No More Clipboard

Taking Dead Aim at Health Care

             For crushing observations on the state of health care in the U.S., February was a banner month.  We had Clayton Christensen and colleagues predicting the failure of Accountable Care, saying: “The Affordable Care Act’s updated versions of HMOs are based on flawed assumptions about doctor and patient behavior.”  Clayton Christensen, a Harvard professor and author of The Innovator’s Dilemma, is considered a giant in the field of innovation thinking.  In his book, The Innovator’s Prescription, Christensen points out that applying technology into old business models has only raised costs.  Persons familiar with Professor Christensen’s diagnostic record are reluctant to dismiss his conclusions.  

            Time Magazine devoted an entire issue to chronicle abusive hospital billing practices, a scorching litany of over-charging based on the price-gouging “Chargemaster” list of billable items behind which, it seems to Time Magazine, that there is no logic other than excess profit, and ironically the rule both in for-profit and in not-for-profit systems.  That these articles generated national conversation in weeks following the “Fiscal Cliff” and during the impending “Sequester,” indicates pervasive disgust with health care costs that bubbles up during Everyman’s conversations about the weather, the Final Four or the resignation of a Pope. 

            The two articles have more in common than being critiques of this or that feature of a dysfunctional health care system.  They go to the heart of culture change and in particular to behavior.  Christensen makes three points.  The success of an accountable care organization (ACO) relies on changing physician behavior, relies on changing patient behavior---primarily by enlisting “patient engagement”---and relies on yielding significant cash savings.  I personally disagree with Christensen that physician behavior cannot be redirected positively, especially given the greater number of physicians who are now employed by, and report to CEOs of each ACO system; improvement may be slow, but physicians respond to data that confirms progress.  It is more difficult to disagree when Christensen points to Congressional Budget Office estimates that predict that 32 advanced ACOs achieving their full desired impact produce savings over the next five years of only $1.1 billion, an amount that is insignificant against the total annual Medicare budget of $468 billion.  Finally, there is the essential matter of patient behavior.  Christensen notes that the 1990s model of HMO left consumers a bad taste because of the visible gatekeeper that limited their choices.  ACOs are launched against this background, and they remain, he says “on the hook for patients who don’t comply with recommended treatment or lifestyle changes.”  For example, the Northern ACO is responsible for the behavior of a patient who may spend half the year in Florida, receiving care there.  “In other words, ACOs hold caregivers accountable without requiring patient accountability.  How can this work?”  Christensen asks. 

            Time Magazine presents those of us who work in health care with a list of allegations many of which we can confirm from our own experience.  Patients who read the article, nod in agreement---what does it mean to receive notice of charges for a surgery totaling $154,000 on a piece of paper that says: “this is not a bill?”  What does it mean that a patient cannot get an accurate estimate of costs prior to receiving care?  What does it do to physician behavior when their knowledge of pricing is limited to hospital charges and not informed by the true costs of what they order?  What does it say when even the hospital has no accurate computation of its own costs?  It does not help that much of this behavior was initiated and is sustained by the insurance system itself, that patients are responsible for too little of their insured bill or are perhaps able to rely on Medicaid or charitable care.  In the new world of ACOs, under the Affordable Care Act and state-by-state, gaps in coverage are certain, and there will be no better cost visibility and scant reason to believe that patients will be engaged in cost control and designs for their own care.  In fact insurance exchanges in a system that may no longer provide subsidies for charitable care may leave inner-city hospitals reliant on Medicaid deeply in the red if they choose to continue to provide charity care. 

            If ACOs are to succeed, Christensen says, innovation will require greater systematic disruption: more use of walk in clinics, extensive use of technical applications such as “tele-health” remote care, greater use of nurse practitioners and care extenders and changes in regulations.  In fact, many of those things are waiting to happen, and many have been introduced that are gaining traction.  What is less assured is patient engagement.

             Patient engagement requires that the patient sit at the table on equal footing, communicating digitally with physicians, hospitals, insurers, laboratories and pharmacies.  Meaningful use regulations anticipate this by requiring that this technology be present to enable patient PHRs to communicate using standard formats, secure networks and mobile devices.  This anticipates linking the patient to more than a patient portal tethered to a particular hospital or clinic practice; such portals, little better than business cards, limit or even prevent useful patient interaction.  Patient engagement using digital devices, and logically the patients’ own personal health record, allow the level of interaction that serves the purpose of chronic disease management---without recourse to an emergency room visit and in avoidance of hospital admission.  Obviously, this creates significant savings but it also produces better health outcomes, and does so using fewer personnel and existing technology: the PHR, a secure network, mobile devices, portal connections, and even portable clinics.  A real-life clinic program, of this type, over the past five years has leveraged the difference between the $21,000 average cost of a single hospital admission for a diabetic patient against the annual cost of a digitally enabled clinic of $1500 per patient to produce cash savings and better control of diabetic symptoms.  It works in theory, and it works in the field.

