Will 2015 be the year your watch teaches you about your health?

There is no known medical condition that enables an individual to predict the future. While such an ability would be extremely useful for myriad reasons, we have, instead, learned to hone and leverage our analytic skills to deduce what might occur, relying on the data we cull and parse to help forecast the future. So, when it comes to predicting the year ahead, we should consider the one we just had.

Regardless of which side of the exam table you sit, we’re all healthcare consumers

Consumer technology is often a good indicator of what type of capabilities and functionalities might be in store for health IT. This past year, we saw major players in the tech space announce their forays into healthcare. While this will not be without its challenges, it does not diminish the underlying fact that there is a need and want for better technology in healthcare— regardless of whether you are a patient looking to effectively manage your weight or a physician struggling to juggle patient care and administrative duties.

In the last year, we saw a wave of next-generation wearable devices flood the market, and as a result, we, as patient consumers, now have streamlined access to information such as our daily step count and average heart-rate on our watches. We know that ease-of-use, understandability, and some level of gameification:

“Congratulations! You’ve reached your target heart rate today!”

are vital to maintaining engagement.

I believe this is the beginning of something much larger, a groundswell movement that will result in patients wanting more information about their health data, and, more importantly, craving a better understanding of what all these numbers actually mean and how to positively impact them. Achieving this level of engagement demands a simpler intelligent interface that doesn’t require a learning curve, but is one that consumers can just use. Clever user interface designs can only go so far, particularly given the small visual real estate available on wearable devices, and the addition of capabilities such as intelligent voice assistants will be an integral part of this explosion of personal health management.

Having a heart-to-heart about your heart

Technology holds the potential to create clinical synergy, bringing patient consumers (who have become professional health IT consumers, or health prosumers) better intelligence about their personal health data and outlining the proactive measures they can take to become better partners in their own health. The average patient consumer may not have a reaction to the phrase

“Your Protime this week is 3.3,” but for someone with a heart condition, this number is very important and indicates how fast her blood is clotting. The data, while extremely useful to a clinician, is only helpful to the patient if she understands what it means and how she can take the right actions as a result.

The future is about patients managing their own care and working alongside clinicians to drive better outcomes. To the woman who has a Protime of 3.3, access to these results supplemented with clinical guidelines would mean that she wouldn’t need to wait for her physician to call with diet recommendations, she would know her blood is clotting too slowly and that she might have an inadequate protein consumption or might need to increase her vitamin K intake. If the number required that her Coumadin dosage be adjusted, this would be the point where her physician would reach out to her to discuss.

Although a basic example, it is one that has endless permutations when it comes to building a more engaged patient population. There is no one more invested in your health than you, and the person who cares the next most about keeping you well, is your physician. I believe that clinical synergy will be driven by both patients, who want to actively manage their chronic conditions and take meaningful preventative care measures, and physicians who want to empower their patients to better understand how the choices they make have significant health implications. Technology is the connective fiber that can enable the transmission of this important data, and help translate it into wisdom. And that truly is the crux—the data flowing between patient and physician must be relevant and meaningful. That ability for technology to determine the relevancy of health data information is just around the corner and soon our wearables will be able to notify our health information data that deviates from our personal “normal” results.

Approximately 75 percent of U.S. healthcare expenditure is related to chronic care management, imagine the impact this level of clinical synergy will have on driving a healthier population while reducing cost. I’m ready, are you?

This post originally appeared on WhatsNext

Bridging the Digital DIvide

This week I will be at the Medicine 2.0 Conference on a panel Bridging the Patient Digital Divide moderated by
Melody Smith Jones

and includes
Lauren Still

and
Nick Genes

The session was put together by Melody to take on the oft talked about but perhaps poorly understood “Digital Divide”. Patients spend less than 1% of their time with doctors - the balance of our time represents (lost) opportunity to interact with people helping them live fulfilling healthy lives and making the best possible choices.

On average, patients only spend 1% of their time in the clinical care setting.  Traditional medicine has focused upon patient engagement during that eight minute doctor visit.  Yet, it is the other 99% of the time, when patients are at home, at work, at school, and in their communities that matters most.  It is outreach to patients while they are living, working, and playing that determines how their overall wellness is managed.

We have seen a plethora of technologies that attempt to address this area with everything from diet and fitness apps to specific applications designed to address long term health issues.
But there is variability with access in the community to information technology preventing access and knowledge and skills necessary to derive the value from these tools. Melody has addressed this divide specifically focusing on apps doe Low-Income Mothers in her recent post: 3 High Health Apps for Low-Income Moms. Check out Melody’s top 3 picks for low income mothers - some great apps focusing on the Food stamps including clever use of Bar code scanning technology to check eligibility of food and the nutritional value and a novel use of simple text messaging to improve maternal and newborn health <----- approach="" font="" love="" of="" simplicity="" the="" this="">

As she points out many of us make assumptions about accessibility to technology in lower social economic groups- as she puts it

Many make an assumption that those with low income or low education levels would not have mobile technology to use in the first place

But despite the budgetary restrictions we see a very high level of adoption of mobile technology - this is true worldwide as demonstrated by the statistics of mobile phone in the world: More People Have Cell Phones Than Toilets, U.N. Study Shows.

Out of the world’s estimated 7 billion people, 6 billion have access to mobile phones. Only 4.5 billion have access to working toilets.

In one of my personal areas of passion - Africa that is replete with examples of successful use of technology to impact the health of the population at levels that we can only dream of here in “the West".  Here in this study: Text message reminders improve healthcare practice in rural Africa
and this piece in the Atlantic: Medicine by Text Message: Learning From the Developing World

It might seem counter intuitive to spend money on what some might consider a luxury or discretionary spend - but for some this is the only means of communication replacing the plain old telephone line (POTS) and these devices come with capabilities and a reach that was pervasively unavailable to many in our society. The statics suggest as many as 80% of low income consumers own a mobile device.

