent and significant granularity. She also plugs health record banking.

Rob Kolodner began on a humorous note by reminding the audience that in contrast to Dr. Peel, Dr. Kolodner's psychiatric training in St. Louis as a "Renardian" his approach was more data driven. (Only psychiatrists can fully appreciate this pun).

Kolodner gave an excellent overview and spoke of the four principles of the current strategic plan. He points out that Congress gives us room by not over-specifying "qualified record," "meaningful use," and other terms. He reassures that the plan will be aligned with health care reform. His goal is to realize $10 impact for every dollar spent. ARRA is about increased quality with decreased cost, in his view. There are four things that are necessary: must have an impact on standards; standards have to be sufficient but need to be able to move the entire record even if standards don't exist; need to be able to eliminate the disincentives associated with health information exchange; need to move forward with quality reporting; need to unleash innovation. Dr. Kolodner claims that resistance is from people who were in the initial wave and who aren't pleased that the wave has passed.

Mark Smith of the California Healthcare Foundation, gave a rousing sermon-like talk emphasizing three major themese:

Reimbursement. In Hawaii Kaiser visits dropped 20% but the incentives are such that such a move is OK there but would not be acceptable in fee-for-service organizations. He wants IT to "unleash us from the tyranny of the visit."
Comparative effectiveness. At present, your incentives are to get as big a grant as possible for as long as possible leaving at the end no impact on the delivery system whatsoever. We need to break out of the paradigm of "research-only data streams." A Wal-Mart spokesperson once said "we know more about a box of cereal than you know about a patient you've cared for over 10 years,"
Regulations that entrench encumbents. He said we need to address the regulations that protect the incumbents. He described Amazon and Travelocity - new organizations in the world that could not happen without enabling IT. The goal is not to wire the incumbents to do what they do more quickly. We don't want to limit our approach to wiring the incumbents (through definitions of "interoperability" and "meaningful use") and if we do this, we just "give the book store a computer" rather than bringing forth forms of service that we cannot yet imagine. He cites "OpenTable" as a model for bringing to smaller practices the capacity they need for "kaiserness."

Carol Diamond summarized the scene as follows:

The world of health IT as we know it has changed and we have to get it right; the is an unprecedented push towards accountability
Getting it right means using IT to stimulate health improvements
Rapid innovation is essential; there is a new and pressing need for new services and technologies.
There is a new demand for assessing population health and improving decisions at the care level.

Jon White gave a brief closing statement thanking the participants. He argued strongly and eloquently for sober, thoughtful and critical evaluation at every step of the way who are involved in implementation.

The Health Affairs briefing was remarkable for the common themes and for the relatively rapt attention of a rather large group. Unlike many Washington meetings, most people sat through over three hours of presentations and rarely stepped out to talk or consult their blackberries. These are the same people who have been watching and participating this scene for a long time. One gets the sense that things are changing and that everyone is somewhat in awe of the enormity of the challenges ahead. Perhaps they agree with Dr. Diamond as I do: this is an era of unprecedented opportunity and equally unprecedented accountability.

Obama's Eight Principles

2009-03-06T06:38:00.000-08:00

At this juncture, it is difficult to discern what an outcome from the March 5 White House Summit. It is difficult to find even a list of the attendees. But frequent mention of the "eight principles" warrants their listing. They are:

Protect Families’ Financial Health. Address growing costs and ensure families do not become bankrupt over health care.
Make Health Coverage Affordable. Address administrative costs, duplication, and other inefficiencies.
Aim for Universality. Provide a "clear path" that affords health care coverage for everyone.
Provide Portability of Coverage. Develop a system that does not lock individuals into specific jobs and that eliminates pre-existing condition clauses.
Guarantee Choice. Provide a choice of health plans and physicians including continuing employer-based coverage.
Invest in Prevention and Wellness. Target areas include obesity, sedentary lifestyles, and smoking. Provide guaranteed access "to proven preventive treatments."
Improve Patient Safety and Quality Care. Eliminate unnecessary variability in care; support "widespread use" in health care technology and "the development of data on the effectiveness of medical interventions to improve the quality of care delivered."
Maintain Long-Term Fiscal Sustainability. The plan must be self sustaining through lower cost increases, improving efficiency, and identification of additional funding sources.

Dear Mr President (Government Health IT) - February 2009

2009-02-28T17:23:00.000-08:00

The following is reprinted from a series in Government Health IT:

Follow this link to entire set of essays

January 26, 2009

Build Version 1.0 first
Don’t automate until you achieve a consensus on what our health care system — as a real system — should look like. If you merely automate our current ineffective and complex system, you may make it harder to effect real change. As Chicago’s Richard Daley infamously misspoke in 1968, “The police are not here to create disorder; they are here to preserve disorder.” Do not pay for systems that preserve disorder.

There are steps that can be taken now. Build on Tennessee Gov. Phil Bredesen’s admonition to build Version 1.0 first. Focus on areas where technology can reduce complexity. These include providing a secure medication history for every American in every care setting [and] providing federal Medicaid funds for health IT only for those systems that can ensure availability of information across systems through health information exchange.

Charge America’s computer scientists to rethink health IT as an informatics effort aimed at more effective knowledge management. Teach those who maintain computer systems to understand medical technology and privacy. Work with banks and other knowledgeable groups to address identity management and data security.

Remember that the architect Louis Sullivan said, “Form ever follows function.” If you foster the creation of a functional, effective, equitable health care system, good informatics will follow.

Dr. Mark Frisse
Professor of Biomedical Informatics,
Vanderbilt University

UMass NGA Report

2009-02-25T06:40:00.001-08:00

A report produced by the University of Massachusetts was released today. It is entitled "Public Governance Models for a Sustainable Health Information Exchange Industry."

Follow this link to the PDF report

Although it breaks no new ground, it summarizes at a high level three possible frameworks.

Model 1 – Government-Led Electronic HIE: Direct Government Provision of the Electronic HIE Infrastructure and Oversight of Its Use;
Model 2 – Electronic HIE Public Utility with Strong Government Oversight: Public Sector Serves an Oversight Role and Regulates Private-Sector Provision of Electronic HIE; and
Model 3 – Private-Sector-Led Electronic HIE with Government Collaboration: Government Collaborates and Advises as a Stakeholder in the Private-Sector Provision of Electronic HIE.

Governor Phil Bredesen a Member in NGA Task Force on Health Care Reform

2009-02-23T18:41:00.000-08:00

On February 23, 2009, the National Governors' Association appointed a task force to address Health Care Reform. "The Task Force is designed to identify and define gubernatorial priorities and to inform and advise the work of Congress and the Administration."

Follow this link for the press release

Members of the Task Force include:

NGA Vice Chair Vermont Gov. Jim Douglas, co-chair
Michigan Gov. Jennifer M. Granholm, co-chair
NGA Chair Pennsylvania Gov. Edward G. Rendell
Connecticut Gov. M. Jodi Rell
Georgia Gov. Sonny Perdue
Kansas Gov. Kathleen Sebelius
Massachusetts Gov. Deval Patrick
Minnesota Gov. Tim Pawlenty
North Dakota Gov. John Hoeven
Tennessee Gov. Phil Bredesen
Utah Gov. Jon Huntsman, Jr.
Washington Gov. Chris O. Gregoire

Visualizing the Stimulus Bill - the Hive Group

2009-02-20T14:16:00.001-08:00

During an informal talk, Rob Kolodner showed an interesting graphic developed by the Hive Group to visualize the ARRA. It's worth a look.

http://www.hivegroup.com/stimulus/

Rob tells me it is his brilliant son, Ben, at the U. of Maryland who brought this site to his attention. Bravo, Ben!

for some history, see:

http://www.cs.umd.edu/hcil/treemap-history/

Phil Bredesen and TennCare: Links Concerning the Medicaid Crisis

2009-02-10T04:34:00.000-08:00

Given the coverage of Governor Bredesen in the last few days, it seems valuable to provide some links that emphasize the dire state of the Medicaid program in the first part of this decade.

McKinsey & Company

Governor Phil Bredesen

Chronology

Tenncare Timeline (U of Memphis)

Opposing views

Tennessee Justice Center: TennCare summary

Bipartisan Agreement and Impact on Health IT (Saturday morning, 2-February)

2009-02-07T08:11:00.001-08:00

The bipartisan agreement announced tonight to amend the American Recovery and Reinvestment Act of 2009 will update a number of provisions in the underlying bill (S. Amendment 98 to H.R. 1).

What follows is a summary gleaned from several sources, including:

My read:

Appropriations Provisions

ONC: $3 billion. This is a $1b over the House language and a $2b reduction from the Senate language (the $18 b or so adoption incentives are presumably still within the appropriations).
AHRQ (NIH, and Secretary of HHS): $1.1 billion for comparative effectiveness research. Despite rumors to the contrary, at this juncture, I infer that the House language has been retained.
Broadband: $7 billion for the National Telecommunications and Information Administration’s (NTIA) Broadband Technology Opportunities Program for competitive grants to increase broadband access and usage in unserved and underserved areas . (Fifty percent of the funds are to be used for projects in rural areas.)
A $2 billion appropriation for broadband through the Department of Agriculture seems to have been removed.

Finance Provisions

Health Information Technology (IT) Rural Critical Access Hospitals: A cap of $1.5 million per hospital is expected to reduce expenditures by $2 billion.

Other Provisions

Public Health and Social Services Emergency Fund (prevention and wellness): These appropriations have been eliminated. (They were $3 billion in the House and $5.8 billion in the Senate).
Public Health and Social Services Emergency Fund (pandemic flu and the Biomedical Advance Research and Development Authority): These appropriations have been eliminated. (They were $900 million in the House and $850 million in the Senate).
Health Resources and Services Administration (HRSA): Appropriation of $1.87 billion for community health centers and infrastructure. Approximately $1.1 billion of House measures (not present in the Senate language) have been removed.

