Gratitude to Dr. Rob Kolodner

After 31 years, today - September 22 - represents Dr. Rob Kolodner's last day in federal service. Although Rob may best be remembered by many for his service in ONC, he was an outstanding clinician, a major contributor to the VA's HIT efforts, and over the decades has been an active participant in the national debate.

In a widely distributed email, Dr. Kolodner summarizes:

I am humbled by the superb quality of the people with whom I have had the good fortune to know and work with in the federal government. And I have been very impressed that we have a “deep bench” in federal service, with excellent people stepping up again and again to carry on, and even surpass, the work and the vision of the previous wave of leaders and key staff.

I am delighted to not only to have had the honor to serve our nation’s veterans for almost three decades, and be able to help them in their time of need after so many of them put themselves in harm’s way on our behalf, but also to have had the privilege of participating in VA-wide and nationwide activities to improve the quality, safety, and efficiency of patient-centered health care. Hopefully, this time we will finally succeed in achieving sufficient health reform to trigger the transformations in health and care that we so desperately need in the U.S.

Over the years, I’ve done my best to reinforce and contribute to the understanding that the advances we have been pursuing in health IT have not been about technology, nor even primarily about health care, but instead have been – and are still – about improving the health and wellbeing of individuals and communities.

We are fortunate indeed that Dr. Kolodner will continue to apply his considerable talents to our field and to American health care.

Thanks Dr. Kolodner.

Francis Collins at the NIH

It was a great pleasure to read of Dr. Collins' Senate confirmation to serve as Director of the NIH. As newspapers, magazines, and the medical literature all demonstrate, Dr. Collins is an extraordinary scientist and an extraordinary human being. Friends at the University of Michigan often spoke of his absences to do medical missionary work. Like Maynard Olsen and a host of other pioneers in human genetics, Dr. Collins was firmly trained in the physical sciences and applied his rigor with a deep philosophical bent to the elucidation of the action of human genes.

I had one personal experience with Dr. Collins. At an early meeting on the human genome project - 1992 or there abouts - I happened to be in a room alone with him for some time. I believe we talked about his clinical work and his passion for motorcycles. His charisma and ability to connect were apparent. Much to my surprise, I revealed that my wife had recently been diagnosed with breast cancer. With a heightened look of concern on his face, Dr. Collins reached forward, stared me in the eyes, and said with great passion: "Mark, I'm going to find those genes."

His words were therapeutic. Upon later reflection, I concluded that finding those genes would be of little immediate use to my wife. I underestimated the wisdom of his words. Subsequent drugs based on our stronger understanding of the human genome project have helped my wife and thousands of other women. Few people have made such a difference.

But on that day, on that crisp Michigan morning, I was left with one strong impression: I had just met a compassionate, brilliant, and dedicated man who was going to make a difference.

I am sure great progress lies ahead because of his leadership. But I will always be grateful to Dr. Collins for that one brief but healing conversation over a decade ago.

Lincoln and Darwin turn 2000

McKinley High School, Russell Boulevard, St. Louis:

The auditorium of this school - now a magnet school for the performing arts, has several amazing features. Above the stage is a large painting of William McKinley brining peace to the savage peoples long under Spanish control. It is a vivid expression of American imperialism.

More striking perhaps, are the two large marble plaques (each about 3 x 4 feet) on each side of the auditorium. Each has the name of a famous person, a quotation, and the day, month, and year of their birth. They are Lincoln and Darwin. Few notice these now, and even few noted they had the same date of birth. (I know I have photographs somewhere)

But as I've looked at these plaques, I've often asked myself: why don't we have plaques like this any more? What happened to Lincoln's presence. And one wonders if any public school would be so bold as to place a plaque praising Darwin in its auditorium.

I don't miss the spirit of imperialism expressed in the McKinley mural, but I miss Lincoln, and even more, a miss the spirit of an age that was proud to express Darwin's accomplishment so publicly. And I miss the kind of superb public education I like to believe those kids received back in South St. Louis then.

Gee... I'd take Watson and Crick, even... but one wonders...are these forms of public expression behind us?

Reid Hastie and John Cleese on Meetings

I read in the Sunday NY Times a delightful essay by Reid Hastie from the University of Chicago.

Entitled "Meetings Are a Matter of Precious Time," the article provides a few simple rules.

It is a bit reminiscent of John Cleese's equally enjoyable video "Meetings, Bloody Meetings" produced in 1993.

• Follow this link for the NY Times article

Here is the bottom line (quoted):

1. Whoever calls a meeting should be explicit about its objectives. This means specifying tangible goals and assigning responsibility for creating, summarizing and reporting on them. Ask yourself this question: Specifically, what do we want accomplished when we walk out of the room?
2. Everyone should think carefully about the opportunity costs of a meeting: How many participants are really needed? (Almost all business teams and committees are too big.) How long should the meeting last? Set a definite ending time. Anyone who doubts that the meeting is necessary, or thinks it’s too long, should speak up.
3. After productive or unproductive meetings, assign credit or blame to the person in charge. Then, if people have track records of leading ineffective meetings, don’t let them lead future sessions. When their expertise is essential, make them subordinate to an effective meeting leader.
   

California Privacy and Security Advisory Board Symposium Keynote

On October 28, I gave a keynote for the California Privacy and Security Advisory Board's "Cornerstones for Information Exchange" symposium. When first asked to give this presentation several months ago, I thought hard about reviewing the complex California privacy landscape. I concluded I could provide no insights to the experts attending the symposium. I then thought about summarizing activities in other states. But when I saw the leaders from throughout the nation who are also presenting, I thought they could do a better job at that.

Through the ensuing few months, I kept saying to myself, "this is too complicated" and "states don't have the budgets to make this this complex." Then came the financial crisis. So, the title of my keynote?

Fear, Greed, and Consequences, and our Privacy.

• Follow this link for a PowerPoint show (pps)
• Follow this link for a narrative
• Follow this link for my bio sketch
• Follow this link for the conference web site

Vanderbilt noon seminar presentation: September 1, 2008

I have recently given a broad overview of the regional informatics initiative in Memphis. It is high-level with little detail. There is some overlap with my Medicaid MMIS keynote.

• Follow this link to the PowerPoint

Nashville MMIS Conference

I had the pleasure of delivering a keynote address to the Medicaid MMIS Conference held in Nashville the week of September 15.

• Follow this link to the Meeting Home Page
• Follow this link to my slides (ppsx)

The slides are not particularly informative and must be examined in presentation mode.

The conference theme was "harmony"
I linked three major concerns with three definitions of harmony and addressed some simple approaches to each concern. The concerns and definitions were:

• Complexity - congruity of parts with one another and the whole
• Quality - Agreement
• Value - Compatibility in opinioin and action

These slides do not stand "on their own" but I've received requests, so here they are.

September 11

No matter how busy I was this morning, I felt it important to pause for a few minutes and reflect on the catastrophic events of September 11, 2001 as well as our collective response to these events.

We all know where we were when we heard of the twin towers. Many of us remember that the Pentagon was also attacked. A minority, I suspect, reflect on this day as well about the heroic passengers who thwarted an attack and lost their lives in the Pennsylvania crash.

Our memory seems to fade - even from the most horrible of events. This, one could argue, is a healthy response to grief.

A fading memory, however, is not a healthy response when looking back on how our Nation responded to this trauma. We cannot forget about "weapons of mass destruction," two wars, domestic surveillance, the security checks at our airports, Guantanamo, water boarding, and the heroic men and women who have - since these days - been away from their homes and families trying to fight to see such events never happen again.

I cannot disagree with anyone who makes a sincere interpretation of the facts. I certainly am not sure what decisions I would have made in these circumstances other than to do all I can to protect and love my country and its people. But I can get fairly upset with those who forget history, distort what facts we have, and interpret the World's response as a set of historic vignettes more worthy of a comic book than of history.

If we cannot - on this day if any other - remove our blinders and bias, look at one another, and re-discover anew what September 11 and our response have done to our nation and the world, what hope have we?

We should have the deepest faith that the wrongs against our people will be righted. But we should also be mindful that the wrongs we have inflicted against others will be subject to the same calculus. As Jefferson said: "“I tremble for my country when I reflect that God is just; that his justice cannot sleep forever."

So we must, at least for a moment, look beyond the ignorant campaign rhetoric and the many other inane efforts organizations take to demean our intelligence. We must examine common spiritual bonds that are far deeper than any individual political position. We must be certain that what we are doing as a country is for the Good, or, we should consider extending Lincoln's words and expect to pay in further blood and pain for “all the wealth piled by the bondsman's two hundred and fifty years of unrequited toil” to the damages inflicted on our earth and our fellow man by individuals and groups who would feel at home with the bondsman of past centuries.

I do not have answers. My only real position is a simple one: My heart and prayers go out to a Nation traumatized by a catastrophic day; a Nation whose wounds fester as our response to this day leads to further death, pain, and loss.

The only response to this day is silence, reflection, and a commitment to examine our world through new eyes so that we can find peace in the past and a clear direction going forward. Mr. Lincoln's words only a few weeks before his death also seem apropos both to the losses we have already incurred and to the pain we face ahead. He said "It is rather for us to be here dedicated to the great task remaining before us -- that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion."

If only we could agree on what measures such devotion should take.

A prayer, then, for all of those who died, for all of those who wait for loved ones to return home, and for the rest of us - who one way or another - bear some resulting burden that we will pass down to future generations.

http:// Mark Eats Crow

To see Mark eat crow, follow this link.

Long ago, I was a reviewer of one of the first manuscripts by Tim Berners-Lee in which he proposed the concept of the URL. Obsessed with the notion of bi-directional links and imbued with the combinatorics of such links when the number of nodes was large, I simply could not get my head around the simplicity of a uni-directional link.

Last year while at a PHR conference at Torrey Pines, Tom Munnecke took the pains to document publicly my admission of error. As I told Tom, I was really wrong then and hope to be wrong again many times in the future. Such is the price of progress.

Mea culpa, Tim.

Mark

P.S. Tom has a remarkable video diary. I would recommend adding his rss feed and you can hear remarks from a lot of people who are making a difference.

His rss feed is: http://munnecke.blip.tv/rss

P.P.S. In truth, it was Mosaic that made response fast enough to have the "URL not found" message acceptable; for those interested, this just reaffired the CMU ZOG experiments of the 1970s that demonstrated how important response time was when browsing."

Of course, I told John Doerr shortly after forming Mosaic (later NetScape) that I wasn't sure these technologies would bring as great a return as some of his biotechnology investments. Wrong again. :-)

Memorial Day

What little I really know of our military comes from my infrequent stops at a Starbucks in Clarksville, Tennessee. There, men and women from Fort Campbell sit with their children and family and, it seems, live within a context most of us have not experienced.

While most of us go about our business as if our military and our country is not at risk; while news channel "situation rooms" fill our plasma screens with collages of talking heads arguing about tie pins, clergy endorsements, misspoken words, and the attitudes of retirement home residents in Florida, these courageous families go about their errands in Clarksville, simply hoping and praying that their family members return. They wonder if the sacrifices they and their military family members are making will be recognized by the Congress and the public through a commitment to provide the mental and physical care that will be necessary to heal bodies and minds subjected to the trauma so many of the rest of us simply choose to ignore.

This essay will not address the anomalies of military health care and the odd administrative silos created through Department of Defense and Veterans Affairs facilities. The issue for Memorial Day is not to argue on behalf of one mechanism of support over another; our obligation is not just to pay tribute to the Fallen; more deeply, our responsibility is to plead for broader recognition of a remarkably brave and deserved body of American citizens whose primary concern is supporting one another through difficult times as those they love serve in foreign and often lethal venues.

Let us hope this Memorial Day that we remember not just the Veterans of our past great wars - Europe, the Pacific, Korea, Vietnam - but also those who have only recently fallen and those many hundreds of thousands of people who either current serve in the military or support someone who does; let us hope for the physical and psychological recovery of those who pay a dear price for their military service; let us hope that our Nation wakes up to their daily effort.

When my father and his generation speak of the war through the dimming memories of decades, it seems increasingly like a myth. When you buy a cup of coffee in the Clarksville Starbucks, you see the present with a poignant clarity not usually found on television; it's just real people, living real lives, hoping for a good outcome.

And if you make it to the Clarksville Starbucks, think about picking up the tab for the mother, grandmother, or grandfather in line behind you. Odds are someone they love is making a far greater sacrifice than most understand. Let's do more to hold up our end of the bargain these strong families have made.

Thanks to those who serve or who have served; those who love them; and those who care for them.

Memphis Health Information Exchange Beginning 3rd Year of Clinical Operations

On May 3, 2008, our Memphis-based health information exchange has been in operation for two years. Funded by AHRQ, the State of Tennesse, and Vanderbilt and governed by the non-profit MidSouth eHealth Alliance, the Exchange has come a long way

The Exchange currently has 356 people using the system for clinical care.

• Physician / Provider roles - 199
• Nurse roles - 109
  
• Registrars and unit clerk functions - 48

These numbers will change as the last major system goes "near real time" in the next few weeks and as more ambulatory care providers are introduced to the program. The number of clinicians will increase and the number of registrars and unit clerks will decrease dramatically.

Data are accessed by authorized personnel in 30 sites, including 11 emergency rooms, 15 primary care clinics, and 4 hospitalist groups. Expansion to other emergency department settings is taking place in May and June of 2008. Access is only through two-factor authentication and secure Web browsers in restricted settings. 100% of access transactions undergo some form of audit. Use is restricted to clinical settings. No aggregate data or metrics are kept. Patients may "opt out" at the institutional level.

The Exchange grants secure access to almost 3 million patient encounters.

• Total number of unique individuals - 1,050,000
• Total number of unique individuals with clinical data (not
  just claims) - 809,000

Our latest inventory of data elements from the two-years of operation counts:

• Over 64 million laboratory tests (growing at an average of 88,000 test results a day).
  