But despite this opportunity the technology and apps are often times targeted at the higher income who already have fitter healthier lifestyles. Some of this is because of the existing developer community (higher social economic group) who develop for the problems they perceive and the harsh economics - this is where the money is (or at least we think it is). Despite Malaria being such a big killer there is limited investment in prevention and treatment of the disease as it affects the poor nations with limited capacity to buy any solutions that are developed despite significant progress and the impact of World Malaria Day

This was covered eloquently by J.C. Herz at wired in this piece: Wearables Are Totally Failing the People Who Need Them Most. We are awash with wearables, new devices and new apps and buckling under a Tsunami of data but:

...developers continue flocking to a saturated market filled with hipster pet rocks, devices that gather reams of largely superficial information for young people whose health isn’t in question, or at risk. It’s a shame because the people who could most benefit from this technology—the old, the chronically ill, the poor—are being ignored. Indeed, companies seem more interested in helping the affluent and tech-savvy sculpt their abs and run 5Ks than navigating the labyrinthine world of the FDA, HIPAA, and the other alphabet soup bureaucracies.

There are some economic reasons for these current trends, some social aspects of the development community but these may be based on false belief of the economics when you consider the opportunity exists to shake up the $2 trillion annual cost of chronic disease….!
I’m with Kabir Kasagood, director of business development for Qualcomm Life who said

Go from the children’s table to the grown-up table...If you’re serious about this, embrace the FDA. Learn how HIPAA works... move away from fitness and go hardcore into health. That’s where the money is

Around 45% of US adults are dealing with at least on chronic condition and picking on one Diabetes and look at the market opportunity of $6.3 Billion spent on blood glucose strips gives you a sense of the economics of this market. These are motivated people for whom the quantified self can mean the difference between an (expensive) admission to hospital or managing and improving at home.

At some point, you’ve got to ask yourself whether it’s just the friction created by health-industry regulation—the HIPAA security rules and FDA approval (or waiver) process and the hassle of integration with legacy systems. Or is it too daunting for a twenty-something engineer to develop technology for people who aren’t like them at all? An obese diabetic on a motorized scooter? Or a frail old lady with memory loss? Or her caregiver? Someone who’s three bus transfers away from a doctor’s office? 

We plan to address these issues in our panel - if you can’t join us maybe you can join the conversation using the hash tag from the conference #Med2 here at Symplur

Health Insurance Reform - It's Not a Bumper to Bumper Warranty

We have some Healthcare reform in the US but we are still challenged with a system that is failing to deliver results. This piece recently: America Ranks No. 1 for Over-Priced, Inefficient Health Care featured the chart from the Commonwealth fund

That ranks the US last in a group of 11 industrialized countries.

As he puts it:

There is one way America is clearly exceptional:  we have a healthcare system that is dramatically more expensive than the rest of the industrialized world, but it doesn’t manage to make us any healthier.While  the Affordable Care Act attempts to address access it does little to address the cost of the system and the inefficiencies. This does not require a reduction in premiums it needs to address the costs built in to the system that we are all paying for in on form or another

Dr Hans Duvefelt wrote this piece on the healthcare blog: A Swedish Country Doctor’s Proposal for Health Insurance Reform that draws on his personal experience in "socialized medicine, student health, cash-only practices and government-sponsored rural health clinic working for an underserved, underinsured rural population."

His focus is as a primary care physician but most would agree this is one of the most challenging areas for reform with the shortage in clinicians and low reimbursement rates that is driving doctors out and certainly no encouraging our new generating of clinicians to dive into this essential area.

His main proposals center on basic services that are covered by a flat rate for populations

• Have the insurance company provide a flat rate in the $500/year range to patients’ freely chosen Primary Care Provider, similar to membership fees in Direct Care Medical Practices.
• Provide a prepaid card for basic healthcare, free from billing expenses and administration.

but importantly changing the responsibility and feedback on the cost from a central purchasing authority (the government for example) to the user themselves.

• Unused balances can be rolled over to the following years, letting patients “save” money to cover copays for future elective procedures.

And offers a pathway to specialty care with some appropriate oversight and appriroate levels of reimbursement.

• Keep prior authorizations for big-ticket items, both testing and procedures, if necessary for the health of the system.
• Keep specialty care fee-for-service.

 These are clever suggestions and would do much to encourage the patient engagement that will be, as Leonard Kish stated

Patient Engagement is the  Blockbuster drug of the century

He rightly points out that the current health “insurance” products are often poorly named - given that insurance that pays and copiers to identify diseases with screening but then stops short of paying to treat conditions and diseases when they are found through that screening. But most of all Insurance should be user driven and priorities and decision left in the hands of the individual and their clinician and not relegated to others who sit in offices emoted from clinical practice and focused on fiscal drivers not on care and quality fo life

Health insurance is not like anything else we call insurance; all other insurance products cover the unexpected and not the expected. Most people never collect on their homeowners’ insurance, and most people never total their car. Health insurance, on the other hand, is expected by many to be like a bumper-to-bumper warranty that insulates us from every misfortune or inconvenience by covering everything from the smallest and most mundane to the most catastrophic or esoteric.

His point about setting of priorities is important - no matter how you cut it there is no unlimited pot of money o resources to treat everything and everybody. These are difficult conversation and ripe for abuse by those with their own agenda’s through fear mongering and use of emotive terms like “Death Panels”.

None of this aspect of reform is simple but it needs to be addressed and included.

