Incentivization and Cautionary Tails

It seems  we will only do things with monetary rewards

Wander off to this website, dedicated to spending the tax payers money for the purpose of installing and using electronic health records in provider offices.  The rule making is only 169 pages long. The devil is in the details.

 

 

It is apparent that most providers want nothing to do with EMR, but have been convinced by 'others' that we must do it, because they know better than we do what is 'good for us'.

Another factor in the equation is that EHRs can be considered to be medical devices, or even 'biomedical equipment".  I think most  of you can see where this is headed.  The Food and Drug Administration (FDA)regulates medical devices as well as pharmaceuticals.

Consider this:  Biomedical equipment must be annually inspected and certified by the appropriate biomedical engineer to be used for patient care.  Devices usually are subject to a 'clinical trial' or reports, or an IDE (Investigative Device Exemption)

EMRs are intimately intertwined with patient care, and involve patient safety issues. 

Where the  feds are involved expect to see more bureaucracy, regulation and oversight.  The feds are just not going to incentivize without regulation. Build in more overhead for regulation.

 

Certification will not be the end of the story. Just as new drugs require approval by the FDA, so too will software upgrades. After all who knows what an upgrade might cause?

The Yo-Yo Effect

The past several months reveal how disconnected the plan for health care reform has evolved. There was little transparency regarding the evolution of the bill, except for political posturing. The present administration has no experience in business leadership, nor basic economic theory.

The fact that the flawed SGR formula, hastily conceived in the early 1990s, was not addressed in the health reform bill attests to the simple fact that cost is a major factor in the legislation. Universal care was never a top priority except to assuage the proletariat.  SGR was and is held out as a bargaining chip and as a diversion for most  physicians.

The effects of the SGR impact very severely on ophthalmologists, urologists, geriatricians, some internists  and somewhat on cardiologists and pulmonologists.  These practices serve a large medicare population, and the SGR impact as presently structured or not eliminated will be devastating.

Primary care physicians can select to minimize medicare or eliminate it all together from their business model, with much less impact on their practices.

Thus, some specialists will have little choice but to either quit entirely, or fire half their staff, and reduce the quality and accessiblity of their practices to senior citizens.  These practices will ill afford to acquire new technology.  The physical structures of medicine will decline, poor maintenance, bare floors, and peeling paint.

The past several months have been  a Yo yo  for physicians  with hope for resolution of the SGR fiasco, and then dashed as we are used as a political football.

del.icio.us Tags: yo yo effect,sgr,political footbal,bargaining chip,healthtrain express

Health Train Surfing on the Web

One of the great things about the internet is how rapidly one can research topics of interest.

Today's posting is a collection of interviews with a number of politicians.

Governor George Pataki on Health Care Reform from CMPI on Vimeo.

The Center for Medicine in The Public Interest, or CMPI hosts a large number of video interviews on their website.

This organization is very pro doctor.

The Clothesline

I don't know about you, but I and most physicians are fed up with being hung out to 'dry'.

Same old, same old.

Doctors with Medicare patients will start seeing a 21 percent pay cut this week after Congress failed to defer the cuts by two more years.

This Story appears today in the Washington Post.

• The Senate had until June 1 to avert the cuts. It is not expected to vote by Tuesday, when the Center for Medicare and Medicaid Services' temporary hold on Medicare claims expires.

Some members of the American Medical Association signed white lab coats instead of a petition to voice their displeasure on Sunday at the group's annual meetings in Chicago. The coats will be delivered to lawmakers in Washington on Friday, a spokeswoman said.

"The Senate's failure to act before June 1 made the 21 percent cut the law of the land," AMA President J. James Rohack said in a statement. "Physicians will start seeing a 21 percent cut in Medicare payments this week that will hurt seniors' health care as physicians are forced to make practice changes to keep their practice doors open."

Legislation to restore doctor's pay -- known as the "doc fix" -- is part of a broader aid package that includes jobless benefits and more financial aid for the states. In his Saturday radio address, President Obama called on lawmakers to avert the pay cuts, faulting Republicans for the delay. "After years of voting to defer these cuts, the other party is now willing to walk away from the needs of our doctors and our seniors," Obama said.