• 1.3 million radiology reports (growing at almost 2,000 per day)
  
• Over 16 thousand dictated discharge summaries
• Over 218 thousand anatomic pathology reports
• Approximately 40 thousand other clinical notes

(Follow this link to compare with our February 2008 update)

More data and implications will soon be found at our Regional Informatics Site

The Microsoft HealthVault Be Well Fund

On February 25, Microsoft announced a $3 million dollar effort called the Microsoft HealthVault Be Well Fund. The initiative is designed to "empower providers with targeted funding to stimulate the research and development of online tools that improve health." Microsoft expects to fund approximately 20 qualified institutions with an average award of $150,000 (maximum of $500,000). Indirect costs are not funded by the Microsoft proposal. Proposals must be submitted by May 9, 2008 12:00 (noon) PST and notification will occur no later than July 1, 2008.

• Follow this link for the Microsoft Press Release
• Follow this link for the Microsoft HealthVault Be Well Fund FAQ sheet
  
• Follow this link for the HealthVault Be Well Fund RFP
• Follow this link for the HealthVault Software Developers Kit (SDK)

Microsoft envisions a range of application areas, including but not restricted to (quoting):

Primary Prevention Applications (Track 1)
Proposals targeting primary prevention could help people and caregivers create and maintain strategies that prevent or delay onset of disease by reinforcing healthy lifestyle factors and addressing modifiable risk factors such as hypertension and weight.

Secondary Prevention Applications (Track 2)
The identification of major modifiable risk factors (such as dyslipidemia, hypertension, smoking, obesity and inactivity) is a prerequisite to the implementation of preventative interventions — known as secondary prevention. Proposals in this category could help people and their caregivers measure things such as blood pressure, lipid profile components (LDL and HDL cholesterol and triglycerides), diet and nutrition, weight, smoking, and activity level to create the optimal plan to prevent or delay morbidity and acute care.

Acute Care Applications (Track 3)
Certain conditions require immediate diagnosis and treatment, whether at the doctor’s office or in an urgent care setting. Proposals targeting acute care scenarios might track progress, improve communication and share data between the silos in the healthcare system, providing caregivers with a longitudinal view of a patient’s health history that ultimately may lead to superior outcomes.

Juvenile Disease Management Applications (Track 4)
Health conditions in children often require specialized detection, diagnosis and treatment. Parents typically become eager partners in the plan of care, and seek information specifically related to their child’s condition. Proposals focusing on juvenile disease management might provide age-appropriate tools to help children, parents and caregivers understand and manage their conditions.

Women’s Health Management Applications (Track 5)
Women’s health issues can be complex and are often influenced by biopsychosocial and environmental factors. Proposals targeting this track might choose to create online tools or services that help manage health within the context of lifestyle and family.

Community and Social Health Applications (Track 6)
Patients and caregivers dealing with illness or people interested in wellness are increasingly sharing information and support with each other through various Web-based social applications. Proposals targeting this category might include applications for health in areas such as collaboration, communication and the use of social relationships to improve care.

Universal Internet Connectivity

Today AT&T announced a major program with the State of Tennessee.

Pertinent links:

• AT&T Press Release (February 25, 2008)
• San Antonio Business Journal (February 25, 2008)
• Tennessean (Nashville) article (February 25, 2008)
  
• Tennessee eHealth Council
• TN eHealth physician connectivity grant page
• Sample grant contract

Here's a portion what the AT&T press release said:

AT&T is actively engaged with the state and health care providers statewide in building the eHealth Exchange Zone. Plans call for eHealth applications to be phased in as participation by health care providers grows.

The AT&T solution features a secure online collaboration center — a Virtual Private Network (VPN)-based portal — designed to safely and securely enable such applications as:

• Prescribing pharmaceuticals online (also known as "ePrescribing").
• Securing clinical messaging among the state's health care providers.
• Sharing high-density images, including X-rays, MRIs and CT scans.
• Exchanging patient information via portable health records, which provides patient profiles, medical history, prescriptions, etc.
• Delivering telemedicine applications for remote diagnostics and care.
• Accessing Tennessee Department of Health applications, including the immunization registry, disease registries, death certificate applications and processing and medical license renewal.
• Accessing other health care applications and systems, including laboratory systems.

The network has an added component especially for protecting health information provided by the Covisint OnDemand Platform. The platform is a hosted solution that provides dual-factor authentication of health care providers using the VPN-based portal, which supports HIPAA privacy requirements. It also centralizes, automates and streamlines the access to information across health care communities statewide by giving physicians the ability to use many health-information applications with a single sign-on. The platform from Covisint, a division of Compuware Corporation (NASDAQ: CPWR), provides an on-demand, industry-leading infrastructure for secure collaboration and interoperability among health care providers.

Reading carefully, the AT&T announcement does not declare an intention to become the "exchange zone," to provide health care applications, or do more than two very important things: 1.) establish Internet connectivity for providers who do not have this capabilities because of locale; 2.) work with Covisint to provide dual-factor authentication - a critical aspect of any future health care application (don't you want to be sure that clinicians accessing your personal health information are who they say they are?) Covisint has been active in this area. See, for example, the testimony of their Chief Security officer to the U.S. Senate Judiciary Committee on the Future of e-Prescribing of Controlled Substances.

Reading carefully, the AT&T announcement does not seem to be exclusive, but potential grants from the state may be available to those who wish to use this network or switch to AT&T from their current means of Internet access.

According to the TN eHealth Council physician connectivity grant Web site, the State of Tennessee will distribute through intermediary organizations connectivity grants designed to "offset the costs offset the costs of connecting health care providers to Tennessee eHealth resources" including "hardware, software, peripherals, broadband connectivity, and HIPAA compliant authentication." The grant contract funding includes $3,500 per actively practicing physician as well as $6,000 per site.

This is a boon especially to rural practitioners who at this date do not have access to high-speed internet services in their community. It is not clear how much practitioners will be charged for this connectivity, nor is it clear how the Covisint authentication will work, but both seem to be good ideas in selected circumstances.

But what are the requirements?

Excerpting from the sample grant contract at the TN eHealth site one notes the following conditions:

• A.3.d Grantee agrees, for a period of two (2) years, to actively participate in electronic prescribing (ePrescribing) and capturing prescription information to populate a patient’s medication history as directed by the eHealth Council. Grantee should use a software application with SureScripts and/or RxHub certifications.
• A.3.d.1. Electronic prescribing, as defined by the National Council for Prescription Drug Programs (NCPDP), is two way [electronic] communication between physicians and pharmacies involving new prescriptions, refill authorizations, change requests, cancel prescriptions, and prescription fill messages to track patient compliance. Electronic prescribing is not Faxing or printing paper prescriptions. ePrescribing also includes the potential for information sharing with other health are partners including eligibility/formulary information and medication history.
• A.3.e. Grantee agrees to participate in discussions with any health information exchange “HIE” or regional health information organization “RHIO” operating in that geographic area.
• A.4. Grantees, who are TennCare providers, must adopt the health information technology in accordance with TennCare metrics. When serving TennCare patients, Grantee agrees to use an electronic medical record to document and track pertinent preventive health services (e.g. immunizations, pap smears, mammograms) and/or access and populate (as appropriate) a claims-based electronic health record for the same purpose.

What are the implications of these provisions? Here's one person's guess:

A.3.d
This measure will ensure that e-prescribing is adopted in a way that ensures security and authentication. This measure will place practitioners ahead of the curve - particularly if controlled substances and stronger authentication are required. One problem with the current system: It is not clear how many rural pharmacies are ready to accept e-prescriptions. Progress in the chains is striking and growth of adoption in independent pharmacies is rapid, but some communities may have to await new initiatives by independent pharmacists to achieve Internet connectivity and upgrade their systems.

E-prescribing brings new opportunities to communities. Because the linkages are between the prescriber and the pharmacy (with eligibility checks via RxHub or SureScripts in some instances), there is the potential for a leaner system and new methods of ensuring better compliance with needed medications. Remember, the real "quick win" with e-prescribing may be simplifying refills and ensuring that patients take the meds required to avoid long-term complications.

One unknown: it is not clear what "population of a medication history" means. This will be resolved. But clearly both providers with e-prescribing and plans have these data and additional overhead does not seem warranted.

A.3.e
This caveat seems to urge collaboration but does not impose additional burdens on practitioners. It is not clear which "RHIOs" are really valid here - and which are even exchanging data. It is assumed that the list includes initiatives in Memphis, Knoxville, the Tri-Cities area, and the Shared Health Initiative.

A.4.
This clause focuses on TennCare. It is not clear what "TennCare metrics" are, but the need to document care for these patients is acute. One requirement is that for TennCare patients, providers must "use an electronic medical record to document and track pertinent preventive health services (e.g. immunizations, pap smears, mammograms) and/or access and populate (as appropriate) a claims-based electronic health record for the same purpose."

Optimists can read this as a means of enabling choice among ambulatory care systems, although it's not clear how such systems will transmit "TennCare metrics" to the State. The only "claims-based electronic health record" available is Shared Health. Cynics can argue that such a requirement limits choice. In reality, it all depends on the extent to which the state encourages open choices among exchanges. The objective - improving the care of TennCare patients - seems a good one.

The Suggestion of a Framework

There are several different components that are alluded to in these documents:

• The "back end" - a database that TennCare uses to document care and quality
• One or more "health information exchanges" - the means by which health care providers (and someday consumers) communicate their information among authorized parties
• Authentication mechanisms - means by which one can be sure of valid communications
• Authorization - means by which policies and technologies ensure that the person authenticated is authorized to transmit or receive information
• The "front end" - the means by which data are captured by clinicians, consumers, and fiscal intermediaries

Aligning all of these moving parts is complex and involves assuring that components at each layer are able to communicate with others. Such "interoprability" is important so that each consumer and provider can chose systems best suited for these needs. (Example: as much as we Tennesseans like Nissan, I don't think we all want to drive a Tundra, nor do we want excessing intrusion into our auto purchasing decisions.)

Unanswered Questions

This program seems worthy of strong consideration by practitioners who do not at present have access to the Internet. Among the unanswered questions are:

• Internet connectivity is essential to health care delivery. But what of those who already have such access by some other means? In essence, receiving grant funding would require them to change carriers to AT&T. And what about pharmacies, nursing homes, and other essential care sites? Ultimately, every care provider is going to have to pay their way, so understanding the total cost of participation - over a 5 year period - would be valuable.
  

• Authentication is a vital service. Can a physician gain access to these services without using AT&T? Is there any grant funding for this? Will other means of authentication be developed over time, or is Covisint the only authorized authentication broker?
  

• Choice is important. Many practices are adopting comprehensive electronic medical record systems? How will these systems interact with the authentication mechanisms proposed? How will exchanges collaborate? How will the public's concerns over privacy and confidentiality be addressed?

Each of these topics has been the matter of hard work and collaboration. It may take time for answers to emerge.

This announcement should be viewed as a part of a broader framework enabling better care. Putting the pieces together will be somewhat a process of trial and error; that's the price a state pays for staying ahead of the curve.

The Economy - February 24, 2008

At times, articles randomly perused give the appearance of deeper linkages. Such is the case when comparing two front-page articles on Sunday February 24 from the St. Louis Post Dispatch and the New York Times. The Post's article is entited "Recession resilient: why we may be able to bounce back faster this time around." It's sub-title in the back pages sums up the picture: "More jobs in service sector weather a downturn." It highlights a wide range of individuals who are pursuing careers in nursing.

The New York Times front-page article is entitled "Once immune, Utah is feeling economic dip." This article mentions that Utah's relatively lower rate of retiree emigration anti-recessionary "non-wage" spending patterns of this demographic. Utah also recently cut its 2008 job projections by a third (to 2% annual growth). But the treatment of health care is the most compelling contrast to the St. Louis Post article. Quoting:

"And in what is perhaps the cruelest paradox of all, Utah spends less on health care than its neighbors, according to Headwaters, with health habits, fewer old people, and abstention from alcohol and tobacco by practicing Mormons the biggest factors. Health care spending is usually one of the most stable sectors of all in a downturn."


A table created from the St. Louis Post and other sources summarizes the change in the St. Louis economy. Several things are apparent about the St. Louis picture. First, manufacturing has diminished. The acquisition of McDonnell Douglas by Boeing is but one indicator. Similarly, one sees consolidation of some industries (groceries, telecommunications, retail) and dispersal of others (Unity health system). The percentage growth rates are also of interest, but difficult to interpret without some unit of output. It may be rather easy to calculate the efficiency per worker of a McDonalds or Wal-Mart, but more difficult for BJC and Washington University.

• Follow this link for the table

What does this all mean? Extrapolated to an extreme, we may some day be a country where the economy can best be described a population of health care workers employed caring for a population of agricultural and fast food workers. Extrapolated to an extreme, we become a country that not only makes fewer things but given the relative diminution in engineering and scientific talent also realizes fewer ambitions and ideas.

Looking at the recent issue of Health Affairs also emphasizes the degree of direct financial input by government. We are told that in 2005 Medicaid paid for 20% of the 39 million hospital stays in that year. Adding Medicare almost doubles that. Adding Medicaid managed care adds 25 - 50% to the Medicaid spend. Entitlements and defense, it seems, drive the country's economic engine, all fueled by bonds held by others. Sobering stuff.

MidSouth eHealth Alliance Update - February 2008

The MidSouth eHealth Alliance published its first newsletter in January of this year. The newsletter provides some background on the Alliance's recent work and data on our health information exchange in Memphis.

Additionally, the CHCF report was cited today by the Health Affairs blog and makes mention of our work in Memphis.

• Follow this link to the Midsouth eHealth Alliance Newsletter
• Follow this link to the Health Affairs Blog reference

What can be said of the Exchange in early 2009?

