The last article in this series — Time for EHRs to Become Plug-and-Play — used words to describe a major industry shift underway in health IT.

Sometimes pictures help to make a point. Here are several diagrams that you can also download as PowerPoint slides.

 Computer Industry 1983 to 2002

  Source: Venkatraman, N. Winning in a Network Centric Era, 2006

Blueprint for Health IT Shift

From EMR 1.0 — 2008…

…to Clinical Groupware/EHR 2.0 — 2012 (more…)

by Scott Shreeve, MD

We are entering an unprecedented season of change for the United States health care system. Americans are united by their desire to fundamentally reform our current system into one that delivers on the promise of freedom, equity, and best outcomes for best value. In this season of reform, we will see all kinds of ideas presented from all across the political spectrum. Many of these ideas will be prescriptive, and don’t harness the power of innovation to create the dramatic breakthroughs required to create a next generation health system.

We believe there is a better way.

This belief is founded in the idea that aligned incentives can be a powerful way to spur innovation and seek breakthrough ideas from the most unlikely sources. Many of the reform ideas being put forward may not include some of the best thinking, the collective experience, and the most meaningful ways to truly implement change. To address this issue, the X PRIZE Foundation, along with WellPoint Inc and WellPoint Foundation as sponsor, has introduced a $10MM prize for health care innovators to implement a new model of health. The focus of the prize is to increase health care value by 50% in a 10,000 person community over a three year period.

The Healthcare X PRIZE team has released an Initial Prize Design and is actively seeking public comment. We are hoping, and encouraging everyone at every opportunity, to engage in this effort to help design a system of care that can produce dramatic breakthroughs at both an individual vitality and community health level.

Here is your opportunity to contribute: (more…)

The remarkable report, “Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home,” published in the May/June issue of Annals of Family Medicine, the Nutting Report, makes this point about the state of primary care IT offerings:

Technology needed in a PCMH is not “plug and play.” The hodge-podge of information technology marketed to primary care practices resembles more a pile of jigsaw pieces than components of an integrated and interoperable system.

Surprise!  Well, actually, no surprise.  We all recognize that health IT implementation in family practices, even under the best conditions and with the best of planning, is difficult and can be an ongoing challenge.   

What is surprising to us, however, is that Dr. Nutting and co-authors make this comment in their recommendations section:

…[I]t is possible and sometimes preferable to implement e-prescribing, local hospital system connections, evidence at the point of care, disease registries, and interactive patient Web portals without an EMR. (more…)

What if the health care payer were re-imagined as a service to the primary care doctor – supplying the tools, information and funding primary care physicians needed to meet the call to reform health delivery?

The structure of physician payment is considered one of the most problematic aspects of our health care system.  Driven by volume instead of coordinated, proactive care and favoring procedures over cognitive work, the payment system has driven primary care into decline and stifled improvements in quality and efficiency.  Indeed, primary care physicians are overstressed and demoralized by demands, coming from every direction, that drive them only to see more patients, as quickly as possible.   In this state, primary care cannot attract new physicians at a time when an expansion of the primary care workforce is desperately needed.  Without new primary care doctors, how will medicine meet the future volume demands of the aging “baby boomers”, much less deliver the kind of comprehensive approach to patient health needed to correct the defects in today’s care?  Despite these growing concerns, little in the way of innovation is arising from payers.

So, what if the payer model was re-imagined?  What would such a payer look like?  At ESSENCE Healthcare, we have developed the Collaborative Payer Model (CPM), which takes the first steps at answering these questions. 

The CPM brings a new approach to address what is missing in much of health care reform, including: (more…)

The forthcoming definition of the “meaningful use” of health information technology will set the direction of the Obama administration’s strategy for health IT adoption, said David Blumenthal, the new national coordinator for health IT. Government HealthIT, April 28, 2009

…but not everyone sees eye-to-eye on the definitions of “meaningful use” and “certification”.  [See the first post in this series for a refresher on the dog (disruptive innovator) and cat (incumbent EHR vendor) points of view.]

Markle Foundation –  Best Articulation of the Dog (Disruptive Innovator) POV 

Achieving the Health IT Objectives of the American Recovery and Reinvestment Act
A Framework for ‘Meaningful Use’ and ‘Certified or Qualified’ EHR
Markle Foundation; April 30, 2009

HIMSS and EHRA — Best Articulation of the Cat (Incumbent EHR Vendor) POV 

HIMSS Publishes Its Definitions of ‘Meaningful Use’
HIMSS News; April 27, 2009

HIMSS Electronic Health Record Association Executives Testify at NCVHS Hearings on ‘Meaningful Use’ Criteria
RedOrbit; April 28, 2009

Many Others Weigh In…. (more…)

For those of you who have not seen earlier posts in this series, please understand that the reference to “goes to the dogs” is a great compliment.

In a joint press release, the American Medical Association and Covisint unveiled an agreement yesterday:

Compuware Corporation (NASDAQ: CPWR) announced today that its Covisint subsidiary signed an agreement with the American Medical Association (AMA) to deploy an innovative health information exchange solution delivering value to its 240,000 member physicians and the physician population at large….

Covisint will enable AMA physicians to have access to a variety of health information technologies via an AMA-branded, web-based solution.  The AMA said it will use the Covisint platform to deliver to physicians a variety of products, services and resources aimed at increasing medical practice efficiency and facilitating the adoption of health information technology (HIT), including help with implementing electronic health records (EHRs). Current product categories that the AMA is exploring include: practice management tools, resources for professional development and clinical management services. The new platform will provide personalized content, search capabilities and learning and networking opportunities, among other valuable offerings

The features of Covisint’s offering are described on its website.