             The same use of digital technology works to provide useful cost clarity for physicians using tablet technology, when ordering tests and medications.  A Southeastern, U.S., hospital system, using carefully computed true costs accessible from the physicians’ tablets, displays to doctors the actual cost of tests, medicines and devices as each item is ordered, producing a running total and a comparison to higher billed costs.  This affects physician and patient behavior.  For example using the example of a knee injury, if the true cost of an MRI is $280, obtaining the study prior to ordering 6 weeks of physical therapy may be less expensive.  The $1800 Chargemaster cost of the MRI can serve to cause the physician to avoid ordering imaging and to impose a cautious, prolonged waiting period when, had he sooner known the knee disruption would require surgical repair, he would have deferred physical therapy, in this case more costly than the MRI, to the appropriate time.  Physicians and patients cannot engage in partnering for efficient care when a Robin Hood-like system of internal cross-subsidies confuse the true costs of care for both physician and patient.  The physician’s tablet is linked to the patient’s PHR to receive orders, to explain medications, to display images and to accommodate patient education materials.  The combined use provides an accurate transfer of information, and it adds less than two minutes to a patient visit and saves numerous phone calls for both.  The PHR-stored information is available to the referring physician as well as to patient-selected family members however distant. 

             It is this combined use of technology, embracing patient engagement to facilitate efficient visits, to manage chronic disease, and to allow for care at a distance that will fuel the kinds of innovation encouraged by Professor Christensen and his colleagues.  In many hospitals, the EHR exists primarily to deliver coding for the purpose of maximizing billing, in addition of course to the more generic functions of data base searching and document management.  Additionally, the EHR provider often disallows connectivity even to secure software applications, “apps” from outside the walled-garden of the single source supplier.  This restriction not only drives higher pricing, that of the $100 million dollar hospital EHR, but also stifles innovation of the type needed for ACOs to prosper.  The public, media, elected officials and business interests have taken dead aim at health care as it now exists.  It is only by engaging with patients that caregivers can endure to guide health care.  A quote from The Leopard, a novel chronicling the battles to unify Sicily with Italy, is appropriate: “If things are to remain the way they are, everything must change.”  

Blogger's Note: I've taken a few years off from blogging.  During that hiatus, I've retired from active ENT practice and continued working in health care software and, in particular, patient engagement. Thank you for reading.  Bill Cast, M.D.  www.nomoreclipboard.com 

HIMSS 2010: Problems with the Rear View Mirror

Health care IT: Heading for a Curve

Old saying:  You can't drive a crooked road looking in the rear view mirror.  That thought came to mind as I walked the huge exhibit floors at Atlanta HIMSS.  The thought resurfaced as I listened to today's NPR, Diane Rehm show discussing Electronic Medical Records.

Lots of time-worn assumptions about Meaningful Use: "It will slow docs down, said the MGMA survey."  "AAFP asks CMS for significant changes to 'Meaningful Use' criteria," reports iHealthBeat.  "Can I afford an EHR if I am nearing retirement?"  "Beware of the EMR 'Ponzi' scheme," said Dr. L. Gordon Moore.  "Too Much, Too Soon! Too Aggressive, Too Expensive, Too Rigid, Too many Quality Measures . . .," HealthcareITnews. 

Looking backwards into the mirror, it once took days to install EHR programs on office servers, weeks of physician and personnel training and months of work flow adaptation.  Larger practices hired someone to do IT maintenance; smaller practices could not afford the average $50,000 per physician total cost.  Software was inflexible, and often the goal was point and click using the same template for every physician regardless of practice style.  The true cost was even higher because of cost overrun surprises, and commonly physicians lost income from seeing fewer patients.  Often physicians under-coded, under charged, in order to finish a visit more quickly leading to lower billings.  Only gradually did things improve, often leading to productivity rifts between physicians and validating the comment "six months of hell." 

And so, many critical statements are deserved through true experiences---from the past.  But much has changed for the better.  Software as a service means no server; less need for a dedicated IT employee.  More band width equals better viewing of images, faster downloads.  Better software design includes natively web-based, integrated packages with document management, EHR, and RIS/PACs options.  Interoperability provides universal connections with PHRs and Health Information Exchanges.  And, all of this is inexpensively down loaded; free trial period; configurable by each physician and for each physician's practice style.  There are several such companies that have good products for this market: (link example, link example, link example, link example, link example, link example) All of these products differ in some way---but more exist and more are in development, however your conclusion should be that affordable, existing products can satisfy meaningful use. We can safely ignore whining from vendors who resist change.

