Monday, April 20, 2009

Health Information Technology Stimulus, a note from the field.


I am not a member of your distribution list but recently received a request from Anthony Williams of ChemSpider to respond to your concerns regarding the cost-benefit of electronic health records.

To begin with I want to clarify that I write this through multiple perspectives: I am a patient with multiple co-morbid conditions e.g. diabetes and arthritis; a clinical information systems consultant and former director of a cardiopulmonary rehabilitation program (Respiratory Therapist). I have been employed as clinician, vendor of ‘high tech’ products and community organizer.

So, you probably expect that this will be a cheering disagreement with ANYONE who dare be skeptical about the return on investment projected from electronic health record adoption initiatives. When speaking to that person who suffers from chronic disease in a failing healthcare system you would be correct. For that view, see my blog at American Citizen. For a more objective review, please read on.

Since this is an informal communication, I will not perform an exhaustive review of the literature or ‘deep dive’ as suggested; but then again I have been swimming with sharks for quite some time now. That said, I point the reader to a few websites which might serve as a starting place these are: The California Healthcare Foundation and Health Affairs. I have found both the Foundation and the Journal Health Affairs to be objective with regard to the adoption of public health initiatives and peer review.

After 30 years in healthcare with the last ten focusing on clinical informatics –a fancy market-term for computer science applied to a specific business domain; I agree with anyone who questions the validity of broad conclusions that a single technology will address the current catastrophic situation we face in our healthcare economy. THIS IS NOT THE APOLLO PROGRAM in which my father was employed as an aerospace scientist. Many draw this parallel incorrectly. In a social sense we are gathering momentum toward a national goal as we did in the 60s, but the similarities stop there. The aerospace industry was new in 1960 and was created from the programs ‘launched’ (sorry couldn’t help it) during that decade. The implementation of electronic health records and similar technologies in the decade of 2011 will require a significant change-management effort. Our existing business model in healthcare is well established and resistant to reform. So don’t hold your breath for the savings.

Primary Care Physicians and their staffs are far too encumbered by routine workflows that prohibit the expenditure of time required to adopt these technologies, learn new processes for population management and deploy a tactical plan for sustainability in the practice. Folks like myself who spend time working directly with physician practices, hospital systems and outpatient services are aware of the ‘adoption barriers’ and feel overwhelmed by the scope of the task at hand. We spend our time assisting ‘systems of care’ with technology adoption; focusing our efforts on wise selection based on both direct and indirect investment. The education effort alone requires many HOURS of hand holding, before which many DAYS are spent addressing the cultural issues e.g. “we see fifty patients a day now, how is this going to help us see more”.

A fundamental problem is just that; “how is this going to help us see more patients?”

Our economic rewards model in healthcare is askew. Physicians and hospital systems have readily used new technologies and procedures to expand revenues in the past (which only makes sense) and the ‘not for profits’ have used these revenues to offset losses from care for our indigent (becoming more and more of us huh?).

The interested reader will note that payers (insurance company’s etc.) have recently adopted the use of pay-for-performance initiatives which are the starting point for reimbursement reform. These programs require data collection both from claims systems and the point-of-care thereby requiring expensive human capital. I am not sure if any of the programs have addressed these costs when calculating investment returns. An additional third tier for payment is now being considered wherein physicians will receive monthly case-rates for managing complex patients like myself. This blend of incentives: pay for procedure + pay for outcomes+ pay for services such as care coordination makes blatant sense.


Unfortunately- with the additional workloads associated with the new model it will become necessary to implement information systems which allow physicians to manage a population of patients as well as -one case at a time-. Since doctors are overwhelmed with tasks; decision support systems at the point of care will facilitate safer, more cost effective transactions between patient and provider. This is all common sense, right?

“BUT WAIT” you say! “Why do we need to do all of this?” ………………………Well, I won’t insult you with data, but you will note we do more procedures, use more new drugs and spend thousands more per capita yet have no significant difference in our health outcomes when compared with European nations. I call this the CABG (Coronary Artery Bypass Graft) factor: Revascularization procedure volume has no relationship to coronary disease mortality rate. However the Primary Care Factor does and it is well established that a tight bond with a primary care practitioner facilitates improved health outcomes. You will also note that pharmacy costs in our country are $752 per person vs. $424 in Switzerland, so perhaps if we do less surgery, use fewer drugs and establish a culture of mutual partnership between patient and primary care physician we will begin to see a reversal. Of course the problem with this is the fact that it ‘stinks of HMO methods’ similar to those of the early 1980’s –remember Gatekeepers! Good-luck getting the providers to take full risk on their patient-panels again!

So which policies should we consider to back off a $ Trillion or so in our annual healthcare budget. I imagine our administration has focused on the primary-care coordination model and electronic prescribing initiatives for this reason: Primary-care and patient relationship and decision support during treatment is the low hanging fruit.