• Security and confidentiality remain paramount. Use and participation is governed by patietn consent, data sharing agreements, and user agreements
• Information from the secure Web browser is used to care for 100 - 200 individuals today in most of Memphis' major emergency departments and a growing number of ambulatory settings.
• Over 2 million events can be accessed on over 1.3 million medical records or demographic files from over 900,000 unique individuals.
• Over 50 million laboratory tests are available, as well as discharge summaries, radiography reports, some medications, and a range of other clinical data elements.
• Annual costs are less than $3 per person per year.
• The Exchange remains committed to the care of every consenting individual without regard to health care coverage.

What are priorities for the year?

• The Exchange continues to work through integration with an array of ambulatory care systems and providers.
• The Exchange seeks to follow national guidelines to foster collaboration with other systems and exchanges in the region, the state, and the country.
• The focus of the Exchange remains identification of ways to improve the quality of care provided to individuals both by presenting valuable clinical information and studying. consumer-driven "version 1.0" markets where patients and providers can focus first on their care and secondarily on the complexities of reimbursement.

GAO: Awaiting a Strategic plan from the Office of the Network Coordinator

The considerable progress in health information technology correlated with the HHS Office of the Network Coordinator is summarized in the most recent GAO report on this office. This report describes a "numerator" of programs funded by ONC, but fails to include the "denominator" that would include the far greater degree of innovation congruent with the Secretary's vision but equally the product of thousands of professionals and consumers across our country who - on their own and without strong government mandate - have concluded that a more effective health care technology infrastructure is essential to any improvements in our ailing health care system.

A "coordinator," one could argue, should address how the growing momentum created by all of these myriad programs can be harnessed to a greater social good. This writer remains a cautious optimist in this regard.

In testimony before the Senate Committee on the Budget on February 14, Valerie C. Melvin of the GAO summarized the overall HHS efforts, urging again for a national strategy.

• Follow this link to the report (GAO-08-499T)

The report describes the considerable progress achieved . And it concludes with mention of the strategic planning process underway by the relatively new leadership at ONC.

The report states:

The National Coordinator ...told us that HHS intended to release a strategic plan with detailed plans and milestones in late 2006. Nonetheless, today the office still lacks the detailed plans, milestones, and performance measures that are needed. According to its fiscal year 2009 performance plans, the Office of the National Coordinator has prepared a draft health IT strategic plan, which it intends to release in the second quarter of 2008. If properly developed and implemented, this strategy should help ensure that HHS’s various health IT initiatives are integrated and effectively support the goal of widespread adoption of interoperable electronic health records.

The current GAO report builds on previous reports cited and provides a high-level overview of budgets, progress, and challenges. The report repeatedly makes statements like "HHS has not yet defined detailed plans and milestones for integrating the various initiatives, nor has it developed performance measures for tracking progress toward the President’s goal for widespread adoption of interoperable electronic health records by 2014. "

Since 2002, ONC has received about $200 million and has made considerable progress along several critical areas. Cited in the report are details on the progress made in:

• Advancing the implementation of both outpatient and in-patient electronic health records
• Recognition by the Secretary of some interoperability standards
• Trial "NHIN II" implementations
• A toolkit and report on the extensive privacy and security efforts at the state and national level

One could challenge the impact of some of these efforts. This writer is of the belief that the NHIN I initiate was conducted in too much haste over too short a time to achieve its true impact. The GAO report states (p 10) that "according to HHS, in early 2007 its contrators delivered final prototypes that could form the foundation (emphasis added) of a nationwide network for health information exchange. The NHIN I summary report cited 24 "core services" 12 "common transaction features," and 14 "annexes on common themes like identity arbitration, consumer data-sharing permission, and data routing. Among these 50 "things" (not counting the many other features and specifications decried by the use cases, one hopes that some immediate and fundamental high priority steps will emerge as initial steps in the road map. This writer believes that about 12 of the core services lists are "must do" high priorities, but that many others may best be left for later consideration.

The report later states (p 11) that at the end of the first contract year (September 2008), "HHS intends for the nine organizations and the federal agencies that provide health care services to test their ability to work together and to demonstrate real-time information exchange based on the nationwide health information exchange specifications they define." The specifications and test materials will be placed in the public domain so that "they can be used by other health information exchange organizations to guide their efforts to adopt interoperable health IT." These documents will be valuable. (One hopes that the NHIN I materials will someday be more easily accessed as well.)

But how should - and how can - even an organization as talented as ONC develop a national strategy. This writer has a few suggestions:

Look to the successes, not just NHIN contractors. A lot is going on in health care delivery organizations, health plans, and exchanges that are funded by AHRQ, private resources, and other sources. Indeed, many of the largest and most vibrant exchanges have chosen not to participate in NHIN at this juncture.

• Build on the idea - first raised by the Commission on Systemic Interoperability - that strongly suggested the availability of a medication history for every American as a top priority
• If a second "quick win" is desired, focus the same approach on clinical laboratories
• Create guidelines for identity management. This is a critical topic for consumers, for e-prescribing, and for other applications. If e-prescribing is expanded to include controlled substances, identity management will become even more pressing
• Focus on simple core guidelines for confidentiality and privacy that transcend applications that that can serve as a basis for new and revised legislative and policy remedy
• Focus - as HHS is - on incentives to adopt helpful technologies that foster a more effective system of care
• Table or adjourn 50% of the discussions taking place on topics that are not "foundational." To paraphrase Governor Phil Bredesen's remarks at the 2007 HIMSS meeting, don't try to build version 6.0 before you've got version 1.0 working.

The literature - and our experience - are full of examples of successful approaches to strategy. Such a strategy is possible in a way that transcends the transfer of power at the executive branch of the federal government and the ongoing changes in states and communities. Central to every approach is a realistic set of expectations, focus, and incremental steps.

Governor Bredesen Mentions Memphis in his Annual Address to the Legislature

Four years ago - Feburary, 2004 - Governor Bredesen made note of a newly-formed collaboration between the Regional Medical Center in Memphis and Vanderbilt University. This collaboration led to the AHRQ initiative governed by the MidSouth eHealth Alliance and managed by the Vanderbilt Regional Informatics Group.

On January 28, 2008 the Governor returned to the Memphis project briefly in his address to the legislature.

He made two remarks that are relevant to the direct health care value of the Exchange as well as a way it may be used as part of the State's emergency preparedness efforts.

The Governor’s talk:

http://www.tennesseeanytime.org/govfiles/2008-SOS-Address.pdf

Security and preparedness. This is a bedrock responsibility of any Governor. This past summer Tennessee was named by the U.S. Department of Homeland Security as one of the ten states in the nation to achieve their highest ranking for our disaster response plans. And we were one of eight states to get a perfect score--10 out of 10--from the Trust for America's Health for emergency preparedness. To David Mitchell and Jim Basham and Gus Hargett and Susan Cooper, and to all your supporters in the General Assembly, thank you.

.............

Education, safety, jobs, employees. I'd like now to address the subject of health.
We have a lot of things underway in the health field.

I'm particularly proud of the efforts that our state is making to fight some of the underlying causes of serious health problems, particularly in the areas of obesity and smoking. This is the real frontier in public health, and we're starting to show some real successes here; the smoking rate in middle school has declined from 17% to 10% over the past year, for example. That 10% is still 10% too high.

We are also a national leader in e-health, in the use of electronic data and communication technology to maintain and make accessible to providers a person's health records. There are advantages to both the cost and quality of health care that flow from this use of technology. We have paid a great deal of attention to the privacy and security of these records as we have proceeded. The initiative we have developed in conjunction with Vanderbilt University in the greater Memphis area is frequently held up as one of the two or three top e-health efforts in the nation.

CMS, DRGs, and Hospital-acquired complications

PLEASE REFER TO MY NEW BLOG SITE

The Federal Register (Vol. 72, No. 85) of Thursday, May 3, 2007 has a 457-page listing of proposed changes to the hospital inpatient prospective payment system for the 2008 fiscal yer. These proposals affect 42 CFR Parts 411, 412, 413, and 489.

This is essential reading. The posting of these proposed changes is a watershed event with implications that may extend far beyond the altruistic intentions of CMS.

• Follow this link for the Federal Register pages
• Follow this link for commentary sumitted to CMS
• Follow this link to the specific Federal Register pages (pdf)
• Follow this link to Mark's HTML summary pages
  

Page 24716, Section F begins a lengthy discussion of how CMS proposes to reimburse hospital-acquired conditions, including infections. The changes are revolutionary and will have a tremendous impact on how hospitals - and other organizations - manage health information.

CMS has proposed some target conditions. At least to this writer's limited understanding, if one of these conditions is developed during a hospitalization, CMS would not reimburse for any higher DRG rates but instead would reimburse for the DRG that is not associated with the complication. Proposed conditions include:

• Catheter-associated urinary tract infections.
• Pressure ulcers
  
• Air emboli resulting from injection
• Stephylococcus septicemia
• Erroneous transfusion with the wrong blood type
  
• Ventilator-associated pneumonia.
• Infections relating from intra-vascular infection
  
• Clostridium difficile-associated gastrointestinal infections
  
• Drug-resistant staphyloccocus infection
  
• Surgical site infections.
• Wrong surgery.
• Falls

The legislative authority is clear. Quoting from the Federal Register:

Section 5001(c) of Pub. L. 109–171 requires the Secretary to select, by October 1, 2007, at least two conditions that are
(a) high cost or high volume or both,
(b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and
(c) could reasonably have been prevented through the application of evidence-based guidelines.
For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case will be paid as though the secondary diagnosis was not present. Section 5001(c) provides that we can revise the list of conditions from time to time, as long as the list contains at least two conditions. Section 5001(c) also requires hospitals to submit the secondary diagnoses that are present at admission when reporting payment information for discharges on or after October 1, 2007.

The mere targeting of this vital issue may transform both the means by which data are collected in the hospital and the means by which the status of a patient must be determined prior to hospitalization (the "present on admission"indicator becomes crucial). It will lead to better health care, greater systemic application of best practices, greater complexity, higher administrative costs, and perhaps add additional weight to the arguments made by proponents of global capitation or a single-payer health care system.

---

Aside: What is the Present on Admision indicator? Maybe this quote from the Register can help - or at least demonstrate again how health care is mired in the complexity business.

The current electronic format used by hospitals to obtain this information (ASC X12N 837, Version 4010) does not provide a field to obtain the POA information. We are in the process of issuing instructions to require acute care IPPS hospitals to submit the POA indicator for all diagnosis codes effective October 1, 2007. The instructions will specify how hospitals under the IPPS will submit this information in segment K3 in the 2300 loop, data element K301 on the ASC X12N 837, Version 4010 claim.

Now, isn't that clear?

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The intent of these regulations is laudable. Who, after all, should be responsible for the costs incurred when the wrong limb is amputated, when a sponge is left in a body, when the wrong type of blood is transfured, or when a catheter is left too long unattended and leads to septicemia? That said, some of the areas are far more problematic. Complications - including septicemia, C. difficile happen under the best of practices. Where decubitus ulcers are concerned, determining the onset of these conditions is problematic - particularly in the case of patients who are bedridden or largely sedentary prior to admission.

In addition to the obvious coding and IT implications, these regulations may have other implications:

• A far more extensive investigation for pre-existing conditions at the time of admission - expect every patient to have a more extensive set of tests and perhaps photographic documentation of state of skin care. Expect a tension between those who "up code" at admissions and those who suspect fraudulent behavior.
• An escalation of the "blame game" between long-term care facilities and hospitals
• A significant financial impact on hospitals as the same regulations are adopted by commercial health plans
• A new basis for malpractice claims

There are other, perhaps unlikely long-term implications. As our system becomes more and more complex and as more and more dollars go towards coding and assigning blame rather than treating, at the same time providers will be adopting health care guidelines with greater enthusiasm, payers will be revolting over the escalation in costs associated with documentation rather than care. Proponents of single-payer systems - long arguing that the administrative costs of health care in America are prohibitive - will have a new and powerful arrow in their quiver.

The Best Healthcare System in the World - Sometimes

PLEASE REFER TO MY NEW BLOG SITE:
posted at http://www.markfrisse.com/policy/

An August 12 Editorial in the New York Times reviews the findings from a recent Commonwealth Fund report on the relative performance of the U.S. health care system when compared with other countries.

• Follow this link to the NY Times editorial (subscription may be required)
• Follow this link to the Commonwealth Fund home page for the study mentioned
• Follow this link for the Commonwealth Fund's Commission on a High Performance Health System

Let's start with the good news. According to the report and the editorial, our Nation ranks very high in following certain guidelines for preventive care. The Times states that three-fourths of Americans "rate their medical care as excellent or good, so it could be hard to motivate these people for the wholesale change thought by the disaffected." The Commonwealth Fund polls, the editorial states, rate U.S. opinions as very negative stating that a third of the "adults surveyed called for rebuilding the entire [health care] system, compared with only 13 percent who feel that way in Britain and 14 percent in Canada."

In the "Dark Ages"

The editorial emphasizes what we already know: "despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines." Admittedly, these claims must be considered in light of the correlation between payer complexity and automation and the reports of dissatisfaction and information technology snafus in the U.K. and elswhere, but it does seem unconscionable for a sector controlling this much of the GDP to have allowed such neglect in our infrastructure.

Other issues

The editorial adds to a long list of factors that we as citizens ought to weigh when we consider the state of our health care in the present and for our Nation's children and grandchildren. These include:

• Access. Try to find care on a weekend. The editorial and report point out we as a nation are les likely to have a long-te3rm doctor, less able to see a doctor on the day when sick, and less apt to get our questions answered.
• Disparities. Try to find care on a weekend if you have no insurance
• Insurance coverage. It is difficult to say anything new here.
• Life and death. We score high in some critical areas
• Healthy lives. We have a shameful infant mortality rate, but we seem to neglect our own care as well as that of our infants; we rank very low in healthy life expectancy at age 60.
• Quality. The report mentions our inability to coordinate the care of our chronically ill, emphasizing again that our "system" of care arguably forces silos of care to compete - to the disadvantage of our own care. This writer believes such coordination can only be realized if we address the information technology infrastructure in the right way.
  