This deal is a  slap in the face to incumbent EMR vendors who have been attempting to develop the electronic plumbing in physicians’ offices for the past decade. You could interpret it as a vote of no-confidence in EMR vendor abilities to develop these web-based collaboration and care coordination tools.  It’s at least a strong expression of “we’re not going to wait around to see whether you can extend your existing EMRs with these types of capabilities”.

…and it’s a strong validation for the technologies and business models of emerging, innovative companies enabling EHR 2.0 capabilities, e.g., RMD Networks, Shared Health.

What are some other possible implications?

(more…)

by Deven McGraw JD, MPH, Center for Democracy & Technology

Introduction

There has been considerable discussion lately about whether or not the stimulus legislation (ARRA) extends HIPAA coverage to commercial vendors of personal health records (PHRs) any time they contract with entities already covered by HIPAA like hospitals, health plans or physicians groups.  (For those of you who don’t know, HIPAA is the Health Insurance Portability and Accountability Act of 1996.  The HIPAA privacy and security regulations form our national health privacy and security rules.)

The provision in question (Section 13408) states that “each vendor that contracts with a covered entity to allow that covered entity to offer a personal health record to patients as part of its electronic health record” is required to enter into a business associate agreement with the covered entity.   Under ARRA, business associates must comply with key provisions of the HIPAA privacy and security regulations. 

In this post, I argue that PHR vendors should be covered under HIPAA only under certain circumstances.  PHRs should be governed by a comprehensive framework of privacy and security protections, but HIPAA would provide inadequate privacy protection for people using these tools (at least as the HIPAA rules are currently structured).  As a result, I argue that this provision in ARRA should not be read to require the automatic application of HIPAA to PHR vendors any time they contract with covered entities to offer a PHR.   Instead, I suggest that HIPAA should cover a PHR vendor’s activities when the nature of the relationship between the vendor and the covered entity (hospital, health plan, physician office) primarily concerns the vendor performing a service for the covered entity. 

However, where the contractual relationship is primarily about improving the value of the PHR to the consumer, HIPAA should not apply.  (I know, not an easy line to draw – but I do suggest some factors that should influence the decision.) 

Finally, I urge the prompt adoption of separate, targeted privacy provisions to protect consumers using PHRs so that the choice is not HIPAA or limited protections under other federal laws. 

Why Not HIPAA – Isn’t it Better Than Nothing? (more…)

Modifications to HIPAA Privacy Laws: Impact on Microsoft HealthVault, Google Health, and other PHRs. 

We’ll explore how recent changes in privacy provisions of  ARRA/HITECH Federal stimulus legislation affect personal health information (PHI) platform companies (e.g., HealthVault, Google Health,  Dossia) and personal health record (PHR) companies.

Health IT expert and journalist Neil Versel described the issue in the April 7 issue of BNET Healthcare:

Although Google and Microsoft have gotten plenty of attention for their Web-based personal health records, both companies have long maintained that they’re not bound by the privacy protections of a 1996 federal law known as HIPAA. And despite a recent HIPAA change — one intended to extend its privacy provisions to services like Google Health and Microsoft’s HealthVault — both companies still insist they’re not bound by the law.

…“Our understanding is that HITECH, which is the jargon for [the health IT] part of the legislation, did not change the definition for a covered entity or a business associate, so our service is offered directly to the consumer,” Google Health Product Manager Roni Zeiger told Modern Healthcare last month. “[O]ur understanding is that we are neither a covered entity nor a business associate,” he continued. “We’re providing a service directly to the consumer or a patient.”

Microsoft offered a similar assessment at the annual Healthcare Information and Management Systems Society conference in Chicago. “We’re still outside [of HIPAA],” said David Cerino, general manager of Microsoft’s Health Solutions Group.

Not everybody agrees with Microsoft and Google. Versel commented in his own blog:

Excuse me? I’ve been struck since Day 1 with the arrogance Google seems to be exhibiting with its entry into healthcare …  it seems to me Zeiger is intimating that the law doesn’t apply to Google.

In the BNET article, Versel also quotes David Brailer, the first head of the Office of the National Coordinator for Health Information Technology at HHS: (more…)

What a difference in attitude! Compare two press announcements from April 5:

1) CCHIT:  Interoperability Isn’t Doable With Today’s Technology .

Certification Commission for Health Information Technology (CCHIT), Interoperability: Supplying the Building Blocks for a Patient-centered EHR , April 5, 2009

This report…(is)  also an attempt to inject a dose of reality into the discussion of interoperability – from practical expectations for the near term and future years to the challenges of developing software architecture and implementation guides that can execute new interoperability criteria uniformly and successfully.

2) New York Presbyterian/Microsoft: We’re Creating Patient Data Liquidity Today!

New York-Presbyterian Hospital Pioneers New Personal Health Record, Press Release; April 6, 2009

Patients can reference their actual, up-to-date health records, which are organized and stored through Microsoft’s Amalga and HealthVault technologies and stored by the patient in a personal account following visits to their hospital, doctors and health care providers.

(more…)

One of the potential dangers of limiting $17 B HITECH federal stimulus funds to electronic health records (EHRs) is the risk of locking-in outdated technologies. Let’s consider what this might mean.