Republicans call the package fiscally irresponsible and said it would add $80 billion to a bloated federal deficit. Some moderate Republicans say they will vote for the package if the cost is offset by cuts elsewhere in the federal budget.

President Obama this weekend told us all how much he 'cares' about doctor reimbursement. 

 

What a sham.  

 

If that were the case there should have been room in the monstrous 1200 page heath reform bill to (link takes a while to load))include a permanent fix to the SGR (sustainable growth rate)

Better pony up and get some more clothespins....before they are all gone!!

The Shadow over Health Care

Will quality heath care survive "the eclipse"??

 

However, there is still hope.

Will EMR correct these entries in the medical record??

Are these "Never Events"?

Will "time-outs" prevent these misfortunes?

 

1 . The patient refused autopsy.

2. The patient has no previous history of suicides.

3. Patient has left white blood cells at another hospital.

4. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.

5. Patient has chest pain if she lies on her left side for over a year.

6. On the second day, the knee was better, and on the third day it disappeared.

7. The patient is tearful and crying constantly. She also appears to be depressed.

8 The patient has been depressed since she began seeing me in 1993.

9. Discharge status: Alive but without permission.

10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.

11. Patient had waffles for breakfast and anorexia for lunch.

12. She is numb from her toes down.

13. While in ER, she was examined, x-rated and sent home.

14. The skin was moist and dry.

15. Occasional, constant infrequent headaches.

16. Patient was alert and unresponsive.

17. Rectal examination revealed a normal size thyroid.

18. She stated that she had been constipated for most of her life, until she got a divorce.

19. I saw your patient today, who is still under our car for physical therapy.

20. Both breasts are equal and reactive to light and accommodation.

21. Examination of genitalia reveals that he is circus sized.

22. The lab test indicated abnormal lover function.

23. Skin: somewhat pale but present.

24. The pelvic exam will be done later on the floor.

25. Patient has two normal teenage children, but no other abnormalities.

Is Help on The Way?

 

The issue of how much medical malpractice adds to the cost of healthcare in the United States has been on the front burner for physicians, yet legislators turn a deaf ear to this challenge. Medical malpractice adds to the cost of each patient encounter not only due to the premiums physicians pay, but the even more significant costs of practicing 'defensive medicine'.  This fuels the additional non medically indicated ordering of high tech laboratory and other expensive imaging and other tests.

 

By Katherine Hobson

Today the government begins to hand out $25 million in funding for demonstration projects attempting to find some fixes for the medical malpractice system, the WSJ reports. The one- and three-year grantees include projects focusing on alternative dispute resolution programs, rapid medical error disclosure and the development of guidelines to reduce lawsuits.

This project was initiated last year, in the heat of the health-care debate. But the overhaul bill that ultimately passed Congress included another $50 million in grants for states that want to explore alternatives to traditional tort reform proposals, American Medical News reported this week. (The paper is published by the AMA.)

Grant-winners haven’t been announced yet. But experts told medical liability insurers at a recent meeting about several different alternatives that might be funded as test projects, AMN says. Here they are:

Health courts: The notion of courts dedicated to medical malpractice has kicked around for a while and was endorsed in 2007 by then-presidential candidate Mitt Romney. The courts would have judges who specialize in medical-liability cases, as well as “neutral experts, preset timelines and compensation schedules,” which hopefully would produce a more predictable and efficient system, AMN reports.

Early offers: Just what the name indicates — a defendant could opt to pay economic damages and lawyers’ costs within 180 days of a claim, avoiding lengthy litigation. The patient, however, would have to skip non-economic damages.

Apology programs: The hope is that when doctors apologize for or at least communicate about errors with patients and family members rather than immediately lawyering up, the risk of litigation may decline. (Here’s a WSJ story on the subject.)

