Butterfly Effect

Quote of the day:

You see, wire telegraph is a kind of a very, very long cat. You pull his tail in New York and his head is meowing in Los Angeles. Do you understand this? And radio operates exactly the same way: you send signals here, they receive them there. The only difference is that there is no cat. - Albert Einstein

 

Those of you who are physicists or students of chaos theory know what the butterfly effect is.  This is a theory that someone turning on a fan in Brazil can cause a domino effect which causes a tornado in Kansas. It can be applied to politics, weather-forcasting, and even health care and health care policy. It is the law of unintended consequences......a coconut falling off a tree in Jamaica causing a series of earthquakes in California.

Few forsaw the effect of Medicare introduction in the 1960s and what would cascade forward with the huge growth of senior citizens, increased longevity, decreased birth rates, inflationary booms and recessions.  The necessity of managed care, evolution of integrated healthcare delivery systems to cope with increasing technologies, demand for health care services.  The economic effects of poor reimbursement to primary (used to be called, family doctors, or general practitioners) care providers that would transform primary care in many localities to "triage" offices.

The uptick in consumer directed medicine and internet social networking allows a transfer of heath information among consumers, (patients) prior to physician office visits.  This too is health information exchange, at the grass roots level.

In Health Information Exchanges in relation to medical care

ie, patient goes to doctor, doctor sees patient, doctor treats patient  Besides, say opponents, a computer in the same room situated between a doctor and a patient changes the human chemistry between the two. Some things are best expressed through the head of a pen rather than the click of mouse. Computers are not magical machines. Computers are human too(ls)

Reading Below the first Blog Entry

Like most things , blog readers have short attention spans. How many of you read beyond the first or second entry.

I thought I would summarize a few items that are posted on the left hand side of the blog, or you can read it here. (have I lost you already?)

This blog is meant to "stimulate" discussion about all things regarding health care changes.  I invite readers to comment.

Anyone who would like to write a guest entry may contact me directly at gmlevinmd123@hotmail.com .

You may notice I have a few blog links down the left hand side of my blog.  I rarely have my coffee in the AM without obsessing over Surgeon's Blog, Medinnovation, Panda Bear, Kevin MD, Edwin Leap and at time Health Care Blog. If I am in the mood to be nauseated I will read "Leavitt's Blog"  This is not a personal attack on Michael.....( it has everything to do with our schizophrenic CMS).Michael Leavitt  has had a long and distinguished career as an administrator and  "policy maker".  I also think  he is on our side. (Depending on who "our' is. (I know that is a a broken fragment since my ABC tells me  so, but it sounds nice.

Anyway to get back from my ramble readers are invited (encouraged) to link to my site (please). I need some more hits otherwise my spouse will make me do  more house chores.

The Golden Rule

"He who has the gold, rules"

Consumer Directed Health Care (CDHR) is beginning to make major intrusions and fund IT.  CALPERS is acting on behalf of it's employees by directing it's pension fund to  invest in Health IT. Beyond that they are directing their insurers to do the same, following their lead.  No doubt CALPERS has enormous purchasing power in the market place.!

California Retirement Fund Backs Statewide Health Data Exchange

The California Public Employees' Retirement System -- which serves 1.2 million state and local employees, retirees and dependents -- has endorsed and will support the California Regional Health Information Organization's statewide health information exchange, called CalRHIO, Health Data Management reports.
CalPERS has directed its health insurers -- Anthem Blue Cross, formerly known as Blue Cross of California, Blue Shield of California and Kaiser Permanente -- to negotiate contracts with CalRHIO. CalPERS also plans to work with CalRHIO to ensure the privacy and security of member information as it is transferred over the health data exchange (Health Data Management, 4/24).
"The electronic exchange of health data will lead to increased safety, higher quality and better coordination of care," Rob Feckner, CalPERS Board of Administration president, said (CalPERS press release, 4/23).
CalRHIO is supporting the development of local health exchanges intended to be interoperable and help form a statewide network. CalRHIO's initial project will create a resource in which physicians in high-volume emergency departments will be able to access patient data (Health Data Management, 4/24).