The Many Meanings of "Shovel-Ready"

2009-02-01T08:46:00.000-08:00

Those responsible for seeing our federal health information technology expenditures realize their full potential should be mindful of two important realities:

Culture eats strategy for lunch.
Cultural change - even positive change - cannot be accelerated through money alone.

Words mean many things. The challenge to the reader of current economic recovery legislation is not to understand the intent of specific Congressional actions but instead to understand how such intentions will be transformed into effective plans of action that make a difference. Funding for health information technology may indeed be the "best $20b you will ever spend." Or maybe not. Only time will tell.

As our Nation moves from legislation to action, one must be aware that traditional uses of the term "shovel-ready" health IT seem to fall into three loose categories:

Those projects that can be implemented with near-certain success and near-term positive economic consequences
Those projects that can be implemented, have less near-term economic consequences but create an infrastructure for greater efficiency and effectiveness (and hence positive economic consequence) for many years to come
Those projects are products that make sense and might even be proven in limited settings but whose widespread utility with additional funding is far, far, from a sure bet.

I would like to focus on a fourth interpretation of the term:

Can't "shovel ready" be used to describe activities that should be buried or at least put on hold until broader health care reform issues are sorted out?

Much has been accomplished over the past decade. There has been an important shift away from technology for its own sake and toward the use of technology to meet the needs of individuals and societies. This trend is evident as one reads of "data liquidity," personal health records, consumer portals, privacy initiatives, and and other efforts that recognize that policy - not technology - is the major challenge.

But as our sense of urgency to address our dire financial challenges has mingled with a pent-up demand for equally needed social reforms. A climate of deliberation has devolved into a circus carnival and feeding frenzy.

Writing the first draft of this posting on Super Bowl Sunday, this writer feels as if our Nation seeks to crown a Super Bowl champion not through a series of contests each involving two teams and one ball but instead by filling the stadium with eight teams, four balls, four different sets of referees, and every available fan. What on the field may seem like a noble and exciting competition makes little sense when observing from the stands. Popcorn sales will be brisk, but soon hunger will return. Passion on the fields and in the stands will in a matter of time be replaced by dissatisfaction over a lack of a clear and measurable outcome.

Increasingly, voices are being raised asking: will more money - distributed quickly be the best way to improve our economic condition, and serve as a foundation for a more effective and efficient better health care system? Or will additional funding only make things worse by:

Imposing systems that do not address fundamental structural fragmentation and complexity in our health care delivery and financing system?
Imposing information technologies that do not meet the expectations of patients or care-givers because they do not focus on outcomes or address fundamental and very complex work-flow challenges?
Imposing systems that, in their cost and complexity, hinder - and not enable - innovation in health care delivery and financing.?

Remember: complex technologies implemented poorly may impede health care reform proposals from across the political spectrum - everything from consumer-based health savings, first-dollar coverage approaches to single-payer approaches. They will use up our limited funds, breed cynicism, and arguably do little retain costs and improve care quality.

Many have posted or written to me with some surprise over the extent to which well-informed people believe that more standards, more privacy provisions, more incentives, and more certification will solve all. This may be the case, but more likely, a greater degree of focus will be all the more essential if there is more funding rather than less.

Some have argued that all only programs essential to direct economic stimulus should be immediately funded. David Brooks has said it well in speech and writing when he states that even areas in which he has passion (e.g., pre-K education) should not be part of the immediate stimulus package. In testimony before the Senate Budget Committee, Alice M. Rivlin makes the important distinction "between a short-term 'anti-recession package' (aka 'stimulus') and a more
permanent shift of resources into public investment in future growth."

There is consensus we need both. It appears funding will be allocated to both. So we must address both tasks well and with long-term consequences in mind.

So one must ask:

If we are to get out our shovels to build or to improve, aren't there some initiatives, committees, work groups, or programs that should be "buried" or placed in hibernation so that our Nation can focus on critical priorities?

This writer would suggest there are such initiatives (or parts of initiatives) and that adding more zeros to their funding will only worsen things. But this writer is often terribly wrong....

So, how should we apply our fiscal shovels?

We are ready to get to work.

State Budgets

2009-01-24T05:36:00.000-08:00

The Center on Budget and Policy Priorities updated on January 14 it's projections for state deficits. The numbers are alarming. Keynesians argue that the Federal Government must introduce capital into the economy or face dire consequences. The President in his actions seems to agree. Arguments abound on how the Federal Government can best ensure that our collective federal expenditures lead to promised results. Yet the answer lies closer to the ground. If such expenditures do not lead to economic expansion in our states and communities, they will be squandered and leave future generations with an even deeper price to pay for our failure to act with responsible consequences.

The Center's report has a table listing projected deficits for each state as well as a project deficit over then next two years. It does a good job of explaining why numbers are hard to get and differ - and an even better job at driving home the implications. The following table comes from the report. The reader is urged to consult the primary sources.

Krugman
Krugman, on December 28, 2008, said that "even as Washington tries to rescue the economy, the nation will be reeling from the actions of 50 Herbert Hoovers — state governors who are slashing spending in a time of recession, often at the expense both of their most vulnerable constituents and of the nation’s economic future." He further describes these budget reductions as ranging from "small acts of cruelty to giant acts of panic."

Coordination
An effective response to this crisis will require an unparalleled act of coordination between the Congress, the Executive, and our state and local governments. Current economic recover bills provide some heartening focus on some priorities. The trick will be to find ways of executing on these changes in a way that fosters local innovation and response while avoiding the excesses and temptations of monolithic efforts focused primarily on economic gain to the few rather than economic opportunity for the many.

Prescription Medication Histories - an Approach

2009-01-22T15:57:00.000-08:00

There has been a growing awareness of the value of a prescription drug history in every care setting. Increasingly at least one vendor (SureScripts-RxHub) is collecting such information from the majority of America's pharmacies and a growing number of PBMs. These data are both claims (from PBMs) and dispensed meds in SCRIPT format (from the SureScripts side).

If one uses a certified e-prescribing device, it is said, one will get formulary information (particularly from participating PMBs) and medication histories "for free." This makes sense. After all, despite the prevalent rhetoric on the potential of these technologies to increase the safet of presribing, benefits also accrue the PBMs (through formulary compliance, automated prior authorization, and mail order pharmacy coordination; this was a rationale for the PBM investment) and at least the large pharmacies (through lower labor costs that can be offset by reducing personnel; the latter reductions are the justification for the fees pharmacies are charged when they receive a digital prescription).

But what of all of the other clinical settings in which prescription medication histories are vital? Were I taking medications that could critically influence my care, I'd want that history available in a secure way to anyont authorized to care for me. How will this be done?

One way is simly to charge money for the transaction fee. Prices evidently range from $0.50 per transaction to $3 per transaction. Prescribers ask: "I changed my processes to help PBMs and pharmacies out; the marginal cost to provide a prescription drug history from the service is almost zero (the care facility could incur the cost of authorization and certification); so why do you charge me again for something that I've already contributed to?

At the same time we as individuals are seeking answers to these questions, each state government has developed one or more databases to house prescription drug information for regulatory purposes. The most common example is databases for controlled substances. In most instances, these databases collect batch files of separate fees from pharmacies and, with the help of a lot of often expensive technology consultants (they have to love it), develop their own ad hoc approach. 50 states - possibly 50 different proposals.

So this writer wonders if one can save the states money and serve the public at the same time by taking a more progressive and real-time approach to state needs and setting certain conditions on what the vendor meeting these needs must do in return for the public. The proposal has two parts.

ONE: The States use a uniform approach to data representation and all contract with a vendor like SureScripts-RxHub for real-time feeds.
Among the constraints:

The development of these databases would follow a national architcture and would be funded through the economic recovery legislation
The states would pay a small - and I mean small - annual per capita fee to the vendor (like SureScripts-RxHub). The cost of this fee should be less than the cost of maintaining their current infrastructureus.
The state database would only be used for authorized state purposes; the database would not be used as a "hub" for secondary distribution for clinical purposes
The states get out of the "one off" approach; that's the only way they will save significant sums
The states could also begin, informally, to converge on best practices for use of these data (i.e. narcotics databases, adherence reporting for public health

TWO: The same vendor must gurantee to provide the same feed "for free" to all certified care settings under reasonable authorization and authentication provisions.
This means:

All medication histories are made available from a point-to-point, SCRIPT standard-based "utility."
States stay out of the secondary distribution business
Everyone else more or less stays clear as well of the secondary distribution businessunless they can provide all of the prescription history service to a states' citizens
National standards would be used for "certification." I would think the ones used for e-prescribing today ought to suffice for other care settings. If the don't then perhaps our e-prescribing authentication and authorization methods are too lax

Who won't like this:

Vendors to states databases - they become less critical to software development but have opportunities by making the data more useful to their state clients
Some health plans - perhaps some plans enjoy some advantage by sitting in the middle of the transactions; but claims are the wrong way to present medication histories when dispensed data in SCRIPT format is avilalable
Vendors. Who would not want to get a dollar a transaction and see these mythical revenue forcastes disappear. But the reality, in my view, is that prescribers should not adopt the current e-prescribing approaches unless rules are simplified (e.g., formularies, prior authorization), and unless neither their patients nor their care delivery organizations are forced to pay onerous prices for something that has both been financed and which is a vital public good

Just an idea. But it would seem to this writer that such an approach would help our states do their job, contribute to a national care (e.g., NHIN) infrastructure, reduce complexity, eliminar costly intermediaries, and improve care.