Medical review panels: Already used in many states, these nonbinding panels of medical and legal experts review suits before they go to trial to cull the most egregiously silly and advise plaintiffs and defendants on the merits of the evidence. (Here’s a 2009 AMN story about the concept.)

The AMN reports some caution on the second round of grants: Funds have to be appropriated by Congress, and by the terms of the program, test projects can’t limit the rights of plaintiffs and defendants to pursue claims through traditional means.

Some sucess has already occurred with "caps' on awards for punitive damages in several states.

The funding for this initiative has yet to be passed by the congress.

The Transformative Potential of Health IT

Mark Smith, MD President and CEO of the California Health Foundation discusses the potential of health information technology to transform medical care. It will transform medical care much in the same way that online travel agencies such as expedia and travelocity revolutionized the way people travel and plan trips.

He remarks that Wal-mart knows more about that can of beans on the shelf...where it came from, where it is now, where it is going, who bought it, and what else they bought on that shopping excursion.

I don't know beans about that but I do know that health IT has the potential to revolutionize the way we care for our patients.

Our system is now based on 'visits' and coding.  Improving our efficiency and reducing patient visits by 10-20% will reign economic catastrophe upon our present system.  Imagine your business sustaining a drop of 20% (and possibly more) in volume and/or income. 

Much as was accomplished in the hospital environment in the later 1980s and 1990s, where the DRG drove shorter stays, and reductions in admissions and only for acute and/or critical illnesses, so too will this next wave of innovation drive a reduction in visits to  physicians offices for routine care. The visit will no longer be sustainable, unless indicated and that service could not otherwise be delivered.   Much care will be delivered electronically by telemedicine, remote monitoring, video conferencing, email, etc. 

This will be the true power of the transformative potential of health IT.

None of the above is my idea.  It is well covered in Dr. Smith's presentation. Definitely food for thought.

Medicare fueled tremendous inflation in medical care, it has had it's beneficial effects on the elderly population. We now see more government infusion into health care in the area of information technology.  Will this drive further inflation for health care and health care IT?

What we need is not hundred thousand dollar EMRs and million dollar health information exchanges based upon complex networking, but a simple cheap solution to address the clinicians' challenges.

One such device is the 'Medi-Chip" and the 'Key 2 Life', both innovative ideas produced by Norman Eisenberg of Miami, Florida. I recommend you link over to his website to learn more about it

 

 

 

And that is my two cents for today.

President Obama's EMR Fiasco

My morning cup of coffee included an email from SERMO where there was a post regarding EMR usage.

I thought it worthwhile to include this commentary from
Stan Feld, MD, FACP, MACE

 

"President Obama's goal for healthcare reform is to increase the quality of medical care, increase efficiency of medical care and decrease the cost of care. The goal is admirable. The route he is taking is wrong. In the process he might destroy the medical workforce.

The route the electronic medical record (EMR) stimulus package should take should be flexible and educational for patients and physicians. It should use modern software technology instead of subsidizing old inflexible technology that is set up to be punitive to physicians and patients to the advantage of the government and the healthcare insurance industry.

The term "quality medical care' is used loosely. It has not been appropriately defined. The practice of evidence based medicine has been used to define quality medical care. The problem is evidence based medicine is changing daily.

A better definition should be the best clinical outcome with the most efficient financial outcome. It is assumed that practicing evidence based medicine will lead to the best clinical outcome at the most efficient cost.

Clinical guidelines are defined by "experts" interpreting evidence based medicine. I am/was one of those experts and appreciate its short comings.

Some guidelines are essential and should be inflexible. Others are ever changing and must be flexible. In bureaurocratic systems it is difficult to create flexible rules. Also, all patients are different. Clinical judgment plays an important role in treatment.

Physicians should not be penalized for using clinical judgment. Nonetheless, physicians are penalized in a pay for performance evaluation for deviating from inflexible clinical guidelines. Since some clinical guidelines are always changing the weakness of the approach is obvious.

