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Monday, May 25, 2009

Art----Computer----Science----Patient

Paul Ravetz: Can the art of medicine exist in the computer age?

In today's post on KevinMD,  Paul Ravetz recognizes what most of us already understand (where the rubber hits the road).  Tell it to the HIT group, salivating  over the ARRA.

 

"Does the “Art of Medicine” really exist, or perhaps more important, can it do so in the computer age?

 Aesclepius

Computers are both the boon and the bane of medicine. Electronic medical records (EMRs) are excellent for retrieval of information about labs, medications, and past medical history of our patients. These records are much easier to access than our old paper charts. However, I feel that the Achilles Heel of these advances lies in the fact that physicians are so busy inputting information into their computers that they do not spend enough time communicating with the patient.

Communication with your patient is the epitome of the Art of Medicine.

However, the way things are presently being done cheats the patient out of the most important part of the doctor patient relationship - time to communicate. I always remember the precept advanced by Sir William Osler, the father of modern medicine, “Listen carefully doctor, the patient is giving you the diagnosis.”

So, who will you communicate with? Will it be the patient, or your workstation?

Sunday, May 17, 2009

Health Train Express----Shortening the Trains

 

In the past ten years we have experienced an Internet bubble, a Housing bubble, and Financial Markets Bubble.  What is the next bubble to burst.

Could it be a health care bubble?

George Lundberg in a recent post on The Health Care Blog enumerates on the development of bubbles in real estate, silicone valley, financial markets, and presents a scary prediction of what may very well occur in health care.  Some experts predict a sixty percent (60%) adjustment in overall health care expenditures as compared to the present portion healthcare consumes (or adds) to the GDP.

Trimming Health Care Costs

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There is a movement afoot to nominate George Lundberg for Surgeon General. For those of you who wish to support this movement, you can go to  the Web Site to sign the petition.

While we are on the topic if influential people for the Obama administration and their ties to the administration, here are some interesting facts for your evening game of Trivial pursuit.

What highly placed official at the NIH (National Institutes of Health is related to a key player in the White House?

Answer:  Ezekiel Emmanuel, MD  is the brother of  Rahm Emanuel, Barak Obama's Chief of Staff.

Rahm Emanuel

Ezekiel-Emanuel-190 Ezekiel Emanuel

Another key figure in Health Care Reform, and it's impact on the Federal budet is Peter Orzsag.

Mr. Orzsag holds a cabinet positon as Director of the Office of Management of the Budget (OMB).

Mr Orzsag is presented as the 'ultimate  nerd' combined with political savy.  He has a keen interest in health care economics, health care reform, and brings key analytical tools merged with knowledge of how to apply it to the political process.

His animating passions are far grander — health care, energy policy and Social Security overhaul, for starters.

Soon he will focus more closely on health care, his central policy obsession. In recent years, many say, he has helped popularize the idea that reducing health care costs is essential to the country’s economic future and the sustainability of the federal budget.

To address the problem, he wants to do no less than change the way medicine is practiced, eliminating unnecessary tests and unproven treatments in favor of what he calls a higher-value approach that he says will actually improve health. But no one quite knows how much money such measures would save, and Republicans already accuse him of trying to limit care

Tuesday, May 12, 2009

The Ultimate Medical Home -The White House

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Can the medical home reconcile the high cost of HIT? Was Marcus Welby MD the penultimate medical home?

Despite the "warm fuzzy" acronym of "Medical Home" readers should realize policy makers are not proposing a Marcus Welby MD for every patient.

Two of the best articles on this subject of HIT and medical homes are in todays" columns on The Health Care Blog.

Elsewhere,

Some of our congressional leaders still do not 'get it". Charles Schumer proposes that any government run program in health care reform follow the standards and regulations of private insurers. Many of our current problems relate to the manner in which private insurers operate. Mr Schumer is a powerful power player in the New York Financial Banking and Wall Street world.

Democrats in Congress hope to shift the debate from the question of whether to create a public health insurance plan to the question of how it would work.

George Lundberg

George Lundberg MD contemplates a 60% reduction in health care expenditures with an 'implosion' imminent in the health care bubble.

The White House has held a 'briefing of stakeholders' this week. who promise a reduction of over 2 trillion dollars in health costs over the next ten years. The complete listing is at the above link.  My question is how can the AMA guarrantee these reductions?

The vast majority of the White House statement is 'politically correct, and couched in meaningless promises. 

Tuesday, May 5, 2009

The Myth of Health IT

In an opinion piece, former HHS Deputy Secretary Tevi Troy challenges common beliefs about health IT and questions whether the $20 billion included in the federal stimulus package for health IT will improve the country's health care system. Washington Post.