If you think of today’s EHR technology as EHR 1.0, what might EHR 2.0 look like? This post presents a number of innovative ways to conceptualize EHR 2.0:

• EHR as Platform + Applications
• EHR as Clinical Groupware
• EHR Integrated with PHR
• EHR as Software-as-a-Service (SaaS)
• EHR as a “Publish-Discover” Search Engine
• EHR + Disease Management Services = Care Coordination
• DRT-Enabled EHR

My point here is not to provide an exhausting listing of what’s possible, but simply to get you to begin to think about what’s outside the existing EHR box. These concepts are not mutually exclusive and you’ll see there’s overlap.

Let’s look at each of these innovative approaches. (more…)

On March 24, Stand for Quality — a new group representing 165 diverse health care organizations — called for a new era of quality in health care. Their white paper is titled Building a Foundation for High Quality, Affordable Health Care: Linking Performance Measurement to Health Reform .

The perspectives of Stand for Quality are a remarkable break from the past and have significant implications for future investment in health information technology. The Stand for Quality document unequivocally supports the dog  (disruptive innovator) POV — that providers should be paid for improvements in quality and outcomes. It rejects the cat (incumbent EHR vendors and supporters) POV — that providers should be reimbursed for simply acquiring health IT , with the expectation that quality will naturally follow.  (For a refresher on definitions of the dog/cat POV, see the first post of this series .)

Stand for Quality is a who’s who list that includes substantial representation from the physician, hospital, and health plan communities, as well as many others.  A listing of initial supporters is provided at the bottom of this posting.

The key recommendations of the white paper are:

• We must improve quality in health care and make it more affordable.
• Performance measurement is a core building block to provide high quality affordable care
• Public investments are needed to support the performance measurement, reporting and improvement enterprise.
• We should build upon the existing public-private performance measurement, reporting and improvement enterprise.
• Investment in health information technology should be linked to improving care (emphasis added).
• Performance measurement must be dramatically expanded, but measurement alone is not enough.

From having barely been on the radar screen six months ago, is the dog (disruptive innovator) POV rapidly becoming the majority perspective? Here’s the text from the 5^th recommendation:

(more…)

Even though I am a self-admitted dog person, Hoover is my buddy.

Hoover got a new shoebox as a Christmas present.  While most cats are very tied to their existing surroundings and don’t like things to change, Hoover is not your average cat.

The following photos were taken over about a two week period. Hoover hopes you enjoy them! (more…)

Sometimes laws are passed and the statute itself represents 95% of the work — there aren’t many details to figure out or loose ends to tidy up.

That isn’t the case with HITECH. The HITECH statute is just the beginning.

Whether you’re a cat or a dog, you’ll have hopes and fears about aspects of HITECH that are unclear or yet to-be-determined (TBD).

These include:

(more…)

What do cats (incumbent EHR vendors and their supporters) have to smile about over HITECH?

A lot.

…and it’s not very complicated.  HITECH directs $17 B to the cat community, and leaves scraps for the dogs.

(As a refresher, the cat POV is that HITECH stimulus funds should simply pay directly for electronic health record (EHR) technology — that providers will figure out how to use the technology to improve quality and outcomes; the dog POV is that HITECH should pay for improved quality and outcomes — change incentives and IT will naturally follow. See the first post in this series for more detailed explanations.)

There are three aspects of HITECH that are particularly favorable to cats: (more…)

Download a copy here .  Excerpts from the Executive Summary:

Effective Interventions

Three types of interventions have been demonstrated to be effective in reducing hospitalizations for Medicare beneficiaries with multiple chronic conditions who in general are not cognitively impaired:

• Transitional care interventions in which patients are first engaged while in the hospital and then followed intensively over the 4 – 6 weeks after discharge
• Self-management education interventions that engage patients for 4 -7 weeks in community-based programs designed to “activate” them in the management of their chronic conditions
• Coordinated care interventions that identify patients with chronic conditions at high risk of hospitalization in the coming year, conduct initial assessments and care planning, and provide ongoing monitoring of patients’ symptoms and self-care working with the patient, primary care physician, and caregivers to improve the exchange of information. …In-depth analysis of program details has revealed that six
  key components distinguished the successful…programs from the ineffective ones:

(more…)

In the first post of this series, I suggested that HITECH favors cats by about 60/40 and noted that the single most cat-like feature of HITECH is providing incentives for physicians and hospitals to acquire and implement EHRs  — but only EHRs. Reader “Mark” commented:

“How does this work out to 60/40? Looks to me like 100% cats.”

Let’s look a bit deeper to see how HITECH creates opportunities for disruptive innovation . (As a refresher, the cat POV is that HITECH stimulus funds should simply pay directly for EHR technology — that providers will figure out how to use the technology to improve quality and outcomes; the dog POV is that HITECH should pay for improved quality and outcomes — change incentives and IT will naturally follow. See the first post for more detailed explanations.)

The next three posts in this series will examine various aspects of HITECH from differing points-of-view:

• What’s dog-like (innovative)?  — today’s post.
• What’s cat-like (protecting incumbents)?
• What’s yet to-be-determined (TBD) or unclear?

