The Science of Spread

Quote of the Day:
Resentment is like taking poison and hoping the other person dies.
--St. Augustine

 

Batten down the hatches....this post is going to be rather long, not a sound byte.  Thomas Bodenheimer  M.D.wrote for the California Health Care Foundation a treatise on this subject which bears reexamination at this juncture in the development of Health IT and the proposed NHIN. Dr Bodenheimer is on the faculty at UCSF.

He summarizes the literature on "spread theory" by Everett Rogers (1962), and Malcom Gladwell's "Tipping Point" . Paul Plesk cites Rogers and Gladwell "to argue that once 10-20% of the target population has adopted an innovation the tipping point has been reached."  Plesk than goes on to discuss "stages of change", "precontemplation", contemplation and action, followed by maintenance.

It can be said that EMRs and RHIOs, and NHIN are in all phases of Plesk's analysis of "Spreading Good Ideas for Better Health Care"

He offers several tools that might help improvement champions that analyze the systems and individuals that make up the spread target population....more later

Health 2.0 Conference Results

Three years ago I had no idea how blogging would provide a platform for everyone and anyone interested in health care. The spectrum of participants ranges from physicians, payors, patients, political pundits, and others.
This forum lies outside the framework of "officialdom"; It has become the water cooler and allows much intercourse. Early on there were some disputes and "retaliation" against employees when their opinions reached "management".....However I believe freedom of speech issues prevailed as long as there was no libel or slander involved.

This year's Health 2.0 was planned for 200 participants, and over 400 registered. The introduction piece was very impressive. I am providing the link here. Health 2.0 Intro-http://www.icyou.com/events/health-2-0-conference?folder=All

The video by scribemedia was truly impressive: http://www.scribemedia.org/2007/09/20/health-20-conference/


While most reporters waxed on enthusiastically, the San Jose Mercury News threw some cold water on Health 2.0, most of which was unwarranted. They criticized health 2.0 and the blogs as not being well grounded in 'business models'. While some blogs do generate revenue, most proponents of health 2.0 blogs or health blogs in general did not nor want to have a rigid business model....I am also sure some will develop entrepeneurial motives or at least there blogs will network them into "greener" pastures.

I also think that unrecognized is the fact that Web 2.0 applicatons are rapidly being deployed for EMRs, Practice management systems, and other applications for healthcare. These applications do away with the heavy cost of capitalizing for hardware, ie servers, etc. A monthly subscription fee covers maintenance, upgrades, and technical support.

Without a doubt the environment of health blogging is one of free speech, enthusiasm, and just plain "glory" at seeing one's words printed on the world wide web. It is a great "equalizer."

Alternate Road to Health Information Exchange

Saturday, September 22, 2007

Roadmap (Alternate) to Health Information Exchanges
RHIO and HIE development is a highly complex undertaking and not for the weak of heart. As I was driving into Los Angeles the other morning I encountered one of the routine "sigalerts". For those of you who have never been in California and live in a rural area I will explain this is a system of alerts from the Callifornia Transit Authority whereby notifications are sent out by television, radio and internet about blocks in traffic due to "events" such as accidents, toxic waste, police activities, construction activites, etc. Recently my oldest son, who has rapidly passed me by in the world of high tech (he has smaller thumbs than I do) and I were in the car together and as we bogged down and did not move for several minutes, the GPS asked if we wanted to plot an alternate route, and suggested about five different ways around the thrombosed artery.
I believe that the current roadmap is flawed as designed and hoped for by several agencies with good intent. Our Health Train Express is now in a "sigalert status" The problems with "roadmap" is that requires funding from unknown or difficult and confounding sources such as grant making organizations ranging from county to state and federal and combinations thereof. Often times these grants are tied to the momentary "political expediency" of the moment, ie, Katrina, Homeland Security, Bioterrorism, and even "Global Warming"
Often and most of the time it is totally dependent on the whim of the moment of legislatures both federal and state, impacted by competing budgetary priorities of peace and war. education, immigration issues, and more.
The "road not taken" as Robert Frost so aptly stated requires a minimalist approach with obtainable goals that step through the process. Rather than swallowing the whole cow, we must take small bites, chew an digest each piece individually. This rather graphic and seemingly unrelated metaphor sums up a new roadmap.
It is difficult for providers and hospitals to grasp the RHIO concept because it is rather like dropping an Atom Bomb. It overwhelms most executives who are fully engrossed in just running their institutions on a day to day basis.
Developing one functionality that would maximize a return on investment in one area as a demonstration without disruptive technology gives an HIE a "foot in the door" When a user (provider or hospital) subscribes to this service for a relatively small sum the revenues derived and create cash flow for the HIE as a revenue cycle. The single functionality must demonstrate it's own cost effectiveness and ROI in less than one month. It must be demonstrated as successful in a regional pilot program. It must be self funding, elective and non binding without contractual obligation, and also offered as a 30 day free trial........more later