Where do the jobs come from? A perspective from the Information Technology & Innovation Foundation

2009-01-17T07:51:00.001-08:00

In a January, 2009 report entitled "The Digital Road to Recovery: A Stimulus Plan to Create Jobs, Boost Productivity and Revitalize America," Robert D. Atkinson, Daniel Castro, and Steven J. Ezell of the Information Technology & Innovation Foundation estimate jobs produced for broadband, health care and the smart power grid. This report has been referenced frequently in the WSJ and elsewhere.

The Information Technology & Innovation Foundation is a non-profit whose board is composed primarily of active or former legislators as well as some academics, government liaisons (e.g., MIT), and a few major technology firms (e.g., Cisco, Microsoft, IBM).

The report claims that a $10 billion dollar stimulus in Health IT would lead to 212,105 additional jobs (see table).

According to the report, "The complete transition to EHRs for all inpatient and ambulatory care providers is estimated to cost, on average, $7.6 billion annually over 15 years. [Rand Corporation, 2005] Current spending on IT (not exclusively on EHRs) by health care providers and payers is expected to exceed $30 billion in 2008. Spending in this area is projected to grow at approximately 4.5 percent annually over the next 5 years."

According to the report, "approximately 43,400 of these jobs would come from direct spending by hospitals and health care providers on health IT systems. These jobs will come in high-paying industries such as computer hardware manufacturing (5,800), software (10,600), and IT services (27,000). Another 36,000 indirect jobs would be created from spending on intermediate inputs involved in producing hardware, software and IT services. Respending by the additional workers employed by these direct and indirect jobs would create another 79,000 jobs."

The report estimates "at least an additional 33 percent employment gain, or approximately 53,000 jobs." through a network effect. This increase is attributed to the "almost limitless possibilities of using digital health information to advance medical research, drug discovery and evaluation, and even personal health. Thus, for example, advancements in health IT will likely serve as a catalyst for the use of Web 2.0 technologies for health care including health information portals, personal health records, and health-related social networking. Websites such as WebMD and Revolution Health may develop new services for consumers that provide personalized medical information based on a patient’s health data. "

The methods used are well-documented and the limitations of estimates acknowledged.

Although the report suggests a five-year investment of $10b annually, the report is clear that the total number of jobs would equal the number in the first year but this level of total jobs would be sustained over the five-year period. Specifically, a footnote states: "The $50 billion health IT stimulus proposed would consist of a $10 billion stimulus in each of 5 years. Each $10 billion stimulus would create 212,000 jobs that would last for 1 year. Thus, the $50 billion health IT stimulus would create 212,000 jobs that would last 5 years. The $50 billion stimulus would not create 212,000 jobs each year for a total of 1,060,000 jobs."

House Economic Recovery Bill Released

2009-01-15T11:44:00.001-08:00

The House released the bill on January 15, 2009.

Some quotes from the press release:

LOWER HEALTHCARE COSTS
To save not only jobs, but money and lives, we will update and computerize our healthcare system to cut red tape, prevent medical mistakes, and help reduce healthcare costs by billions of dollars each year.

Health Information Technology: $20 billion to jumpstart efforts to computerize health records to cut costs and reduce medical errors.
Prevention and Wellness Fund: $3 billion to fight preventable chronic diseases, the leading cause of deaths in the U.S., and infectious diseases. Preventing disease rather than treating illnesses is the most effective way to reduce healthcare costs. This includes hospital infection prevention, Preventive Health and Health Services Block Grants for state and local public health departments, immunization programs, and evidence-based disease prevention.
Healthcare Effectiveness Research: $1.1 billion for Healthcare Research and Quality programs to compare the effectiveness of different medical treatments funded by Medicare, Medicaid, and SCHIP. Finding out what works best and educating patients and doctors will improve treatment and save taxpayers money.
Community Health Centers: $1.5 billion, including $500 million to increase the number of uninsured Americans who receive quality healthcare and $1 billion to renovate clinics and make health information technology improvements. More than 400 applications submitted earlier this year for new or expanded CHC sites remain unfunded.
Training Primary Care Providers: $600 million to address shortages and prepare our country for universal healthcare by training primary healthcare providers including doctors, dentists, and nurses as well as helping pay medical school expenses for students who agree to practice in underserved communities through the National Health Service Corps.
Indian Health Service Facilities: $550 million to modernize aging hospitals and health clinics and make healthcare technology upgrades to improve healthcare for underserved rural populations.

also mentioned

$6 billion also recommended for broadband "to expand.. internet access so businesses in rural and other underserved areas can link up to the global economy"

Medicaid. Medicaid Aid to States (FMAP): $87 billion to states, increasing through the end of FY 2010 the share of Medicaid costs the federal government reimburses states, with additional relief tied to rates of unemployment. This approach has been used in previous recessions to prevent cuts to health benefits for their increased low-income patient loads at a time when state revenues are declining.

Medicaid Coverage for the Unemployed: Provides 100 percent federal funding through 2010 for optional State Medicaid coverage of individuals (and their dependents) who are involuntarily unemployed and whose family income does not exceed a State-determined level, but is no higher than 200 percent of poverty, or who are receiving food stamps.

Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions

2009-01-10T13:43:00.000-08:00

On January 9, an very important report on the state of health care technology was released by the National Resource Council. Entitled "Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, this report is the product of some of the finest minds in computer science and health care informatics. Dr. William Stead from Vanderbilt was the Chair of this report. The effort involved numerous site visits, interviews, and literature reviews. It is ground-breaking work.

The pioneering work performed by the institutions visited (and the many other institutions discussed) demonstrates the many challenges ahead. Those responsible for this worked saw that even in the most advanced settings, information systems are not realizing their true potential.

Among the reports primary conclusions are (in this writer's words):

Our current approach - aimed at "information technology" rather than "informatics will not be sufficient to achieve the vision of 21st century health care. Indeed, merely automating the status quo and accelerating the current direction without more thought and change may be detrimental to the long-term well-being of our health care system.
Success will depend on our ability to place greater emphasis on cognitive support to providers, consumers, and policy makers. There is a greater need to focus on the decisions we all make and less on the transaction by-products of such decisions.

Much more will be written about this report, and it is only a start of a longer process. In addition, the report acknowledges up front that it does not address small practices, health care reimbursement and many other critical issues. But the take home point - let's focus on using the best we have available across various engineering and health disciplines and focus on the real health issues and not merely automate the myriad of transactions that are by-products of the way we think about these issues.

The report also provides principles for change. The first five principles are considered supportive of "evolutionary change" and the last four supportive of "radical change."

Principles

Focus on improvements in care - technology is secondary.
Seek incremental gain from incremental effort.
Record available data so that today’s biomedical knowledge can be used to interpret them to drive care, process improvement, and research.
Design for human and organizational factors so that social and institutional processes will not pose barriers to appropriately taking advantage of technology.
Support the cognitive functions of all caregivers, including health professionals,patients, and their families.
Architect information and work flow systems to accommodate disruptive change.
Archive data for subsequent re-interpretation, that is, in anticipation of future advances in biomedical knowledge that may change today’s interpretation of data and advances in computer science that may provide new ways extracting meaningful and useful knowledge from existing data stores.
Seek and develop technologies that identify and eliminate ineffective work processes.
Seek and develop technologies that clarify the context of data.

This is an extraordinary contribution well worth the read.

Here are some of the thoughts I had when reading this report.

The report really emphasizes a few critical themes: think, don't automate; focus on the individual; avoid monolithic projects and think in terms of incremental progress. Only late in the report does the report hone in on empowering patients and their families but to empower individuals and improve care, we must blur e boundaries and expand the focus of care from traditional care delivery settings to the home. This is particularly important for chronic disease and to meet the varying needs of the elderly – progressive, intermittent frailty cannot be optimally addressed through our current model but can be addressed through the notions you present.
Although the Institute of Medicine is often cited as a basis for safety and learning health care systems and serves as a rationale for greater investment in the current generation of information technologies, most of these technologies fall far short of the IOM’s goals.
Why are clinicians reluctant to embrace IT? This report suggests some answers. Their reluctance may be the result of a rational skepticism of the acute impact of these systems in care delivery settings. If systems do not improve efficiency or quality at the point of care, they will be used only reluctantly. If systems are not used, expenditures towards these systems will be wasted effort.
Why is the public are people not embracing these ideas? Perhaps it is because many systems do not help us think more clearly as patients. Using report-speak, the phrase "cognitive functions" is often used. In the context of the individual or family facing illness, I think “cognitive functions” can be translated as: “help individuals and their family think more clearly about critical health care decisions and to make such decisions based on information they understand and guided by values they hold.”

Automation: The current state

The report rightfully claims that many current health care IT systems are monolithic and complex. Rather than enabling small effective changes, the many interdependencies result in an “all or nothing” approach which at times garners no improvement and at other times does harm.
Information exchange is not encouraged, so the health care needs and convenience of the individual are not met and care efficiency is not realized. Failures in these contexts are spectacular and have been described for over two decades. Paul Strassmann, among others, has been writing about this for years. Also Ed Yourdon, who's book "Death March" remains a classic in my mind.
IT "automates things" whether the processes automated are efficient or unecessarily complex
IT does not distinguish between efficient, informed care and care that is inadequate, unnecessarily complex, suboptimal, or possibly harmful.
Health care systems should ensure that clinicians and patients do what is best for care – even if doing what’s best requires changes in clinical behaviors and work flows. Doing what’s best changes as further evidence is gained. If systems are rigid practitioners and individuals cannot easily change their behaviors to accommodate new and better methods of care.