The Need for Innovation

Lack of innovation is the heart of the problem in today’s health IT marketplace. Writing specifically about the market for hospital EHRs, my colleague David Kibbe and I have previously characterized the prevalent HIT business model:

• Proprietary, non-interoperable software
• Low volume, high margin sales (there are only about 5,000 hospitals in the country)
• Customers (hospitals) have high needs for installation support and customization. Customization for individual customers further challenges opportunities for creating interfaces and achieving interoperability.
• High costs of purchase and installation result in high switching costs and customer lock-in.

We questioned whether interoperability was in the economic interests of current health IT vendors:

• Interoperability will tend to commoditize data and reduce opportunities for high margin pricing
• Interoperability will reduce customer needs for software customization
• Interoperability will reduce switching costs and potential for lock-in
• Although it might seem contradictory…hospital customers aren’t asking for it

The market for physician EHRs is very similar.

What’s needed are technology and business models that will create disruptive innovation  in today’s HIT marketplace.

How Does HITECH Create Potential for Disruptive Innovation?

Here are five aspects of HITECH that lay groundwork for future innovation in health care: (more…)

It’s a mixed bag — HITECH legislation  is both dog-like (innovative) and catlike (protecting incumbents).  I’ll refresh your memory below on more specific definitions of cats and dogs.

Among many other reasons, HITECH is dog-like primarily because it has ended the question of WHETHER the U.S. is really serious about health IT reform.  HITECH spells out clear policy goals working toward interoperable health IT and dedicates an initial $19B in federal stimulus funds to begin the work. HITECH begins to create an environment for innovation in health care reform.

There are many open questions as to HOW best to go about this — how to spend the federal stimulus funds in ways that encourage innovation.

HOWEVER,

On balance, HITECH favors cats by about 60/40.

Why?

(more…)

Study breaks new ground in calculating the "normal impairment factor."

We know that poor health accounts for a considerable amount of productivity loss-anywhere from 1 ½ to 3 times direct medical costs.  The potential for disease prevention and disease management programs to reduce productivity loss has, for obvious reasons, caught the attention of healthcare purchasers.  But let’s be careful about making big claims to "recapture" productivity loss.  People find it tough to change health behaviors.  And, even if someone is perfectly healthy, they aren’t 100% productive 100% of the time!  (Possibly with the exception of the current reader.)

Although the association between poor health and reduced productivity is reportedly quite high, employers don’t know how much productivity loss can realistically be recaptured .  There is a need to quantify the portion of productivity loss that can be regained through health management strategies.

Without knowing that amount of impairment, employers and their population health management providers can’t set realistic objectives for their health and productivity strategies.  A recently published article in the Journal of Occupational and Environmental Medicine (Riedel et al with StayWell Health Management) sheds some light on this issue.

(more…)

They all relate to care coordination.  As shown in the diagram below from the Kansas Health Policy Authority (KHPA), there’s a lot of overlap.

A larger copy of the slide is available in this March 2 PowerPoint presentation by Marcia Neilsen , Executive Director, KHPA.

What are some of the implications?

(more…)

Part Medical Home 101,  part strategy session to rescue primary care, part revival meeting — the National Medical Home Summit held earlier this week in Philadelphia was an amazing event.

The optimism, energy, and dogged persistence of attendees and presenters was pervasive. The event was standing room only with another 200 people tuning in to a live Internet video cast.

Dr. Joseph Scherger captured the mood of the day when he proclaimed:

The Medical Home “model” has become the Medical Home Movement !

For those of you unable to attend, here are some key links and publicly available PowerPoint presentations:

(more…)

Here’s a recap:  On a Saturday evening Dorothy took her 86 year old aunt to a hospital in Montgomery, Alabama. Frustrated after an overnight stay in the ER which she said yielded “little treatment”, she requested a copy of her aunt’s medical records before leaving. When she was told that it was hospital policy to request records “in writing”, Dorothy escalated her requests for the records. Refusing to leave without the records, she was brought to the floor by security guards and arrested on charges of  criminal trespassing.

The Chicago Tribune reports that Dorothy has been VINDICATED! (more…)

Warrantee

War`ran*tee"\, noun. A written assurance that some product or service will be provided or will meet certain specifications.

Today when we buy practically any consumer item we expect a warrantee.

What’s the “warrantee” after you are discharged from a hospital?

Last September I wrote a post posing the question “What’s the Best Way to Get Hospitals Involved in Care Coordination? ” The short answer was:  Pay them to do it, take money away when they don’t — make hospitals accountable for their role in avoiding unnecessary readmissions.

President Obama’s FY 2010 Budget begins to project savings from avoiding unnecessary hospital readmissions. “Jumpstarting the Economy and Investing for the Future ”  lays the groundwork for hospitals being required to “warrantee” their services:

Improving Care after Hospitalizations and Reduce Hospital Readmission Rates. Nearly 18 percent of hospitalization of Medicare beneficiaries resulted in the readmission of patients who had been discharged in the hospital within the last 30 days. Sometimes the readmission could not have been prevented, but many of these readmissions are avoidable. To improve this situation, hospitals will receive bundled payments that cover not just the hospitalization, but care from certain post-acute providers the 30 days after the hospitalization, and hospitals with high rates of readmission will be paid less if patients are re-admitted to the hospital within the same 30-day period. This combination of incentives and penalties should lead to better care after a hospital stay and result in fewer readmissions—saving roughly $26 billion of wasted money over 10 years. The money saved will also be contributed to the reserve fund for health care reform. [p.28]

Will this be politically challenging? Not likely…this is a continuation of reforms started under President Bush.