The view from Here

Just a reminder to take a look at my "parallel blog" at http://anyviewfromhere.blogspot.com

Health Train Express is Slowing Down

As I travel on the health train express I have noticed the "local trains" which are stopping along the way at each station. Of course I am on the express track, or the high occupancy vehicle lane. In my 'rush' to reach my destination I am missing a lot of interesting places.

I may be posting less here and if you miss my meanderings you may find me at my new blog,
The View from Here (http://anyviewfromhere.blogspot.com/ It seemed apropos for a name for an ophthalmologist's commentary about matters of "great significance"

For those of you going to Health 2.0 enjoy!!

And thank you to Dimitriy for his great expose on Google....

EverythingHealth: Katrina Nursing Home Owners Aquited

EverythingHealth: Katrina Nursing Home Owners Aquited

Roadmap (Alternate) to RHIO and HIE

 

RHIO and HIE development is a highly complex undertaking and not for the weak of heart.  As I was driving into Los Angeles the other morning I encountered one of the routine "sigalerts". For those of you who have never been in California and live in a rural area I will explain this is a system of alerts from the Callifornia Transit Authority whereby notifications are sent out by television, radio and internet about blocks in traffic due to "events" such as accidents, toxic waste, police activities, construction activites, etc.  Recently my oldest son, who has rapidly  passed me by in the world of high tech (he has smaller thumbs than I do) and I were in the car together and as we bogged down and did not move for several minutes, the GPS asked if we wanted to plot an alternate route, and suggested about five different ways around the thrombosed artery.

I believe that the current roadmap is flawed as designed and hoped for by several agencies with good intent.  Our Health Train Express is now in a "sigalert status" The problems with  "roadmap" is that requires funding from unknown or difficult and confounding sources such as grant making  organizations ranging from county to state and federal and combinations thereof.  Often times these grants are tied to the momentary "political expediency" of the moment, ie, Katrina, Homeland Security, Bioterrorism, and even "Global Warming"

Often and most of the time it is totally  dependent on the whim of the moment of legislatures both federal and state, impacted by competing budgetary priorities of peace and war. education, immigration issues, and more.

The   "road not taken" as Robert Frost so aptly stated requires a minimalist approach with obtainable goals that step through the process.  Rather than swallowing the whole cow,  we must take small bites, chew an digest each piece individually.  This rather graphic and seemingly unrelated metaphor sums up a new roadmap.

It is difficult for providers and hospitals to grasp the RHIO concept because it is rather like dropping an Atom Bomb. It overwhelms most executives who are fully engrossed in just running their institutions on a day to day basis.

Developing one functionality that would maximize a return on investment in one area as a demonstration without disruptive technology gives an HIE a "foot in the door"  When a  user (provider or hospital) subscribes to this service for a relatively small sum the revenues derived and create cash flow for the HIE as a revenue cycle. The single functionality must demonstrate it's own cost effectiveness and ROI in less than one month.  It must be demonstrated as successful in a regional pilot program.  It must be self funding, elective and non binding without contractual obligation, and also offered as a 30 day free trial.

More on this later........

Surfing on the Labor Day Weekend

The long labor day weekend is upon us all. I plan to spend mine with my feet up, and with a cold drink sightseeing on the hot sands of the Southern California beach.  I even invested in a cell card, so I can now find the internet whether I am floating on my raft, in a dark hole, in a green swamp, or whatever. I realize I am surrounded by   the "can you hear me now" guy and the helicopter flying overhead (Verizon).

As far as health information exchange goes, this weekend, my network is down....