The limitations of technology

Technology often lulls us into complacency. Technology can allow action without thought. Often we keep busy filling out forms, modifying fonts, and formatting.....and we forget to think! If systems are not designed to encourage thinking and focus on typing, complex interfaces, and other mechanical aspects, they may distract thinking from the central issue – improving health. Systems should help individuals and caregivers think about better ways of providing care and not create an situation supporting mindless action.
We still don't know the best way to care for one another. We never will. Improvement is a way of life, not a path with a finite end. Systems should support discovery of better methods for treatment. This is done by “mining” connected bodies of data to enable better decision-making. Information on the care of individuals can be aggregated in ways that maintain privacy and confidentiality.

Near-term directions

On the near-term, the report suggests that we focus on care improvements for the individual across a growing range of settings from hospital to home
Although it acknowledge the importance of claims (“record available data” ) other forms of data are fare more meaningful to patients and clinicians than data created for administrative and payment systems. Left to the current momentum, our health care IT infrastructure trajectory may emphasize “data” derived primarily from claims because that’s the kind of data the current power structure in health care (plans, government) has. To me that’s like the drunk who dropped his keys one night in an alley but looks for them at the corner under the lamp post because there is better lighting.

Long-term directions

On the long-term, it is important to note that the "disruption" in health care has already taken place in the social and economic sphere, and systems we invest in should be used to accommodate these new realities. There is no turning back
The only way out of this mess is to focus on the individual in the context of the present; to retain information about the individual and this context in this time in a way that allows society to improve its methods over time as needs and contexts change.
To do this, one must archive data in a way that allows for relevant re-interpretation – that means holding onto the context in which information was gathered and the intent of such systems.

Federation of American Hospitals - Booz-Allen Report

2009-01-10T13:13:00.000-08:00

On Monday, January 19, Booz-Allen and the Federation of American Hospitals sponsored a 1-hour briefing on their new report entitled "Toward Health Information Liquidity: Realization of Better, More Efficient Care from the Free Flow of Health Information." Although at first glance this report might seem to be a strong support for ongoing certification and standards efforts, it is actually quite different in that it proposes a highly focused and incremental approach to health information technology.

Follow this link to the report

The report recognizes that many things will be changing in our health care system - particularly in the arena of payment and performance - and that these changes cannot be anticipate. It further acknowledges a very real reluctance to adopt EHRs - particularly in small practices - until some of these issues are worked out. Nonetheless, there are topics that can be emphasized now. Although some progress has been made in these topics, this writer believes they have been somewhat submerged by the cacophony of use cases, standards initiatives, and NHIN projects.

A critical theme is "data liquidity." Great benefit to all is realized when health information flows faster and more freely, or becomes more “liquid.” Quoting from the report, "liquid health information can facilitate improvements in healthcare access, quality, safety, efficiency, convenience, and outcomes while opening many doors for new innovations and providing a foundation for a new standard of patient-centered, team-oriented healthcare."

The report defines two broad "accelerators" each with specific actions that can taken now. The report does not claim that nothing is being done in these areas, but instead argues that everyone should focus on these efforts and separate these very important issues from those that may be interesting but are not practical at this juncture.

The first accelerator urges a more intense focus on information flow and communication. It urges:

While adoption is ongoing, additional energy should be devoted to eliminate use of paper-based medicine in critical areas, such as prescriptions, lab results, and medical imaging. The report does not argue for mimicking inefficient systems but instead emphasizes the critical importance of making data more "liquid" and associated with the individual receiving care rather than the organization generating the data on this care.
Reforming payment to align incentives with desired outcomes and processes known to impact outcomes, including decision support and process redesign
Defining a national health information exchange and knowledge management architecture – make sure critical history data, such as pharmacy, lab, and imaging data will flow across organizational boundaries. This definition is not the same as "certifying" health information exchanges as monolithic entities but instead focusing on ensuring reliable delivery of specific data types critical to care and incorporated into a range of current and future information technology projects. These functions will require some guarantee - but as functions and not as closed products.
Accelerating a nationwide e-prescribing network with decision support at the time and place of care. The report places more emphasis on "i-prescribing" and the use of medication histories and not merely connecting various prescribers and dispensers to enhance efficiency. The goal, the report argues, should be focused on enhanced patient care.
Utilizing pharmacy, lab, and imaging histories to improve quality at the point of care and increase reliable and valid reporting for quality and safety.

The second accelerator addresses the "bold steps" required for a patient-centered health care system as a foundation for care delivery. Among the immediate recommended actions are:

Granting individuals consistent, secure, and timely access to their personal health information and the ability to communicate securely with clinicians about it
Defining professional responsibilities and good stewardship policies and practices for health information workflow – define how health information is to be received, used, enhanced or processed, and passed along to others.
Refining policies with respect to health information privacy, confidentiality, and security breaches - assure patients and clinicians that health information is transmitted securely
Creating a voluntary authentication system where individuals can choose a unique personal identifier for care purposes – facilitate secure and convenient patient and clinician access to health information – facilitate health record matching

These recommendations should not be considered a carte blanche for the current policy direction but instead represent part of a growing movement towards immediate trials across a small and highly focused set of critical care needs where the standards exist and where clear attention can make enormous contributions.

Figure out roles and identities, and provide laboratory, prescription medication, and other key test information wherever it is needed. Do it now. Follow this with a broader approach as greater alignment between outcomes and reimubursement is achieved.

Kibbe and Klepper Reboot America's Health IT Conversation Part 2: Beyond EHRs

2009-01-05T05:14:00.000-08:00

David C. Kibbe and Brian Klepper PhD continue their thought-provoking recommendations on the Health 2.0 blog.

Follow this link to the January 5 posting

In a January 5th posting entitled "Let's Reboot America's Health IT Conversation," Kibbe and Klepper state their belief " that most health care professionals are acutely aware that more health IT alone cannot resolve these problems. Despite billions of dollars in health IT investments by health care professionals and organizations, the gap between the health care we believe possible and the current system is widening. persists and is widening."

Kibbe and Klepper argue that we don't need simply more health health IT; instead, we need an array of specific health IT functions and capabilities that can facilitate better care at lower cost, and the adherence to evidence-based rules.

Here are some of the characteristics they ascribe to empowering health IT products:

These systems would focus on Decision Support

New new health IT would help patients, clinicians, managers and purchasers make the best possible clinical and administrative decisions. They would provide guidance with evidence-based approaches that can best mitigate health risks, create alerts and reminders, or help monitor adherence to care plans,.

These systems would untether patients with easily accessible personal health information

These systems would improve care by making summary personal health information available to providers and patients, increasingly independent of location and time.

These systems would empower patients through online linkages to clinicians, other care providers, and other patients

Particularly in the management of chronic illness, these systems would link patients with clinicians, will match problems with the most appropriate solutions, and will use social networking to increase access to patient- and condition-specific information, knowledge, and guidance.

These systems would support participatory medicine, enabling the Medical Home and web-based care

These systems would make data and accountability the routine by-product of the use of health IT

Health IT can help make all health care professionals and organizations - physicians, hospitals, other providers, health plans, drug firms, device firms - more accountable stewards for quality, safety and cost results, and for the engineering required for continuous improvement. Data aggregation and analysis systems would be central to the design of health car information systems and not an afterthought. Incentives would play a significant role here.

These systems would remove the complexity and cost associated with multi-payer claims administration

Kibbe and Klepper envision an all-payer clearinghouse for patient administrative and financial information that is standards- and web-based. As they write, "there also is no good reason why, in the era of PayPal, physicians and hospitals experience Days in Accounts Receivable of 36 and 55, respectively."

These systems would close the collaboration gap

These systems would bridge the gap between the various fragmented delivery and payment systems. As they write, "Clinicians, for example, diagnose disease and set up treatment plans but often are isolated from helping patients cope, manage, or adhere to these plans. Patients, once diagnosed, are motivated to manage their illnesses but often have few tools or methods to assist them. Purchasers and payers want to see clinicians use the most efficacious resources, but typically do not have a way to inform and reward evidence-based purchasing processes. In every case, health IT can facilitate a more collaborative experience that is tailored to the user's purpose, no matter what role that user plays in vast health care space."

The Health 2.0 blog has some of the most insightful perspectives on not just technology but our approach to informatics. Always worth a read. Bravo.

Krugman on the role of state government

2008-12-30T07:39:00.001-08:00

A December 29, 2008 op-ed piece by the Nobel Laureate Paul Krugman drives home the dilemma to state government. Entitled "Fifty Herbert Hoovers," the article points out that a drastic contraction in state government spending will essentially neutralize stimulus provided by the federal government. (These budget reductions are often required for budget neutrality provisions included in some state constitutions; unlike the federal government, states cannot change the money supply by printing more and their only other recourse - bonds or taxes - are either unrealistic or self-defeating economically and politically)

Follow this link to Krugman's article (subscription may be required)

It is for this reason that the federal stimulus package may focus on states both as a conduit for funding and as instruments for coordinated action. (And I would add there are more than 50 "Hoovers" - let's not forget Puerto Rico and the cascading calamity in county and city government.)

Returning to Krugman, here are a few wonderful quotes:

No modern American president would repeat the fiscal mistake of 1932, in which the federal government tried to balance its budget in the face of a severe recession. The Obama administration will put deficit concerns on hold while it fights the economic crisis.

But even as Washington tries to rescue the economy, the nation will be reeling from the actions of 50 Herbert Hoovers — state governors who are slashing spending in a time of recession, often at the expense both of their most vulnerable constituents and of the nation’s economic future.

.....