The United Kingdom’s National Health Service (NHS) may not be perfect but they have started this process of addressing the challenge of allocating resources in an open manner. They developed the the quality-adjusted life years measurement (QALY) out of the National Institute for Health and Care Excellence (NICE). There has been criticism and push back as there will always be but the concept and methodology use is not limited to the UK. While imperfect as Laozi (c 604 bc - c 531 bc) stated:
A journey of a thousand miles begins with a single step

There is lots of detail in this piece and I would encourage you to go over and read it

Are you "Under Observation"

This is not news for many in the healthcare profession as they face the challenges of billing rules and regulations and the sometimes obscure idiosyncrasy - but as you can see form this piece on NBC for many patients this is a surprise and a costly one at that

Visit NBCNews.com for breaking news, world news, and news about the economy

Hospitals are told that they "have to" use this status (Under Observation) if the patient doesn't meet a host of criteria for "Admission" all being driven by a series of guidelines that are publicly available although not well known and much of it in response to the RAC audits
All this is set to get worse with the “Two Midnight” rule (you can see some guidance here and some of the issues on this here)

Thanksgiving, Decency and End of Life - Be Thankful you had the conversation now #health

Patients deserve the same standard and car that doctors receive when they need treatment. But as I have said before (Doctors Die Differently and more recently Treatment Creep in Medicine - sucking Decency out of Patients) we remain challenged especially when it comes to dying.

This piece by Dan Gorenstein, How Doctors Die: Showing Others the Way touched on these issues in a moving a thoughtful way.

Dr. Elizabeth D. McKinley’s battled breast cancer for 17 years but this past spring discovered the cancer had spread to her liver, lungs and brain. Her choice was to undergo more treatment that would have potentially debilitating and mind altering effects on her or change course, accept death and work on getting the best out of what was left of her life...as she put it

..time with her husband, a radiologist, and their two college-age children, and another summer to soak her feet in the Atlantic Ocean...“a little more time being me and not being somebody else.” 

And some of her fight was with her own family - the non-medical members

clinging to the promise of medicine as limitless

And the medical members of her family (her husband is a radiologist)

looking at her disease as doctors, who know the limits of medicine

Its not a difference in the effects of disease and death but rather an advantage of knowledge and information that lead to truly informed decisions "doctors have control over their quality of life before they die and this sadly is control that eludes most other members of society" and it would appear especially try here in the USA. More than half of deaths take place in hospital and not at home surrounded by people we love which is the way most say they want to "go".

So if you do nothing else this Thanksgiving - take the time to talk about the subject with the people you love and create and advance directive or living will. In many respects no better way to be thankful than to set out what is important and let everyone know, now when you are fit and healthy.

Wishing you all a very happy family and friend fill Thanksgiving

Treatment Creep in Medicine - sucking Decency out of Patients

This recent post on the Atlantic: How CPR Became So Popular reminded me of a piece I wrote some time back - Doctors Die Differently. As I said then:

Its not that doctors don't want to die, its just that they knwo they know enough about modern medicine to know its limits, importantly they have talked about this with their families as they want to be sure that no heroic measures will be used during their last moments in this reality

And the chart demonstrating the big discrepancy between what doctors want in life saving measures vs the general public pretty much said it all

So this piece in the Atlantic took it a step further - tracing the history of CPR from the 1960 at Johns Hopkins where the surgeons had

...successfully resuscitated every one of the first 20 patients they treated, 14 of whom (70 percent) survived without brain damage or other ill effects

But their source patients were not typical (young and mostly healthy) and when you extrapolate that out to an elderly population survival can fall to as low as 0% a variation in the effectiveness when performed in the real world
But it was Hollywood adn the media that pushed these procedures into the general awareness suggesting

...that two-thirds of all (fictional) cardiac arrests portrayed on ER (and other doctor shows) involved young patients who had suffered rare events like drowning or lightning strikes, rather than old people with heart disease (who account for 90 percent of cardiac arrests in real-life settings.....most of these fictional TV patients did well, unlike the vast majority of CPR recipients in real life

Dr Peter Benton was well known as all in life saving heroics



In fairness Hollywood was dramatizing some real life events - and they applied their pixie dust to this as they have to many other things.

But the problem remains and health care professionals need to help their patients understand their disease and make good choices, bearing in mind that heroics and life saving may well be a significant driver as it was for Stephen Jay Gould who was diagnosed with a rare and deadly cancer with a median survival of eight months...but as he said in his essay "The Median Isn't the Message".

this median survival means that one-half of patients die within eight months but the other half live longer. Most important, because the mesothelioma survival curve has a very long “tail,” a few lucky patients will live a lot longer

In his case his experimental treatment may have contributed to his 20 year survival past the original diagnosis...leaving a legacy of hope.

Science at Work - Number Of Early Childhood Vaccines Not Linked To Autism

A new study from the Centers for Disease Control and Prevention finds no link between the number of vaccinations a young child receives and the risk of developing autism spectrum disorders.

Jeff J. Mitchell/Getty Images

A large new government study should reassure parents who are afraid that kids are getting autism because they receive too many vaccines too early in life.

The study, by researchers at the Center for Disease Control and Prevention, found no connection between the number of vaccines a child received and his or her risk of autism spectrum disorder. It also found that even though kids are getting more vaccines these days, those vaccines contain many fewer of the substances that provoke an immune response.

The study offers a response to vaccine skeptics who have suggested that getting too many vaccines on one day or in the first two years of life may lead to autism, says Frank DeStefano, director of the Immunization Safety Office of the CDC.

To find out if that was happening, DeStefano led a team that compared the vaccine histories of about 250 children who had autism spectrum disorder with those of 750 typical kids. Specifically, the researchers looked at what scientists call antigens. An antigen is a substance in a vaccine that causes the body to produce antibodies, proteins that help fight off infections.