The Caboose

I suppose the health train express should not have a caboose because that implies the end of the train. However I missed an important addendum from Mike Leavitt's blog which he writes as he travels through Africa, attempting to analyze Africa's challenges, clinical overload, a far cry from the paperwork overload providers face in our country. Mike makes some comments about HIE and RHIOs, the subject of which motivate my original blog. The post which follows here is an important link for you to understand what has been done and what will take place over the next five years. Don't miss the TRAIN !!!

http://www.hhs.gov/healthit/community/background/

from Mike Leavitt's blog:

"Today we had an important meeting at HHS related to electronic medical record standards. The development of standards for interoperable health information systems is one of my most significant goals. I believe the standards required to make this electronic medical records system work have to be collaboratively developed among various stakeholders. About two years ago we created the American Health Information Community for that purpose. Rather than try to write much about it I will ask one of my colleagues to insert a link here to the AHIC website: http://www.hhs.gov/healthit/community/background/
People have been talking about interoperable systems for years but the standards to make them work haven’t materialized. So, those who invest in electronic health records are isolated. Many others put investment off, waiting until the systems mature.
This is an extraordinarily complex problem but the biggest challenges aren’t technological; they’re sociological, i.e. conflicting economic interests and turf. AHIC has successfully created a place and process to sort through them in an orderly way. We are starting to make serious progress which you can read about on the website.
Our plan from the beginning has been to get the standards development process started inside the government and then once it is functioning create a non-profit entity that operates under a highly democratic governance system so the progress can be accelerated and perpetuated. I call the transition moving from AHIC 1.0 to AHIC 2.0.
The government will have to be the biggest participant in the process, but to get these things right, the entire health sector has to be at the table in a meaningful way. The federal government will not only be the biggest participant but we have also committed to use the standards developed there. The President signed an Executive Order last August making clear that all the federal agencies, including Medicare, Medicaid, the Veterans Administration, and Department of Defense etc. will adopt the standards. We need to insist those we pay do the same thing, over time.
Today we held a meeting with interested people and organizations to invite their help in creating the non-profit entity and its governance.
The last several years I have become rather interested in collaboration as a large scale problem solving tool. I’m persuaded skillful organization of collaborations is a 21st century skill set. It is a close cousin to network theory. In fact, I think collaboration is the sociology of network building.
Our world is intuitively organizing itself into networks. Networks require standards to operate. The skills to navigate the creation and governance of networks constitute the next frontier of human productivity. Organizations and societies that learn to solve complex problems using these skills will begin to out pace their competitors.
The development of AHIC 2.0 is a significant venture. I’m optimistic it can produce a vitally important institution but it will require our best statesmanship to overcome the natural tension of competing economic interests and turf.
If readers have a chance to look through the AHIC website, I’d be interested to hear your thoughts."

Hot Weather and HotTopics

Stop, don't click away just because you think you have arrived at the wrong site. As I promised there were going to be some fresh changes at Health Train Express. Not only has Elvis left the building, but so too has Health Train Express.

Every summer at this time of August I mention how fast the summer has gone by. Well, just when I think it's over...it's not. The forecast for the next week is 100-107 degrees. As Yogi Berra has said "It ain't over until it's over".



So too is my forecast about P4P, RHIOs, and EMRs. No one can easily predict the outcomes in this arena. However it certainly fuels entrepeneurial minded providers, third party administrators and a variety of industry vendors into a fury of Category 5 storms.



One of my favorite blogs is that of Phillipa Kenneally, The Entrepeneurial MD. She regularly hosts podcast interviews at her site, which can be found at http://trusted.md/ Her guests are often "out of the box" innovators with examples of where many physicians go when they are not seeing patients.



Richard Reece's blog, medinnovation now has a link on my site . This retired pathologist living along the banks of Long Island Sound will give you much food for thought from his experiences and knowledge base of 30 years of clinical pathology experience, much of which has nothing to do with looking through a microscope.



We will be taking a two week break until after Labor Day, when we will return to continue our new "look" to our blog.

Transitions

Fellow bloggers:

When I first began “blogging” about three years ago I intended it to be a newsletter for a RHIO that I was heading up in my area of the country. About a year ago I chose to rename it “Healthtrain Express”. The term recently coined by others came to my mind in 1989 (that definitely dates me) It was in the pre-DRG, pre RVU, pre managed care (ie, the “golden days”) that my residents often wistfully mention..
I often tell them that no “age in medicine” is trouble free. It’s the nature of the “beast”.