Ted Strickland, the governor of Ohio, is pushing for federal aid to the states on three fronts: help for the neediest, in the form of funding for food stamps and Medicaid; federal funding of state- and local-level infrastructure projects; and federal aid to education. That sounds right — and if the numbers Mr. Strickland proposes are huge, so is the crisis.

And once the crisis is behind us, we should rethink the way we pay for key public services.

Krugman goes on to ask whether or not in the long-term health care, education, and infrastructure should be held captive by the ebb and tide of state financing. It seems to this writer that the federal contributions to Medicaid in particular argue for a stronger common basis for these programs across all states and territories. It's already a reality and proposed increases in FMAP make it only more so.

Acting CBO Director's Posting on the CBO Health Care Reports

2008-12-28T15:07:00.001-08:00

On December, 18, 2008, Acting Congressional Budget Office Director Robert A. Sunshine summarized the two CBO reports on health care.

Follow this link to the Acting Director's December Blog Listings

Commenting on the report entitled "Key Issues in Analyzing Major Health Insurance Proposals," Sunshine noted that there is no clear way out. Clearly, greater cost control and alignment of incentives are critical factors. IT is not a major cost-saving measure, according to CBO. The Acting Director's comments included the following (quoted verbatim as accessed December 27, 2008):

The rising costs of health care and health insurance pose a serious threat to the future fiscal condition of the United States. Under current policies, CBO projects that federal spending on Medicare and Medicaid will rise from about 4 percent of gross domestic product (GDP) in 2009 to nearly 6 percent in 2019 and 12 percent by 2050. Most of that increase will result from rising per capita costs, rather than from the aging of the population.

Without changes in policy, a substantial number of nonelderly people (those younger than 65) are likely to be without health insurance. CBO estimates that the average number of nonelderly people who are uninsured will rise from at least 45 million in 2009 to about 54 million in 2019.

Those problems cannot be solved without making major changes in the financing or provision of health insurance and health care. In considering such changes, policymakers face difficult trade-offs between the objectives of expanding insurance coverage and controlling both federal spending and total costs for health care.

By themselves, premium subsidies or mandates to obtain health insurance would not achieve universal coverage. Proposals could, however, achieve near-universal coverage using a combination of approaches. One option, for example, would be to establish an enforceable mandate for individuals to obtain insurance and provide subsidies for lower-income households to help them pay their required premiums. Another option, under a voluntary system, would be to provide subsidies that cover a very large share of the expected costs of insurance for every enrollee and establish a process to facilitate enrollment (as is done in Medicare). Other policies could achieve substantial reductions in the number of people who are uninsured at a lower budgetary cost.

Serious concerns exist about the efficiency of the health care system, but no simple solutions are available to reduce the level or control the growth of health care costs. Steps to restructure the insurance market and to encourage people to purchase less extensive coverage could reduce the use of treatments that provide minimal benefits, but enrollees would face higher cost sharing or tighter management of their care.

Other approaches—such as the wider adoption of health information technology or greater use of preventive medical care—could improve people’s health but would probably generate either modest reductions in the overall costs of health care or increases in such spending within a 10-year budgetary window.

In many cases, the current health care system does not give doctors, hospitals, and other providers of health care incentives to control costs. Significantly reducing the level or slowing the growth of health care spending would require substantial changes in those incentives.

State of the USA: 20 Key Health Indicators

2008-12-23T08:44:00.000-08:00

A nonprofit, nonpartisan group - State of the USA - and the Institute of Medicine released a list of measurements determined by experts to be key indicators of the nation's health and health care. The list was commissioned by the State of the USA and created from publicly available health indicators by an IOM committee. The resulting 20 metrics are considered a "manageable set" crucial for understanding the state of the nation's health.

The metrics are organized into three categories – health outcomes, health-related behaviors and health systems. The metrics summary is quoted below:

Health Outcomes (Category 1)

Life Expectancy at Birth: "The committee believes that the number of years that a newborn is expected to live if current mortality rates apply is an important indicator both of the health of the nation overall and as a means of identifying disparities among populations within the United States," according to the report.
Infant Mortality: Deaths of infants aged under one year per 1,000 live births "is used as an indicator of the level of child health and overall development and is often used to identify disparities among populations within a specific country."
Life Expectancy at Age 65: "The number of years of life remaining to a person at age 65 if current mortality rates continue to apply is an important indicator of the health of a growing segment of the U.S. population," said the committee. The measure "can be used as a general indicator of the overall health of those over 65, as well as the quality of, and access to, health care services among the elderly."
Injury–Related Mortality: "Age-adjusted mortality rates due to intentional or unintentional injuries" includes deaths due to motor vehicle traffic, poisoning, firearms and falls. In 2004, they were responsible for seven percent of all deaths in the United States, 1.9 million hospitalizations and 32 million initial visits to emergency departments, the committee reported.
Self-Reported Health Status: The percentage of adults reporting fair or poor health is "an important indicator of the health and productivity of a population and a good predictor of morbidity and mortality, as well as health-care seeking activity because people usually seek care only when they feel ill."
Unhealthy Days, Physical and Mental: The committee found that one's "mean number of physically or mentally unhealthy days in the past 30 days" is a valid measure for perceived physical and mental health. In addition, as with self-reported health status, it is "predictive of morbidity, mortality and health-care seeking behavior."
Chronic Disease Prevalence: The committee was unable to find a single indicator reflecting the burden chronic disease places on the American population, so it chose to select specific common chronic diseases using the following criteria: "the disease is associated with substantial morbidity or mortality; quality data are readily available; international comparisons are possible; and the disease is cited in national and international documents." It concluded that "the percentage of adults reporting one or more of six chronic diseases (diabetes, cardiovascular disease, chronic obstructive pulmonary disease [chronic bronchitis and emphysema], asthma, cancer and arthritis)" should be used as a key indicator to track health and health care for the U.S. population.
Serious Psychological Distress: The panel's chosen measure is "percentage of adults with serious psychological distress as indicated by a score of 13 or more on the K6 scale." The K6 scale is a screening tool used by health professionals to identify cases of serious mental illness.

Health-Related Behaviors (Category 2)

Smoking: The recommended indicator is the percentage of adults who have smoked more than 100 cigarettes in their lifetime and who currently smoke some days or every day. "Smoking is a leading cause of death and disability in the United States and is an important modifiable risk factor," the panel wrote.
Physical Activity: "Regular physical activity is an important contributor to health, and yet fewer than 50 percent of people in the U.S. report engaging in moderate physical activity," the committee said. It's proposed measure: the percentage of adults meeting the recommendation for moderate physical activity – at least five days a week for 30 minutes a day of moderate-intensity activity or at least three days a week for 20 minutes a day of vigorous-intensity activity.
Excessive Drinking: Citing excessive alcohol use as the nation's third leading behavior-related cause of death, the committee recommended including the following measure on the State of the USA Web site: Percentage of adults consuming four (women) or five (men) or more drinks on one occasion and/or consuming more than an average of one (women) or two (men) drinks per day during the past 30 days.
Nutrition: Given the relationship of diet to health, the panel recommended tracking "the percentage of adults with a good diet as indicated by a score of 80 or more on the Healthy Eating Index." Created at the Department of Agriculture in 1995, the index measures how well American diets conform to federal dietary guidance.
Obesity: Calling obesity "one of today's most pressing public health issues," the committee called for tracking the percentage of adults reporting a Body Mass Index (a measure of height compared to weight) of 30 or more.
Condom Use: Noting that risk behaviors for sexually transmitted diseases are prevalent among sexually active youth and that, by age 19, seven out of 10 teens have engaged in sexual intercourse, the committee recommended as a key indicator "the proportion of youth in grades 9–12 who are sexually active and who do not use condoms, placing them at risk for sexually transmitted infections."

Health Systems (Category 3)

Health Care Expenditures: The panel recommended tracking per capita health care spending, a measure used for understanding expenditures over time within the U.S. and one of the most widely used measures for comparisons with other countries.
Insurance Coverage: Percentage of adults without health coverage via insurance or entitlement is considered a key measure because lack of coverage is "a well-established determinant of access to care and is responsible for about 18,000 unnecessary deaths in the United States each year," according to the report.
Unmet Medical, Dental, and Prescription Drug Needs: Problems with access to health care, including lack of insurance and limited availability of providers, can be tracked by the "percentage of (non-institutionalized) people who did not receive or delayed receiving needed medical services, dental services, or prescription drugs during the previous year," according to the recommendation.
Preventive Services: The panel suggested the percentage of adults who are up to date with age-appropriate screening services and flu vaccination as an indicator of prevention.
Preventable Hospitalizations: The hospitalization rate for ambulatory care-sensitive conditions should be tracked as an indicator of health care quality and the effectiveness of public health strategies, the report said. "Ambulatory-care sensitive conditions are those for which hospitalization can be avoided if good outpatient care or early intervention to prevent complications is provided."
Childhood Immunization: "High rates of childhood immunization are important to protect not only individual children, but also [to prevent] outbreaks of disease among communities," the committee wrote. As a measure, the group recommended the "percentage of children aged 19–35 months who are up to date with recommended immunizations."

Long-Term Care in New York State

2008-12-15T05:23:00.000-08:00

Over the Spring and Summer, my colleagues and I at the Vanderbilt Center for Better Health had the opportunity to work with a remarkable coalition of individuals and organizations seeking to address one of our Nation's most pressing problems - progressive intermittent frailty.

Our workshop Web site has recently been made public as has the report written by the organizing group, my associates, and me. Since our August workshop, much has changed in New York, but the report, we believe, still rings true. Although the New York region faces greater financial challenges, the rising crisis of our demographics becomes only more acute.