The team looked at medical records to see how many antigens each child received and whether that affected the risk of autism. The results, published in The Journal of Pediatrics, were unequivocal.

"The amount of antigens from vaccines received on one day of vaccination or in total during the first two years of life is not related to the development of autism spectrum disorder in children," DeStefano says.

The finding came as no surprise to researchers who study the immune system, DeStefano says. After all, he says, kids are exposed to antigens all the time in the form of bacteria and viruses. "It's not really clear why a few more antigens from vaccines would be something that the immune system could not handle," he says.

The study also found that even though the number of vaccines has gone up, the number of antigens in vaccines has gone down markedly. In the late-1990s, the vaccination schedule exposed children to several thousand antigens, the study says. But by 2012, that number had fallen to 315.

That dramatic reduction occurred because vaccines have become much more precise in the way they stimulate the immune system, DeStefano says.

“ The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, [researchers are] missing the opportunity to look at what the real causes are. It's not vaccines.

- Ellen Wright Clayton, professor of pediatrics, Vanderbilt University

Hardcore vaccine skeptics are unlikely to be swayed by the new research. But many worried parents should be, says Ellen Wright Clayton, a professor at Vanderbilt University who helped write a report on vaccine safety for the Institute of Medicine.

"I certainly hope that a carefully conducted study like this will get a lot of play, and that some people will find this convincing," Clayton says. That would let researchers pursue more important questions, she says.

"The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, they're missing the opportunity to look at what the real causes are," she says. "It's not vaccines."

Autism Speaks, a major advocacy and research group, seems ready to move beyond the vaccine issue. Geraldine Dawson, the group's top scientist, praised the new study and says the result should clear the way for research on other potential causes of autism.

These include factors like nutrition, which can affect a baby's brain development in the womb, Dawson says. Other factors could include medications and infections during pregnancy, she says, or an infant's exposure to pesticides or pollution.

"As we home in on what is causing autism, I think we are going to have fewer and fewer questions about some of these things that don't appear to be causing autism," Dawson says.

via npr.org

More coverage and science referring to a recent study showing no link between vaccines and autism. This was covered in the SBM Site
The Final Nail in the Coffin - sorry if some of yo have trouble getting to the site as it appears to be having problems

As one commentator articulated

"The sad part is, by focusing on the question of whether vaccines cause autism spectrum disorders, they're missing the opportunity to look at what the real causes are, It's not vaccines."

If you are interested in a detailed analysis of the science and statistical analysis the SBM article is excellent. The analysis

They sliced and diced the data in a variety of ways looking for correlations and didn’t find any

And does an in depth debunking of the lack of science in the broadside from antivaccinationists who's fear mongering seems to date back to the widely and roundly debunked falsification of data by Andrew Wakefield that was described as the most damaging medical hoax of the last 100 years. He was struck of the GMC register and barred from ever practicing medicine in the UK.

As David Gorski in his title the study had not intended to disprove the relationship between the "toxins" used as part of vaccine make up. This study came as close as one can to disproving that relationship:

Which brings us to “too many too soon.” It appeared to be a “hypothesis” that was impossible to falsify, but DeStefano et al came about as close as it’s ethically possible to do to falsifying the hypothesis. No wonder that all that antivaccinationists are left with are calls for “vaxed versus unvaxed” studies and pharma shill ranting.

Science at work!

Posted via email from drnic's posterous

Why EHRs Really Haven’t Made Us Healthier: A Response To Glen Tullman

Brian Klepper

Brian Klepper, Health Care Analyst and TDWI Writers’ Group

Glen Tullman

Recently-fired Allscripts CEO Glen Tullman waxed progressive in a self-promotional Forbes article last week, describing the ways past and forward for electronic health records (EHRs) and health information technology (HIT). It may have been a way of trying to recover from a damning New York Times article that clearly illustrated the relationships between campaign contributions, influence over health information technology policy, and business success.

Tullman recalls building EHRs that moved many physicians away from paper and the errors it fosters. He calls out David C. Kibbe, MD as an example of the forces wanting to preserve paper and opposing EHRs, with quotes from a 2008 blog post suggesting that the current crop are “notoriously expensive,” “difficult to implement” and unable to demonstrate care quality improvements. He predicts that, in the future, the industry will leverage open platforms and interoperability, yielding new monitoring and management utilities that can facilitate better care at lower cost.

Tullman’s forecasts are hardly news, and there are two problems with his portrayals. The first is the dissonance between what he says now and actually did. Tullman became a multi-millionaire crafting products and policy that delivered intentionally costly, unfriendly and incompatible systems. Under his leadership, Allscripts products never embraced a national standard for health information exchange, even though those standards were available, or developed the capacity to seamlessly trade information with other systems.

As a Trustee of the Certification Commission for Health Information Technology (CCHIT), a quasi-governmental credentialing agency and offshoot of the Health Information Management Systems Society (HIMSS), he oversaw policies that favored large, established HIMSS members and set up roadblocks to innovation by technology startups. I testified on this topic to a Health and Human Services (HHS) panel in July, 2009. HHS subsequently rescinded CCHIT’s monopoly on EHR certification, and CCHIT’s Executive Director, Mark Leavitt, resigned shortly afterward.

Tullman’s strong support of and relationship with President Obama facilitated his role as one of the architects of the Meaningful Use (MU) subsidies. Those actions brought billions of dollars to EHR vendors between 2010 and now, but these EHR systems still can’t talk with one another. As I’ve described elsewhere, even while the health IT industry extolled the benefits that would come from easy sharing of health data, they nearly unilaterally resisted interoperability. (If you can’t easily move your data to another vendor’s platform, you’re less likely to make them your vendor.) The result is that our inability to seamlessly exchange health information continues to undermine our ability to coordinate care, costing America thousands of lives and hundreds of billions of dollars a year.