Physician performance should not be evaluated on static measurements. It must be evaluated on physicians' medical judgment. Clinical judgment is a function of a physician's ability to relate to his or her patients. (patient physician relationship)

Healthcare is a team sport. The patient physician relationship failed but was not measured. .

The poor performance was missed by the static digital healthcare evaluation imposed by an inflexible EMR. The importance of the patient physician relationship and not including patient responsibility in the clinical outcome should be part of any performance measurement. A performance measurement should be a measurement of both the patients' and physicians' performance.

Now that the federal government plans to spend $50 billion to spur the use of computerized patient records, the challenge of adopting the technology widely and wisely is becoming increasingly apparent.

There is no question we should have universal electronic medical records. It should be a teaching tool for patients and physicians. The EMR should be inexpensive and flexible. It should not a tool to judge and penalize clinical performance. President Obama is being ill advised. His EMR stimulus program is going to result in a waste of $50 billion dollars.

The software the government is going to spend $50 billion dollars on is going to be too expensive, inflexible and not widely distributed.

"Instead of stimulating use of such software, they say, the government should be a rule-setting referee to encourage the development of an open software platform on which innovators could write electronic health record applications".

EMR software platforms in the cloud should be developed. This link by Christopher Barnatt is an excellent utube explanation of cloud computing. I suggest all watch it.Amazon uses the cloud to sell books. www.Salesforce.com's business model tracks sales force activity at a minimal cost to the company. It is flexible and maintenance free.

"Such an approach, they say, would open the door to competition, flexibility and lower costs — and thus, better health care in the long run.

"If the government's money goes to cement the current technology in place," Dr. Mandl said in an interview, "we will have a very hard time innovating in health care reform."

The rules can be immediately changed. The cost to a medical practice could be minimal. Its effectiveness is maximal. The cost to the government using modern software technology could be between 1-10 % of what the stimulus is proposing to spend. If it is fashioned as an educational tool to patients and physicians the payback will be maximal, quality of care will improve and the cost of care will decrease.

The opinions expressed in the blog "Repairing The Healthcare System" are, mine and mine alone

Stanley Feld M.D.,FACP.MACE

http;//stan.feld.com

Thank you Dr. Feld for this great summary.

del.icio.us Tags: cloud computing,salesforce,clinical judgment,emr,clinical outcome

ObamaCare

No one has ever said that Barak Obama was or is a champion for entrepeneurship.  He fails to follow the path of legislative changes and the consequential secondary impact of sweeping reform.

Change itself is expensive. Nowhere in the legislation does he allow for the expensive overhead of change.

The Patient Protection and  Affordable Care Act mostly presents edicts and commands about what the Secretary of Health and Human Services "shall do".  There is not much room for discussion or input from anyone else. (hard to believe our legislators would sign off on this. (Unless they had more important things to do and just did not want to be bothered.)

My friend Greg Scandlen in  Consumer Power Report # 225 elaborates:

"The impact of ObamaCare is already showing up in some pretty disturbing ways. A new insurance company founded by our friend Paul Kitchen in Virginia has announced it will close its doors. This is a pity because we need more competition, not less in the insurance market. The company, nHealth, was off to a great start. The original idea was to replicate the original Blue Cross model and provide coverage only for hospital inpatient care. It was able to offer substantially lower premiums than other carriers in Virginia.
But innovation is now officially dead in health insurance. And not just innovation, but new competition of any sort. It is impossible for a start-up company to comply with the loss ratio standards in ObamaCare. There are substantial costs in building and promoting a new company and it takes a while before claims start coming in. A start-up company will collect premiums today, but not have any claims to pay for a year or so. It will not be paying out 80% of its premiums for some time.
Indeed, the federal government will not hold itself to the same standard. Part of ObamaCare is creation of "The Class (Community Living Assistance Services and Supports) Act" which establishes a new federal insurance company to pay for long term care. This company will begin collecting premiums of about $150/month per worker, probably in 2012, but it won't start paying claims for five years after that. So, for five years its "medical loss ratio" will be zero.
One standard for the federal government, another standard for everyone else."