To answer the complaints stated at the outset:

1. "It will slow the doctor down."  Not if you use a minimally invasive approach with software that does not force all physicians into the same mold.  Begin by getting rid of charts using document management.  You can use your own forms, scanned into your web-chart; bar codes will sort them into tabs automatically.  A few days' thought will lead you to think about your work flow and allow you to design templates within which you can---if you wish---point and click. If you are judicious in coding, you may wish to use point and click entry for complex cases and a scanned template for simple cases.  Or, you can dictate into the system.  The point is that no all physicians practice in the same way, and they will not be forced into someone else's algorithm.  No doubt, there will be a week or two of learning curve for each physician; but not all physicians will begin at the same time to spare the practice a train wreck.

2. "Can I afford this nearing retirement?"  "Too expensive?"  The new math is not the old.  A caller into NPR cited $50,000 to $100,000 per physician.  That may have been true but is no longer.  The new SaaS products will download (think SalesForce.com) and have a trial period after which prices will begin as low as $250 per month and will satisfy "meaningful use."  More complex modules can be added if needed but also at much lower cost than before.  Each physician will have money left over for other needed tasks from their ARRA stimulus funds even if they approach retirement.

3. "To many patient information requirements?"  Perhaps regulations are not aggressive enough, but certainly not too rigid and having too big a bite.  Given the software available for both EHR and PHRs, requirements for patient communication are easy to satisfy.  Every practice can upgrade an existing website to use such as NoMoreClipboard.com, NMC. This program communicates with all EHRs and will transmit and receive both digital and paper (FAX) patient information. NMC is also available from cell phones and ER computers as well as through office EHRs.  The central fact is that we expect patients to be engaged in their own care, and we cannot expect them to perform without equivalent information.

This has been a long blog.  More next week on digital decisions. 

Meaningful Use Solutions While We Await Perfection

Leave No One Behind:  Necessary Incrementalism

Mr. John Moore, January 14, made his Top Ten Predictions for Healthcare in 2010, a blog item picked up by Healthcare IT News.  As usual, it was a good read.  Among the predictions: HITECH Birthing Pains, Small Practices Look on With Jaundiced Eye, Large Firms Acquiring Smaller Firms, Baby Boomers Struggle Caring for Parents, HealthVault as prime PHR Platform, and the Struggle of Telecom.  All of these predictions relate to yet another published item.

Writing about the new NoMoreClipboard portal as a link between paper and digital communications for physicians and patients---a solution for ARRA---a press release was picked up by The Medical Quack and Inside Indiana Business.  Ms. Barbara Duck, writing in the Medical Quack notes, as does Mr. Moore, that the role of the PHR in healthcare continues to evolve.  She goes on to summarize that NMC (NoMoreClipboard) offers physician groups a portal to allow additional interaction between doctors and patients: appointments, refills and more---with information that can be integrated with an EMR/EHR and also HealthVault and Google Health. 

How does this tie together several of Mr. John Moore's predictions?  Some thoughts:

1. HITECH Birthing Pains?  What percentage of physicians will be digital in a decade?  Maybe half in four years---more or less, varying among regions urban and rural.  The NMC technology using a portal, bar-coding, and patent-pending "fill out the physicians' own forms" technology can bridge an analogue-digital gap for a decade.

2. Small practices can use the MIE, minimally invasive EMR, or a competitor's web-based EMR to link with patients' PHRs.  It seems certain that rural and small practices benefit from such SaaS-based EMRs in that the old server-based solutions were front-loaded with costs and followed by high maintenance.  The nice opportunity for small practices is the minimal down payment and the affordable run-rate that consumes about one-third of the $44,000 stimulus payment over 5 years.  This cost ratio is in line with years of IT-installation experience for software in manufacturing installations. In the interim, the NMC portal links physician and patient offering an easy transition to being fully digital.

3. Large firms acquiring smaller firms.  Certain to happen. Not every good EMR has a PHR.  Logical solutions are  purchase, merger, or leasing.  Many ways exist to solve a problem as long as interoperability and connectivity are present. 