The changes will be profound. (more…)

We have learned that coordinating care of patients — particular care of Medicare patients — is complex and time consuming for physicians.

A breakthrough study quantifies just how complex and challenging care coordination really is.  The study is reported in the February 17 issue of Annals of Internal Medicine and is entitled Primary Care Physicians’ Links to Other Physicians Through Medicare Patients: The Scope of Care Coordination :

We found that in a single year for just fee-for-service Medicare patients, the typical primary care physician needs to coordinate care with 229 other physicians working in 117 different practices…. The number of peers was greater for physicians treating patients with higher chronic illness burden, who may benefit the most from coordination.

My mental visualization of these networks is a series of spider webs.

The authors write that “Coordination involves complex activities that require conscious interactions between providers and between providers and patients, including timely transfer of accurate clinical information, effective communication between the involved parties, and shared decision making.”

The estimate of 229 physicians in 117 different practices is conservative: (more…)

What would you call health care software that:

• Is Web-based and networkable, therefore highly scalable and inexpensive to purchase and use;
• Provides a ‘unified view’ of a patient from multiple sources of data and information;
• Is designed to be used interactively – by providers and patients alike – to coordinate care and create continuity;
• Offers evidence-based guidance and coaching, personalized by access to a person’s health data as it changes;
• Collects, for analysis and reporting, quality and performance measures as the routine by-product of its normal daily use;
• Aims to provide patients and their providers with a collaborative workflow platform for decision support; and
• Creates a care plan for each individual and then monitors the progress of each patient and provider in meeting the goals of that plan?

I call this Clinical Groupware.  The term captures the basic notion that the primary purpose for using these IT systems is to improve clinical care through communications and coordination involving a team of people, the patient included.  And in a manner that fosters accountability in terms of quality and cost.

Clinical Groupware is a departure from the client-server and physician-centric EHR technology of the past 25 years, a fixed database technology that never really became popular.  It is a substantially new and disruptive technology that offers lower price of purchase and use, greater convenience, and is capable of being used by less skilled customers across a broader range of settings than the technology it replaces.

As the name indicates, Clinical Groupware is intended for use by groups of people and not just independent practitioners or individuals.  It is not the same thing as an electronic health record, but may share a number of features in common with EHRs, such as e-Prescribing, decision support, and charting of individual visits or encounters, both face-to-face and virtual.  Neither is Clinical Groupware bloated with extra features and functions that most providers and patients don’t need and, with good reason, don’t want to pay for.

Some Clinical Groupware may look and feel like a web-based "EHR lite." But Clinical Groupware aims to create a unified view of the patient, assembling health data and information that may be stored in many different places and in several different organizations – including HealthVault or Google Health — which most EHRs cannot do.   Clinical Groupware is an evolutionary approach to a shifting health economy in which doing more is not always equated with better care, and the physician or provider role is transforming from autonomous expert to advisor, partner, and guide.   It is also an organic response to the reality that most health care data in electronic format is dispersed across numerous organizations and companies – e.g. hospitals, labs, pharmacies, and devices – and provides a means of accommodating patient demands for a more participatory practice of medicine.

Let me give a couple of examples of this new and emerging class of health software. (more…)

“Where’s the single best place to get up to speed on how the Feds should  spend $20 billion to advance health information technology (HIT)?”

A colleague asked me this question a couple of days ago, and at first I hesitated.  Then it struck me — Matthew Holt’s The Health Care Blog has become the focal point for discussion of this critical topic.

Matthew’s very recent article — Cats & dogs: Can we find unity on health care IT change? — summarizes the two schools of thought that have emerged over the past two months.

His article is important and notable for a number of reasons:

• He crystallizes the two emerging schools of thought — the dog vs. cat POV (see below)
• He summarizes and links to many other key writings on the HIT spending topic
• He suggests that the dog and cat POV can be reconciled — that there’s a middle road
• He suggests several initial options to reconcile the differing schools of thought.  This discussion should continue.

If you’re interested in disease/care management, this is a topic you should be following closely. While the first decade of DM focused on a services based, call center model — the handwriting is on the wall that the next decade will focus much more on a technology based model.

Companies and organizations involved in disease/care management should be positioning themselves to take direct and indirect advantage of the Federal injection of funds.

Here’s Matthew Holt’s summary of the dog vs. cat perspectives: (more…)

These hilarious exchanges are from a book called ‘Disorder in the American Courts’.

They were recorded verbatim and published by Court Reporters that had the torment of staying calm and remaining professional while these exchanges were actually taking place.

ATTORNEY: This myasthenia gravis, does it affect your memory at all?
WITNESS: Yes.
ATTORNEY: And in what ways does it affect your memory?
WITNESS: I forget.
ATTORNEY: You forget? Can you give us an example of something you forgot?
___________________________________________

ATTORNEY: Now doctor, isn’t it true that when a person dies in his sleep, he doesn’t know about it until the next morning?
WITNESS: Did you actually pass the bar exam?
___________________________________________

ATTORNEY: The youngest son, the twenty-year-old, how old is he?
WITNESS: He’s twenty, much like your IQ. (more…)

Dr. Jaan Sidorov conclusively demonstrates his love for showmanship and rock by performing the latest Health Wonk Review at the Disease Management Care Blog.

This unretouched file photo shows Dr. S in his more serious and younger days.