Everyone reads what they believe in such reports. Some may focus on the higher out-of-pocket expenses Americans pay for health care. This claim should be placed in context with the higher out-0f-pocket expenses the middle and upper classes incur for plasma TVs, automobiles, and consumer debt.

No answers or even firm opinions are offered here, but one should ask the broader question - what is the total cost for our social safety net if we include employer tax deductions and other hidden "taxes" we as citizens pay. Perhaps the challenge is to make the true cost of this sincere but faulty system more transparent. The challenge, perhaps, is to lay out the facts in a way that makes the real decisions more apparent. It may be that we are reaching a point where we cannot make any decisions other than painful ones (much as the Romans, no doubt, did not "decide" to let the Goths invade their failing empire.)

For this reason, the issue is not a partisan one but more one of first creating a spirit of true "transparency" in our health care system - something Secretary Leavitt strongly supports. With a more transparent system based on useful data, we can debate our different views on equity, self-reliance, and role of both government and the individual.

The system is broken. Some make the analogy with a trauma patient on life support who will not recover from a their injuries. Some would argue we should work even harder at saving this life as it is currently organized. Others would argue it is time to let this soul go and to start thinking about how to harvest organs. A crude choice, perhaps, but in the end the editorial is not just about ideas, it is about the savage reality of life and death.

Following Intel's CEO

What follows is a compendium of postings from my other sites concerning Intel's visionary CEO. This observer heard his September 2006 address and thought his remarks put our health care delivery crisis in the right context. Enclosed as well are subsequent postings and links.

Barrett, September, 2003

On September 26 at 8:30 am, Intel CEO Craig Barrett spoke at the eHealth Initiative Health Information Technology Summit. He preceded Secretary of HHS Michael Leavitt.

• Follow this link for an unofficial transcript (PDF) of Barrett's talk.
• Follow this link for a transcript of Secretary Mike Leavitt's talk.
  

He prefaced his remarks by emphasizing both his support for the political process but also his frustration with the pace of change and leadership "around the margins." He mentioned in a positive sense his participation in the American Health Information Community.

But Barrett's words were strong and, in the view of this observer, dead on.

Among his comments:

• U.S. jobs will continue to move offshore at a rapid pace unless corporate America exerts its power to force the health care industry to adopt systems that will cut costs and improve efficiency. "Every job that can be moved out of the United States will be moved out ... Because of health care costs," which on the average were in excess of $6,300 per person in 2004.
• "The system is out of control, it's unstable, it's basically bankrupt, it gets worse each year and all we do is tinker around the edges when what we need are major fixes"
• Asking "who should pay for it" is the wrong question. No one can pay for it.
  Even if one makes a massive, one-time change in the chronic care disease management, unless the trend is toward continual improvement, the costs will inexorably climb.
• "Every other industry has adopted this technology and (the health care) industry continues to sit here and debate"
• Why does the health care industry expect subsidies to pay for health care technology? Every other industry makes these investments as a matter of survivability?
• Employers should demand that hospitals select standardized record systems to lower costs or take their company's business elsewhere
• Companies should only do business with health care providers who meet certain standards, including fully electronic patient records and published "best practices" for patient treatment
• Price transparency is critical to employer and consumer engagement. How many other industries can't tell you what a service will cost or explain their charges in a simple way?
• Hospital networks could and should be transformed into "competitive centers for excellence" that are paid to keep employees healthy.

Wal-Mart Stores Inc. Executive VP Linda Dillman joined Barrett on the stage and spoke of Wal-Mart's costs as an employer and their innovative approach to providing health care in pilot settings.

• Barrett said the health care industry could learn from the efficiency of Wal-Mart.
• He claimed Wal-Mart was an information technology company that sells what it tracks and excels by its ability to employ IT in conjunction with effective business models and great customer service

• Follow this link for AP coverage of this presentation
• Follow this link for a Health IT World News article on the talk
• Follow this link for a related posting on this Blog that references Health Affairs articles
• Follow this link for my comments on a NY Times editorial concerning health care costs
• Follow this link to a July 2004 discussion involving Craig Barrett and addressing global competition

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Barrett (November, 2006)

In a September 29 posting to this site, this writer quoted from a presentation given by the CEO of Intel to the eHealth Initiative meeting. Warning of the crisis in health care delivery, he assured the public that large employers will take action.

In a November 29 article in the Wall Street Journal by Gary McWilliams, Barret's "jolt to the health care system" is describe in greater detail. mcWilliams states that in the coming week, Intel, Wal-Mart, British Petroleum, and others will disclose a plan to provide digital health records to their employees "and store them in a multimillion-dollar-data warehouse" linking hospitals, doctors, and pharmacies. (This writer believes the actual technology will be an exchange with strong privacy protections and not a giant data warehouse; a clarification will assuage public concern).

Craig R. Barrett, Intel's chairman, calls this effort part of a "building-block to modify the U.S. health industry" and he doubts that "the industry is capable of modifying itself."

The costs projected for the project seem low; the article claims a contribution of 1.5 million each from 10 employers. The model appears to let "consumers and insurers...evaluate price and performance data from millions of employees." Eliminating duplicate tests and erroneous or lost information would also slash administrative overhead, accounting, according to the article, for up to 40% of medical costs. An appeal to reduction of adverse drug events is also made.

Functionality includes an ability for doctors to "measure which treatments worked best for chronically ill groups of patients" and the ability to prescribe electronically.

The article raises some points that will draw concern. Quoting:

"Coalition members believe that giving consumers control over their own records would help get around the technical and cost issues. But the idea of portable medical records and a massive repository still faces hurdles. Privacy advocates worry that digital records will be misused by employers and insurers to deny jobs or health-care coverage. The watchdog group Patient Privacy Rights Foundation urges employees to shun the approach until there are adequate protections. 'The system is leaking information,' says Chairwoman Deborah C. Peel, a practicing psychiatrist. 'Once out there, it's like a Paris Hilton sex video. It's [there] for the millennium.' "

Other features:

• The employers will insist that health-care providers adopt electronic records and prescribing as a condition of future business.
• Wal-Mart will apply its purchasing power to get bar codes on products intended for hospitals and clinics.
• Employers will expect employees to pick doctors willing to use and update their records, though employee compliance is voluntary.
• The "records will be the property of the employees, and the data will be mined by insurers and others only after the patients' identity is stripped off."
  

Linda Dillman, who was on the stage with Barrett at the eHealth Initiative meeting in September, states that they are "trying to bring all the right people to the table and show them what can be done."

The article also elaborates on some sobering costs, claiming that "Intel figures its health-care spending will be as much as a fifth of its research and development costs by 2009. Wal-Mart says the costs for its 1.3 million U.S. employees, if unchecked, will climb $1 billion annually for the next five years."

The final feature - patient "ownership" will be an interesting driver. Quoting from the article:

The Intel-Wal-Mart plan to offer employees medical records and automatically update those records with hospital, doctor and pharmacy detail "is very ambitious," says Dr. Greenfield, an adviser to Care Focused Procurement LLC., a nonprofit putting together an HMO claims database. "We love the patient as the agent."
"It has always seemed unusual to me that the medical record is seen as the property of the medical system," adds Donald Berwick, chief executive of the Institute for Health Care Improvement, Cambridge, Mass. Tests are duplicated and information lost in the handoff between physicians or clinics. "The best integrator in the end is the patient," Dr. Berwick says.

One expects reaction to be rather diffuse until more clarification is obtained. The "disruptive" element of this plan is note employer drive for digital health as much as, this writer suggests, it will lead to alternative care delivery models. Something that our Nation dearly needs.

Follow-up stories and links

• Follow this link for a December 4 Information Week article by J. Nicholas Hoover
• Follow this link for a December 6 article describing the Omnimedix relationship
• Follow this link to access the Omnimedix dossia site

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Barrett (July 2007)

• Follow this for an even later (summer, 2007, link)

Commonwealth Fund Report

A January 2007 document published by Davis et. al. of the Commonwealth fund addresses means to achieve savings and better value through more efficient and effective health care and insurance systems.

• Follow this link to the report home page. The 33-page report is in PDF format

Entitled "Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?" the report focuses on six strategic areas:

1. Increasing the effectiveness of markets with better information and greater competition
2. Reducing administrative overhead and developing competitive pricing structures
3. Incentives promoting efficient and effective care
4. Patient-centered primary care;
5. Health information technology and other infrastructure approaches
6. Strategic investments to improve access, affordability, and equity.

Medicare - Senate Budget Committee - January 30,2007

Dr. Robert Reischauer (Urban Institute and former chief of the CBO) and colleagues presented details of the implications of the current Medicare Budget. Sen Conrad opened with a statement quoting the Chairman of the Federal Reserve.

Buried within the discussion was a heightened degree of skepticism about the economic value of information technology. To this reader there was no sense of discouraging health IT, just an added emphasis on the importance of doing it right and that the purported economic benefits might not be as great as claimed - and certainly not sufficient to "solve" any of these problems.

• Follow this link for Senator Conrad's statement
• Charts used in the Fed Reserve Chairman's January 18 presentation
• Follow this link to Bernanke's January 18 testimony
• Follow this link for the Reischaur testimony
• Greenstein testimony
• Stuerle testimony

California Healthcare Foundation's Most Popular Reports, 2006

A January 2007 posting from the California HealthCare Foundation lists the 10 most popular reports accessed during the last year. There are some expected titles (e.g., health care costs, MediCal, Part D) and some surprises (e.g., open source software).

• Follow this link for all CHCF publications

Follow these links for the Top 10

• The Guide to Medi-Cal Programs
• Snapshot: Health Care Costs 101
• Open Source Software: A Primer for Health Care Leaders
• Health Care in the Express Lane: The Emergence of Retail Clinics
• IT Tools for Chronic Disease Management: How Do They Measure Up?
• Medi-Cal Facts and Figures: A Look at California's Medicaid Program
• Consumers in Health Care: Creating Decision-Support Tools That Work
• Guide to Health Programs in English
• The Medicare Drug Benefit: How Good Are the Options?
• Snapshot: Employer-Based Insurance: Coverage and Cost

HHS Medicaid Transformation Grants

On January 25, 2007, HHS released notification of awards to 27 states to fund new ways of improving Medicaid efficiency, economy, and quality of care through the development and enhancement of "innovative systems to get more value out of the money they [the states] spend providing care to their low-income elderly, chidren and disabled citizens."

Among the "permissable" uses of grant funds were:

• Reducing patient error rates through the implementation of technology (electronic health records, clinical decision support tools or e-prescribing programs).
• Improving rates of collection from estates of amounts owed under Medicaid.
• Reducing waste, fraud, and abuse under Medicaid, such as reducing improper payment rates. Increasing the utilization of generic drugs through education programs and other incentives.
• Improving access to primary and specialty physician care for the uninsured using integrated university-based hospital and clinic systems.
• Implementation of a medication risk management program as part of a drug use review program.

The primary source links are:

• Follow this link for the HHS press release of 25-January
• Follow this link for the details (some of the URLs are not accurate as of 1-26-07)
• Follow this link for the zip file for states A-I
• Follow this link for the zip file for states J-R
• Follow this link for the zip file for states S-Z
• Follow this link for a nice table and discussion from the Commonwealth Fund
  

The proposals are an interesting mix. Many emphasize health information exchange and some of these link such proposals with e-prescribing. The dominant health information exchange proposals include:

• Arizona - $11,749,500
• Connecticut - $5,000,000
• DC - $9,864,000
• Kentucky - $4,987,583 (primarily claims-based systems)
• Wisconsin - $3,043,272
• Total - $34,644,355
  

Others emphasize this topic to lesser degree - and some - like New Mexico and Tennessee - are restricted to e-prescribing.

Summary of grants from the CommonWealth Fund States in Action (March / April, 2007)

Focus of Grant	Number of Grants	State Grantees
Electronic medical records or health information systems and exchanges	13	AL, AZ, DC, HI, KY, MI, MN, MT, NM, TX, WV (2), WI
Pharmacy HIT tools	7	CT, FL, NM, ND, TN, UT, WV
Electronic verification of citizenship	4	AR, MA, MI, RI
Promoting good health and personal responsibility	2	WV (2)
Predictive modeling system	2	IL, KS
Program integrity (fraud reduction)	2	MD, NY
Medical information for children	1	NJ
Health provider credentialing	1	MI
Medicaid estate recovery	1	IN

A complete table listing can be found at the link above and is included below.