A convergence of altruism and self-interest

2008-12-14T07:32:00.000-08:00

These are strange times. There is growing talk of dramatic changes to our health care financing system in response to the economic crisis and renewed commitment to developing a robust national infrastructure, broadly defined. Yet large health care delivery systems - at least middle managers within these systems - follow a well-worn logical local strategy that may worsen their prospects in any reconstituted health care system. Specifically, while at the Federal level there is a Keynesian belief that increased investments will yield transformation, many health delivery organizations are taking the more traditional short-term view and arguing that they cannot invest in new approaches to patient-focused care because they don't have the money to do so in these difficult times. It's a bit like claiming that when one's car is almost out of gas, one doesn't want to pull off the highway to fill the tank because the side-trip will use gas.

Let's be more clear. There is a growing consensus on several factors:

Health information should be "patient-centric" so that information is available to support the care of the individual wherever required in a way that ensures their confidentiality and empowers their ability to use information.
Health care delivery organizations - hospitals, practices, intermediaries - should not compete over possession of data. This comes at the expense of both improved patient care and a badly needed step towards a more effective health care system.
Health information that is in paper form today must be made available in digital form under security and use provisions that ensure individual and public confidence.

But I continue to hear organizations with extraordinary cash flows and assets argue that in this time of financing crisis, they cannot afford the relatively small investments required to collaborate. In so doing, they abrogate to health plans and intermediaries any opportunity to participate in a patient-focused health care information market. Maybe that's what they want.

This is a strategy that General Motors would relate to. Quoting from Tom Friedman in the NY Times:

"As I think about our bailing out Detroit, I can't help but reflect on what, in my view, is the most important rule of business in today's integrated and digitized global market, where knowledge and innovation tools are so widely distributed. It's this:

Whatever can be done, will be done. The only question is will it be done by you or to you.

Just don't think it won't be done. If you have an idea in Detroit or Tennessee, promise me that you‚ll pursue it, because someone in Denmark or Tel Aviv will do so a second later."

Thomas Friedman, Op-Ed Columnist
While Detroit Slept (December 9, 2008)

http://www.nytimes.com/2008/12/10/opinion/10friedman.html

Parker Palmer helps us understand what is going on. In a recent essay entitled "Repossessing virtue: Economic crisis, morality, and meaning: Trusting our Deeper Knowing: On Cataclysms, Contemplation, and Circles of Trust," Palmer says that if we look inside our spirit, we know full well what has happened and what will come. He speaks of broad economic terror but his logic seems to me to reflect the intuitions of both those in need of care and those who provide care.
Quoting Palmer:

"Alexis de Tocqueville, the nineteenth century French scholar famous for Democracy in America, wrote a less well-known book titled The Old Regime and the Revolution, arguing that the French Revolution happened long before it happened. The eruption that shattered French society at the end of the eighteenth century was the result of small seismic shifts that had been accumulating for decades deep underground. If people had paid attention to the tectonic instabilities caused by greed and injustice, and had responded wisely to the nervous needles on their inner seismographs, the "Reign of Terror" might have been avoided.

A parallel point can be made about the economic terrors that now engulf America: at some level, most of us knew they were coming. Who doesn't know that a society in which the rich get richer while the poor get poorer is a society that will someday have to pay the piper? Who doesn't know that when a relatively small fraction of the world's population uses its power to command and consume a disproportionately large fraction of the world's resources, the chickens will come home to roost? Who doesn't know that an economic system that encourages us to live beyond our means and refuses to regulate greed is one in which our avarice will come back to bite us? Who doesn't know that at every level of life, from personal to global to cosmic, what goes around comes around?"

What goes around, comes around. Failure to create a health care system focused around the long-term care of the individual and focusing instead on short-term return for the hours, days, or years during which an individual does business with you leads to risky transitions in care, financial inefficiencies, consumer confusion, and the perpetuation of markets that compete over almost everything but the quality of care and impact on public health. We know this to be the case, but many in positions of power seem unable to pursue a new and very obvious course that will improve their ledgers and in their public perception. It's not about short-term cash flow, it's about long-term public trust and the importance public trust in envisioning a more effective health care delivery and financing system.

As my daughters would say, Duhhhh...

CCHIT Expansion

2008-11-23T08:24:00.000-08:00

To heighten awareness of certification efforts and the need for focus on functions, I have started a "certification contraction blog." This is somewhat tongue-in-cheek, but I am concerned that more is less. Enclosed is my first posting.

It is the pervading law of all things organic and inorganic,
Of all things physical and metaphysical,
Of all things human and all things super-human,
Of all true manifestations of the head,
Of the heart, of the soul,
That the life is recognizable in its expression,
That form ever follows function. This is the law.

These things, and such others as the arrangement of elevators, for example, have to do strictly with the economics of the building, and I assume them to have been fully considered and disposed of to the satisfaction of purely utilitarian and pecuniary demands......

As I am here seeking not for an individual or special solution, but for a true normal type, the attention must be confined to those conditions that, in the main, are constant in all tall office buildings, and every mere incidental and accidental variation eliminated from the consideration, as harmful to the clearness of the main inquiry.

Louis Sullivan, 1896
Cited in Heitzman

Recently, the Department of Health and Human Services authorized and funded the Certification Commission for Health Care Information Technology "to expand its certification scope of work for ambulatory electronic health record (EHR) products to begin addressing medical specialties and specialized care settings."

Some of the points are very good ones. The original Brailer /Thompson notion of expansion was designed to provide some assurances to ambulatory care practitioners to ensure that products they purchased would meet both their expectations and those of the public. In particular, some discussion of the functionalities required by various specialty groups will be interesting, I suppose. In my own mind, I would be more comfortable if these were issues on the front burner of the professional societies who in turn led the process saying "we need health information technology offerings that can be assured to do the following things." If by "expansion" the goal is to expand the dialogue through clinical and public leadership, I'm all for it. If expansion instead is primarily a vendor-driven effort without sufficient clinical involvement, it seems contrary to the Brailer / Thompson spirit of "informing clinical practice" and "connecting clinicians."

Has CCHIT eliminated a bottleneck in EHR adoption? The evidence would suggest it has. On their site http://ehrdecisions.com/incentive-programs/ , CCHIT states (November, 2008) that the following programs have been launched since the start of the certification process for electronic health record products in 2006:

40 programs offered by government agencies, insurance plans, employer coalitions and public-private partnerships
50 programs, representing 115 hospitals, in response to federal “safe harbor” regulations on health IT donations
43,350 physicians (and other clinicians) receiving or offered financial assistance in purchasing EHR capabilities
$703.2 million in known dollar value of these incentive programs
21 state governments enacting some form of EHR adoption

Whether these incentives would have happened without a certification process is not clear, but it is very plausible to believe that the certification process for ambulatory care systems - as suggested by Brailer and Thompson in July of 2004, has made a positive difference. But the numbers remain small. EHR adoption - really functional adoption expected by the public and by the many who participate in CCHIT discussions - has not yet realized the potential many had hoped for. Similarly the case for e-prescribing.

I continue to argue that CCHIT - like any certification process - is prone to "premature certification syndrome." Some confuse the good practices we need to improve health care with specific technologies that would enable these practices. It is the blurry extension of scope that bears scrutiny. It is hard to conceive of a clinical topic where discussion about standards for health information technology is not warranted, but it is less clear that these discussions should be held under the province of a certification body.

I wrote about this on my blog in October of 2007 and expressed some concerns. There are at present working groups on the following areas:

Ambulatory EHR
Inpatient EHR
Interoperability
Security
Child health
Cardiovascular medicine
HIE
Behavioral health
Emergency department
Personal health records
Privacy and compliance
Electronic prescribing

Many of the "products" are very much evolving. HIEs and PHRs come to mind. Others are practice domain settings or applications where again there is some considerable debate as to the boundaries? One could create an infinite number of stakeholder specialties. Where are nurses? chiropractors? herbalists? rehabilitation medicine? home care? PACS?

Still, the deliberations seem, slowly, to be converging on some very good, functional approaches.

Louis Sullivan had it right. Many of the attributes working groups seem to argue about can be "disposed of to the satisfaction of purely utilitarian and pecuniary demands." They are not essential to health care technology and certainly not to health care technologies only purpose - to enable better health care in the near future.

There are common themes through these certification practices, and it is these functions - not specific products that we should think more about. And even here we should perhaps follow a different order:

To what extent do we need a clearer agreement on what it is our health care system is supposed to do for us? For example, medication adherence still seems to me to be one of the most pressing health issues. What if any functions need to be certified within ambulatory care settings and other technology platforms to ensure that we do this well?
To what extent do our choices lock us into practices, terminologies, or representations that may evolve rapidly in the years ahead. Do we specify ICD-9, ICD-10?
What functions or properties of any patient-focused health information system are essential to the public trust and utility raised by the Brailer Thompson report of 2004?
What functions or properties are not within these criteria and may be "disposed of to the satisfaction of purely utilitarian and pecuniary demands"?

So perhaps we:

We identify core functions everyone agrees on (like about 12 of the NHIN services)
We identify the properties we must insist any function with this label adheres to
We have clear, simple, and unambiguous auditing mechanisms to test these assertions.
We then allow the market to call their products whatever they want "PHR, HIE, whoozit, watchimagimme" and simply assert which of these properties they have

So we ought to look at functions - along (surprise, surprise) some of the NHIN core services described by Wes Rischel (now a member of the CCHIT board). If we looked at these core services and learned how to get these assurances right, we'd have something. They include authorization, authentication, audits, data integrity, record merging, standards represenation,and related other prospects.