Would you like to receive a complimentary issue of a new publication — Medical Home News ?  Click on the link and then on “Sample Issue” in the upper left corner.

Here’s a preview of the first issue:

• Introducing Medical Home News
• An Annotated Guide to the Medicare Medical Home Demonstration (MMHD)
• Subscriber’s Corner
• Johns Hopkins Lipitz Center to Assist Practices in Medical Home Demo
• National Medical Home Summit to be Held March 2nd – 3rd 2009
• Thought Leader’s Corner
• Industry News
• Catching Up With… Paul Grundy, MD

I’m honored to have been asked to serve on the Editorial Advisory Board of Medical Home News.

Like the Institute of Medicine’s (IOM) 2001 counterpart report, "Crossing the Quality Chasm," a new report from the National Research Council of the National Academies is complex, full of new ideas assembled from multiple disciplines, and is likely to have seminal importance in framing public policy from now on . "Computational Technology for Effective Health Care:  Immediate Steps and Strategic Directions " was released last Friday, January 9, 2009 in draft, but there is so much to comment on that I think it’s wise to begin with a quote from the committee that sums up the central conclusion:

In short, the nation faces a health care IT chasm that is analogous to the quality chasm highlighted by the IOM over the past decade. In the quality domain, various improvement efforts have failed to improve health care outcomes, and sometimes even done more harm than good. Similarly, based on an examination of the multiple sources of evidence described above and viewing them through the lens of the committee’s judgment, the committee believes that the nation faces the same risk with health care IT—that current efforts aimed at the nationwide deployment of health care IT will not be sufficient to achieve the vision of 21st century health care, and may even set back the cause if these efforts continue wholly without change from their present course. Success in this regard will require greater emphasis on the goal of improving health care by providing cognitive support for health care providers and even for patients and family caregivers on the part of computer science and health/biomedical informatics researchers. Vendors, health care organizations, and government, too, will also have to pay greater attention to cognitive support. This point is the central conclusion articulated in this report.  (emphasis added)

It would be difficult to find a more sober indictment of US health care IT policy and implementation over the past decade than what is contained here. The report is the result of many meetings and site visits beginning in April 2007. It was written by a committee chaired by William W. Stead, MD, Director of the prestigious Informatics Center at Vanderbilt University Medical Center, and includes not only some of the nation’s top academic computer scientists and health IT engineers, but representatives from the private sector (Google and Intel) as well. (more…)

What’s the right metaphor for Medicare Health Support (MHS), CMS’ major experiment with disease management for Medicare beneficiaries?  We prefer to look it as a bridge failure that presents an opportunity to improve future engineering and design.

We’ve now had the time to read, reread, and reread again the very recent report from Research Triangle Institute (RTI) — Evaluation of Phase I of the Medicare Health Support Pilot Program Under Traditional Fee-for-Service Medicare: 18-Month Interim Analysis .  Here’s a listing of our 8 key takeaway points:

1. There’s Sufficient Evidence to Conclude "MHS Didn’t Work As Expected"
2. Some Quality Measures in MHS Improved, Yet Outcomes Didn’t. Why?
3. MHS Suffered Execution Nightmares
4. Ronald Reagan Was Right — “Trust, But Verify”
5. MHS Has Implications for the Medicare Medical Home Demo (MMHD)
6. Be Wary of Claims from Pre-Post Studies
7. Differences Between Medicare and Commercial DM are Dramatic
8. The Guaranteed Savings Model is a Two Edged Sword

Let’s examine these at these one at a time. (more…)

“…the Medical Home initiative, as currently articulated, ironically fails to emphasize the complex chronically ill patient’s actual home. This represents a failure to recognize the profile of the highest-risk beneficiaries driving much of the high Medicare costs—that is those with or more chronic conditions and activity limitations…

“A promising way to strengthen and broaden the Medical Home initiative for high-risk Medicare beneficiaries may be to make their actual homes the central venue of primary health care. This could be accomplished through another reform agenda that specifically empowers family caregivers, home health and hospice nurses, social workers, therapists, and personal care aides. This agenda places primary care physicians, advanced practice nurses, and physician assistants as partners and advisors to ongoing multidisciplinary care teams in the patient’s home.”

Dr. Landers provides some examples of reforms to consider for pilot testing: (more…)

Thomas Wilson, PhD, DrPH

CMS has just released the 2nd Report to Congress evaluating the Medicare Health Support (MHS) program. MHS is Medicare’s most visible and significant demo focusing on chronic disease management.

We’ve been poring over the report and will provide more detailed analysis and implications later this week. This 2nd Report to Congress covers 18 months of data on this 3 year project. It provides far more details and substantiation than RTI’s first report, which only covered 6 months data.

However, there’s nothing in here to change our January 2008 conclusion:  The rumors of MHS’s death have NOT been greatly exaggerated.

Here are the five key findings: (more…)

Being big fans of Clay Christensen and his theory of disruptive innovation (DI), we have been awaiting his just-released book The Innovator’s Prescription: A Disruptive Solution for Healthcare .  The book is co-authored by Dr. Jerome Grossman and Dr. Jason Hwang.

We have mixed reactions.

The book is mistitled. It should have been titled "The Innovator’s Diagnosis". The book does a fantastic job at diagnosis (Dx) of problems in the U.S. health care system. It presents many new, innovative analytical frameworks and lenses through which to view the U.S. health system.