State Name	Project Name	Total Funded
Alabama	Together for Quality - Health Information Systems	$7,587,000
Arizona	Medicaid Health Information Exchange Utility Project	$11,749,500
Arkansas	Electronic Verification of Proof of Citizenship	$285,513
Connecticut	Health Information Exchange and e-Prescribing	$5,000,000
DC	Comprehensive Medicaid Integration (Patient Data Hub)	$9,864,000
Florida	GenRx Expansion	$1,737,861
Hawaii	Open Vista ASP Network	$3,188,535
Illinois	Predictive Modeling System	$4,849,200
Indiana	Medicaid Estate Recovery Centralization and Automation Project	$124,880
Kansas	Using Predictive Modeling Technology to Improve Preventive Healthcare in the Disabled Medicaid Population	$906,664
Kentucky	Health Information Partnership	$4,987,583
Maryland	Automated Fraud and Abuse Tracking	$576,228
Massachusetts	Secure Verification of Citizenship through Automation of Vital Records	$3,950,440
Michigan	One Source Credentialing	$5,208,759
Michigan	Expansion of Vital Records Automation and Integration Into Medicaid	$3,929,317
Minnesota	Communication and Accountability for Primary Care System (CAPS)	$2,843,340
Mississippi	As One - Together for Health	$1,688,000
Montana	Enhancing EHR - Clinical Decision Making	$1,481,152
New Jersey	Medical Information for Children	$1,516,900
New Mexico	e-Prescribing	$855,220
New Mexico	Electronic Health Record Project	$712,301
New York	Fingerprint Authentication at Point of Service	$5,500,000
North Dakota	Web-based Electronic Pharmacy Claim Submission Interface	$75,000
Rhode Island	IT Infrastructure Transformation	$725,253
Tennessee	Electronic Prescription Pilot Project	$674,204
Texas	Electronic Health Passport for Foster Care	$4,000,000
Utah	Developing a Pharmacotherapy Risk Management System with an Electronic Surveillance Tool	$2,881,662
West Virginia	Healthier Medicaid Members through Personal Responsibility	$1,937,110
West Virginia	Healthier Medicaid Members through a Stronger Medicaid Program	$1,731,680
West Virginia	Healthier Medicaid Members through Health Systems Improvement	$3,895,730
West Virginia	Healthier Medicaid Members through Applied Technology	$1,766,280
West Virginia	Healthier Medicaid Members through Enhanced Medication Mgmt	$4,287,110
Wisconsin	Health Information Exchange Initiative	$3,043,272
Total		$103,559,694

Center for Health Care Strategies and Return-on-Investment

The Center for Health Care Strategies (CHCS has recently published an ROI analysis on integrated substance abuse treatment and medical care management. Of greater acute interest is their recent announcement of a Return on Investment Purchasing Institute designed to help states understand the return on investment (ROI) of various care management iniatives. Quoting from the announcement: "Through this 12-month initiative, up to eight states will receive focused training paired with intensive technical assistance around concepts and methodology for calculating ROI. Participants will evaluate the ROI potential for specific quality initiatives, analyze the implications of ROI analyses for program planning, and package ROI forecasts for use in budget requests. "

On February 16, CHCS announced its eight states.

• Arizona
• Colorado
• Connecticut
• Idaho
• Louisiana
• Oklahoma
• Pennsylvania
• Washington

• Follow this link for the CHCS home page
• Follow this link to the integrated substance abuse treatment ROI page
• Follow this link to the Return on Investment Purchasing Institute announcement
• Follow this link to a summary of the forcasting calculator instrument (pdf)
• Follow this link to the CHCS announcement of the eight states
  

CHCS was established 1995 with support from the Robert Wood Johnson Foundation. Current supporters include:

• Agency for Healthcare Research and Quality
• The Annie E. Casey Foundation
• The California HealthCare Foundation
• The Commonwealth Fund
• The David and Lucille Packard Foundation
• Kaiser Permanente
• Robert Wood Johnson Foundation
• Schaller Anderson, Incorporated
• United Healthcare/Evercare
  

The home page describes the mission as follows:

CHCS advances its mission by working directly with state and federal agencies, health plans, and providers to design and implement cost-effective strategies to improve health care quality. We help these Medicaid stakeholders implement eight Quality Action Steps that are critical to chronic care improvement. These quality strategies form the foundation of CHCS’ core initiatives — the CHCS Purchasing Institute, Best Clinical and Administrative Practices (BCAP) workgroups, and multi-stakeholder collaboratives. These collaborative-learning activities provide unique venues for state Medicaid agencies, health plans, and providers to share best practices and to work together to design programs that reward high quality care.

A Busy Month in DC: January, 2007

Congress has been busy, but the plans for health information technology remain undetermined. Privacy and confidentiality are the primary topics of discussion but more changes to Medicare and Medicaid may be in the works.

Most of the activity is in HHS. In particular, there are three meetings of note.

AHIC - the January meeting will address a wide array of topics.

• Follow this link for the AHIC agenda

The National Health Information Infrastructure Prototype demonstrations - it will be interesting to see what has - and has not - been accomplished in a year. It is difficult to imagine completely engaged communities in a short period of time, but results are demonstrable. Given the expertise of the contractors, a clearer understanding of the costs and benefits should ensue and this alone will be a valuable contribution.

• Follow this link for more information on the NHIN demonstrations

The inaugural meeting of the State Allliance for eHealth - conducted by the National Governors Association.

• Follow this link for more information about the State Alliance for eHealth

Tax Relief and Health Care Act of 2006

The Tax Relief and Health Care Act of 2006 was signed into law on December 21, 2006.

The White House press release emphasizes the health care impact as follows:


The Act Will Help Make Health Care Affordable And Accessible For More Americans. This Act will bring Health Savings Accounts (HSAs) within the reach of more Americans. HSAs allow people to save money for health care tax-free, and to take these accounts with them if they move from job to job. This Act will raise contribution limits and make the accounts more flexible, let people fund their HSAs with one-time transfers from their Individual Retirement Accounts, allow people to contribute up to the annual limit of $2,850 regardless of the deductible for their insurance plan, and give them the option to fully fund their HSAs regardless of what time of year they sign on to a plan.

There, is, of course, much more than that. (including a section entitled "Designation of wines by semi-generic names.")

• the House version can be accessed through this link

The section addressing Medicare and other provisions is called the Medicare Improvements and Extension Act of 2006. It includes:

• One year increase in the Medicare physician fee schedul conversion factor
• Ammendments to the Social Security Act (42 USC 139w4) to have the Secretary of HHS to implement a system for the reporting by eligible professionals of data on quality measures. These measures are the measured identified as 2007 physician quality measures under the Physician Voluntery Reporting Program as published on the CMS web site.
• For 2008, the measures are to be endorsed by a consensus organization such as NQF or AQA. "Such measures shall include structural measures, such as the use of electronic health records and electronic prescribing technology."
• Registries may be used. The legislation states "the Secretary shall address a mechanism whereby an eligible professional may provide data on quality measures through an appropriate medical registry (such as the Society of Thoracic Surgeons National Database), as identified by the Secretary."
• There are limitations to administratvie and judicial review under sections 1869, section 1878 and other relvant codes, of the development and implementation of the reporting system,including identification of quality measures, registries, or identifiers.
• Provision of the appropriate quality measures may qualify practitioners and facilities for a bonus from the Federal Supplementary Medical Insurance Trust fund an amount equal to 1.5% of the estimate of allowed charges for services provided during a reporting period.
• There are definitions of the amount of services. For example if there are no more than three provided that are applicable and each has been reported by 80% of cases, one is eligible. If 4 or more, the reimbursement is allowed if one reports 80% of at least 3 measures
• There are limitations to payment. For example, not more than 300% of the average per measure payment.
• Recommendations for validation are included

As part of this legislation, Section 1848 of the Social Security act is ammended further by creating a new subsection entitled "physician assistance and quality initiative fund."

• This fund will have available funds of $1.35 billion
• the fund will be used to pay for the quality payments
• the legislation describes what will happen if there isn't enough money prior to appropriations

What does this mean?

• Quality metrics are part of the plan
• They will be based on consensus groups
• Use of EMR, e-Rx and other structural measures will be part of the reimbursement

HHS Advances Nationwide Health Information Network Initiative

After many months of speculation, it appears that there may be new life, opportunity, and utility associated with the NHIN prototypes funded through ONC.

• Follow this link to the December 8, 2006 press release
• Follow this link to the January 25-27 AHIC demonstration press release

HHS’ Office of the National Coordinator for Health Information Technology announced today that the department will support trial implementations for the Nationwide Health Information Network (NHIN). Dr. Kolodner stated by "bringing together the significant expertise and work achieved this year by the current efforts with state and local health information exchanges, we can begin to construct the 'network of networks' that will form the basis of the Nationwide Health Information Network."

In the coming months, HHS will announce details of the procurement process for the trial implementations. Proposals to create the trial implementations and work toward integrating them with the broader NHIN initiative will be solicited in spring 2007.

National Conference of Commissioners on Uniform State Laws

The National Conference of Commissioners on Uniform State Laws (NCUUSL) has been participating in some of the state-level discussions on the legal and regulatory issues related to health information exchange. W. Grant Callow, Esq, for example, has been active in the Florida HISPC deliberations.

• Follow this link to a description of the Study Committee on Health Care Information Interoperability chaired by W. Grant Callow
• Follow this link to the Florida Privacy Project

The National Conference of Commissioners on Uniform State Laws (NCCUSL) "provides states with non-partisan, well-conceived and well-drafted legislation that brings clarity and stability to critical areas of state statutory law."

"Conference members must be lawyers, qualified to practice law. They are practicing lawyers, judges, legislators and legislative staff and law professors, who have been appointed by state governments as well as the District of Columbia, Puerto Rico and the U.S. Virgin Islands to research, draft and promote enactment of uniform state laws in areas of state law where uniformity is desirable and practical. "

The Agency for Healthcare Research and Quality (AHRQ) Announces Four New Programs

The Agency for Healthcare Research and Quality has announced four new programs as part of an ambulatory safety and quality (ASQ) initiative. This posting should not be considered definitive.

• To access the four announcements, follow this link or access each individually below
• Follow this link to access the transcript of the January 4 Technical Assistance call

The four initiatives are:

1. ASQ: Risk Assessment in Ambulatory Care: This announcement has a broad view on ambulatory care that includes the ambulatory care clinician, as well as the patient cared for in ambulatory settings and across high risk transitions in care. Research will focus on assessing the risks associated with ambulatory care that have not yet been fully elucidated. Unlike the rest of the ASQ program, this announcement will not include a primary focus on health information technology.
2. ASQ: Improving Quality through Clinician use of Health IT: This announcement has a primary focus on the ambulatory care clinician. Research will focus on strategies to improve medication management and the delivery of evidence to the point-of-care resulting in improved clinical decision-making and clinical quality for priority conditions. Issues to be addressed include the relationship between Health IT and workflow redesign, systemic barriers to Health IT adoption, care for patients with multiple chronic conditions, enhanced patient-centered models of care delivery, and improved use of effective alert strategies for decision support.
3. ASQ: Patient-Centered Health IT: This announcement has a primary focus on patients and their interaction with the ambulatory health care system. Research will focus on strategies to improve the patient experience of care through the use of health IT. It will include work to improve the delivery of patient-centered health information to ensure patients and clinicians have the information they need to make better health care decisions. Specific topics to be addressed include shared decision-making and patient-clinician communication, personal health records, integration of patient information across transitions in care, and patient self-management of chronic conditions.
4. ASQ: Enabling Patient Safety and Quality Measurement through Health IT: This announcement has a primary focus on integrating patient safety and quality measurement with information technology. Research will focus on strategies to improve transparency for patients in ambulatory care through the development, deployment and export of quality measures from electronic health record systems. Issues to be addressed include measure development across episodes of care, clinical data needs for quality measurement export and reporting, and the reporting of quality data for improvement.

The Privacy Agenda

In what this writer suspects will be an opening round in a series of related articles, the NY Times writers Milt Freudenheim and Robert Pear in the December 3 issue contribute a piece entitled "Health hazard: Computers Spilling your History."

The article touches on a vast array of issues, from access within organizations to specific records (e.g., Bill Clinton's surgery) to access by employers to personal health information. Mention is made to the broad support for more health care technology while at the same time raising the very legitimate concerns over what these technologies can do to threaten personal information.

Reference is made to two surveys. The first is the 2005 California Health Care Foundation survey. The second is a recent survey by the Markle Foundation to be released soon and building on a 2005 survey conducted by the same organization.

Other topics mentioned include:

• Lack of enforcement and limitations of HIPAA
• Examples of state enforcement where federal enforcement has been less prominent
• Concerns over recent efforts to pre-empt state consumer protection laws
• The prominent role privacy may play in the congressional agenda (quoting Reps. Dingel of Michigan and Markey of Massachusetts)
• Efforts by employers to promote the use of personal health records (Harriet M. Person, IBM's chief privacy officer, is mentioned as a representative of one of "25 companies meeting...to develop a set of principles and best practices ...that would help persuade people that their employers really did not look at private information stored online.")
• IBM's work with JanLori Goldman and colleagues
• Mention of Dr. Deborah Peel and PatientPrivacyRights.org
  

Not mentioned in the current piece is the ambitious effort by AHRQ and others in HHS to examine laws and privacy at the state level. Awarding contracts to 33 states and one territory, this large and complex project is likely to document the prevalence of specific issues across the country. Although these issues are known and well-described by many, the importance of this work may be in the collateral discussions taking place in so many state and regional levels. Focusing on these concerns, it seems, builds a coalition more educated in appropriate use and policies for information technology.

One expects follow-on articles after the Markle release. These articles may place more focus on what can be done today at the local efforts where policy and legal agreements are concerned. The Memphis, MidSouth eHealth Alliance work implementing the Markle Connecting for Health Framework data sharing agreements is but one example.

• Follow this link for the Memphis data sharing agreements
• Follow this link to Mark Frisse's Confidentiality Blog
• Follow this link to the Health Privacy Project (JanLori Goldman, quoted in NY Times)
• Follow this link to PatientPrivacyRights.org (Dr. Deborah Peel, mentioned in NYT article)

Halfway to National Health Care

As a new contribution to a growing series of articles describing the shift in health care financing from employers to government, Daniel Gross in the December 3 NY Times contributes a piece entitled "National Health Care? We're Halfway There."

Quoting extensively from Thomas M. Selden of AHRQ, Gross points out that the tax subsidy for employment-related coverage is over $200 billion in 2006 - 35% of the amount spent on premiums. In comparison, Medicare spending was $380m and federal spending on Medicaid was $180 billion (not clear that includes state spending). Total public expenditures in 2004 accounted for $888b of the $1.96 trillion spent on health care in that year. Adding premiums paid for public-sector employees, and the total federal expenditure is $1.2 trillion - 61% of the total expenditures.

One of the best resources for related information and what it means is the work of Jacob Hacker. His work is most easily accessed via:

• http://www.greatriskshift.com

His site has an interactive blogger, facts, white papers, and many other supporting documents.