If you ask your doctor today: “how many diabetics do you have that are in poor control” he or she will take a wild guess. If an electronic health record is in place however you will get an answer such as: “less than 20% of my patients are in poor control and we update our list to invite them to education sessions monthly; those who miss appointments are called the day before with a reminder.”

If electronic prescribing is in place the physician is presented with the patients formulary as the prescription is written thereby increasing the likelihood of a generic prescription (see France above). Furthermore, the patient’s entire drug history is presented and a ‘status filled’ flag is sent to the system when the prescription is picked up at the pharmacy. You can imagine the bearing on direct cost and indirect costs e.g. complications from non-compliance that can be achieved in this case.

The problem is: How the heck do we incent our practices to run a report to determine the phone numbers of all patients who did not fill their prescriptions last week then make a phone call to determine the reason? This is where we will need a sincere change management plan for our existing doctors and a method to introduce the strategies into our medical schools (already in place in many).

Ultimately, if we succeed we might see a multi-billion dollar savings. The pressure of course will be exerted downstream on our pharmaceutical manufactures but that is the topic of another note.

If we save even $50.00 per person (a far cry from the $328.00 between France and us) it would calculate to many billions of dollars (approximately $12B I think). This will probably cover the expense of adopting e-Prescribing on common web-native architecture.

So, the technology alone will not account for the savings. The technology AND cultural change AND economic reform will. What I fear is that in three years the American Citizen will hear about the billions of dollars wasted on healthcare information technology without carefully considering the variables and time course for measuring the impact.

Shalom to all,

Jeffrey Halbstein-HarrisAntevasin Consulting GroupAssisting communities to monitor and improve healthcare919-805-1901 Cell919-779-7368"Go to the people, live with them, learn from them....Start with what they know, build with what they have...."Lao Tzu

Wednesday, January 28, 2009

American Healthcare "Works great as long as you are not sick"

January 29, 2009

Okay, five days and counting: Today’s topic medication safety and other rants
Tomorrow is pre-op testing, I was called by the hospital and told to arrive early and be sure to bring a medication list with dosage information.
I asked the representative if the hospital had a web registration and personal health record in which I could upload data. I was told “we are not quite that state of the art yet”. Oh-well, I suppose my paws can scribble a few hundred more lines of redundant information that exists in at least ten electronic medical record and registration systems across Raleigh NC. I have been experimenting with Microsoft’s Health Vault but find that, where it is an excellent technology, the market is not ready with interfaces to the myriad of systems that exist in a single ‘system of care’. This could be addressed with a Federal or State based system which serves as a public utility for personal health information. Unfortunately the market drivers are not in place and various privacy regulations get in the way. Funny how HIPAA, which was designed to standardize information transfer, increase transparency of data for patient safety and enforce security has now created such costly social barriers. We can thank our litigious society, advertisers of legal services seen every three minutes on nightly television and the use of personal information to screen for pre-existing illnesses for the barrier. Too bad, our species has such a history of poor integrity. HAVE YOU BEEN EXPOSED TO ASBESTOS, TAKEN ARTHRITIS MEDICATION, BURNED YOURSELF WITH HOT COFFEE? CALL THE OFFICES OF JOHN SUESTHEMALL FOR A FREE CONSULTATION YOU POOR VICTIM OF AMERICAN BUSINESS CULTURE!
So here are some issues with personal health information that are threatening our safety. I will use myself as an example. Go ahead deny me medical coverage or employment. I’ll just call Attorney Suesthemall.
I have diabetes, chronic hepatitis c (what do you expect I grew up in the 60s and 70s) and post traumatic stress disorder. No big deal, with the advent of modern medicine and personal investment in my health I have done remarkably well! That said, I am on eight maintenance medications which influence a wide variety of biochemical systems. I can guarantee that without constant vigilance on my part, my five physicians would have no reconciliation of my medication data: For a primer on patient safety check out The Institute for Healthcare Improvement. This organization is on the forefront of protecting US PATIENTS and improving our healthcare system.
So, tomorrow I will re-write my medications onto a paper form for the fifth time since I started down this treatment path. Each time I have hand-written my meds, someone has transcribed my data into a medical record and verified (to varying levels of reproducibility) with the patient (ME). When I have provided typed lists, my providers have still required that I complete their paperwork (I imagine the legal system has something to do with this).
By the way, SureScripts-RxHub RxHub has a great solution for medication transparency; I just hope it is affordable to the institutions and providers who need the data at the point of care. They have records on over one hundred million of us that could save our lives. The last time I looked they charged $1.00 per medication history report to an admitting hospital, not sure if it is still the same price.
To keep my records straight I have a few choices as a patient:
Have an incredible memory like all baby-boomers
Make sure one of my relatives has an incredible memory (doubtful)
Keep a reliable notebook and remember where I put it: Best suggestion for folks with chronic disease who prefer pencil and parchment.
Keep a record on my computer with reliable back-ups and pointers to back-up files on my hard-drives, CDs and Flash Media.
Choose one of four personal health records that have been provided by my constantly changing healthcare business environment. For example: I have a record with two payers, one pharmacy benefits group and one beta software that I have been testing for a friend.
On to creating my advanced directive in-case I forget “not to take the drug prescribed by my PCP that is suspended in an aspirin compound”.
I am going to be fine folks, but this is freaking hysterical since I can point to systems in other nations that are more effective at reducing variance in medical outcomes.