Much of Obamacare is based upon Evidence Based Medicine, and the Dartmouth Health Atlas Study, a study regarding difference in medicare expenses in different regions of the country. No attribution was given to the quality of care or the outcomes.  It is now widely regarded as seriously flawed.

A Good Guy or a Bad Guy?

President Obama has nominated Don Berwick MD to be head of CMS in his administration.

Thanks to Todd Rubin of Doctors 4 Patient Care, I have reviewed and posted comments from a recent presentation of his to the NHS.

Don Berwick is a controversial candidate  for being the head of the Medicare (CMS) system.  The name change several years ago from Medicare to CMS (Center for Medicare,Medicaid Services) was a subtle beginning for the projected changes in health care financing and administration.

Dr. Berwick originates from the most socialistic health system in the U.S.   The Commonwealth of  Massachussets. He was an invited speaker  at the  (U.K.)  National Health Service's Live program. It is impossible to miss his socialistic image for  toward medical care.  He  avoids negatives in their system while emphasizing a few strength in their system. During his presentation he addressed several challenges for the NHS :

He advised:

1"Placing the patient at the center of care

2.Stop Restructuring (this brought applause)the organization constantly.

3.Strengthen the Local Health Care Systems (should be core of design and management.) Hospital care maximized,

4. Reinvest in primary and general practice

5. Don't place faith in market forces.

6. Avoid supply driven care like the plague. It makes care unaffordable

7. Develop integrated approach to quality, and performance of the system.

8. Please heal the divide among the profession, management and the government. Rift has developed.

9. Train the healthcare workforce for the future, not the past.  safety, teamwork, measurement, patient centric

10. Aim for health. 

11. Never give up on what you have begun.  Universal,excellent, acessible,and free at it's core ."

My first reaction was "free for whom?"

If you have time it's well worth watching his presentation at NHS Live.

I have some comments regarding each point.

1. Patient centric care is now being touted in the U.S. Witness the proliferation of Health 2.0 applications

2. Stop...restructuring...massive restructuring is being foisted upon the healthcare system in the United States.

3. Local health care systems are being strengthened with govermental financial incentives for "medical homes" and community health centers (mostly funded by public health funding.)

4. Reinvest in primary care and general practice.  Our attempts to fuel more primary care have been ...nurse practitoners, commercial medical clincs at pharmacies, hope to increase interest in primary care.

5.  Don't place faith in market forces.....hmmm, no comments necessary

6.. Supply accessible technology . (but not too much)

7. Integrated care..some success with large clinics, failure with HMO and managed care

8. Heal the divides.  We seem to be headed in the opposite direction.

9. Train the Healthcare workforce.  We seem to be making some progress in that direction.

10.  Aim for health (WHAT have we been doing for the  past millenia?)

11. No comments

It seems to me NHS is headed away from where we are going.

The Community Health Data Initiative

 

Let there be no doubt about it. Health care and the delivery of care has become a process far greater than that of the individual practitioner.

Transparency and open government comes at a time when informatics provides new avenues for health care, patient participation and hopefully increased efficiency and decreased costs.

Initiative Launch

The Community Health Data Initiative was launched in a Forum at the Institute of Medicine in Washington, D.C., on June 2, 2010. Opening speakers were IOM President Harvey Fineberg, HHS Secretary Kathleen Sebelius and HHS Deputy Secretary Bill Corr. About 15 new applications were demonstrated, making health data available in new formats. Press releases were issued by HHS and the IOM. The Forum can be viewed in the video below.

 

The HHS Community Data  set provides numerous data sets that HHS invites participants to use in creating user friendly applications to make this important information available to patients, health care providers, employers and planners.

Among those participants who demonstrated their applications were:

PALENTIR

MICROSOFT BING HEALTH MAPS

HEALTH COMMUNITIES INSTITUTE TRILOGY

NETWORK OF CARE FOR HEALTHY COMMUNITIES

ASTHMAPOLIS

INGENIX AND INSTITUTE FOR HEALTH IMPROVEMENT

HEALTHWAYS- GAMING PLATFORM-ME YOU HEALTH- COMMUNITY CLASH

GOOGLE (GOOGLE FUSION TABLES)

APPS FOR HEALTHY KIDS

MOBILE APPLICATIONS

MEDWATCHER

iTRIAGE

HEALTHTRACK

 

This short list can be expanded and clarified by watching the video above.