April 24, 2008

HHS Secretary Pushes Transparency, Health Care IT Adoption

At the fifth annual World Health Care Congress in Washington, D.C., on Wednesday, HHS Secretary Mike Leavitt said his agency will continue to drive efforts to increase health information transparency and health IT adoption during the final months of the Bush administration, Healthcare IT News reports.
The Bush administration's value-driven health care plan relies on health IT adoption to record quality measures, as well as to collect and provide cost and quality information to consumers. However, only about 10% of small physician practices have adopted IT applications, Leavitt said.
Leavitt dismissed the idea of waiting for the government to pay for health IT. He noted that Internet adoption is being driven by the market and is not funded by the governme

California Retirement Fund Backs Statewide Health Data Exchange

The California Public Employees' Retirement System -- which serves 1.2 million state and local employees, retirees and dependents -- has endorsed and will support the California Regional Health Information Organization's statewide health information exchange, called CalRHIO, Health Data Management reports.
CalPERS has directed its health insurers -- Anthem Blue Cross, formerly known as Blue Cross of California, Blue Shield of California and Kaiser Permanente -- to negotiate contracts with CalRHIO. CalPERS also plans to work with CalRHIO to ensure the privacy and security of member information as it is transferred over the health data exchange (Health Data Management, 4/24).

"The electronic exchange of health data will lead to increased safety, higher quality and better coordination of care," Rob Feckner, CalPERS Board of Administration president, said (CalPERS press release, 4/23).
CalRHIO is supporting the development of local health exchanges intended to be interoperable and help form a statewide network. CalRHIO's initial project will create a resource in which physicians in high-volume emergency departments will be able to access patient data (Health Data Management, 4/24).

THE SPIN STOPS HERE: Michael Leavittt has the real inside scoop. Another unfunded mandate….

Health Train Express version upgrade

Health Train and it's affiliated VARs, Independent software vendors, all levels of the federal government, state governments, DEA,FDA,CMS,PMS,DOD,IHS, INS,FBI, CIA VA,CINCPAC, CINCUS, BBC, VFW, announce the introduction of  Web 2.1a and Health 2.1a .  We will no longer support ver 2.0 despite the petition signed by one health care provider and 100,000 HIT geeks.  Health 2.1a is not backward compatible with Health 2.0 and users may find that certain drivers of health care (illness, chest pain,rashes, sniffles, and other unknown issues) may not be compatible with Health 2.1a. (see KB article 45983-5098-5092-234953098a)  Please be patient, at times our server is under very heavy load due to sharing space with HALO and Microsoft Live.

We are looking for charitable donations to upgrade our dial up 56K to modern 128 K DSL.  Knowledge base articles include the relevant fine points of the user interface which will make your browsing user friendly and intuitive.

Based upon the "wild enthusiasm" and acceptance of ver 1.0 we are releasing ver 2.1a  as a pre-lease beta without charge. It will be valid for 15 minutes after download. Your authorization and download will allow us to send to you your login ID and Password, which must be ulltrasecure with at least five numbers, 10 letters (in any language) five of which must be in upper case, five in lower case, no more than three vowels and three consonants. Numbers and letters may not be sequential, ie a,b,c

1,2,3  etc.  Exceptions will be allowed for Hebrew, Aramic, Farsi,and your choice of  1.German 2. French 3. Hip-hop.

At this time only Windows ver3.1 is supported  You must file a NEMB and a waiver of exclusion from Medi-cal and assign all your router addresses  to us.

After reading the EULA  please check off if you agree or disagree with the licensing restrictions.  Your identity will be stripped off the data, so that you will not be held responsible.  Notice the "other"  check space if you do not agree with  yes or no. Move the sliding bar with your mouse pointer from 1-10 to rate the strength of your "other".