On with the crapshoot with carefully loaded dice in the morning…….


January 28, 2998

As they used to say on Hill Street Blues "Be careful out there".

This year, I find myself disabled with degenerative spinal disease and am awaiting surgery on Tuesday February 3rd. Since I have little else to do, I thought I would archive my experiences on this blog and also post some videos of the adventure.

As I write this stuff, keep in mind that I have spent numerous years working for my cause: universal coverage for all Americans and the deployment of a universal personal health record to prevent errors in clinical judgment and facilitate a smooth transition for all patients between systems of care.

The industry and our politicians are working on this dream, but the issues are complex and numerous so I pray we see it in time for our children’s generation. Many -who have something to gain e.g. politically or financially will tell you that what we need is only a few years away. Where this might be technically feasible; I challenge such enthusiasm with the very real social issues of: alignment of financial incentives between providers and payers and patients and employers, the revision of laws which prohibit access to critical health information e.g. mental health diagnosis. The reluctance of people to adopt new workflows. The current population of burned out primary healthcare providers and their lack of collaborative relationship with insurance companies.

We have a long way to go folks so let’s get started with my 'case' and try to find some humor in the message!

Within the last few weeks I became disabled from neck pain, had and MRI done and found out that I have severe degenerative disease with compression of my spinal cord. I am scheduled for surgery (three level cervical fusion) on Tuesday AM at Rex.

To say I am not frightened would be an outright lie; I know way to much about medical misadventures. That said, I am having a humorous time chronicling my experience and attempts to make sure that 1) no-one kills me due to misinformation and 2) no-one overcharges me due to misinformation. Do you see a theme emerging?

Let’s see

I am in excruciating pain so…
I go to an orthopedist who schedules me for PT and MRI

I go to a see a clinician friend who suggests three neurosurgeons

I struggle to determine if one of the neurosurgeons suggested is in my new health plan.

After research I settle on a doc by searching Pub-Med for clinical outcome info and looking around the country for published quality indicators.

I AM SURPRISED BY the variance in success rates between physicians and facilities

The neurosurgeon I select is one of the best in the area (1500 cases, 97% success, .001% infection)

The neurosurgeon will be working on the part of my anatomy that connects brain to the rest of body (seems like a big deal to me)

The neurosurgeon soothes me with his ego and data (He clearly states that he is one of the best)

The neurosurgeon seems to only consider my neck anatomy when establishing his patients identity (guess this is neck centered vs. patient centered)

The neurosurgeon asked me to make sure I received clearance for cardiovascular risks and my insulin pump (diabetes). I thought they did this but I guess this is a reflection of the new ‘consumer directed and patient centered healthcare system’.

I wonder what folks do that don’t understand the definition of cardiovascular risk?

The surgeons office called for a $1000 deposit even though I have no deductible, co-pay or co-insurance.

I was called by the endocrinologist’s office who I need to clear me for surgery and they gave me 24 hours to come up with insurance info or they were canceling my appointment because “they had a long waiting list”

I called endocrinologist office manager and give her insurance info. While I am at it I ask if they do means testing and adjust fees for self-pay. She states that patients receive a flat 20% discount. I ask if they see Medicaid patients (huge diabetes prevalence rate) and am politely told “NO”. I find myself wondering how people of lesser means get their diabetes care and what happens if they need an endocrinology clearance for surgery? Then I realize that my surgeon probably won’t treat people of lesser means since he already asked me for a down-payment on a procedure for which he is contracted 100% to payer.

My primary care doctor is worried about someone following me closely in the hospital as I have diabetes and other chronic conditions so she writes a stern letter to the surgical team inspiring confidence in this patient.

I ask my primary care doctor to prescribe an aspirin free narcotic since I can’t take aspirin due to potential bleeding complications (I read this is a handout given to me by neurosurgeon and wonder what folks do if they can't read).

I go to CVS to get some codeine and the pharmacist blankly stares and tells me “we don’t have that”. I ask where to get it and she continues to stare at me with a flat affect. I am concerned that she might be having a seizure but take care of myself by suggesting she call another pharmacy which she politely does.

I drive across town to get the codeine, an extremely inexpensive light-duty narcotic that seems to be quite rare since the invention of stronger, more-costly agents that have created a population of new patients for the rehab and detox centers (oxycontin etc).

Tonight I am assembling a living will
I have also arranged for a friend (RN) to monitor me during the hospital stay.

And on it goes……….six days and counting………