4. Mr. Moore references Baby Boomers Caring for Parents.  The web-based PHR, of which one is NoMoreClipboard, is a key to distant care.  Yes, there are problems with proxy sign-offs and Social Security, but many of the problems are solved in the interim.  No More Clipboard offers bar-coding allowing physicians to FAX entire medical records directly and securely into patients' PHR mailbox.  NMC has graphing capability for test results and storage for wills, directives and visitation documents.  The portal extends functionality for secure messaging and more.  The family care giver is too often a distant eldest daughter who can, by sharing a website and, with permission of the parent, a PIN, help manage records, appointments and other communication. 

5. As to HealthVault and Google, NMC has been integrated with both since their inauguration.  In the future, interoperability will need be a feature of every marketing plan---a break with the pre-regulatory past where the "Walled Garden" of software apps made hospitals, physicians and patients pay while they waited for software that suited workflow needs. 

6. Struggling Telecom?  NoMoreClipboard is accessible and may be FAXed from a smartphone today, and more functionality will be incorporated when value can be added.  A large part of the problem is the interface---tiny buttons, tiny screens and dropped calls---all problems waiting to be solved. 

Thus, as health IT policy works toward a new definition through policy changes and standards enunciations, it is likely that interim measures must serve for much of this decade of transition.  This makes it all the more important to choose products designed to solve today's problems with planned transitions into tomorrow's solutions.  Incrementalism is not bad as long as the future is planned for and workflow is understood. Neither physicians nor patients will accept solutions that are slower and seem less secure than paper, and no one wants a product designed for obsolescense.

A Cure for Inefficiency

Physician-Practice Consolidation---Slowed by Better IT ??

"There is an easy solution to every human problem---neat, plausible and wrong," said H.L. Mencken back in 1917.  Little has changed in 93 years.  Frequently, the solution becomes represented by a single word.  In 1967's "The Graduate," Dustin Hoffman is told the future is "Plastics."  Since then, we've had other one-word fads, bubbles in the Internet and Real Estate.  Lucky we have a Stimulus. 

But not all solutions that are simple are wholly wrong.  Writing in the Chicago Tribune---Health, Mr. Bruce Japsen writes: "Doctors seek out cure for inefficiency."  Lead sentence: "All the consolidation that took place in the health care industry in 2009 could have a surprising benefit for patients: greater strides towarrd efficiencies in customer service." Thanks to computers and better IT, information technology, patients spend less time repeating their medical histories and waiting for an appointment. 

Said Alwyn Cassil of the Center for Studying Health System Change: the tools are expensive and "they don't make sense for smaller practices because they don't have the financial wherewithal to implement them."  This affects more than patient convenience.  It causes reduction in coordination, accuracy and also the evaluation of  physicians themselves. 

Ten years ago, 40% of physicians were in a one or two person practice; that has dropped to 33%, and the statistic is falling rapidly.  From every corner of health care, hospitals and clinics and large practices are witnessing a flood of physicians seeking to join large organizations---frequently on salary. 

The tools allowing Mr. Japsen's prediction to come true will be the EMR, delivered as a SaaS (software as a solution) product, best done on-line, natively web-based, with the addition of a PHR---the HIPAA preferred connection to patient choice, privacy and involvement.  But as change just as disruptive as consolidation and IT will come from cost---that is, lower prices paid by physicians. 

The server-based, IT-employee monitored, three-month installation package costing $50,000 per doctor will be gone by 2012 and replaced by software and storage by contract.  Paid by the month as a utility.  And so, the imperative to leave a two-person practice may depend less on IT cost than  other factors---practice management, band-width availability, insurance contracts, etc.  The fact that the PHR inter-operative platform will talk to EMRs that talk to EHRs that talk to Insurers, may provide greater efficiency in a smaller practice than a group of 500 where other frictional losses are endemic.  It will be fascinating to watch.  Will small companies (and there are a dozen or more) with minimally-invasive, flexible EMRs (like the mi-EMR) provide better solutions than the huge companies that have annoyed physicians with their hospital-sized software?  Or, will the big-guys adapt--in time? 

We will see continued consolidation, but one size does not fit all, even in Lycra.  And, smart-useable IT, like "Plastics" will be the key to this generation of Graduates. 

Health Care and Healthcare IT---Comments on 2009

A few thoughts as we head into the holiday season and look to end 2009

1.   Efficiency.   One of the great hopes for health care IT must be efficiency, not merely cost savings, but increased efficiency.  Efficiency will be needed if patient volumes increase as more patients have insurance.  And another important factor will be a largely unreported physician shortage, the result of bad public policy, since Medicare reduced funding of GME in 1977 and the result of miserably inaccurate manpower studies over many decades.