Future releases and their dates are listed below.

Web 2.1.1.1.1  May 1, 2008

Web 2.1.1.1.2  May 2, 2008

Web 2.1.1.1.3  May 3, 2008

Additional releases will be announced with 2 hours notice.

All  versions will be released as pre-beta

Health care providers will receive priority customer support via telephone (remember we are on Singapore  time) between the hours of 1 AM and 2AM  Monday and Sunday.

Please be certain that you back up all important files and data prior to each upgrade   Health 2.0 and later versions will not be responsible for any data corruptions or transmission of infectious diseases.

Health Train Express disavows any support, repudiation, or poliltical innuendos, lobbying activity, and/or earmarks.

HIMSS VIRTUAL CONFERENCE

 HIMSS VIRTUAL SYMPOSIUM

 

Today I am attending the HIMSS Conference from my easy chair at home.  Otherwise the lack of travel challenges, expense and loss of time away from your primary office (which sometimes are enjoyable as a distraction from the hum-ho drone of daily practice life.

This "Second Life" approach to dissemination of knowledge gives the user a very real appearance of a "symposium" duplicated in a virtual world over the internet, one of the best applications of Web 2.0

Jonathan Bush, CEO  AthenaHealth, gave a very articulate and understandable view of the conundrum that doctors and healthcare face in adopting HIT.  Mr Bush correctly states it is like hitting a moving target that not only changes direction, and  speed, but enters new dimensions.  His  presentation reveals the confusion and stress the health information technology industry faces......he offers the reader the opinion that the government is asking for impossible things now and probably well into the future, the complexity of codes, numerators,denomitators. He points out the fact that the provider cannot even get reliable eligibility information or co-pay amounts at the point of service that are accurate.  There is paper everywhere and he does not feel there will be much less paper very soon. He bemoans the fact that EOBs still arrive in paper form. 

John Hamlaka, CIO,CareGroup, Harvard Medical School

Interoperability  Labs, CCHIT, Roadmap, SNOMED,

Historical development, privacy, HIPAA is not uniform, regional differences for privacy concerns from hospital to hospital.

Security standards must address these differences.

Guidelines 10 rules

AHIC USE CASES ROUNDS

STREET DOC

Jay Parkinson MD practices family medicine and pediatrics in Williamsburg,Brookly, N.Y.  His approach to health information exchange has been to use it to revolutionize medical practice using commonly available software and special proprietary software to increase information to patients that most physicians leave to their staff, at considerable expense. Judging from the comments on his web site, this has produced commentary ranging from "ridiculous" to "way to go Jay"

Young physicians are not thoroughly indoctrinated in the "business of medicine"  They are idealistic and want to transform medical practice.  Some of us "older folks"  (myself excluded) have systems set up that we have become comfortable using, even if they don't work as well as we might think.  It's hard to invest a lifetime of education and practice and at the end realize it no longer works well.  The "younger generation" who I anoint with the term "generation T" (which stands for technology) should be encouraged to innovate. The system will pick and chose what thrives and what fails.  It will be along hard road to overcome entrenched systems.  Universal payor may simplify and further entrench outmoded system.

Dr Parkinson offers the following video excerpt. In the tradition of ER, Nip and Tuck, I like to call this "Street Doc"

The Impact of HIT in 2018

Quote of the Day:
When you come to a fork in the road...take it.
--Yogi Berra

 

In my search across the galaxy for the future of health information technology, I came across my son's XBOX 360 and found some relevant video posted on "Placebo Journal", and thank you to blogger  kevin.md

Here it is

Part I, A Medical Odyssey

 

Part II....The Next Day

 

Barriers to Health Information Exchange

Quote of the Day:
Everything that can be invented has been invented.
--Charles H. Duell

 

In this column I often write about promoting health information exchange.

In all cases, however, we must comply with HIPAA and place barriers for confidentiality and privacy to protect patients from unauthorized access to their health records without proper authorization.

