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?

LiveJournal Tags: computer,worksation,art of medicine,aesclepius,paul kravetz,kevinmd

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

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

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

LiveJournal Tags: Rahm Emanuel,Ezekiel Emanuel,Peter Orzsag,OMB,George Lundberg,Health Train Express

The Ultimate Medical Home -The White House

 

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 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. 

LiveJournal Tags: white house,medical home,Schumer,private insurers,medicare,AMA,George Lundberg

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.

Emergency on The Health Train Express???

The  H1N1 viral particle

Okay, what constitutes an emergency??  Our public health authorities now are linked to the Department of Homeland Security.  "Pandemic" is now being used to describe what is not even an epidemic in terms of numbers or morbidity or mortality.

Apparently our bureaucracy of federal and state administration requires the declaration of an 'emergency' to release funding for events such as this.  Let's be clear and scientific about all of this "political posturing' and bad science. We are not in the midst of, nor even approaching a 'pandemic' let alone an epidemic.

On a daily basis we are given figures as to how many deaths and/or reported cases of H1N1 Infuenza have been diagnosed. What we are not being told is how many non H1N1 cases are occuring concurrently.  How does this year's total for 'flu' compare with previous years. 

News travels now at the speed of light, whether true or false. 'Diseases such as flu now travel at the speed of flight.

Fear and panic should not replace caution and sensible behavior.

Public health officials need to inject some sanity into the equation, and media companies need to tone down their rhetoric about H1N1 (now more politically correct than Swine Flu)

Egypt slaughters 300,000 pigs. (Don't they have kosher dietary laws anyway?

Rob and Kevin on the Health Train Express

Kevin MD will be hosting Rob Lambert on a live Q&A at 10 PM EDT  Wednesday, April 29, 2009.  Join us.

Roxana Saberi on the Health Train Express

From THCB,

Bloggers across the web are holding a blog rally in support of Roxana Saberi, who is spending her birthday on a hunger strike in Tehran's Evin Prison, where she has been incarcerated for espionage. According to NPR, "The Iranian Political Prisoners Association lists hundreds of people whose names you would be even less likely to recognize: students, bloggers, dissidents, and others who, in a society that lacks a free press, dare to practice free expression."

 

We here at Health Train Express have decided to join the Blue Ribbon campaign (Blue is for blogging) to honor and show support for those journalists, bloggers, students and writers imprisoned in Evin Prison, nicknamed "Evin University," and other prisons around the world, for speaking and writing their minds. 

Please consider placing a blue ribbon on your blog or website this week to show your support.  Also, please ask others to join this blog rally.

Cystic Fibrosis on the Health Train Express

CURE CYSTIC FIBROSIS.....HONOR YOUR MOM BY SENDING A CF CARD TO HER ON MOTHER'S DAY....MAKE A DONATION, SAVE THOUSANDS OF CHILDREN'S LIVES

Pitfalls of PHR

from: THCB

Should You Keep Your Own Medical Records?

By RAHUL PARIKH, MD as written on "The Health Care Blog"

Personal Electronic health records raise doubt

Google service's inaccuracies may hold wide lesson

Dave deBronkart's records had wrong data.

When Dave deBronkart, a tech-savvy kidney cancer survivor, tried to transfer his medical records from Beth Israel Deaconess Medical Center to Google Health, a new free service that lets patients keep all their health records in one place and easily share them with new doctors, he was stunned at what he found.

Personal health records, such as those offered by Google Health, are a promising tool for patients' empowerment - but inaccuracies could be "a huge problem," said Dr. Paul Tang, the chief medical information officer for the Palo Alto Medical Foundation, who chairs a health technology panel for the National Quality Forum.

For example, he said, an inaccurate diagnosis of gastrointestinal bleeding on a heart attack patient's personal health record could stop an emergency room doctor from administering a life-saving drug.

Google said his cancer had spread to either his brain or spine - a frightening diagnosis deBronkart had never gotten from his doctors - and listed an array of other conditions that he never had, as far as he knew, like chronic lung disease and aortic aneurysm. A warning announced his blood pressure medication required "immediate attention."