It is true that a primary care physician is now spoken of, but that shortage will inevitably be back-filled with nurse practitioners, moving family docs upstream.  The projected shortage by 2025 of 124,000 physicians will include even more critical shortages of specialists more difficult to replace since their training cycles are longer.  Already the U.S. is short over 1000 Neurosurgeons, and the shortage of General Surgeons is perhaps greater.  Even today, there are not enough physicians in Neuro and General Surgery to cover emergency rooms.  Should anyone believe that rationing of health care will produce a benefit, watch carefully and, for yourself, invest in a stable patient-physician relationship. 

2.   Paying for Healthcare Reform.  One cannot avoid noting that many reform proposals include cuts in Medicare and cuts in physician fees.  These are usually accompanied by assurances that physicians should not or do not want to run businesses---only care for patients.  And, if that is true, using the model of K-12 public education may provide insight into a system in which students are assigned a room and a teacher for whom books are prescribed along with approved tests.  The loss of discretion parallels a loss of professionalism.  But, there is and will be a physician shortage, and if market forces prevail, physicians will have options that make difficult a planned policy of yearly salary cuts.  Healthcare IT cannot overcome poor public policy. 

3.   Productivity.  Given attention by Erik Brynjolfsson,'s article, "Productivity Paradox in Information Technology" in 1993, the discrepancy between investment in computers and greater output was noted and studied.  Over time, and with investment in training, retasking and machinery, productivity did increase, but there was a time lag, a lag that will be repeated in healthcare following the stimulus of ARRA.  It can be a lag made worse by falling outputs if the wrong EMRs and PHRs are chosen.  Without carefully designed templates and algorithms chosen or understood by physicians, a "point and click" EMR can add minutes to each visit.  It is all about work flow, and speed.  If bandwidth is inadequate or connection to a hospital encumbered by a series of "go-to-my-PC" interfaces, physicians will abandon the EMR regardless of promised cash payments.  The workable model that can be learned in a few months without changes in personal work flow will be similar to MIE's "minimally invasive" SaaS download, and it will be natively web-based.  There does not need be a train wreck, but there might be.  Physicians should insist on a trial period with no penalties for exiting a contract. 

4.  Meaningful Use.   My guess is that the MU bar will be set low, initially.  I'd also guess that many physicians, those who select software based on manufacturer promises of certification, will abandon attempts to meet MU standards if the software requires additional steps, and time, to verify and record the required reports.  All products will not be equally friendly, but I am optimistic that better-designed programs will profit physicians and reach government goals.  

5. Health Information Exchanges, HIE.  States like Indiana should prove a laboratory for EMR adoption and success for MU.  Indiana should have connected its 5 HIEs sometime in 2010.  In those regions served by HIEs, large areas of Indiana have over 50% EMR use by physicians.  Comparisons of MU success in regions with HIEs vs. those without functioning digital data exchange should prove the synergistic value of EMR and HIE in achieving Meaningful Use.  Biocrossroads, a consortium of the State of Indiana, Universities, Medical products companies and Pharma companies, should be funded by the ARRA stimulus in early 2010 to cover all of Indiana.

PHRs, What Are They Good For? Huh! Absolutely . . .

Why PHRs Are Part of Meaningful Use

How time flies.  Not that long ago, James Brown created similar lyrics about War. Now, we are looking at a battle to create digital standards and achieve adoption, the so-called meaningful use.  *See Correction Below.

Reaching over a year into the past, May 2007, iHealthBeat presented an article on EHRs and PHRs.   Michael Zaroukian, M.D., PhD, chief medical officer at Michigan State University was concerned about PHRs because of a) accuracy, completeness, usefulness, and volume of data, and b) uncompensated time for physicians to sift records, and c) potential for a misdiagnosis if a crucial element in the PHR is overlooked.  Often, he said, "PHR information is poorly organized." 

Joseph Heyman, M.D., and AMA Trustee, of PHRs contrasted the PHR being a "snapshot of the patient and their most important demographics" to the entirely different "entire medical history for life." 

"Making sense of unorganized or complicated PHRs can take up to four or five hours---paper or electronic,: noted Dr. Peter Basch of MedStar Health, Washington, DC.  Said Basch: "A two or three-minute oral history during the physician visit can be more helpful than an extensive PHR."

Yes, time flies, but attitudes change more slowly, partially because a majority of physicians have no EMR with the familiarity that comes with digitized work flow and partially because, as my Dean once told me: "if you are not up on something, you will be down on it."  