However, it’s weak on prescription (Rx): many of the proposed solutions are speculative, ungrounded, and/or defy political reality.

We understand that the very nature of disruptive innovation implies inevitable resistance from organizations that benefit economically from the status quo. But at some point a proposed solution becomes so disruptive that you have to suspend reality to believe that it could be adopted or implemented — and many proposed solutions in this book enter that realm.

(more…)

by Vince Kuraitis and David C. Kibbe MD, MBA

Have you ever heard anyone tell a happy story of how easy it is to get a copy of their paper medical records?

Departing Health and Human Services Secretary Mike Leavitt is laying the groundwork for this same story to apply to access to YOUR electronic personal health information.

Here’s an overview to what evolved into a long posting:

1. Analysis: The Leavitt Framework Uses the HIPAA Privacy Rule as a Baseline for Electronic Access to Personal Health Information
2. Implication: Extending the HIPAA Privacy Rule Could Restrict Your Electronic Access to Your Personal Health Information
   • A.The HIPAA Privacy Rule Should Not Be the Baseline for Governing Access to Your Personal Health Information
   • B. Examples: Extending the HIPAA Privacy Rule Creates Barriers and Confusion
3. Implication: Extending the HIPAA Privacy Rule Protects Incumbents at the Expense of Innovators Like Microsoft and Google
4. Conclusion: The Leavitt Framework Creates Bad Public Policy (more…)

The Population Health Impact Institute (PHII) has convened national experts to develop a practical, comparative-based system to help purchasers and payers evaluate the methods and results used in all kinds of population health management programs – including medical, case and disease management, benefit design, value-based purchasing and more.

Join us on Thursday, December 18 at 2:00 pm (EST) for a one-hour complimentary webinar to learn more about the PHII Methods Evaluation Process™ (MEP), including the:

(more…)

It seems likely that the Obama administration and Congress will spend a significant amount on health IT by attaching it as a first-order priority to the fiscal stimulus package. We take the President-elect at his word when he recently said:

"…we must also ensure that our hospitals are connected to each other through the Internet. That is why the economic recovery plan I’m proposing will help modernize our health care system – and that won’t just save jobs, it will save lives. We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year." (December, 6, 2008)

Whether the health IT money is well spent will depend on how it is distributed and what it buys. Most observers suppose that federal health IT investment dollars will be used to help doctors’ offices and hospitals acquire and implement electronic health record systems (EHRs or EMRs). These are commercial software suites for entering, storing and managing patient health data within a practice or health organization.

We agree that some of the federal health IT money should go to purchase EHRs, especially to doctors and hospitals in rural and under-served areas, which otherwise could not afford them.

The Easy, Wrong Solution

The easy solution would be to spend most of the health IT funds on EHRs. The EHR industry has made it easy by establishing a mechanism to "certify" EHR products if they incorporate certain features and functions.

But the easy solution would not be the right one. (more…)

This is the city: Los Angeles, California. I work here. I carry a badge blog. My name’s Friday.

Click here (short) or here (long) for Dragnet theme music.

A crime of disorderly conduct has been committed. The U.S. health care system is the prime suspect. My partner Gannon and I will investigate. (more…)

Vince

by Alexandra Drane and the Engage With Grace team

We make choices throughout our lives – where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don’t express our intent or tell our loved ones about it.

This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they’ve talked to them about their preferences.

But our end of life experiences are about a lot more than statistics. They’re about all of us. So the first thing we need to do is start talking.

Engage With Grace : The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences. And we’re asking people to share this One Slide – wherever and whenever they can…at a presentation, at dinner, at their book club. Just One Slide, just five questions.

Lets start a global discussion that, until now, most of us haven’t had.

Here is what we are asking you: Download The One Slide and share it at any opportunity – with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Let’s start a viral movement driven by the change we as individuals can effect…and the incredibly positive impact we could have collectively. Help ensure that all of us – and the people we care for – can end our lives in the same purposeful way we live them.

Just One Slide, just one goal. Think of the enormous difference we can make together.

(To learn more please go to www.engagewithgrace.org . This post was written by Alexandra Drane and the Engage With Grace team)

Yabut is a term coined by my esteemed colleague, the late Paul Fetrow.  It stands for “Yeah….but….”

Yabuts are the gotchas, the fine print, the details that affect the terms of any agreement.  For example, the telecom companies will tell you its easy to switch carriers now that we have number portability.  Yeah…but it will cost you $175 for an early termination fee.

Yesterday’s post ended with the optimistic observation that Google Health and Microsoft HealthVault have agreed in principle that the platforms will be open and interoperable. (Presumably) you’ll be able to either 1) move all your data from Google Health to HealthVault, or vice versa, and 2) be able to transfer data across networks, e.g., your doctor has signed up with HealthVault and the lab belongs to Google Health, but because the platforms are open and interoperable data will pass across the network and your doctor will get lab results seamlessly.

Again, the analogy here is the telephone network — where you know that you can pick up the phone and call anyone in the world, regardless of the technical networks required to pass your voice.

What are some of the yabuts to Google Health and Microsoft HealthVault exchanging data? In this case yabuts refers to customer lock-in tactics and switching costs that might be imposed. (more…)

The Election Is Over Edition

Thanks Louise!

What will the PHIN look like?  Will there be multiple, non-interoperable, competing networks or just one interoperable network?

This question is being answered with the best possible answer:  the PHIN is evolving as one, interoperable network.