Health Insurance Portability and Accountability Act of 1996 (HIPAA) is an expansive set of rules to privacy for patient information.  The lesser known aspects of it may be largely unknown by physicians.  I came across a survey of dentists which had some interesting information, although not all aspects apply to medical offices. It is available for a full read at:Dental Survey

Several lesser known requirements are:

Inventory and Control of all hardware and software

Security and disposal of all media

Log of maintenace of hardware/software

WRITTEN work station

Further details are in the article itself.

Such questions arise such as:

Should patients have the option to specify that their medical records not be shared on a common HIE?

Should there be an audit trail for 'shared information'?

More on Health Information Exchanges

Although the advent of the RHIO as a business structure for the development of  Health Information Exchanges has largely failed to do what it was intended to do, the motivation for HIE will largely be driven by  CMS mandates and well as quality and safety concerns. 

(HealthDay News) -- "From 2004 through 2006, patient safety errors resulted in 238,337 potentially preventable deaths of U.S. Medicare patients and cost the Medicare program $8.8 billion, according to the fifth annual Patient Safety in American Hospitals Study

This analysis of 41 million Medicare patient records, released April 8 by HealthGrades, a health care ratings organization, found that patients treated at top-performing hospitals were, on average, 43 percent less likely to experience one or more medical errors than patients at the poorest-performing hospitals.

This analysis of 41 million Medicare patient records, released April 8 by HealthGrades, a health care ratings organization, found that patients treated at top-performing hospitals were, on average, 43 percent less likely to experience one or more medical errors than patients at the poorest-performing hospitals.

The overall medical error rate was about 3 percent for all Medicare patients, which works out to about 1.1 million patient safety incidents during the three years included in the analysis

"HealthGrades has documented in numerous studies the significant and largely unchanging gap between top-performing and poor-performing hospitals. It is imperative that hospitals recognize the benchmarks set by the Distinguished Hospitals for Patient Safety are achievable and associated with higher safety and markedly lower cost," Collier said. "

The entire article can be found at  Washington Post.

Of some interest to me is no mention whether their was a difference in the use of "health information technoloogy" between the "high achievers" and the underperforming" hospitals. Does anyone have statistics on this metric?

The Fifth Annual Health Grades Patient Safety in American Hospitals Study

Consumer Health Information Exchange

We as health care providers, hospitals, laboratories, emergency departments and others view health information and data exchange through a narrow prism from our side of the health care system.

Patients (consumers) also have begun to form their own virtual world of support groups and education amongst themselves. For years there have been patient oriented support groups and organizations.

Web 2.0 now has some very innovative offerings for patients.

Healing in Community Online offers a "second life" aspect to these interchanges of support and education.  It's construct is much like the real world, with provider offices, laboratories, hospitals, and all the usual everyday accoutrements of healthcare.

Diabetes Mine offers a wealth of patient oriented commentary for diabetics.

Patients Like Me offers links to specific disease entities, which include these "communities:

Motor Neuron Disease

Anxiety

Bipolar

Depression

AIDS

Multiple Sclerosis

OCD (Obsessive-Compulsive Disorder)

Parkinson's Disease

PTSD (Post-Traumatic Stress Disorder)

Quote of the Day:
Light travels faster than sound so some people appear bright until you hear them speak.
--Joe Messmore

Innovation

Quote of the Day:
If you really want to do something, you will find a way. If you don't, you will find an excuse.
--Anonymous

 

Clinicians each day face innovation, like it or not. It traverses our day from the hospital to our office and to our business engines.

Continuing medical education, and staff training are a key methodology of "technology transfer" from the boiler-rooms of academia and practice management gurus.

We are all involved in some aspect of the process, the rising impact of consumerism, monitoring of outcomes, performance measures, reimbursement based upon compliance with reporting these metrics, and the influx of information technology.