Tullman also paints Kibbe and the American Academy of Family Physicians (AAFP) as obstacles to HIT progress, when in fact it was Tullman and his EHR vendor colleagues who engineered the barriers to interoperability. The quotes by Dr. Kibbe are taken out of context and misrepresent him as an opponent of EHRs. In fact – and Mr. Tullman knows this – Dr. Kibbe has been in the vanguard of EHR use. He was the lead architect of the Continuity of Care Record (CCR) standard, the forerunner of the Consolidated Clinical Document Architecture (CCDA) which has become the standard of choice for MU data structure during health information exchange. When he was Executive Director of the American Academy of Family Physicians’ Center for Health Information Technology (AAFP CHIT), his campaigns resulted in a five-fold increase in the percentage of family physicians with EHRs, from 10 percent to 50 percent between 2003 and 2007. Today, he spearheads DirectTrust, an approach to securely and privately transfer health information by email, independent of platform. If anyone has moved health information generally and EHR technology specifically forward in this country to the common benefit, it is Dr. Kibbe. By contrast, Mr. Tullman has represented the special interest, blocking advances to make as much money as possible.

Physicians, purchasers and patients should take umbrage at Tullman’s article. Along with EPIC, Cerner, NextGen and other old guard EHR vendors, Tullman and Allscripts are directly responsible for most current EHRs’ outrageous costliness, lack of usability and interoperability, and their limited clinical decision support. Through their scale and influence over policy, they have effectively manipulated the EHR market, gouging purchasers and delivering marginally capable products. Health care costs more, and outcomes have suffered as a result.

Most Forbes readers won’t have enough health industry background to place Tullman’s comments into context. They are opportunism masquerading as good policy. Past performance is indicative of what we can expect in the future. Caveat emptor.

Tagged as: Allscripts, CCHIT, CDA, Continuity of Care Record Standard, Electronic Health Record Technology, Glen Tullman, health information technology, HIMSS

via thedoctorweighsin.com

Nice piece responding the the disingenuous quotes and references taken out of context suggesting David Kibbe is against implementation of EHR's. HE like many of us is in favor but has long been an advocate of and vanguard of EHR use

Dr. Kibbe has been in the vanguard of EHR use. He was the lead architect of the Continuity of Care Record (CCR) standard, the forerunner of the Consolidated Clinical Document Architecture (CCDA) which has become the standard of choice for MU data structure during health information exchange. When he was Executive Director of the American Academy of Family Physicians’ Center for Health Information Technology (AAFP CHIT), his campaigns resulted in a five-fold increase in the percentage of family physicians with EHRs, from 10 percent to 50 percent between 2003 and 2007. Today, he spearheads DirectTrust, an approach to securely and privately transfer health information by email, independent of platform. If anyone has moved health information generally and EHR technology specifically forward in this country to the common benefit, it is Dr. Kibbe

Quite! Long standing advocate and unlike many of the commercial interests who spend much time, energy and resources blocking open access.

There remain challenges and the competing interests embedded in commercial incentives but to call out an icon in #HealthIT and unnecessary

Posted via email from drnic's posterous

Bitter Pill: Why Medical Bills Are Killing Us

via healthland.time.com

THere is something fundamentally wrong and flawed with a system that bills patients at highly variable rates, the highest to those with no "insurance" or poor "insurance".
Insurance in this instance seems like a poor term to describe a system that even with full standard coverage still costs patients thousands if not tens of thousands of dollars of unexpected cost.

It has gotten worse and as the McKinsey study cited in the article highlights

we spend more on health care than the next 10 biggest spenders combined: Japan, Germany, France, China, the U.K., Italy, Canada, Brazil, Spain and Australia. We may be shocked at the $60 billion price tag for cleaning up after Hurricane Sandy. We spent almost that much last week on health care. We spend more every year on artificial knees and hips than what Hollywood collects at the box office. We spend two or three times that much on durable medical devices like canes and wheelchairs, in part because a heavily lobbied Congress forces Medicare to pay 25% to 75% more for this equipment than it would cost at Walmart

There are many drivers but central to them are the disconnect between the payers and the people accessing care. Without any personal accountability it is easy to access the care with no thought of the cost or the possible alternatives and better choices.

Some of the reasons behind this are vested in the history of healthcare and how we got here - but just because that was the way it was done before does not mean it is the way we have to do it now.

There has to be a better way - the same as there has to be a better way of compensating the healthcare providers fairly for the work they do. The system currently is designed to pay for things done not for outcomes and results. And clinicians are locked into a system that forces them to document in great detail, oftentimes repeating information that is already in the medical record - because if they don't they don't get paid
Many wi ll tell you the information is unnecessary and we see some of the effects with reports of duplicate data. So much better to capture decision making, real information and allow the documentation to be the communication tool between clinicians (which was always the original intent) and then determine the care provided and a fair compensation for the hospital, the provider and everyone involved for delivering that care (and importantly linked ot results not to just delivering the care)

I know I am hoping this is on a pathway to getting fixed. At some point I will be facing bills and challenges such as these - and since the education system (thats a whole other blog posting on the meteoric rise of education costs) has essentially stripped me of any savings and value in my one big investment (my house) I like many others are probably tapped out and have little to call upon when we will inevitably face these challenges. That puts me rooting for major change in healthcare, the system with a move to pay for performance much of which is embodied in the ACO initiative.