Indeed, the PHR working group - and I oppose certifying PHRs since I don't think we yet know what they are - in fact seems to be certifying functions that these systems - and hopefully other systems should have. This move towards functionality and away from product specification seems like an important, logical, intermediate step. They seem to be doing the right things and posting their findings publicly at: http://phrdecisions.com/

But there is a trap. Lee Castonguay, in a Q&A, asked how one can avoid confusing the public since Microsoft allegedly claimed its product is not a PHR. The answer is, well, complex, and worthy of study by foreign diplomats and negotiators.

"The Advisory Task Force and the PHR Work Group are working hard to have certification accommodate all the various models for delivering personal health information to consumers, but be simple enough not to confuse the public. It is possible that there may be several ‘flavors’ of PHR certification. Some examples could include linked PHRs, independent PHRs or perhaps even PHR platforms. But again, the more we try to differentiate, the more potential for complexity and confusion. Perhaps the best thing is to determine which distinctions are absolutely imperative to make and then keep it as straightforward as possible."

Rather than focus on attributes, we focus on flavors? But the answer in the end - listen to Louis Sullivan.

Think Big? Think Small?

2008-11-17T09:15:00.000-08:00

The New York Times recently posted two contrasting positions from Ezekiel Emanuel (National Institutes of Health) and Stewart Butler (Heritage Foundation). Emanuel's position is entited "Think Big" while Butler's is entitled "Think Small." The articles are a wonderful, cross-referenced exposition of this critical issue. Both resonate

Emanuel
First, Emanuel's major points:

Think big. "In health care, big plans are necessary not only to motivate people but as a matter of sound policy." It's about a system of care, or, as he says "reform must include changing the delivery system and how we pay for care. "
Health policy is fiscal policy. "Forget Social Security or defense, health care costs are the long-term driving force in federal and state budgets." He points out that Orzag and rumored candidates for new positions (Summers, Cooper, and Furman are mentioned) all get health care. (Certainly this fan of Jim Cooper's believes he does like few others).
Comprehensive care is cheaper care. "One of the secrets of health care reform that has not yet sunk in, is that bigger changes to the system actually cost less. " Emanuel references a previous blog posting about a Lewin Group Analysis.
Institutionalize tinkering. Arguing that no plan is perfect, Emanuel believes that "good reform will make addressing these issues easy by not requiring major legislation for each adjustment."
Everything is connected. He is persuasive, arguing that "health care is so big — $1 out of every $6 in the economy, dwarfing automobiles and all other economic segments. Everything is affected by health policy, and every decision should be examined for its impact on health care reform." It works both ways, every issue affects health care and health care policies affect every other issue. He identifies this relationship through example "Similarly, every favor to a constituency should be linked to support for the health care reform agenda. If the automakers want a bail out, then they and their suppliers have to agree to support and lobby for the administration’s health care reform effort."

See also a link on his plan at: http://www.reformplans.com/ReformPlans-Blog/Ezekiel-Emanuel-health-care-reform-Obama.html

Butler
Butler's pragmatic advice is equally pursuasive. He makes four points:

Make a strong commitment to bipartisanship. Citing bipartisan proposals and state-led initiatives, Butler urgest the President-elect to "tell the more triumphalist liberal supporters on Capitol Hill to chill, and that he’s looking for common ground."
Find better ways to use the money we are currently spending on health. He state that "rather than throwing tens of billions in new money at the health industry in an effort to expand coverage." and emphasizes on the critical need to reallocate the $200 billion tax expenditure on the tax exclusion. The Baucus proposal, released in white paper form last week "opens the door" to this possibility.
Allow states flexibility to redesign existing health programs and use money more efficiently to reach the goal of maximizing affordable coverage. This was covered in one of his previous posts entitled "States are Good Guinea Pigs."
Remember that Americans are very conservative about their health care. Given the President-elects own appeal to this conservative instinct when discussing Senator McCain's phase-out of the employer deduction, it would seem that this awareness is embedded. At the same time, we have a President-elect who often stated that he spent the last year of his mother's life contesting plan exclusions and other bureacratic issues. Perhaps our new President will be the first to have first-hand experience with the difficulties under our current system.

Both of these remarkable thinkers make sound points. Is there a chance to pursue both? Can Medicare be extended and stretch while at the same time allowing some experimentation and differentiation in the states? Is such differentiation even possible given the (as of this date) projected net decreases in State expenditures this year of over $66 billion?

What We Need to Learn from the "Old" Automotive Industry

2008-11-13T07:01:00.001-08:00

As I write this, the "old" automotive industry - GM, Ford, and Chrysler (most notably GM) - dominates the headlines. They are out of money, we are told. They need loans to innovate. Millions of jobs are at stake. Something must be done.

This is not news. I remember the gas lines of the Carter administration. The first car my wife and I bought was a Dodge Omni Miser introduced as part of Lee Iacocca's government-led Chrylser "bail out" and purchased in by us 1981. It had a four-cylinder engine, a heater, a stick shift, and that was about it. No radio of any kind. It was a great car.

Yet over the ensuing decades, little in the "old" automotive industry seemed to change. Rather than improve mileage significantly, a coalition of manufacturers, unions, and image managers kept us focused on immediate gratification. But in the ensuing decades, an entirely different "new automotive industry" emerged funded largely by foreign producers who created factories and jobs primarily in the "right to work" states. While the "old industry" encumbered greater legacy costs from generous benefits, and aging workforce, and products appealing to those who did not consider energy costs, the "new" automotive industry developed a younger, healthier workforce, products often (but not always) focused on greater economy, and more flexible manufacturing methods. The point is not to compare the "old" and "new" but to recognize that there are two distinct automotive industries in our country and that one is doing better than the other.

Far wiser people have made recommendations, but there are several common themes:

The "old" manufacturers seem to have forgotten they are in the transportation business and not just the automobile business. (This case has been made recently by Robert Goodman who in turn cited a 1972 Stewart Udall article in the Atlantic Monthly).
The "old" manufacturers are not making sufficient quantities of the kind of products people need for transportation
The "old manufacturers are not making products that are affordable to the people who need them
The "old" manufacturers are not addressing thorny problems of workforce equity. These range from exorbitant salaries for their senior leaders, generous benefits packages that for decades place few responsibilities on beneficiaries, and inadequate benefits for the many mechanics and service workforce essential for their industry but employed by dealers, garages, and suppliers.
Advocates for the "old" manufacturers are having trouble breaking free of the very bonds with industry, unions, and selfish public expectation that got us into this mess.

There seem to be parallels between my experience with my automobiles and my experience in the health care system. While I waited for gasoline in the 1970s, I watched the "cost-plus" health care financing methods and saw the inequities even then between those who had access and those who did not. After buying my Omni Miser, I saw the first glimpse of accountability through TEFRA and other health care financing changes. And then, like the auto industry, I saw things stall out. I saw an increased focus on profits, I saw more unnecessary complexity, and I saw organizations competing over the wrong issues at the expense of the long term social and economic good.

Perhaps we can learn from the various "bail-out" proposals for our automotive industry? To what extent do we finance the status quo. (Interesting that one of America's larges corporations is asking for federal financing to "innovate." As Thomas Friedman asks "If we give you another $25 billion, will you also do accounting?"

Aren't there parallels?

Do the organizations that deliver, manage and finance care understand that they are in the health care business and that this business is a system of care focused on the individual?
Are these organizations enabling us to experience the degree of health we need?
Are these organizations delivering these services in a way that is affordable?
Is compensation and workforce development aligned with incentives to improve or is it designed primarily to enrichen the few at the top?

We are in the middle of a rich debate. Should GM be allowed to drift into bankruptcy? Should they be allowed simply to get additional funding from us? Should support be tied with strings managed by our federal government? Should we learn from the "new" automotive industry as we examine what went wrong? Should we look at the automotive industry in the context of the broader transportation crises in our country? A country where railroads are crumbling, bus transportation is second-rate, and mass transportation of other types is virtually non-existent?

I believe we need a transportation policy. Without a clear view of transportation as a whole, an infusion of money will not address a problem that has been apparent for decades. Similarly, I believe we need a health care policy that places the plight of our providers in the context of a populace that is increasingly undermedicated, uninsured, and prone to unhealthy life styles.

Neither the automotive crisis nor our health care crises can be solved by money alone. Neither can be improved overnight. But in each case, a clear understanding of purpose, a focus on what we really need, a renewed commitment to affordability, and a recognition of the workforce seem to be good places to start.

As a country, we are now in the "bail out" business. We must focus on the price we must pay, but even more important, we should focus on fixing the fundamentals. This will not be easy.

A December update: Take a look at Tom Friedman's December 9th New York Times Op-Ed piece entitled "While Detroit Slept" and describing a new approach to the "mobility business." Makes you think...

Unsolicited Advice for the President-elect

2008-11-04T09:11:00.001-08:00

As I write this, Americans are still voting in one of the most polarizing and critical elections in modern history. Although our preferences for presidents and other elected officials may differ, we Americans face a common reality, and it is this reality, I believe that must be the cornerstone of the inevitable re-evaluation that comes with an election of this significance.

Here are a few principles I would recommend to the new Administration.

Stop the hype
It is perhaps disingenuous to call for a cessation of exaggerated claims after one of the most acrimonious and expensive campaigns in history, but recipients of the many email press releases and announcements of HIT "accomplishments" are no strangers to the very real disconnect between what people say they are doing and what really works. Debate must be moved forward by a realistic assessment of our past accomplishments, not by exaggerated claims made by vendors, agencies, delivery organizations, and even the HIT "Illuminati." Let's build our delivery system on the basis of what we know can work rather than on what we hope will happen.