In fairness to those quoted above, nearly two years of IT change have created second and third generation software platforms with little resemblance to PHRs of their comments.  Taken one at a time:

• There are several good PHRs, the characteristics of which are automatic coding, orderly and directed entry patterns, prompts, integrated data bases for drugs both branded and generic, integration with EMRs and interoperability with devices.  They create summaries of abnormal entries and summarize current drugs and allergies.  They send and receive data digitally, by FAX and PDA phone.  They have storage for files, reports, wills, directives---and they graph results. They have many of the features of a good EMR. 

• The mental picture of a harried physician leafing through dog-eared pages is more likely that of a physician digging into a paper chart than one using a modern PHR.

•  Before or after looking at a PHR, or after receiving the report of an Aide who looked at the PHR, the physician is quite likely to ask better questions during the physical exam. 

•  And indeed, the PHR can be an accurate reflection of the patients entire history, or using the summary of abnormal entries, it can be a snapshot of illness as well as medications, allergies and statement of present illness.  Additionally, the PHR can contain documents: CT and MRI reports, laboratory values, visitation privileges and health care directives. 

• A seldom-mentioned benefit to the physician is that, for purposes of coding compliance, the PHR can provide a dated, time-stamped proof that history was received and checked. 

•  For the chronically ill, a rule of thumb is that the patient comes to know a great deal about that illness, sometimes rivaling the knowlege of his/her physicians.  Many such patients carry extensive records---a few well organized but many more quite fragmented.  The PHR offers an orderly chronology, offers graphing, and if the PHR is web-based and integrated with digital reconciliation software, a human interface can quickly eliminate duplications and errors both in the PHR and in the physician record. 

• Web-based information in a secure cloud, offers the additional benefit of being everywhere portable and accessible.  The PHR is ideal for "adult children" who care for elderly parents at a distance of many miles.  A distant ER report can be scanned and FAXED to the PHR in minutes.

• With regard to privacy, it is the patient who owns the PHR and controls its entries.  To those who say, "How can you believe what a patient enters," one can perhaps best respond using Doctor William Osler's phrases.  "It is more important to know what sort of patient has a disease than what disease a patient has."  The PHR, misconceptions included, tells much about patients' views of themselves.  It is, as always, left to the physician to make sense of the history.  "Listen to the patient carefully, and they will tell you the diagnosis," said Osler.  And, it is the feature of ownership that allows the patient to use the PHR to deal with HIPAA most effectively. 

For the quick visit, the PHR is a quick refresher for allergies and medication changes.  One need only to ask when it was updated, inquiring about changes.  For the complex, long visit, the PHR points quickly to the systems most important about which to seek more information.  And, the filing cabinet features allow for review of physicians dictation and discharge summaries.

What is different about PHRs since 2007 is that they are like EMRs, built on flexible interactive platforms, with full integration into portals, medical devices, Internet, and telecommunications.  They will save physician time and be yet another instance whereby information systems provide safer treatments. 

This is Part I of three parts.  In Part II, we will review the fine recent article by John Moore and in Part III review the part played by PHRs in Population Health. 

*Correction:  "War" is a song written by Norman Whitfield and Barrett Strong in 1969.  Editor

Little-Noticed HIE First: Indiana-Ohio

Remember BioCrossroads? 

Indiana and Ohio Health Information Exchanges will connect in a multi-region Clinical Information Exchange.  In a previous post, I highlighted BioCrossroads, the Indiana Life Sciences Consortium that has on-lline a power point Exibhit Indiana showing the overlapping HIE areas in the state. 

Now, Bloomington, IN, home of HealthLINC and Indiana University, and Indianapolis, IN, home of IHIE and the Regenstrief Institute, and Cincinnati, OH, home of Healthbridge HIE, all are connecting to link their regions. 

This will be part of an effort, led by Biocrossroads to link every community in the State of Indiana.  Fort Wayne, IN, home of the MEDWEB HIE, covers the northeast portion of the state and transmits to individual hospitals and physicians offices in Western Ohio but not to an Ohio HIE. In northern Indiana, MHIN, in South Bend, home of Notre Dame University, will also connect under the proposal being constructed under the leadership of Biocrossroads.  

How-To-Do EMR with Ease and Profit: A Testimonial from Dr. Mirro

A Minimally-Invasive Path to "Meaningful Use"

Writing on Friday, 28 August, in InformationWeek's Healthcare Blogs, Dr. Michael Mirro posts "Minimally Invasive, Incremental Approach to EMRs.  Dr. Mirro speaks from experience.  He has served as Trustee of the American College of Cardiology and has been Chair of their Health IT Committee.  He is a clinical professor at the Indiana University School of Medicine. 