Posted via email from drnic's posterous

NY Times rewrites Health IT History

The approach came in 2009, in a presentation to doctors by Allscripts Healthcare Solutions of Chicago, a well-connected player in the lucrative business of digital medical records. That February, after years of behind-the-scenes lobbying by Allscripts and others, legislation to promote the use of electronic records was signed into law as part of President Obama’s economic stimulus bill. The rewards, Allscripts suggested, were at hand.

But today, as doctors and hospitals struggle to make new records systems work, the clear winners are big companies like Allscripts that lobbied for that legislation and pushed aside smaller competitors.

While proponents say new record-keeping technologies will one day reduce costs and improve care, profits and sales are soaring now across the records industry. At Allscripts, annual sales have more than doubled from $548 million in 2009 to an estimated $1.44 billion last year, partly reflecting daring acquisitions made on the bet that the legislation would be a boon for the industry. At the Cerner Corporation of Kansas City, Mo., sales rose 60 percent during that period. With money pouring in, top executives are enjoying Wall Street-style paydays.

None of that would have happened without the health records legislation that was included in the 2009 economic stimulus bill — and the lobbying that helped produce it. Along the way, the records industry made hundreds of thousands of dollars of political contributions to both Democrats and Republicans. In some cases, the ties went deeper. Glen E. Tullman, until recently the chief executive of Allscripts, was health technology adviser to the 2008 Obama campaign. As C.E.O. of Allscripts, he visited the White House no fewer than seven times after President Obama took office in 2009, according to White House records.

Mr. Tullman, who left Allscripts late last year after a boardroom power struggle, characterized his activities in Washington as an attempt to educate lawmakers and the administration.

“We really haven’t done any lobbying,” Mr. Tullman said in an interview. “I think it’s very common with every administration that when they want to talk about the automotive industry, they convene automotive executives, and when they want to talk about the Internet, they convene Internet executives.”

Between 2008 and 2012, a time of intense lobbying in the area around the passage of the legislation and how the rules for government incentives would be shaped, Mr. Tullman personally made $225,000 in political contributions. While tens of thousands of those dollars went to the Democratic Senatorial Campaign Committee, money was also being sprinkled toward Senator Max Baucus, the Democratic senator from Montana who is chairman of the Senate Finance Committee, and Jay D. Rockefeller, the Democrat from West Virginia who heads the Commerce Committee. Mr. Tullman said his recent personal contributions to various politicians had largely been driven by his interest in supporting President Obama and in seeing his re-election.

Cerner’s lobbying dollars doubled to nearly $400,000 between 2006 and last year, according to the Center for Responsive Politics. While its political action committee contributed a little to some Democrats in 2008, including Senator Baucus, its contributions last year went almost entirely to Republicans, with a large amount going to the Mitt Romney campaign.

Current and former industry executives say that big digital records companies like Cerner, Allscripts and Epic Systems of Verona, Wis., have reaped enormous rewards because of the legislation they pushed for. “Nothing that these companies did in my eyes was spectacular,” said John Gomez, the former head of technology at Allscripts. “They grew as a result of government incentives.”

Executives at smaller records companies say the legislation cemented the established companies’ leading positions in the field, making it difficult for others to break into the business and innovate. Until the 2009 legislation, growth at the leading records firms was steady; since then, it has been explosive. Annual sales growth at Cerner, for instance, has doubled to 20 percent from 10 percent.

“We called it the Sunny von Bülow bill. These companies that should have been dead were being put on machines and kept alive for another few years,” said Jonathan Bush, co-founder of the cloud-based firm Athenahealth and a first cousin to former President George W. Bush. “The biggest players drew this incredible huddle around the rule-makers and the rules are ridiculously favorable to these companies and ridiculously unfavorable to society.”

This industry, which was pioneered in the late 1970s, first gained widespread attention in 2004 when President Bush in his State of the Union speech called for digitizing national health records.

“After that, every technology C.E.O. wanting a piece of health care would have visited me every day if I had let them,” said David Brailer, whom President Bush appointed as the nation’s first health information czar. Over the next few years, Cerner and many of the other health care data companies increased their presence on Capitol Hill.

The records systems sold by the biggest vendors have their fans, who argue that, among other things, the systems ease prescribing medications electronically. But these systems also have many critics, who contend that they can be difficult to use, cannot share patient information with other systems and are sometimes adding hours to the time physicians spend documenting patient care.

“On a really good day, you might be able to call the system mediocre, but most of the time, it’s lousy,” said Michael Callaham, the chairman of the department of emergency medicine at the University of California, San Francisco Medical Center, which eight months ago turned on its $160 million digital records system from Epic. Michael Blum, the hospital’s chief medical information officer, said a majority of doctors there like the Epic system.

Whatever the case, the legislation has been a windfall to top executives at the leading health records companies. Neal L. Patterson, who grew up on a farm near Manchester, Okla., population 100, co-founded Cerner in 1979. As Cerner’s sales have soared in recent years, so have Mr. Patterson’s fortunes. From 2007 to 2011, he received more than $21 million in total compensation, according to the executive compensation research firm Equilar, and his stake in the company is worth $1 billion.

In recent years, Mr. Patterson and his wife, Jeanne Lillig-Patterson, who ran as a Republican for Congress in 2004, have emerged as social and business leaders in the Kansas City, Mo., area. Mr. Patterson is also co-owner of a real estate development firm whose ventures include a 1,200-acre community near Kansas City called the Village of Loch Lloyd, featuring a Tom Watson-designed golf course.

A spokeswoman for Cerner said Mr. Patterson was unavailable for comment.

The medical records industry did not have much of a presence in Washington before President Bush highlighted it in 2004. Then in November that year, the industry created its first association, the Healthcare Information and Management Systems Society EHR Vendor Association, to make the case for electronic records. Its founding members included Allscripts, Cerner and Epic.