DeBronkart eventually discovered the problem: Some of the information in his Google Health record was drawn from billing records, which sometimes reflect imprecise information plugged into codes required by insurers. Google Health and others in the fast-growing personal health record business say they are offering a revolutionary tool to help patients navigate a fragmented healthcare system, but some doctors fear that inaccurate information from billing data could lead to improper treatment.

 

DeBronkart - who blogged about his Google Health experience on the website e-patients.net - has some simple advice for patients who use personal health records.

"Check it," he said. "See if it's accurate."

"Claims data is notoriously inaccurate and notoriously incomplete with respect to an expression of the problems a person has," said David Kibbe MD,  a senior technology adviser to the American Academy of Family Physicians

This fact negates the proposed effectivenss of a CMS' program of Pay for Performance, based upon claims data from physicians. For years Medicare has based cost containment on raw data regarding utilization from coding information on claims made without regard to the clinical data behind the claims.   Few of us are privy to their exact 'thought process'.

11 Classic blog posts on EMR adoption

Our greatest glory is not in never failing, but in rising every time we fail."
~ Confucius

###########################################

KevinMD posts a summary 11 classic posts since 2004 on electronic medical records.  Some of these are still valid. However, there seems to be a gradual but definite shift towards HIT adoption.

1. The low adoption rate of electronic records
2. Will physicians sacrifice for the future of health IT?
3. How to fund electronic medical records wisely
4. Medical students who are used to electronic records
5. Funding electronic medical records and bailing out the Big Three automakers
6. Do electronic medical records really reduce malpractice risk?
7. Do electronic medical records lead to fraudulent documentation?
8. Are hospitals the primary beneficiaries of the health IT stimulus?
9. How the widespread adoption of electronic medical records can raise health care costs
10. Are poor products to blame for the slow adoption of EMRs?
11. Op-ed: Why doctors still balk at electronic medical records

Now HIT funding and adoption seems inextricably woven into the fabric of the "stimulus package".  Healthcare now has additional responsibilities that go way beyond patient care.  Healthcare now accounts for a significant portion of the GDP, and is now the recipient of "stimulus" money at the taxpayer's largesse. Thus adds to the chaos and dysfunction of taking care of 'a patient'.

It now becomes more difficult for the doctor to make correct treatments for the patient, since he now has to worry about how his decisions and orders effect overall health budgets.  

 

del.icio.us Tags: healthtrain express,emr,hitech,emr adoption

Health Train's New Track

Make everything as simple as possible, but not simpler. Albert Einstein

 

Are they Listening? Apparently so. Providers now have an eager, and respected voice at one of the ‘decision making’ levels in the bureaucracy of those inside the “beltway”. David Blumenthal the new head of ONCHIT has made some public statements in regard to ‘haste makes waste’. In his recent statements in the April 9, 2009 edition of the NEJM Dr Blumenthal reiterates what most all providers already know. “Keep it simple”.

Dr. Blumenthal, most recently director of the Institute for Health Policy at Massachusetts General Hospital/Partners HealthCare System in Boston, states in the NEJM article that one challenge for HITECH is a tight schedule. "The infrastructure to support HIT [health information technology] should be in place well before 2011 if physicians and hospitals are to be prepared to benefit from the most generous Medicare and Medicaid bonuses," he writes. Appointed last month as the national coordinator for health information technology in the Department of Health and Human Services, internist David Blumenthal, MD, will play a key role in implementing a portion of the American Recovery and Reinvestment Act dubbed the Health Information Technology for Economic and Clinical Health (HITECH) Act.

Don't Force Physicians to Buy User-Unfriendly Systems

What those standards and policies will look like is Dr. Blumenthal's other big worry. According to HITECH, only a certified EHR system qualifies for a bonus, yet the law doesn't specify who will perform the certification. There's a contender in the wings — the Certification Commission for Healthcare Information Technology (CCHIT) — but Dr. Blumenthal writes that many CCHIT-certified programs "are neither user-friendly nor designed to meet HITECH's ambitious goal of improving quality and efficiency in the health care system."