Healthtrain express conjures up the rapid changes that constantly occur in medicine. For those of you who have read “Future Shock “ by Alvin Tofler , this has always applied to medicine. I highly recommend this reading.

It also denotes a vehicle with a tremendous amount of inertia, barreling down a “track” . If you are on the track you had better be moving fast enough to stay ahead of the train. If you are stationery, then you must either move aside or be “smashed”.

Returning to more specifics of our “age in medicine” we see the predictions and evolution of pay for performance and reporting, health information technology, the methodology of reimbursement change, including CMS intention to not reimburse for “poor outcomes” or those due to “poor care”. Medicine will continue to be increasingly directed by third parties, consumers, and political and social planners. Most of whom have never treated a patient. This one issue frustrates most physicians, although it has become a fait acompli, I know it continues to “gall” most doctors.

Physician-hospital relations continue to be in a state of flux. Gone forever in most areas is the leadership of the medical staff as it pertains to the board of directors, or trustees of the hospitals. In some rural areas this may remain intact, unless the hospital is part of a larger financial “holding company”. Creative financing has allowed many hospitals to continue operations with “leaseback arrangements” for management, and other issues.

Looming on the horizon is radical change in hospital accreditation organizations.
The JCAH authority is about to be undermined by pending legislation and some hospitals chose to use alternative accreditation sources This may or may not be a good thing, given that operating requirements have radically changed for hospitals.

For those of my readers you may notice on the sidebar the expansion of medically related blogs. Over the next month this list will be expanded. This is going to involve a significant amount of my time selecting and moderating my personal favorites.

I am also extending a personal invitation for co-authors to contribute to “healthtrain express”. Please email me if you wish to do so. email gmlevinmd@gmail.com

GML

Change in Direction

For the past three years I have been beating the drum about the development of HIE and RHIOs. I have not come to any final conclusions about the destiny of this "visionary" prospect. There are a great deal of positives and negatives regarding HIE and EMRs.
I will deal with some of the negatives first.

1. Most providers complain about the complexity and bureaucracy of practicing medicine, in regard to regulatory requirements, the hurdles of reimbursement, and exponential increases in business overhead.
2. The burden of Health IT may outweigh the benefits.
3. HIT is very expensive
4. Automation and the impersonal nature of IT does not really fit in to the paradigm of medical care. Despite patient enthusiasm for all things technical most providers are reluctant to introduce an infrastructure that will make them dependent on third parties.
5. Most physician providers operate on the basis of accountability, reliability, and a one on one relationship with each patient. IT is not going to improve the patient relationship.
6. Medical care has always been a unique portion of our economy, and recently outside forces have forced change, some good, and some very detrimental to patient care.

Positive:
1. The introduction of web 2.0 has greatly expanded patient education, and allows patients to ask more relevant questions.
2. Web 2,0 also introduces transparency and allow for "error checking" on the part of patients
3. Web 2.0 also increases the providers outreach for reliable information instantly at the point of care.
4. Most providers who have installed EMR speak positively about having it, and "would not go back to the old system" (my comments are that they could not even if they wanted to, because of their heavy investment in the system.

That's my meager summary after three years, it is not all inclusive.

Beginning next week Health Train Express will change direction. Look for a change in content first, then a change in the front end. I hope to maintain the title "Health Train Express" however our domain name may change.

Mike Leavitt Sec HHS joins blogger world

HHS Secretary Leavitt Launches Blog To Boost Health Care Discussion
HHS Secretary Mike Leavitt this week launched a blog to foster public discussion and exchange ideas on health care issues, The Hill reports."If I can do it justice, we will continue," Leavitt said, adding, "If not -- we won't." Leavitt, who plans to write all his blog entries himself and read "as many of the comments as time allows," said he will "wade in a little deeper into blogdom" this month.Unlike some blogs, all comments will be screened prior to being posted, The Hill reports.One day after his first blog posting, Leavitt already had received more than a dozen comments, including one that had to be removed because it was inappropriate or offensive, according to a spokesperson (Retter, The Hill, 8/15).