Four years later, in December 2008, H. Stephen Lieber, chief executive of the group, wrote an open letter to President-elect Obama calling for a minimum government investment of $25 billion to help hospitals and physicians adopt electronic records. The industry ultimately got at least $19 billion in federal and state money.

In the months after that windfall arrived, sales climbed for leading vendors as hospitals and physicians scrambled to buy systems to meet tight timetables to collect the incentive dollars. At Allscripts, Mr. Tullman soon announced what looked like a game-changing deal: the acquisition of another records company, Eclipsys, for $1.3 billion.

“We are at the beginning of what we believe will be the fastest transformation of any industry in U.S. history,” Mr. Tullman said when the deal was announced.

Last spring, some of the Eclipsys board members left after a power struggle; Mr. Tullman left in December. He is now at a company he co-founded that focuses on solar energy — another area that, after Obama administration and Congress expanded government incentives in the 2009 stimulus bill, has been swept by a gold-rush mentality, too.

This article has been revised to reflect the following correction:

Correction: February 20, 2013

An earlier version of this article omitted part of the name of the institution that employs Michael Callaham and Michael Blum. It is the University of California, San Francisco Medical Center, not the San Francisco Medical Center.

via nytimes.com

To use Paul Harvey's line....now here's the rest of the story
Yes the stimulus has increased uptake of technology but in so many respects money well spent - would anyone challenge that our old system of single access paper records that were full of redundant, duplicate information, much of it inaccessible and certainly of limited value to the care of complex clinical conditions and management of patient health....this time borrowoign from Monty Python...if we were lucky

No comment about the significant positive job impact - big increase in healthcare jobs and employment

And as one commentator put it in another thread:

There's a good bit of history rewriting in this article

As they pointed out much of the competitive landscape had been formed prior to the Act and they were delivering profits long before the stimulus package

We are seeing the benefits and value of these technologies. Many forget it was not the government that sent us down this track
1999 - To Err is Human
2001 - Crossing the Quality Chasm
2006 - Preventing Medication Errors
Not to mention other countries who have demonstrated the value of Healthcare Technology.

Is it perfect - probably not but if this was the tipping point to push everyone towards the same goal then it has had the desired effect, and like many technologies, its good for you on its own, but so much better if everyone participates.

I'm excited to be part of this "Tipping Point" and glad to be working with one of the top 50 disruptive companies in this space.

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Khan Academy Approach Poised to Solve a "Wicked Problem" in Healthcare

here

via thedoctorweighsin.com

Great article on the potential for social media in healthcare and highlighting the phenomenal job the Salaman Khan has done (of the Khan Academy,/a>) with education online.
There are some nice examples of use of video and social media to help in patient engagement and education and as David Chase points out addressing the exploding number of patients who will be accessing the healthcare system will need these kind fo tools and techniques if we are going to be abel to cope and keep up

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A shift in how healthcare is paid for

CHELMSFORD, Mass. — It's hard work being one of Dr. Damian Folch's diabetic patients.

If a lab test shows high cholesterol, Folch is quick to call or email. No patient can leave the office without scheduling an annual eye exam, a key preventive test. A missed exam or an appointment leads to another call.

"We are a real pain in their necks," joked Folch, a primary care physician in suburban Boston. "We track them down."

That kind of attention has always been good medicine. For Folch, 59, it's now good business. He is among thousands of physicians in Massachusetts whose pay depends on how their patients fare, not just on how many times they see them. If patients stay healthy and avoid costly medical care, he gets more money.

This simple shift in how healthcare is paid for — long seen as key to taming costs — has been occurring in pockets of the country. But nowhere is it happening more systematically than in Massachusetts, the state that blazed a trail in 2006 by guaranteeing its residents health insurance. Now Massachusetts, a model for President Obama's 2010 national healthcare law, may offer another template for national leaders looking to control health spending.

"There have been few greater periods of change in American medical history … and this is the epicenter," said Dr. Kevin Tabb, a former chief medical officer at Stanford Hospital and Clinics in Northern California who now heads Beth Israel Deaconess Medical Center, one of Boston's leading hospitals. "It is striking how different Massachusetts is from the rest of the nation."

In the last three years, commercial insurers in the state have moved nearly 1 million patients into health plans that reward doctors and hospitals that control costs while improving quality.

About 180,000 Massachusetts seniors are on track to get care from physicians paid this way by Medicare through a new initiative included in the national health law. And this summer, state lawmakers passed legislation aimed at moving 1.7 million government employees and Medicaid recipients into similar health plans.

Within a few years, close to half of the state's 6.5 million residents could be in a health plan that pays for medical care in a fundamentally different way.

Massachusetts' move to reshape how healthcare is financed is still in its infancy. And the state continues to have the nation's highest medical costs, spending nearly 50% more per person than the national average.

That has fueled skepticism from conservatives who see too much government involvement and from liberals who say the state should more aggressively set medical prices. "I don't see how we can rely on market forces," said Nancy Turnbull, associate dean of the Harvard School of Public Health.

But early research in Massachusetts suggests the approach may be slowing health spending. And medical providers, business leaders and elected officials are increasingly hopeful they are making headway.

"Whether this is sustainable remains to be seen," said James Roosevelt Jr., president of Tufts Health Plan, one of the state's largest insurers. "But there is a broad consensus that it makes more sense to pay for healthcare this way."

The building block of the Massachusetts experiment is a contract between insurers and groups of doctors known as a global payment. In such contracts, physicians receive a budget to care for a cohort of patients. If doctors can care for their patients more economically, they keep a portion of the savings. If patient care exceeds the budget, they pay a penalty.

That is supposed to encourage physicians to keep their patients healthier and direct them to lower-cost hospitals and specialists.