Perhaps more importantly, Dr. Mirro's cardiology group, Fort Wayne Cardiology, uses a web-based electronic medical record and has done so for many years.  What is more, it is fully functional with document management (no record room), image viewing, e-Rx, and enhancements that allow the software to gather quality measures for compliance reporting.  This allows  the 23 practice physicians to collect $3800 each from the Medicare Physician Quality Reporting Incentive program---not a trivial amount considering that it does not interfere with workflow since the software does the work.

When you read the linked article, you will see that painful installation need not be part of the process and software need not interfere with work flow.  Not all of the twenty-three physicians practice in the same style; a rigid point-and-click algorithm is not a requirement. 

Space did not permit a full report from Dr. Mirro, and I will share answers to questions that I asked Dr. Mirro and other doctors who use his software.

1. Q: Your EMR is web-based.  We recognize that this is less costly and requires minimal IT personnel in your office, but have you been troubled by crashes or Internet outages?         A: No.  In seven years, we have had rare occurrences of two or three consecutive hours of down time, less actually than we have had with our server-based programs.  We have worked around them using FAX, but they are usually so brief as to be only a nuisance.  A complete electrical power outage is more disruptive than an Internet outage for most practices, and fortunately they have been equally uncommon.
2. Q: Are you comfortable with patient data security?      A: Our software programs and data storage are encrypted similarly to ATM data; security has been no problem.  The way physicians use their laptops is the more critical factor in privacy, and rules must be observed.  In candor, privacy is more respected digitally than when we had piles of charts lying on physicians' desks and in their automobile's when they traveled to clinics.
3. Q: Can you maintain the same pace seeing patients with and without the software?      A: Yes.  There is a learning curve, a transition period similar to that of working in a different hospital, but once a physician establishes his style of use, actually more patients can be seen in an equal period of time.  This is because there is less search time for data and images; greater ease of viewing past visits; and more rapid support for compliance and coding.  A choice of methods of data entry is also a key to maintaining a proper pace. 
4. Q: Will you make changes to obtain "meaningful use?"   A:  I think not but cannot say until the rules are promulgated.  I see nothing in requirements discussed that we cannot already do.
5. Q:  Conflict of Interest Statement?    A: Many Fort Wayne physicians were involved in starting MIE and the HIE that they operate in NE Indiana.  Several physicians own stock; I own shares purchased after working with the company and its product. 

Thank you to Dr. Mirro and his fellow physicians for their time and cooperation. 

Pearl Diver: "Health Care System, Vulnerable At Its Core"

Pearl Diver is in the Life Sciences Information business.  It provides "intelligent access" to a massive patient, clinical trial and adverse event database. 

A White Paper

When you click on Pearl Diver, you will be asked to click on "Our first white paper."  It is an analysis of variations in cost among geographic regions.  It focuses its large database on the orthopedic industry and the 75 million patients that seek care for musculo-skeletal maladies.  The headline, above, hints at its conclusions: "Any system where the consumer pays more to receive less is vulnerable at its core." 

It seems obvious that spending more for poorer care is a legitimate target for reform.  And it is equally obvious that it will take health care IT to get the job done.  As the paper states: "The movement towards correlating patient outcomes with cost data is driving the national discussion of health care reform, yet the institutions providing care do not yet have a clear set of tools for comparing their quality of care, patient outcomes and cost."

If these health care issues, and some nice graphics, interest you, go to Pearl Diver and read its "first white paper."  And, if you notice that the company phone number has a 260 prefix, you'll also know that it is answered in Indiana, home to both the center of the orthopedic implant industry and some of the nation's most advanced IT. 

Health Care PHR: What Do People Really Want?

Polling Health Care

The Harris Poll in The Health Care Blog on 20 August, Mr. Humphrey Taylor, Chairman of The Harris Poll, presented a broad view of health care reform, presenting public opinion as it is seen through a variety of polls.  He bullet-points thirteen (13) points cautioning that consumers are unfamiliar with many terms and much jargon; that the issues are extraordinarily complex; and that all nations' health care systems are in perpetual crisis.  The question was "What Do People Want?: and as Mr. Taylor says: "A clear picture emerges;" to summarize:

• People favor reform, and in the U.S., dissatisfaction is greater than in other nations.
• Government should help, but probably not "run" the system.
• A minority want to completely rebuild the system.
• People believe costs are too high and that more people should be covered.
• People have no collective agreement as to why costs are too high.
• Proposals to "take away" are very unpopular
• No agreement exists as to "free and equal" coverage for everyone paid for by taxes.
• Republicans and Democrats disagree on health care as a right.
• Peoples' opinions are not based on fine details of the drivers of cost, nor do they want to see formulae based on those details used to deny access to procedures