5 Myths on Health Care's Electronic Fix-It

In The Washington Post:

By Tevi Troy
Sunday, April 26, 2009

Are electronic health records the panacea for all our health-care ills? Congress seems to think so: With strong cheerleading from President Obama, it has approved $20 billion for EHRs as part of the stimulus package. Health information technology undeniably holds a lot of promise, but it's still in its infancy. Is it worth a stimulus now? A look at some health IT myths:

1. Electronic health records will cure our health system.

EHRs will potentially provide a lot of benefits, most notably by reducing medical errors -- e.g., doctors prescribing medications to patients with an allergy to them -- that kill as many as 98,000 Americans each year. A much-cited 2005 Rand Corp. study of EHRs found that they could save $77 billion annually and potentially eliminate 200,000 adverse drug reactions. Yet a more recent analysis, by Stephen Parente and Jeffrey McCullough in Health Affairs, found that "the evidence base is not yet sufficient" to show that EHRs would improve outcomes.

Implementing EHRs to improve billing -- which would be the simplest and least creative way to spend Congress's money -- is not enough. EHRs can improve our system and help achieve the assumed cost savings only if they bring about changes in the way we practice medicine. Doctors have extremely limited time with their patients. EHRs would help by giving them access to the patients' documents, including all previous tests and conditions, in advance, and by allowing patients to communicate with physicians via e-mail. With the right kind of EHRs, doctors could obtain real-time guidance on the best care for a specific patient from databases containing all the latest diagnostic and therapeutic guidelines.

But this technology is evolving rapidly, and implementing systems in the right way will require thoughtfulness and creativity. As pediatrician and health IT expert Kenneth Mandl, who co-wrote a skeptical analysis of subsidizing EHRs for the New England Journal of Medicine, told the New York Times, "If the government's money goes to cement the current technology in place, we will have a very hard time innovating in health care reform."

2. Federal carrots and sticks are the only way to get doctors and hospitals to adopt EHRs.

It's true that far too few doctors and hospitals have electronic systems in place. The Congressional Budget Office has estimated that about 12 percent of physicians use them. According to a recent study in the NEJM, only 1.5 percent of U.S. hospitals have a comprehensive electronic records system available in all clinical units, and another 7.6 percent have a basic system available in at least one clinical unit. Seventeen percent of hospitals let doctors prescribe medicines electronically.

The stimulus package established 10-year EHR adoption goals of 70 percent for hospitals and about 90 percent for physicians. But even without the stimulus, the CBO estimates that 45 percent of hospitals and 65 percent of physicians will have EHRs by 2019. In other words, many doctors and hospitals are likely to adopt electronic systems even without the subsidies, which begin in 2011, and the potential penalties for failing to adopt, which are expected to begin in 2016.

3. Cost is the only reason the United States has such low adoption rates.

The initial capital investment in EHRs, estimated at between $15,000 and $50,000 for a practice and $10 million for a midsize hospital, is definitely a deterrent, but there are other reasons for delay. On the economic side, the financial incentives in medicine don't reward doctors for performance, so improving performance with EHRs is not a necessarily a priority. Cultural issues, especially among older doctors, are also a big obstacle. A 2008 study sponsored by the Department of Health and Human Services and the Robert Wood Johnson Foundation found that 29 percent of non-computerized hospitals cited doctor resistance as a major barrier to adopting health IT, and 42 percent claimed it as a minor barrier. David Blumenthal, the Obama administration's recently appointed health IT czar, wrote in the NEJM that beyond cost, the barriers to adoption of EHRs include "the perceived lack of financial return from investing in them, the technical and logistic challenges involved in installing, maintaining, and updating them, and consumers' and physicians' concerns about the privacy and security of electronic health information."

4. Subsidizing EHRs will stimulate the economy or EHR adoption in the short term.

The stimulus package contains bonus payments of $44,000 to $64,000 to physicians who adopt and use EHRs effectively, beginning in 2011 and continuing through 2015, with the largest total spending taking place in 2014. After that point, doctors who do not use EHRs may be penalized. But even if the law called for the money to be spent earlier, the Department of Health and Human Services is not yet close to being ready with the payment rules, certification standards or definitions of key terms such as "meaningful use," which are called for by the end of 2009. Federal encouragement of EHRs could actually serve as an anti-stimulus, because IT companies could be reluctant to develop new products until the government sets the certification standards. Furthermore, doctors and hospitals, seeing the promise of federal dollars 20 months away, will be unlikely to buy new record systems until the government money starts to flow.

5. We know how much we're investing in this effort to promote health IT.

The media typically describes the investment in EHRs as $20 billion. But this doesn't count $12 billion in estimated savings for EHR adoption that may or may not happen, so the real number is closer to $32 billion. And the $32 billion is only an estimate, since the bulk of the stimulus dollars for health IT is in what is known as mandatory spending, meaning that the money is paid out as long as applying doctors and hospitals meet the appropriate requirements. So the actual number could go as high as $50 billion or even higher. This is unsurprising, since Obama called for an investment of $20 to $50 billion in health IT on the campaign trail. So we may not know the actual amount -- but in Washington, it's always a good idea to bet on the higher number.

ttroy@hudson.org

Tevi Troy, deputy secretary of the Department of Health and Human Services from 2007-2009, is a visiting fellow at the Hudson Institute.