If poorly designed, the arrangement can create a financial incentive to skimp on care. That perceived problem undermined earlier experiments with global payments and provoked a backlash against managed care in the 1990s.

"The most widespread attempts to do this failed," acknowledged Andrew Dreyfus, president of Blue Cross Blue Shield of Massachusetts, the state's largest health plan and a leading proponent of the new generation of global payment contracts. "There was no quality measurement.... It was really just about dollars."

In a key change, Blue Cross now links its contracts to dozens of quality metrics that track whether patients get the right screenings and exams, whether doctors and hospitals prescribe the correct drugs — even whether patients are satisfied with their care. That means a doctor who withholds care in hopes of saving money faces a penalty if patients suffer or are unhappy.

In Folch's suite outside Boston, these measurements have been transformational.

On a shelf in his tidy office are reams of spreadsheets, updated constantly, that outline how each of his patients is faring, which tests they have taken and which are due. With bonus payments from Blue Cross, he has hired new aides and installed a new computer system to better track his patients.

"We had to change the way we practiced," Folch said.

Folch also had to explain to patients why he wants them to get X-rays, eye exams and other routine care at the community hospital rather than at one of Boston's famous teaching hospitals, where an MRI that normally runs about $1,100 can cost as much as $1,650.

That wasn't easy.

"I try to explain that I'm not throwing them to the lions. I am referring them to people that I go to," Folch said. "If you have some rare form of cancer, then of course we're going to, say, get a second opinion.... But I had a lot of difficult conversations at first."

Some patients quit his practice.

Change has not come easily around the state, particularly for hospitals that depend on filling beds, not on keeping patients healthy enough to prevent hospitalizations.

"It's a dramatic reorientation," said Dr. Tom Lee, an executive with Partners HealthCare, the state's dominant hospital group.

Medical practices like Folch's are already making significant strides, however.

Between 2008 and 2011, the percentage of Folch's patients getting recommended colorectal cancer screenings increased from 61% to 82%. The share of patients with cardiovascular conditions managing their cholesterol jumped from 75% to 89%. And last year, all of Folch's diabetic patients successfully managed their cholesterol and had their yearly diabetic eye exams.

"If he sees something he doesn't like, he contacts me right away," said Bill Wooster, a 59-year-old sales representative who began seeing Folch after having a stroke four years ago. "I'm his patient, but I feel like more of a friend."

Those results are mirrored elsewhere. Statewide, the quality of care provided by physicians in a Blue Cross contract like Folch's — known as an Alternative Quality Contract — outpaced that of other medical providers, according to an analysis by Harvard Medical School researchers published in the journal Health Affairs.

Although the cost savings were modest, healthcare spending increased more slowly for the Blue Cross medical practices compared with others. Patients were hospitalized less and used fewer expensive services like advanced imaging. "These results suggest that global budgets with pay-for-performance can begin to slow underlying growth in medical spending while improving quality of care," the researchers concluded.

It's unclear whether other states, especially those where political resistance to the national health law remains fervent, will follow Massachusetts' lead on cost control. "Much of the rest of the country is still battling over the merits of covering everybody," said Alan Weil, president of the National Academy for State Health Policy.

In Massachusetts, however, the reforms remain very popular. "This has allowed me to be a better doctor," Folch said. "And it's better for my patients."

noam.levey@latimes.com

via latimes.com

A simple idea that is not news as I have pointed out on several occasions
Universal Health Care – Pay While You are Healthy and Reassessing Primary Care.
The Chinese principle of paying the local doctor while you are well may seem like an oversimplification but as Einstein said

Everything should be made as simple as possible, but not simpler

This seems like a really simple and a great strategy - it would help to capture data in sufficient detail to be able to demonstrate value and quality in the population. The capture of this data would be secondary to the actual health management and delivery of care that is keeping patients well. Unlike the current system which focuses on the documentation as verification of clinical activity and consumes much of the doctors time. I'm willing to bet most clinicians would be supportive of any system that focuses on the care and generates sufficient information to demonstrate the health improvement rather than burdening the care providers with data entry tasks.

 

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How Speech Recognition Improves Military Medical Care

via fedtechmagazine.com

Dr Robert walker among a growing band of physicians finding benefit in dictating in front of his patients. As he puts it:

Before I started dictating in front of patients, I would have said I don’t make many mistakes. But now once or twice a week they correct me — they say it was their left knee, not their right, or that the accident happened two weeks ago, not last week. In that way, the patient verifies what’s going into their medical record, and it gives them ownership of it.

Speech brings efficiencies that saved the Army $3 Million but the process of creating the medical record in front of the patient brings additional quality control and greater detail in the medical record.

The tips to help successful adoption are good but I would include the primary requirement is good training and configuration

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The Terrifying State of "Unaccountable" Healthcare

via online.wsj.com

The latest book exposing the healthcare system and how broken it is from Dr Makary a surgeon from Johns Hopkins. As he says

Meet 'Shrek,' a doctor who insists on surgery in every case—and has a surgical-incision infection rate of 20%.

and more troubling

He quotes a recent Hopkins survey of employees of 60 high-quality hospitals, where more than half of the respondents said they would not feel comfortable receiving care in the unit in which they work

He makes the case for flat rate payment that removes the incentive for steering care to individual specialties devoid of any decision making that is for the benefit of the patient.

Take pancreatic cancer, half of Dr. Makary's practice at Hopkins. With only a 15% cure rate, surgery is the only hope. But if the cancer is inoperable, patients may be offered chemo and radiation, which confer minimal benefit and yet make money for doctors and hospitals

There are detractors to this and without incentive there is a corresponding decline in efficiency so finding a balance between these two competing ideals seems necessary

Looks like another book to add to the reading list

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