The past three years as a health informatics researcher, I have devoted much time by interviewing vendors and the different approaches they use for their own business models.  Understandably they are in it to make a profit.

Most observers realize that HIT has undergone a rapid evolution with many failures, and some successes.

In past years some vendors would offer "beta" systems to practices for a reduced amount to build their software. There were many problems with this approach. A clinical practice setting operates on a daily basis and does not have the IT resources to support the many software and/or hardware "bugs" that are part and parcel of poorly written or undeveloped software.

In the development of Health Information Exchanges I have seen many different approaches to this new challenge.

An early question from the vendors is "who are your stakeholders"

Sales people like to develop lists of hospitals and clinicians they can approach to display their wares. Some are ethical and truly are dedicated to improve health care by using HIT.  As a consultant and physician working with a company the company gains some credibilty by having a fellow physician "vette" their offering.  Unfortunately in this process I have investigated multiple companies and have disqualified most.  Many are smaller companies who do not have  adequate support. Many of their "demos" are fancy power point presentations which do not truly exhibit the flaws in the actual operation of their system.

Many of them are very "defocused" attempting to have a large marketing department and not focus on truly developing a pilot program to demonstrate their offering(s).  Some are not focused on health information exchanges and want to  use this as a marketing bridge for EMRs, transcription systems.  Many are the result of mergers, acquisitons, to expand the functionality of their offerings.  In some cases they market systems that are not truly connected.  In some cases they will offer a complete solution when they do not  have the pieces integrated, other than fancy tricolor glossy marketing pieces.  They often speak in terms that are unfamiliar to clinicians, such as "revenue cycle management".

They imply practices can "plug and play" as if it operates like a usb port on a personal computer.  This is inherent in their asp online solutions (also known as web 2.0). On the surface this has been offered as a "hosted application" residing elsewhere much like a "mainframe"  All the practice needs is a "thin client" (formerly known as a workstation. This is connected via the internet. We have al witnessed significant decline in internet performance which degrades swift data entry and/or retrieval.

Initially it is offered on a reasonable monthly subscription cost, much less than the investment of a inhouse client-server system

As the offer evolves you will find surcharges for training and maintenance charges.

If one truly wishes to research health IT, it is worthwhile to attend one of the annual HIMSS meetings.  www.himss.org

The Healthcare Information and Management Systems Society (HIMSS) is the healthcare industry's membership organization exclusively focused on providing leadership for the optimal use of healthcare information technology (IT) and management systems for the betterment of healthcare. more >

Attend in the role of an interested observer, not as a place where  you select a vendor.

In my next blog we'll discuss weblog's that are resources for innovative ideas, and most important written by knowledgable experienced thought leaders.

AMERICAN MEDICAL NEWS -What's in a Name?

Washington -- The jumble of terms in health information technology soon could be simplified. The National Alliance for Health Information Technology announced March 24 that it finished proposed definitions for five key HIT terms and will seek public comment on them until April 9.

The ONC chose the terms because they are the most often confused. Lawmakers have proposed bills that use the terms in different ways, said Karen M. Bell, MD, director of the ONC's Office of HIT Adoption.

 

After the definitions are finalized, the ONC will officially adopt them and use them in its contract language, said alliance Vice President and Chief Marketing Officer Jane Horowitz, who leads the project. Organizations and companies should follow and operationalize the definitions throughout health care, she said

One of the most significant developments would be distinguishing EMRs from EHRs. The two are frequently used interchangeably. The alliance proposed identifying an EMR as medical information on an individual patient from a single organization, including affiliated settings. EHRs would be data on a patient aggregated from multiple organizations.

The National Alliance for Health Information Technology has proposed definitions for several common health IT terms:

Electronic medical record: A computer-accessible resource of medical and administrative information available on an individual collected from and accessible by health care professionals involved in the patient's care within a single care setting.

Electronic health record: A computer-accessible, interoperable resource of clinical and administrative information pertinent to the health of an individual. The information, drawn from multiple clinical and administrative resources, is used by a broad spectrum of clinical personnel. This enables them to coordinate the patient's care and promote wellness.