His proposal for expanding Medicare can be accessed through his Yale site.

• http://pantheon.yale.edu/~jhacker/Medicare%20Plus.pdf

Graphic from the December 3 NY Times article by David Gross:

Intel Follows Through

In a September 29 posting to this site, this writer quoted from a presentation given by the CEO of Intel to the eHealth Initiative meeting. Warning of the crisis in health care delivery, he assured the public that large employers will take action.

• Follow this for an even later (summer, 2007, link)

In a November 29 article in the Wall Street Journal by Gary McWilliams, Barret's "jolt to the health care system" is describe in greater detail. mcWilliams states that in the coming week, Intel, Wal-Mart, British Petroleum, and others will disclose a plan to provide digital health records to their employees "and store them in a multimillion-dollar-data warehouse" linking hospitals, doctors, and pharmacies. (This writer believes the actual technology will be an exchange with strong privacy protections and not a giant data warehouse; a clarification will assuage public concern).

Craig R. Barrett, Intel's chairman, calls this effort part of a "building-block to modify the U.S. health industry" and he doubts that "the industry is capable of modifying itself."

The costs projected for the project seem low; the article claims a contribution of 1.5 million each from 10 employers. The model appears to let "consumers and insurers...evaluate price and performance data from millions of employees." Eliminating duplicate tests and erroneous or lost information would also slash administrative overhead, accounting, according to the article, for up to 40% of medical costs. An appeal to reduction of adverse drug events is also made.

Functionality includes an ability for doctors to "measure which treatments worked best for chronically ill groups of patients" and the ability to prescribe electronically.

The article raises some points that will draw concern. Quoting:

"Coalition members believe that giving consumers control over their own records would help get around the technical and cost issues. But the idea of portable medical records and a massive repository still faces hurdles. Privacy advocates worry that digital records will be misused by employers and insurers to deny jobs or health-care coverage. The watchdog group Patient Privacy Rights Foundation urges employees to shun the approach until there are adequate protections. 'The system is leaking information,' says Chairwoman Deborah C. Peel, a practicing psychiatrist. 'Once out there, it's like a Paris Hilton sex video. It's [there] for the millennium.' "

Other features:

• The employers will insist that health-care providers adopt electronic records and prescribing as a condition of future business.
• Wal-Mart will apply its purchasing power to get bar codes on products intended for hospitals and clinics.
• Employers will expect employees to pick doctors willing to use and update their records, though employee compliance is voluntary.
• The "records will be the property of the employees, and the data will be mined by insurers and others only after the patients' identity is stripped off."
  

Linda Dillman, who was on the stage with Barrett at the eHealth Initiative meeting in September, states that they are "trying to bring all the right people to the table and show them what can be done."

The article also elaborates on some sobering costs, claiming that "Intel figures its health-care spending will be as much as a fifth of its research and development costs by 2009. Wal-Mart says the costs for its 1.3 million U.S. employees, if unchecked, will climb $1 billion annually for the next five years."

The final feature - patient "ownership" will be an interesting driver. Quoting from the article:

The Intel-Wal-Mart plan to offer employees medical records and automatically update those records with hospital, doctor and pharmacy detail "is very ambitious," says Dr. Greenfield, an adviser to Care Focused Procurement LLC., a nonprofit putting together an HMO claims database. "We love the patient as the agent."
"It has always seemed unusual to me that the medical record is seen as the property of the medical system," adds Donald Berwick, chief executive of the Institute for Health Care Improvement, Cambridge, Mass. Tests are duplicated and information lost in the handoff between physicians or clinics. "The best integrator in the end is the patient," Dr. Berwick says.

One expects reaction to be rather diffuse until more clarification is obtained. The "disruptive" element of this plan is note employer drive for digital health as much as, this writer suggests, it will lead to alternative care delivery models. Something that our Nation dearly needs.

Follow-up stories and links

• Follow this link for a December 4 Information Week article by J. Nicholas Hoover
• Follow this link for a December 6 article describing the Omnimedix relationship
• Follow this link to access the Omnimedix dossia site

The Adoption Gap in Physician Office Practice

A November 2006 issue brief by Joy M. Grossman and Marie C. Reed of the Center for Studying Health System Change is entitled "Clinician Information Technology Gaps Persist Among Physicians."

• Follow this link for the publication

The study is based on a nationally representative telephone survey of physicians involved in direct patient care drawn from the AMA and AOA master files. All candidates were active, non-federal, office- and hospital-based practitioners who spent at least 20 hours a week in direct patient care (residents and fellows were excluded). 12,000 physicians responded in 2001 and 6,600 responded in 2005 (52% response rate).

Among the questions, physicians were asked "in your practice, are computer or other forms of information technology used:

1. to obtain information about treatment alternative or recommended guidelines
2. for clinical data and image exchange with other physicians
3. to access patient notes, medication lists, or problems
4. to generate reminders for you about preventive services, and
5. to write prescriptions"

They were not asked if they themselves used computers, nor were they asked specific details such as the use of an EMR, practice-management system, or Web-based portal. So the data for use are an upper bound for physician practice and subject to the limitation of all surveys of this type.

• Follow this link to the data table

Overall, use of computers in clinical practice settings is growing. Most interesting is the claim that 50% exchanging clinical data, 50% are accessing clinical notes, 30% are using reminders, and 22% are using e-prescribing.

Small groups (3-9 physicians) claim 43 % use clinical data exchange, 40% access notes, 25% generate reminders, and 12% write prescriptions. Lower numbers for accessing notes and exchange data are found in 1-2 physician practices with approximately 30% claiming to use computers to exchange data and to access patient notes.

These data seem to suggest that the use of a portal to a hospital is considered data exchange by the respondents.

All data demonstrate a significant difference in availability of functions as a result of physician practice size.

Interestingly, the authors claim that high Medicaid providers (> %25 of total practice revenue) were as likely or more likely than others to report HIT use for each of the clinical activities both in the current survey and in the 2001 survey. Although data are not presented, the authors claim this access is not a function of practice size and that the of high Medicaid providers in solo (37%) or two physician (21%) practices were as likely to use HIT as their peers.

Commission on Systemic Interoperability; One Year Later

A recent report from the National Alliance for Health Information Technology suggests considerable progress on many of the recommendations made by the Commission on Systemic Interoperability. The Commission was mandated by Congress as part of the Medicare Modernization act. It addressed a variety of market and regulatory issues. One theme of note was a plan for the creation of a national prescription drug "utility" that would make information available in a secure and confidential manner when it is warranted at the point of care. To many of us, such a program is an essential component of the NHIN and arguably the best "quick win" available.

• Follow this link to the report

Among the most notable achievements cited by NAHIT are:

• Exceptions to Stark and antikickback rules
• A certification process for electronic health record systems that ensures a minimum level of functionality; this process has certified many systems already
• Identifying technical standards required for more effective use of health care information

To this writer, much more has to be done. Including:

• Means of financing health care information technology in small practice settings. This writer believes it is the responsibility of providers to finance their own systems as a key element of business management in small practice. Interfaces to specific hospitals, plans, and care delivery units are essential to effective practice but such interfaces are different than creating a way to finance small practice systems and re-engineer processes. (Small retail pharmacies face similar challenges and should be included in financing and re-engineering approaches.)
• The certification process must in its next iteration require more in the way of e-prescribing standards promulgated in November. At present, one can be certified but not have to demonstrate the capability to obtain medical history and perform other e-prescribing functions that are also a part of the MMA agenda. This lag is due to timing but hopefully will be addressed.
• Identifying means of implementing standards. A part of the national agenda must be to understand how to implement standards, study them, and apply them effectively. An example of a successful approach may be the AHRQ/ CMS e-prescribing pilots

Pay-For-Performance

In the November 2, 2006 issue of the New England Journal of Medicine (pp. 1845-1847) Elliott S. Fisher of Dartmouth provides a brief overview of pay-for-performance. He mentions the IOM study (also linked on this blog) as well as the AQA Quality set. The general concerns are summarized:

• Feasibility of implementation - most still emphasize provider-focused episodes and hence may make "fragmented care by multiple providers appear 'efficient'."
• Sufficiency of rewards - the arguments of collection cost vs. benefit and winners / losers as seen from the provider perspective
• Unintended consequences - includes mention that physicians may select heatlhier patients and refuse care to others; impact on the chronically ill

He argues for:

Implementation of P4P "as a means to learn hot to modify the payment system to foster higher performance and encourage systemwide and comprehensive improvement."

Targeting multiple dimensions of care including technical quality, patient-centered care and efficiency but "kmoving toward longitudinal and health-outcome measures as soon as it is feasible."

Systems that encourage "measures and rewards tha foster shared accountability and coordination of care."

Allowing Medicare beneficiaries to identify a primary care provider and then rewarding such providers

Voluntary participation by small-practice providers because of the serious data-collection challenges

Creation of modest funding pools derived from currentpayments to improve adoption by providers

A stronger evidential base for pay-for-performance in the "context of an effective monitoring and evaluation system that assesses early experiences...evaluates the approach's impact broadly...and identifies and disseminates informaiton on how to best improver performance.

Citing the weakness or current efforts, Fisher argues that "little attention is being devoted to designing or building a comprehensive evalution framework that would allow us to learn from our inevitable mistakes."

More on State Health IT Initiatives

An October 26, 2006 iHealthBeat item made reference to a Modern Healthcare article on the diverse health IT activities within states. More interesting than the content, perhaps, were the titles. The iHealthBeat item was entitled: "State Health IT Groups Not Tracked" and the Modern Healthcare article was entitled: "State Health IT Groups Proliferate." One can imply from these titles that a lack of systematic study is problematic and that "proliferation" is a symptom of disorder rather than experimentation in the early, unformed states of social change. It is, one can claim, important to understand a problem by tracking but to avoid premature solutions.

• Follow this link to the iHealthBeat item
• Follow this link to the Modern Heatlhcare article

The article cites are real desire among states to understand what others are doing. It mentions but possibly understates some of the state-resources already extant through HIMSS, AHIMA, NCSL, and eHI. It speaks of "standards" and "model laws" - very good ideas.

Still one wonders at the right mechanism and pace for coordination. One can argue that several federal approaches over the past year have been incomplete, premature, or somewhat rushed. One can argue that it is too soon to really provide much systematic guidance - all the more reason to emphasize tracking and observing.

The initiative to which the articles refer was originally termed "SHADES" (State Healthcare Alliance for Data Exchange Solutions) and describes a two-year sole-source contract from ONC to the National Governors Association.

• Follow this link for the sources Sought Notice of June 13, 2006

What should be emphasized in these initiatives? Several critical elements, in this writer's mind:

• Simple, centrist model legislative frameworks for states and Congress
• Medicaid
• Care of the uninsured
• Financial sustainability of the entire health care system, not just any individual aspect. A "self-sustaining" state-level RHIO is not the point. A self-sustaining American health care system - at the federal, state, and local level - is the point.
• Roles for health plans as well as alternatives like health savings accounts, banks, consumer-driven care
• Confidentiality, consent, and security - focusing on policy first, not legislation.

Data exchange is a prerequisite for change, but cannot be understood in isolation.

There may be a tendency to continuing the current trajectory, focusing on legislative harmonization (and pre-emption), regulations (e.g., CLIA), and state-level RHIOS. Others would argue

States may be clamoring for help and strategies with health information technology, but if they are, one hopes they begin their discussions with how increased effort can improve and enhance state Medicaid, public health, and public-private partnerships.

CHCF ED Report

The California Health Care Foundation has issued a report and other materials on the use of emergency departments. This October, 2006 report citest an increase use driven primarily among the insured and ofoten for reasons that would not generally meet criteria for emergency care. Almost 1 in 15 Californians used an emergency department in the past year (the CDC reports a national percentage of 20%). Only 2% of Californians have been to the ED three or more times but their use constitutes 35 percent of all ED visits in California over the past year.

• Follow this link to the Report home page.
• Follow this link to the Report (pdf)
• Follow this link to the 51 page Harris poll (pdf)
  

Though a Harris Interactive poll, the Foundation identified four key factors in driving avoidable users to emergency departments.

• Lack of access to medical care outside the ED
• Lack of advice from physicians on how to handle acute medical conditions
• Lack of alternatives to the ED
• Positive attitudes toward EDs

Leavitt 10: Kotter 8 - some useful principles

Both Secretary of HHS Mike Leavitt and Harvard Professor John Kotter have given 10 reasons for success (Leavitt) or failure (Kotter) in complex enterprises.

• Kotter's complete article is available through the Harvard Business Review and a summary is available at: http://www.power-projects.com/LeadingChange.pdf
• Secretary Leavitt's points were made at a Western CIO Forum

Kotter's 8 points:

1. Establish a sense of urgency
2. Form a Powerful Guiding Coalition
3. Create a vision
4. Communicate the vision
5. Empowering others to act on the vision
6. Planning for and creating short-term wins
7. Consolidate improvements and produce still more change
8. Institutionalizing new approaches

Leavitt's 10 Points:

1. Common pain – It may be opportunity, greed or fear.
2. A convener of stature. Some individual or group has to bring everyone together.
3. A critical mass of players (market players).
4. A non-proprietary neutral venue and neutral governance process.
5. Clear and appointed leader or leaders. They keep things moving forward and the right people at the table.
6. Every participant has to have financial interest in the process.
7. There must be a sufficient narrow purpose. Achievable goal that can be built on.
8. Defining outcomes and not directly working on standards themselves. Focus on the outcomes, not on how we get to the outcomes.
9. Open architect[ures]
10. The end product can be commercialized

Leavitt's points were made in context with his experience in other regulatory areas. He also raised the question: How are governance processes and standards created? His options:

• One way is federal government compels others to follow standards
• Second way is the last vendor standing method. We let the vendors do battle until one is standing and then we adopt those standards or governance processes.
• The third way is a process of organically growing the standards. People have to leave their proprietary stuff at home. Then a neutral stand can be made and can actually become the charter.