Aneesh Chopra, CTO for the administration announced a competition to develop new applications for extracting data in readabe formats from the current information found in multiple health data bases previously sequestered in public but inaccesible databases.

These awards will be presented in early October at the Health 2.0 Conference to  be held in San Francisco.

The Health Care Challenge (Health 2.0 in San Francisco, October 2010)

What is most interesting is that these applications were developed over a very short time period (about six months).  Collectively they offer a glimpse into what is coming at the frontier of the merger between information technology and healthcare.

This was one of the most exciting sessions I have been priveleged to witness. And I did not have to travel to Washington, DC to be at the meeting.  It was all presented (for free, no travel, no lost time from work) over the world wide web. 

This presentation and many more like it presented by Open Government will be at you disposable, PRN .

del.icio.us Tags: open gov,aneesh chopra,CTO,institute of medicine,sebelius,fineberg,hhs,community health data initiative

Health 2.0

This week Health 2.0 is ongoing in Washington, D.C.  Another kudo to Matt Holt and Indu who had this visionary idea to promote many web based consumer directed systems for health education.

The Health 2.0 Show with Indu & Matthew, June 1 from Health 2.0 on Vimeo.

Much of this meeting will be broadcast via webinars. Much of the functionality of these systems meets the ONC's requirement to meet their definition of meaningful use.

So its seems the market power for meaningful use overpowers governmental edicts for funding.  The feds are already behind in implementation for ONCHIT.

One of the innovative sites is a cooperative agreement between the FDA. CDC, NIH and the National Library of Medicine. This new solution is called "PILLBOX".   It offers readibly accessible information about pill identification in a user friendly format. The information is extracted from NLM, NIH, FDA, and CDC databases.

Pillbox (beta) can be accessed via the web. It is still in a prototype release with limited functionality.

Another exciting application in development is a telephone accessible voice recognition tree to identify a pill. It is demonstrated in the webinar from Health 2.0.

Much of this information is available on either PDAs or Smartphones using downloadable applications.

All in all the rest of this week in D.C. should be exciting with many new Health 2.0 applications.  Enjoy the show!!

Now, along a slightly different track on the Health Train Express is information about Governmental transparency... If health information is going to be more transparent, then perhaps so should governmental policy.

del.icio.us Tags: health 2.0,the Health Care Blog,matt holt,voice recognition,pillbox,fda,cdc,nih,nlm,publicequalsonline

EMR and HIT Usability

The Feds well meaning attempt to stimulate HIT development addresses only one aspect of the reticence of physicians reluctance to move toward using EMR.

The other large stumbling block is 'usability'. How user friendly is the system?  Can the user enter data with the least number of key strokes and/or mouse movements and clicks?  Who analyzes and gathers this data?  I call for each vendor to produce this data.

I know this to be a fact since I have used several EMR systems, AHLTA and VISTA/CPRS.  These perhaps are not the best indicators of usability.  Neither can usability be generalized for primary care, vs specialty care.  Each requires different indicators for successful implementation.

Successful implementation in the ambulatory physician setting is not the same as in a hospital setting.  The range of users in hospital is far greater than in the physician office.

How can collaboration improve the user rate of compliance.

Some of the aspects of compliance regarding post hospitalization protocols may be adapted for EMR usage as well.

Sensitivity to operations,

Deference to expertise,

 Reluctance to simplify, 

Resilience,  

Preoccupation with failure:

 

Jonathon Bush of Athena Health has this to say about HITECH,  Meaningful Use, and other topical interests: (Caution you are entering the 'no spin zone' and some material may not be suitable for some watchers.)

Jonathan Bush, CEO, AthenaHealth from Health 2.0 on Vimeo.