Never advance health information technology for its own sake.
Translated. Fix the health care system first, then draft health IT legislation. Information technology is a way to enable processes and realize goals. As Carol Diamond and Clay Shirkey recently wrote in Health Affairs: "If you computerize an inefficient system, you will simply make it inefficient, faster."

Acknowledge scarcity
There is little money for HIT at the federal, state, local, organizational, or individual level. We must do more with less. Demand for health outstrips supply. Priorities must be set. Every effort must be directed towards avoiding a catastrophic recession.

View health care as a central component of our economic infrastructure, not as a service.
Health care - like education and public safety - is essential for economic prosperity. We invest in schools and teachers to help create an educated populace; we invest in law enforcement to ensure the safety necessary for public prosperity. We invest in health to ensure that our citizens are not limited unduly through avoidable illnesses or inadequate treatment. Health care is about the individual! If we start with the goal of a healthier individual, we will realize healthier families and communities and, in the process refine our health care system to assure the achievement of these central aims. We would put an end to delivery silos that do not make sense and would move naturally toward a system where knowledge, coordination of care, self-sufficiency, and evidence dominate.

Build on what works
A lot of good ideas have been advanced over the past eight years (and some rather flawed ones). It is critical to build on the ideas that are gaining momentum and where additional effort can align these efforts with near-term outcomes. These would include ongoing efforts to achieve price and quality transparency, a growing consensus on the problems with our current privacy infrastructure, and our emphasis on prescription medications. Each of these efforts need a lot more work than press releases would imply. But they are important and positive legacies.

Give providers a stable mechanism for payment
If providers have a reasonably reliable forecast of what they are to be paid to do, and if these forecasts treat everyone more or less the same (i.e. fewer networks, differences in payment, coverage for everyone), I have every faith that providers will invest their own funds on systems that work to achieve their aims more efficiently. Right now, we ask providers to invest heavily in EHRs that often cannot realize their potential because communication with labs, pharmacies, and other care providers is not optimized, because critical workflow issues have not been resolved, or because they cannot support ongoing expenses to accommodate an ever-changing payment system growing in complexity. is not available or because

Develop the health care workforce
The aging population will create unparalleled demand for a flexible workforce capable of meeting growing needs. At the delivery level, we do not have sufficient home health aids, nurses, nurse aides, and other care workers required to meet the demand. In many cases, these very care providers are not able to pay for health care coverage for themselves or their families. At the administrative level, cut-backs and early retirements in government threaten to eliminate critical organizational memory at the very time where we must work even harder to simplify program administration and advance coordination. A commitment to a workforce must be a top priority.

Kill all unnecessary complexity
Complexity without measurable value is arguably the most immediate target for change. Every unnecessary administrative step saps our health care system of dollars that could be spent on care. Clinicians are told repeatedly they must standardized care based on best available evidence. I agree. But should not intermediaries do the same thing? If so, will we continue to see the hundreds of different formularies, prior authorization rules, network negotiations, and other administrative nuances that make every plan different than another? Progress is being made here, but there is still much work to be done, and the message must be made loud and clear that best practices will drive both the administration and payment of care as well as care delivery itself.

Incorporate health care services training into our educational system
At the community college level, teach the next generation of computer technicians what HIPAA means and what the differences are between servicing a convenience shop computer and servicing a system in a health care setting
At the work force level, create more programs that produce flexible health care workers who pursue lifelong learning and who are adept at both the humanism and technologies required to provide care for our aging society

Focus on functions, not products
There has been a tendency to objectify nascent efforts instead of viewing these efforts as unique and evolving combinations of specific components and discrete services. When we speak RHIOs, PHRs, and even EHRs we are really talking about combinations of services like medication histories, clinician notes, laboratory values, and alerts alerts. These in turn rely on core principles like data integrity, auditing, non-repudiation, authentication, and authorization. Principles should guide the use of specific services and efforts must be made to encourage secure "data liquidity" to ensure the right information is made available at the right time. By focusing on these services rather than on products, we advance the public trust without immobilizing innovation in the bureaucratic morass or product certification or accreditation.

Simplify NHIN
If there is to be an NHIN, there are about 12 core services that I believe should gain top priority. My priorities are to be found on my blog and has been discussed in a trade press article.

Conclusions
Enormous amounts of effort have been expended over the past eight years to create a more effective health care system. But somehow, things have gone awry. I often make the analogy to a soccer game. Health care is like a soccer game with 10 teams and 14 balls. Everyone is running around kicking, but since there appear to be no rules or order, the "game" is mere exercise. It makes no sense beyond that. The efforts of these countless hours and many projects have contributed to the collective wisdom. We now must be honest with ourselves and ask:

what is the primary problem we want to solve? (I'd claim it is a healthier society)
what preconditions are required to ensure that technologies can make a difference?
what have we done that gets us closer to a solution?
what have we done that has only worsened the "problem" and distracted us from our goals?

I think it is time to take a deep breath and think very hard about what it is we want to accomplish; then ask ourselves how we can help; then re-visit our principles and revise our policies; and only then, start programs and legislation to ensure we get what we now know we need.

And more than anything else, we should - individually and collectively - promise each other that if we are doing things that do not help, we will cease our efforts in these directions and turn towards more positive things.

Is it Time for Comprehensive Health Reform? Revisiting Fuchs and Emanuel

2008-11-02T16:18:00.000-08:00

reprinted from an October 2008 posting at markfrisse.com

In November of 2005 Victor Fuchs and Ezekiel J. Emanuel published an article in the Journal Health Affairs entitled "Health Care Reform: Why? What? When?

Follow this link for the abstract and full text (subscription may be required)

This article has been on my mind of late as our world financial system has been dramtically disrupted and the roles played by government have changed in ways few would have predicted only a few years ago. In 2005, when few would have thought such interventions would be necessary, Fuchs and Emanuel were not optimistic that comprehensive health care reform would be easy to realize. They said that "over the long term, reform is likely to come in response to a major war, depression, or large-scale civil unrest."

Their article is worth revisiting. I will quote one paragraph and summarize earlier points. I urge the readers to go back to Health Affairs and take a look.

The authors described three general scenarios in which comprehensive reform may take place:

Quoting (with formatting changes):

What might set the stage for comprehensive reform of healthcare?

A major war, a depression, or large-scale civil unrest might well set in motion a change in the political climate that would overpower the obstacles that prevail in normal times.
A national health crisis, such as a flu pandemic, might also light the fuse of change.
Short of a major economic, social,political, or health crisis, there might be a confluence of forces that together would propel the nation toward comprehensive reform over the next decade, such as widespread dissatisfaction of the business community with employer-based insurance; state governments’ inability to sustain the ever-growing fiscal drain of federally mandated, means-tested insurance; or a financial crisis with Medicare. Leadership from the business community and states might together galvanize comprehensive reform.
Finally,there might be a growing realization by average Americans that the risks of the current system to them personally and to the country as a whole outweigh the risks of comprehensive reform.

Where do we stand today relative to 2005?

We still have a war (or two) - and to some, they are major
We have a serious recession and a new push to "bail out" and incur national investments in vital infrastructure issues - finance, and, one predicts, future infusions to state governments, individuals, and perhaps endangered manufacturing sectors. And this will lead to more support for small business.
We do have a confluence of forces that will lead to some change.
We are experiencing widespread dissatisfaction of the business community with employer-based insurance
Current projections suggest that state governments will not be able to sustain the ever-growing fiscal drain of federally mandated, means-tested insurance
We do have a financial crisis with Medicare.
Average Americans are more driven by fear of losing their health care coverage than they were a few years ago; those who have little recourse have become more vocal; health care costs again are a major source of bankruptcy as was said to be the case in the 60s during the Medicare debate.

The issue isn't whether or not these events are taking place, but the extent to which the public believes that these events compel a serious examination of a more radical system sooner rather than later. As we have seen in financial sectors, the retreat from the "hands off" roll of the federal government has led to a broader interpretation of the term "moral hazard" and issues of fairness are leading many to draw new boundaries between government and private-sector roles. To the extent that a viable and substantive comprehensive new approach must be introduced will, ironically, be advanced by those who traditionally are averse to government intervention and management - until they need it personally. Major manufacturers facing bankruptcy will no doubt look at their health care cost as a drag on their plans for recovery. Small businesses seeking better access to credit may be more amenable to coupling these subsidies with a requirement to provide basic health care coverage for all full-time employees.

In the article, Fuchs and Emanuel provide a brief history lesson. They describe the fragmentation of employer-based health insurance, the disappearance of community-rated premiums, the reality of high administrative costs, and consequences of Medicare's open-ended entitlements. They also provide brief discussions on the implications of health IT, confusion over quality metrics, and disagreements in cost-benefit trade-offs.

The authors summarize both incremental and comprehensive approaches to health care reform and discuss some implications of each approach. Their summary - published shortly after the 2004 elections, seems just as relevant as we approach another election day.

They then list the following incremental reform approaches

Employer mandates
Subsidies
Expanding Medicare and Medicaid programs
Health savings accounts
Managed competition - including caps on tax-exempt plan expenses
Quality incentives

Their comprehensive reform approaches are:

Personal mandates and subsidies
Single-payer proposals
Voucher programs

The overviews help frame the central question: to what extent will the current collapse of the global financial infrastructure change the Nation's appetite for incremental or comprehensive change?

The current financial crisis should not be viewed only as an economic tragedy but perhaps also as a basis upon which we can initiate a meaningful and productive public debate. This writer fears that many of the drivers for comprehensive reform identified by Fuchs and Emanuel are looming. It's time to think about these well-known proposals in the context of our current dilemma.