From the General to the Specific:  The PHR

Reducing the summary even further: The public wants to cut costs but never benefits; wants better care but less complexity; and is uneasy about Government reform.  When it comes to personal health records, there is no Harris Poll.  Were there one, based on our experience at (NMC) NoMoreClipboard I would expect responses to show:

• An over-riding concern: Are they safe and secure?
• On learning that PHR's security is like an ATM's, a majority believed PHRs are a good idea.
• Upon adopting a PHR, a healthy majority populated it minimally and then forgot about it.
• Motivated by severe illness, a significant cohort adopted, used and sing the praises of PHRs.
• Motivated by frustration, the "eldest daughter" manages her aged Mother's PHR from a distance.
• Motivated by chronic illness, the technically savvy appreciated PHR benefits
• From Facebook and Student Portal experience, the young expect PHR benefits.
• Physicians using web-based EMRs, promoted patient use of PHRs

Based on NMC conversations with Arizona patients who participated in learning experiences through CMS's Arizona Medicare Choice Plan, intended to promote the adoption of PHRs, we found a significant number of early adopters pleased with their new PHR.  Some have given testimonials.  But, it is clear that healthy persons will not eagerly adopt and use PHRs, unless there is a continued recognized penalty: inconvenience and slower access to care, not experienced by their friends with PHRs.  When preference is given to those with PHRs, use will increase.  It is not a matter of computer phobia or wealth.  A majority of Wal*Mart customers go to the Web to look for in-store bargains. 

Physicians who now use web-based EMRs are promoters of patient PHRs because of time-saved in data transfer, because of improved accuracy and because of IT cost savings.  As Physicians respond to the "carrot and stick" stimulus for EMR, they will prod patients to participate with PHRs.  Physicians are the most effective source for testimony that PHRs make better care possible.   Early attempts to push patients in that direction with Kiosks and on-line registration faced a physician population primarily on paper, a situation soon to change.  Paper PHRs are of limited value to physicians unless the patient uses the physician practices' own forms.  Without "eye-memory" a foreign PHR saves little time for the physician. 

What Needs To Be Done to Promote PHR Adoption and Use?

1. Focus on the chronically ill and their physicians.
2. Focus on the young who expect a digital solution.
3. Focus on corporate adoption: hospitals, employees of businesses
4. Focus on the niches: patients with focused problems, oncology, transplantation, genetics
5. Focus on the mobile: patients who transfer records from one physician to another
6. Hold the course in education.  A half a decade is projected for physicians' EMRs.  Patient PHRs will follow as physicians, and the health care system, rewards PHR use.  
7. Hospital adoption and physician adoption will drive the numbers. 

Indiana: A Surprising Lead in Health Care IT

Here is Our Hope

Dr. David Blumenthal, M.D., HHS, National Coordinator for Health Information Technology wrote an open letter this week urging support for "every American to benefit from an electronic health record."  Said he, "I spent the first twenty years (of 30) shuffling papers in search of missing studies . . ." But, he allowed: "The goal of assuring an electronic health record for every American is daunting."

How Might It Look and Feel?

A good hint may be found in Indiana.  Yes, Indiana, a mid-western state between Ohio and Illinois, to help locate it for our coastal friends.  In the Northeast corner, where Fort Wayne looks east to Ohio and north to Michigan and serves a good hunk of Indiana, there has been an operating, self-funding HIE for over a decade.  About 65% of physicians have an EMR in their offices.  The natively web-based HIE transmits over a million documents a month and connects 95% of providers in an area about 120 miles north-south and about 80 miles east-west.  And there are five (5) HIE's in operation in Indiana including the better-known academic model at Indiana University's Regenstrief Center where digitalized records date back into the 1960's. 

Want a Look?

   Biocrossroads, a not-for-profit organization, supports Indiana's Life Sciences.  Biocrossroads website displays: Exhibit Indiana     

At the link above, you will find a powerpoint: Click on: Exhibit Indiana Overview that shows the state-wide system.

Few states can match the clinical utility of this up-and-running system.  It is well on its way to being the system described by Dr. Blumenthal. 

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BioCrossroads is supported by Indiana University, Notre Dame, Purdue University, Rose Hulman University, Eli Lilly, Roche, Dow Agricultural, Cook Medical, Wellpoint, Clarian Hospitals, Pfizer, the Regenstrief Foundation and more local members. 

Link to Open Letter of Dr. David Blumenthal: Open Letter