Personal health record: A computer-accessible, interoperable resource of pertinent health information on an individual. Unlike the EHR, however, the PHR is managed by the patient, and the patient determines who has the right to access and use it. The information originates from multiple sources and is used by individuals and their authorized clinical and wellness professionals to help guide and make health decisions.

 

The terms health information exchange and regional health information organization have overlapped, the alliance said. It based its definitions on their root meanings. HIE reflects the technological aspects of sharing data, while RHIO reflects the drive for better health care quality and efficiency within a region.

So the alliance defined HIE as the electronic movement of health-related data across nonaffiliated organizations in a way that protects privacy and security.

It defined a RHIO as a multi-stakeholder governing entity responsible for electronic information exchange within a geographic area. A RHIO must involve data sharing between separate entities in a defined area whose collaboration crosses organizational boundaries. It also must be focused on the greater good of a defined population area, instead of specific disease communities, such as a network exchanging information only on diabetics.

The Chart at the Foot of the Bed is Gone

Sorry for being absent the past several weeks. Recently I had the unexpected opportunity to catch up on technology at the bedside (in the bed) at my local community hospital which I had been on the staff 16 years ago.  I had been away in another community and only recently had returned to the area but practice in a more rural community in the same town.  Some things change, and others never change. Chest pain is chest pain and shortness of breath are the same complaints.  My arm band now had a bar code on it. The nurses all used wireless laptops for charting and reading orders.

The doctors were all still at the nursing stations either dictating or writing their chart notes. The doctors seem to be the last link in the chain of IT.  I definitely had the feeling IT was "leaking in".

At my post operative visit in the cardiologist's office he was able to retrieve summaries, op reports and demographics via a portal, although he had not yet implemented EMR in his office.

I am now the beneficiary of a cardiac stent, placed into a ten  year old coronary vein graft which had only 1% flow through it. Although ten years had passed without incident the old leg scar is still quite evident, more so than the long chest scar.

At the end of the rather prolonged angioplasty I was given a CD with a DICOM viewer and video for my own personal health record.  Pictures are worth a thousand words and in the future if I have to have any other procedures this will be instantly available.

This was a far cry from the CABG (4 vessels) that was performed on me ten years ago.  I was given a hand sketch of that procedure, which was lost many years ago and unavailable on short notice.

(not many patients are given advanced notice of acute coronary syndrome).

Just six months ago I had returned to near full time ophthalmology practice......the volume was up from 40 patients a day to over 50 patients a day. The practice had no EMR. Those are the numbers in productivity that are needed in some setting with capitation and/or heavy managed care intrustion, unless one adds cosmetic and/or refractive surgery to the mix.  Most doctors want one thing from an EMR....improved efficiency and reduced cost, and not over a pay back of more than one year. ROIs must be short because the only predictability of reimbursement is that it will decrease and bureaucracy will increase.  Common sense must intrude into the mix of the business of medicine.

Too many think tanks and doctor wannabees are draining dollars from patient care. Much of medicare's "fraud and abuse" mechanism revolve around inaccurate coding (obsolete ones), and complex schemes that require a graduate level education to understand.

My outlook is rather dismal....I used to be one of those optimistic "the glass is half full", now it is the other way around..."it is half empty".  Yes, those who can negotiate the system get excellent care.....there will be more care for fewer patients.

The economic engine for a typical practice bears no relationship to how doctors are trained, nor how they want to practice medicine.....Non practitioners have no idea of the stresses involved and why doctors burn out from a profession that initially was very gratifying and rewarding. 

I remain hopeful that IT will assist us all in patient care, and not become another misguided burden in caring for patients.

And, oh, by the way the bar coder broke and the nurse was delayed by over an hour trying to get medication for me. Imagine what it will be like when the server "crashes" (not if)

Happy Passover and Easter to all