Other “power players” in the advisory role for HIT, David Kibbe, Sam Karp, and Ben Park all summed it up by stating the following:

All the EHR authorities interviewed by Medscape Medical News agreed with Dr. Blumenthal's assertion that physicians will feel more motivated to use EHRs if third-party payers reimburse them for improving the quality and efficiency of healthcare. Family physician Ben Park, MD, an EHR user for 30 years and CEO of a 200-physician network in Indiana and Ohio, said more pay-for-performance programs and their reliance on data collection would hasten EHR adoption, assuming payers put more money on the table. "Right now, it's peanuts for performance," he said.

For many physicians and HIT advocates, the "meaningful use" requirements of HITECH represent another unsettling question mark because they have' not been fully spelled out. For example, physicians must use their EHRs to report how they perform on clinical quality measures that HHS has yet to select, but which will lean toward the management of high-cost, chronic diseases. Dr. Blumenthal warns in his NEJM article that the bar for meaningful use could be set too high, frustrating physicians and hospitals. Sam Karp recommends starting low, with quality measures as elemental as receiving lab results electronically, or reducing adverse drug interactions (made possible by automatic alerts that pop up during electronic prescribing).

Don't Force Physicians to Buy User-Unfriendly Systems

What those standards and policies will look like is Dr. Blumenthal's other big worry. According to HITECH, only a certified EHR system qualifies for a bonus, yet the law doesn't specify who will perform the certification. There's a contender in the wings — the Certification Commission for Healthcare Information Technology (CCHIT) — but Dr. Blumenthal writes that many CCHIT-certified programs "are neither user-friendly nor designed to meet HITECH's ambitious goal of improving quality and efficiency in the health care system."

Dr. Park's desire for higher pay also applies to the HITECH incentives, which he considers too low. Sharing his view is Micky Tripathi, president and CEO of the nonprofit Massachusetts eHealth Collaborative, which has helped some 600 physicians implement EHR systems. Based on his group's experience, Mr. Tripathi estimates that $44,000 in incentives under Medicare would cover only about two thirds of a physician's EHR costs over 5 years.

"The way this program is currently structured, the odds are quite low that EHRs will get high adoption," Mr. Tripathi said.

del.icio.us Tags: onchit,blumenthal,healthtrain express,karp,nejm,ehealth collaborative,ehr,hie,cchit,hhs,hitech

HIMMS REPORT from iHealthbeat

Federal Stimulus Package Hot Topic of This Month's Annual HIMSS Conference

This Audiocast  Special Report from iHealthbeat discusses the overall view of new funding of health IT.

New Stimulus package incentive payment estimates

Newly Named Health IT Chief Addresses Federal Stimulus Funding

And it just keeps getting better and better. "I'm from the government and I am here to help you."

Recovery

Recovery Dialogue:

IT Solutions
For one week beginning April 27th, The Recovery Accountability and Transparency Board and the Office of Management and Budget in partnership with the National Academy of Public Administration, will host a national online dialogue to engage leading information technology (IT) vendors, thinkers, and consumers in answering a key question:

What ideas, tools, and approaches can make Recovery.gov a place where all citizens can transparently monitor the expenditure and use of recovery funds?

Participants from across the IT community will be able to recommend, discuss, and vote on the best ideas, tools, and approaches. Your ideas can directly impact how Recovery.gov operates and ensure that our economic recovery is the most transparent and accountable in history. Mark your calendars and check back for the web link and additional information.

New NIH Recovery Act Opportunity Seeks to Fund High Impact, Large-Scale, Accelerated Research

Monday, April 13, 2009

Goal to Promote Growth and Investment in Biomedical R&D, Public Health and Health Care Delivery

The National Institutes of Health highlighted a new funding opportunity under the Recovery Act that will support approximately $200 million in large-scale research projects that have a high likelihood of enabling growth and investment in biomedical research and development, public health and health care delivery. The purpose of this new program, the Research and Research Infrastructure "Grand Opportunities" (GO), is to support high impact ideas that lend themselves to short-term funding and may lay the foundation for new fields of scientific inquiry.

Read More.

 

del.icio.us Tags: healthtrain express,recovery.gov nih recovery act opportunity,health information technology vendors