Follow this link to the talk notes and audience Q&A

Minute Clinics to Adopt CCR Standard

In an October 9 press release, MinuteClinic, Inc. a CVS subsidiary, announced plans to utlize the continuity of care record standard (ASTM CCR E2369-05) to allow inteeroperability between MinuteClinics and patients' family physician offices. The press release states that MinuteClinic already supplies patient-approved visit summaries to physicians via fax and mail, but claim this automation step will improve timeliness, usability, and consistency. The MinuteClinic standard EHR will create both paper and digital records including patient demographics, problems and diagnoses, medication list,allergies, vital signs, lab results, immunizations, and other CCR elements.

• Follow this link to the press release
• Follow this link to the AAFP-developed CCR Standard

Good Recommendations from California

The California HealthCare Foundation (CHCF) has released an issue brief outlining ten key recommendations to help transform health care in the state through adoption and effective use of health information technology. The recommendations will be presented Thursday, Oct. 12, at Governor Schwarzenegger's eHealth Action Forum. The report is entitled: "California can lead the way in health information technology."

• Follow this link to the full report (pdf)

The press release identifies six "leverage points":

• Empower California’s consumers with information about their health care providers, health insurers, and their own personal health care, with stringent safeguards to ensure privacy and confidentiality;
• Equip providers, especially those who care for underserved populations, with effective and affordable health IT tools to improve performance and efficiency of clinical care;
• Educate and expand California’s health care workforce in the use of IT
• Build a robust infrastructure that will keep Californians safe in the event of an emergency and serve as a foundation for transforming health care
• Provide leadership that will coordinate the health IT activities of the state’s many departments and programs and align public and private sector actions
• Support investments that recognize the social good that can come from targeted applications of health IT.

They issued 10 recommendations:

1. Recommendation 1: Support the right of Californians to securely access and control their personal health information. Adopt policy and legal changes to ensure consumers have access to and control over t heir personal health information. Definite the obligations of providers, payers and other stakeholders to provide Californians with electronic access to portable, secure, and affordable personal health information. Californians should have the right to store their own information directly, or with a custodian of their choice, based on their interests and preferences.
   
2. Recommendation 2: Provide Californians with easy-to-understand, comparative information about health care quality and cost. Expand existing public and private efforts to provide consumers access to the information they need to make informed decisions about their health care providers and health plans. This is feasible only if health care information is collected, sorted and analyzed electronically. Use the purchasing power of the state to crate incentives for providers and health plans to provide this information, and report their degree of participation to Californians.
   
3. Recommendation 3: Close the health IT gap for community clinics, small physician practices, and rural health centers. Provide coordinated public and private incentives and subsidies to equip these providers with the same capabilities available at large, urban practices. Accelerate the adoption of certified electronic health records (EHRs), ensure interoperability of software applications, and promote participation in community-wide health information exchange initiative to improve care for low-income populations.
   
4. Recommendation 4: Develop an IT-savvy health care workforce. Direct the chancellors of the California State University and the California Community College systems to develop curriculum and training certification programs to ensure that California has sufficient health care workers trained in the effective use of health IT.
   
5. Recommendation 5: Develop a statewide emergency health IT infrastructure. Prepare California for a state of emergency by financing a statewide health IT infrastructure with the capacity to retrieve and exchange lab and pharmacy information. The networks would be a foundation for an eventual statewide health information infrastructure to support patients, providers, and other important public health, research, and health industry requirements.
   
6. Recommendation 6: Develop a telehealth and telemedicine system to improve health care access for rural and underserved communities. Create an action plan to develop, staff, and maintain a statewide, broadband telemedicine network. Such an effort should be multidisciplinary drawing on the strengths of the state's academic medical centers, business schools, and other relevant disciplines.
   
7. Recommendation 7: Adopt and implement national and state health IT standards. Employ the state's purchasing power to require those who develop, purchase, and use health IT systems to adopt uniform standards to promote the flow of secure information. Endorse national standards where they exist; forge ahead with state standards where there are none.
   
8. Recommendation 8: Coordinate the actions of all state agencies and programs to leverage health it to improve access, quality, and affordability of care. Direct the Department of Health Services in its administration of Medi-Cal and other programs, the Department of Managed Health Care, and other state agencies to advance the health IT agenda articulated in the eHealth Action Plan. Encourage CalPERS to pursue the same agenda. Coordinate state policies and incentive programs with those of the private sector.
   
9. Recommendation 9: Align public and private sector actions to innovate and transform health care. Create mechanisms for engaging the private sector in developing innovative health IT solutions and work with them to improve the health care system. Recognize that the state government cannot do it alone.
   
10. Recommendation 10: Create a social investment fund to support and sustain health care innovation and transformation through health IT in California. Focus the fund's investments on health care innovation and transformation for the public benefit of the residents of California. These investments should seed the key actions of the governor's eHealth Action Plan and stimulate the private marketplace to accelerate its investments in health IT.

"RHIO Nation" Quotes

From the February 2006 Health Management Technology magazine article entitled "RHIO Nation."

A fragment:

Patients: The Center of the Universe

"It’s about power," says Mark Frisse, M.D., Accenture Professor of Biomedical Informatics at Vanderbilt Center for BetterHealth, Nashville, and a shift of power from those who provide care to those who receive care. "Until the public is more informed and more insistent about the quality of its healthcare, things won’t change."

Like [Holt] Anderson [North Carolina], Frisse is at the front of a long line of healthcare experts who place patients at the center of the NHIN and RHIO equations. He’s clear—patients are why we are building the national machinery. But he also is realistic and quick to challenge the authenticity of public assumptions.

"Let’s look at the facts. We know the healthcare system doesn’t meet the needs of many, and that the current approach is not sustainable. We know every dollar is spent somewhere, and that large amounts are spent. We know there aren’t enough dollars spent on patient care."

So we must question, he says, whether the transfer of dollars spent on patient care to the means to reach the objective—better patient care—is a correct approach. "Find another industry that spends money in this way," he says.

At the same time, he admits, "How can we not afford to do this?" Frisse doesn’t support challengers who have questioned the vast amounts of funding necessary for an NHIN, and whether the nation wouldn’t be better off conservatively building one or two successful state-level RHIO demonstration projects. "Every state is doing great things," in its own way, he says. "Everyone is teaching us a different part of the answer. As a nation, we have never made great decisions by relegating responsibility to one particular state."

Frisse is especially encouraged by two trends emanating from critical audiences. One is IPA-centered communication and exchange networks........in which hundreds of providers can electronically communicate, request data and exchange information. He agrees with [Tom] Lee [ePocrates]: Inclusion of small practices in large electronic networks that "enable care through information technology" is the last mile, and it needs to be planned for and accommodated. He counts on IPA-based networks to pave the way.

A second trend is increased consumer involvement in personal health records and electronic management of personal health and financial data. Employers that furnish employees with electronic management capability, either as a company benefit or through an employer-sponsored health plan, are moving consumers toward empowerment and, hopefully, activated decision-making.

Similarly, software vendors are venturing into this market segment with products geared to electronic health and health administration management for consumers. It’s like Quicken for allergies and HSAs.

A Warning from the Intel CEO

On September 26 at 8:30 am, Intel CEO Craig Barrett spoke at the eHealth Initiative Health Information Technology Summit. He preceded Secretary of HHS Michael Leavitt.

• Follow this link for an unofficial transcript (PDF) of Barrett's talk.
• Follow this link for a transcript of Secretary Mike Leavitt's talk.
  

He prefaced his remarks by emphasizing both his support for the political process but also his frustration with the pace of change and leadership "around the margins." He mentioned in a positive sense his participation in the American Health Information Community.

But Barrett's words were strong and, in the view of this observer, dead on.

Among his comments:

• U.S. jobs will continue to move offshore at a rapid pace unless corporate America exerts its power to force the health care industry to adopt systems that will cut costs and improve efficiency. "Every job that can be moved out of the United States will be moved out ... Because of health care costs," which on the average were in excess of $6,300 per person in 2004.
• "The system is out of control, it's unstable, it's basically bankrupt, it gets worse each year and all we do is tinker around the edges when what we need are major fixes"
• Asking "who should pay for it" is the wrong question. No one can pay for it.
  Even if one makes a massive, one-time change in the chronic care disease management, unless the trend is toward continual improvement, the costs will inexorably climb.
• "Every other industry has adopted this technology and (the health care) industry continues to sit here and debate"
• Why does the health care industry expect subsidies to pay for health care technology? Every other industry makes these investments as a matter of survivability?
• Employers should demand that hospitals select standardized record systems to lower costs or take their company's business elsewhere
• Companies should only do business with health care providers who meet certain standards, including fully electronic patient records and published "best practices" for patient treatment
• Price transparency is critical to employer and consumer engagement. How many other industries can't tell you what a service will cost or explain their charges in a simple way?
• Hospital networks could and should be transformed into "competitive centers for excellence" that are paid to keep employees healthy.

Wal-Mart Stores Inc. Executive VP Linda Dillman joined Barrett on the stage and spoke of Wal-Mart's costs as an employer and their innovative approach to providing health care in pilot settings.

• Barrett said the health care industry could learn from the efficiency of Wal-Mart.
• He claimed Wal-Mart was an information technology company that sells what it tracks and excels by its ability to employ IT in conjunction with effective business models and great customer service

• Follow this link for AP coverage of this presentation
• Follow this link for a Health IT World News article on the talk
• Follow this link for a related posting on this Blog that references Health Affairs articles
• Follow this link for my comments on a NY Times editorial concerning health care costs
• Follow this link to a July 2004 discussion involving Craig Barrett and addressing global competition

New from the Institute of Medicine

September was an exciting month for those awaiting reports from the Institute of Medicine. Two significant reports have come forth that consolidate prevailing opinions, identify controversies, and set a possible course of action to improve the safety and delivery or health care in this country.

The September 21 release of "Rewarding Provider Performance: Aligning Incentives in Medicare" analyzes the promise and risks of instituting a pay-for-performance program within Medicare to encourage a more effective health care system.

The September 22 release of "The Future of Drug Safety: Promoting and Protecting the Health of the Public" raises concerns and controversies surrounding the safety of medications and the processes the FDA employs to achieve its mission.

Provider Performance
Concerning provider performance, the IOM report provides a long list of recommendations:

• The Secretary of the Department of Health and Human Services (DHHS) should implement pay for performance in Medicare using a phased approach as a stimulus to foster comprehensive and system-wide improvements in the quality of health care.
• Congress should derive initial funding (over the next 3-5 years) for a pay-for-performance program in Medicare largely from existing funds. Congress should give the Secretary of DHHS the authority to aggregate the pools for different care settings into one consolidated pool from which all providers would be rewarded when the development of new performance measures allows for shared accountability and more coordinated care across provider settings. In designing a pay-for-performance program, the Secretary of DHHS should initially reward health care that is of high clinical quality, patient-centered, and efficient.
• The Secretary of DHHS should design a pay-for performance program that initially rewards both providers who improve performance significantly and those who achieve high performance.
• Because public reporting of performance measures should be an integral component of a pay-for-performance program for Medicare, the Secretary of DHHS should offer incentives to providers for the submission of performance data, and ensure that information pertaining to provider performance is transparent and made public in ways that are both meaningful and understandable to consumers.
• The Secretary of DHHS should develop and implement a strategy for ensuring that virtually all Medicare providers submit performance measures for public reporting and participate in pay for performance as soon as possible. Initially, measure sets may need to be narrow, but they should evolve over time to provide more comprehensive and longitudinal assessments of provider and system performance. For many institutional providers, participation in public reporting and pay for performance can and should begin immediately. For physicians, a voluntary approach should be pursued initially, relying on financial incentives sufficient to ensure broad participation and recognizing that the initial set of measures and the pace of expansion of measure sets will need to be sensitive to the operational challenges faced by providers in small practice settings. Three years after the release of this report, the Secretary of DHHS should determine whether progress toward universal participation is sufficient and whether stronger actions- such as mandating provider participation are required.
• CMS should design the Medicare pay-for-performance program to include components that promote, recognize, and reward improved coordination of care across providers and through entire episodes of illness. Thus, CMS should (1) encourage beneficiaries and providers to identify providers who would be considered their principal responsible source of care, and (2) pay for and reward successful care coordination that meets specified standards for providers who take on that role.
• Because electronic health information technology will increase the probability of a successful pay-for-performance program, the Secretary of DHHS should explore a variety of approaches for assisting providers in the implementation of electronic data collection and reporting systems to strengthen the use of consistent performance measures.
• The Secretary of DHHS should implement a monitoring and evaluation system for the Medicare pay-for-performance program in order to:
  - Assess early experiences with implementation so timely corrective action can be taken.
  - Evaluate the overall impact of pay for performance on clinical quality, patient-centeredness and efficiency.
  - Identify the best practices of high-performing delivery settings that should be shared with others to improve care throughout the nation.

Complementary recent publications in this area include:

• Medicare's Quality Improvement Organization: Maximizing Potential (March 2006)
• Performance Measurement: Accelerating Improvement (December 2006)

Drug Safety

In the drug safety publication, the committee found that:

• There is a perception of crisis that has compromised the credibility of FDA and of the pharmaceutical industry. Most stakeholders--the agency, the industry, consumer organizations, Congress, professional societies, health care entities--appear to agree on the need for certain improvements in the system.
• The drug safety system is impaired by the following factors: serious resource constraints that weaken the quality and quantity of the science that is brought to bear on drug safety; an organizational culture in CDER that is not optimally functional; and unclear and insufficient regulatory authorities particularly with respect to enforcement.
• FDA and the pharmaceutical industry do not consistently demonstrate accountability and transparency to the public by communicating safety concerns in a timely and effective fashion.
• Noting that resources and therefore efforts to monitor medications' risk-benefit profiles taper off after approval, the committee that wrote the report offered a broad set of recommendations to ensure that consideration of safety extends from before product approval through the entire time the product is marketed and used.