Consider 3 scenarios:

• Scenario One: Status Quo — Your Personal Health Information Today
• Scenario Two: The PHIN — Multiple, non-interoperable platforms
• Scenario Three: The PHIN—Multiple, interoperable platforms

In this post, I’ll present  images of these scenarios as a foundation for a series of upcoming posts.  David and I will address questions such as “What’s really different about the PHIN? What elements create the transformative potential that has attracted Internet Titans to health care?”

Let’s take a look at these one at a time: (more…)

From what’s been said, the PCs are nice folks and will make good neighbors.  They’re friendly, many are Episcopalian, they like white picket fences, and they have barbeques on Sunday afternoons. The neighborhood they’re coming from is not as well off nor as pristine — they’re said to be suffering from urban flight.

The current neighborhood residents are generally quite well off.  They include the Employers, the Hospitals, the Health Plans, the Specialists, and the Disease Management clan.

The long-timers in the neighborhood are aware that parts of the world are not so well off and suffer from spiraling health care costs, inconsistent quality, and frustrated patients who don’t get coordinated care — but they don’t rock the boat too much because the system has generally been good to them.

Here’s the scene: this afternoon the Employers sponsored a pot-luck dinner to welcome the PCs to the neighborhood.  It was a festive event. The party’s over and everyone has gone back to their own houses.

What do the neighbors say about the PCs when they get back to the comfort of their own homes? Let’s listen in on a few discussions.

(more…)

The current draft of the PHR Certification Criteria specifies use of the HL7 Continuity of Care Document (CCD) as the only endorsed standard for interoperable exchange of information to and from PHRs.  This is extremely short-sighted.

I wrote a comment to the PHR Work Group explaining why it’s important to adopt BOTH the HL7 CCD and the ASTM Continuity of Care Record (CCR) .  I suspect most professionals commenting on these criteria will be looking through the lenses of health information technology, so I thought it would be important to share a different view — one through the lenses of business strategy and public policy.  Here’s my commentary:

(more…)

The basic premise of the medical home concept is continuous, uninterrupted care that is managed and coordinated by a personal provider with the right tools that will lead to better health outcomes.

In 2007, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, released the Joint Principles of the Patient-Centered Medical Home. In this document they state the characteristics of the Patient Centered Medical Home:

• Personal Relationship
• Team Approach
• Comprehensive
• Coordination
• Quality and Safety
• Expanded Access
• Added Value

While these characteristics, in theory, may be achieved without the use of health information technology (health IT), it is also true that their realization is more likely to occur if health IT is successfully deployed. Health IT can be an empowering facilitator to the establishment of a medical home, a fact supported by experience.
What is not obvious are the best ways in which health IT should be deployed to reach the objectives of the medical home desired by patients, providers, and payers. Nor is it clear that "one size fits all" when trying to match health IT products and services with the desired characteristics, and to do so in a manner that is affordable and sustainable across a variety of practice types, large and small.

Rather than attempt to list products or suppliers of health IT, e.g. electronic medical records, EMRs, as single "solutions" to the problem of transforming practices into medical homes, we suggest here that a wiser approach is to describe the capabilities that health IT ought to provide or enhance if a medical practice is to become a successful medical home. This approach has the advantage of being vendor-neutral, allowing for innovation, variation and choice in reaching the goal of the agreed upon medical home principles and characteristics listed above.

The list below of Empowering Health IT for the Medical Home is not intended to be complete or exclusive. Over time it may expand or be modified according to the evolution of both the concept of the medical home and the technologies themselves. This flexibility is necessary in a time of constant change. However, we believe this is a reasonable description of the health IT that will empower medical practices to become medical homes in the near future.

We define Empowering Health IT for the Medical Home as computer hardware, software, and related technology that provides or enhances: (more…)

An email from CMS arrived in my inbox this morning at 2 am.  That email notified me that they have updated the MMHD homepage .  A quick click lead me to 8 new documents containing 155 pages of newly available details on the MMHD.

If you have time to read just ONE document, take a look a this PowerPoint summary of the MMHD — it’s so fresh that it’s dated October 28, 2008.

Based on a quick perusal, here are some highlights about how the MMHD will be structured. To separate fact from opinion, I’ve put brackets [ ] around my commentary:

(more…)

Jason Shafrin of Healthcare Economist provides “700 billion reasons to read the Health Wonk Review ”.

Read about how the bail out might affect health care from the POV of:

• Wall Street
• Health Insurers
• Healthcare Reformers
• Doctors
• The Uninsured
• Kids

This toolkit describes how to implement the Chronic Care Model (CCM) in your medical practice. The CCM is embedded in the Patient Centered Medical Home (PCMH) model and can be consider a foundational element of the PCMH.

I would call this toolkit “The Medical Home for Dummies, Vol. I”, but then I’m sure the Dummies copyright police would knock on my front door, so I won’t.

Here are a few more details:

(more…)

Mark E. Miller, Ph.D., Executive Director, Medicare Payment Advisory Commission testified recently in front of the U.S. Senate Committee on Finance. He opened his remarks by stating:

The health care delivery system we see today is not a true system: care coordination is rare, specialist care is favored over primary care, quality of care is often poor, and costs are high and increasing at an unsustainable rate.

About a quarter of Mr. Miller’s testimony focused on an issue that hasn’t received much attention: avoidable hospital readmissions . Here are some key excerpts:

(more…)