Recommendations of the committee include:

• Labeling requirements and advertising limits for new medications
• Clarified authority and additional enforcement tools for the agency
• Clarification of FDA's role in gathering and communicating additional information on marketed products' risks and benefits
• Mandatory registration of clinical trial results to facilitate public access to drug safety information
• An increased role for FDA's drug safety staff A large boost in funding and staffing for the agency

What's Really Propping Up the Economy and the Monster at Our Door

The September 26, 2006, Business Week cover story is entitled:"What's Really Propping Up The Economy."

• Follow this link to the Business Week Story
• Follow this link to Robert J. Samuelson's Medicare story entitled: "The MOnster at Our Door."
  

Among the assertions in the article:

"Since 2001, 1.7 million new jobs have been added in the health-care sector, which includes related industries such as pharmaceuticals and health insurance. Meanwhile, the number of private-sector jobs outside of health care is no higher than it was five years ago."

"The U.S. unemployment rate is 4.7%, compared with 8.2% and 8.9%, respectively, in Germany and France. But the health-care systems of those two countries added very few jobs from 1997 to 2004, according to new data from the Organization for Economic Cooperation & Development, while U.S. hospitals and physician offices never stopped growing. Take away health-care hiring in the U.S., and quicker than you can say cardiac bypass, the U.S. unemployment rate would be 1 to 2 percentage points higher."

"Almost invisibly, health care has become the main American job program for the 21st century, replacing, at least for the moment, all the other industries that are vanishing from the landscape. With more than $2 trillion in spending -- half public, half private -- health care is propping up local job markets in the Northeast, Midwest, and South, the regions hit hardest by globalization and the collapse of manufacturing "

"Make no mistake, though: The U.S. could eventually pay a big economic price for all these jobs. Ballooning government spending on health care is a major reason why Washington is running an enormous budget deficit, since federal outlays for health care totaled more than $600 billion in 2005, or roughly one quarter of the whole federal budget. Rising prices for medical care are making it harder for the average American to afford health insurance, leaving 47 million uninsured."

"Moreover, as the high cost of health care lowers the competitiveness of U.S. corporations, it may accelerate the outflow of jobs in a self-reinforcing cycle. In fact, one explanation for the huge U.S. trade deficit is that the country is borrowing from overseas to fund creation of health care jobs."

"There's another enormous long-term problem: If current trends continue, 30% to 40% of all new jobs created over the next 25 years will be in health care. That sort of lopsided job creation is not the blueprint for a well-functioning economy. One solution would be to make health care less labor-intensive by investing a lot more in information technology. 'Low productivity in health is mostly a product of low investment,' says Harvard University economist Dale Jorgenson."

This concern is echoed by Robert J. Samuelson in the September 18, 2006 Newsweek in an article entitled "The Monster at Our Door." Describing Medicaid, he states:

If "monster" seems like rhetorical overkill, then recall what the aging baby boom does to government. Federal spending on the elderly is plausibly projected to double from 2000 to 2030 as a share of national income. About three quarters of that increase will be health spending—mostly Medicare, but also Medicaid (70 percent of Medicaid spending goes to the old and disabled). The rise in health spending exceeds all of today's discretionary domestic spending on schools, the FBI, the environment and much more.
Now, uncontrolled health spending will dominate the federal budget and pose ugly choices: (a) raise taxes sharply, (b) gut other programs and (c) run ever-larger—and more dangerous—deficits.

Some economists believe that we've gotten our money's worth from higher health spending. Since 1960, life expectancy at birth has risen from about 70 to 77. Harvard health economist David Cutler attributes about half the increases to medical advances—new drugs, surgeries and therapies. (Candidates for the other half: less smoking, less punishing jobs, fewer accidents.) Academic studies suggest that people value an extra year of life at about $100,000, says Cutler. That's how much they'd pay—in theory—to live a year longer. On average, the extra health spending needed to increase life expectancy a year has cost less than $100,000 per person. Therefore, we've gotten value for money.

By this logic, higher health spending is nonthreatening. In a recent paper, economists Robert Hall of Stanford and Charles Jones of the University of California, Berkeley, suggest that health spending may reach 30 percent of national income by 2050, up from 16 percent today and 5 percent in 1950. But they are unperturbed, because as Americans get richer, they prefer more health spending—longer and better lives—to a "third car [or] yet another television."

We should overhaul Medicare, but just how is unclear. To know, we need to answer three questions: (1) How much health spending can the economy absorb without having higher taxes or depressed wages reduce economic growth? (2) Who should pay for Medicare—that is, should older people pay more (lessening the burden on the young)? And (3) how can we pay physicians in hospitals for better outcomes and not just for more tests, hospitalizations and visits? These questions apply to any system we might adopt—from a government-run "single payer" system to more "consumer driven" health care.

AHIMA / FORE Releases Report on State-Level Health Information Exchange Initiatives

On September 12, 2006, AHIMA/FORE released a report produced under contract with the Office of the Network Coordinator. The report is entitled Development of State-Level Health Information Exchange Initiatives.

• Follow this link to the AHIMA/Fore Site - StateRHIO.org

The findings are fairly straightforward:

• Most state-level HIE initiatives are still in an early stage of development;
• They differ in their origins, drivers, and goals;
• They reflect the uniqueness of their market characteristics;
• They used a wide variety of approaches;
• They are all rapidly evolving organizations committed to improving healthcare in their states.

Among the key recommendations are the following FIVE:

I. Institute mechanisms to promote strategic synergy between state and federal health information exchange (HIE) agendas and initiatives:

• Establish a coordinating body to promote communication and collaboration among states and between states and federal agencies to advance HIE. This coordinating body will address areas of concern and opportunities for effective action through collaboration. It will ensure clear communications with and among states and a voice for state issues in the federal agenda. Consider how the American Health Information Community and Office of the National
• Coordinator can work with state and national policy makers to address the barriers state-level HIE initiatives encounter.
• Develop mechanisms to engage state-level HIE initiatives in the development and deployment of relevant federal initiatives, including feedback on the effect of the federal HIT and HIE agenda.
  

II. Identify salient financial models for sustainable HIE that state-level HIE initiatives can apply:

• Inventory and describe in detail HIE projects that have achieved financial sustainability and are demonstrating positive outcomes or appear to have identified sufficient revenues and cost data to argue for financial sustainability.
• Identify revenue models currently in use that have generated real savings or revenue and improvement.
• Analyze the programmatic details of each model.

• Describe pros and cons for each: ease of implementation, the infrastructure needed, requisite state-level policy features, the critical mass of stakeholders that need to be involved, the market characteristics that make the model feasible, how healthcare is affected or improved, the estimated costs and revenue from the model, and the expected timing for design and implementation.

  Recommend implementation approaches.

• Identify the top few most feasible options for early successful HIE implementation.
• Identify models the complexity and cost of which suggest that they be deferred.
• Recommend how to disseminate these results.
  

III. Conduct an analysis in the areas listed below to understand and leverage the role and influence of public and private payers in advancing HIE initiatives, and develop and implement a payer involvement strategy for HIE.

• Roles payers (public and private) have in statewide and local HIE initiatives:

The criticality of involving payers (public or private),

When engagement is most beneficial, How to engage payers

The feasibility of a national strategy to create common methodologies for payer contribution to HIT financing.

• The importance of state Medicaid and Medicare programs’ participation in state-level HIE initiatives:

Ways in which Centers for Medicare & Medicaid Services CMS) policy might accelerate or constrain the ability of state Medicaid to take actions to facilitate HIE.

Identify how to engage CMS and other public payers early in the design process to ensure aligned agendas.

How adoption of Medicaid Information Technology Architecture (MITA) affects HIE.

Identify how to ensure integration of Medicare and Medicaid population data for HIE purposes.

Make recommendations for any federal statutory changes that may be necessary to integrate Medicaid and Medicare in this way.

• The private payer perspective (including traditional health plans and self-funded plans):

Business goals, strategic direction, collaborative and competitive advantage as it relates to multi-stakeholder HIE.

Specifically consider how the evolution of payer-sponsored personal health records (PHRs) may affect HIE initiatives.

• Identify ways for payers to collaborate and support HIE.
• Identify and describe risks that payers may inhibit HIE or block innovation.
• Identify and consider any limitations or downsides of market-driven evolution of HIE with respect to payers.
• How public payers influence and affect private payer behavior.
• How states’ payer mix affects HIE (e.g., number of payers, types of payers, respective market share).
• The effect of federal regulation of employer benefits (e.g., mployee Retirement Income Security Act (ERISA), Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other regulations on state-level HIE.
• The role of public employee and retiree coverage and care (e.g., U.S. Department of Veterans Affairs, U.S. Department of Defense, federal employee program, state employee program) in HIE.
  

IV. Advance understanding of how state policy makers and government can best be involved in state-level HIE initiatives:

• Identify the most feasible and productive ways for state governments and policy makers to provide leadership for HIE.

Should the state designate the state-level HIE initiative?

If so, how is this best accomplished (e.g., governor, Department of Health, Medicaid, state legislature, state licensure division, by means of consensus, bidding, appointment)?

State government should communicate internally and coordinate between the various state agencies and departments to develop and implement a unified approach for the state HIE agenda and collaborate on ways to reduce internal barriers to statewide HIE.

• Develop models of how state government can collaborate with the private sector to develop public-private vehicle to advance HIE, including:

How to engage state government while remaining flexible to respond to market demands for healthcare (e.g., healthcare costs, availability, quality, effect on business climate).

Role of state government in the relationship (e.g., more as a regulator or more as a partner similar to economic development function). Consider the minimal role that state government can play in creating an environment for engaging portions of the private sector that can respond to market demand issues.

Options for formal entities or vehicles that involve public and private sectors in HIE, including pros and cons of each.

How to take advantage of opportunities available only to a state-level
public-private HIE initiative.

Examine what has worked in other industries.

How to maintain the necessary balance required to grow the public-private
partnership.

Consider developing standard language that federal, state, and other purchasers of healthcare can include in their contracting cycle to facilitate the deployment of HIT and ensure interoperability while not negatively affecting the business climate unnecessarily.

• Engage with NCSL, National Governors’ Association (NGA), and other key stakeholder groups to discuss these issues.
  

V. Develop ways to support state-level HIE initiatives, including:

• Develop a plan for creating a “learning community” of state-level HIE initiatives:

Accelerate information sharing through education and communication mechanisms, such as webinars, discussion forums, listserv, periodic meetings(e.g., regional, national, quarterly, annually).

Continue to refine the State-Level Health Information Exchange Initiative Development Workbook developed through this project and/or create supplementary
tools based on it.

Examples of such tools include PowerPoint presentations, consumer-education booklets, and other materials deemed valuable by the state.

Explore development of a Web site as a resource.

Consider developing content to educate all stakeholders on the benefits of HIE, framing it as a global healthcare and economic issue rather than simply a technology initiative.

• Determine the ways to reach out to and engage states in the learning community through coordinated efforts of various entities (e.g., through NGA, NCSL).
• Support for HIE Executive Directors from initial formative stages through more advanced operations of the state-level HIE initiative through consulting, mentoring, and formal training resources.

Is the VA System a Panacea?

Is the Veterans Administration system a panacea and model for the US health care system? In a September 4, 2006 NY Times op-end piece, Paul Krugman labels this system a "stunning success."

The key to this success, Krugman says, "is its long-term relationship with its clients: veterans, once in the V.A. system, normally stay in it for life." He points out that such long-term relationships "save money by investing heavily in preventive medicine."

Krugman claims that preventive medicine is an area in which "the private sector, which makes money by treating the sick, not by keeping people healthy, has shown little interest."

Citing specifically the Vererans Administration's health care information system, he points out that this technology "can easily keep track of a patient's medical history, allowing it to make much better use of information technology than other health care providers. Unlike all but a few doctors in the private sector, V.A. doctors have instant access to patients' medical records via a systemwide network, which reduces both costs and medical errors. "

An alternative interpretation is that the interest in the private sector is very high, but the alignment of incentives and the means of establishing continuity of care through interoperability are not attainableinble at present in America's real health care system. An alternative interpretation would suggest that even acknowledging the strengths of the Veteran's Administration's health information technology and care infrastructure, a rapid transition from where we are to where we as a nation must be is not possible. To create a V.A. model, entire segments of the economy must transition from fee-based reimbursement to alternative models. The key insight to Krugman's argument (an argument often made) is that the very foundations for reimbursement and care are different in the V.A. system and it is these foundations that are critical to an evolution of our delivery system and the technologies required to support it.

In a letter published in the March/April 2006 issue of Health Affairs, Stanford Economist Alain Enthoven states that "health spending has doubled its share of gross domestic product (GDP) in the past twenty-five years. Absent some quite fundamental change, this will double again in the next twenty-five, seriously straining public finances." He claims that "a fundamental change in financial incentives for consumers (making a cost-conscious choice of a full health plan instead of selecting a low-priced doctor) and providers (replacing fee-for-service with per capita prepayment and salaries). Perhaps when things get bad enough, such fundamental change will become politically feasible."

Are things getting bad enough? Fuchs and Emanuel argue in the Nov/Dec issue of Health Affairs that such a change will take place only in the event of a "a major war, a depression, or large-scale civil unrest" or a "national health care crisis, such as a flu pandemic." (Health Affairs, 24, no. 6 (2005): 1399-1414 )

Henry Simmons of the National Coalition on Health Care presents an alternative scenario driven by widespread employer frustration with the "trajectory" of health care costs, the states' Medicaid crises, and the looming Medicare cost burden. He argues that pressure to reform is growing among pension funds, health care providers, unions, and religious groups. (Health Affairs, 25, no. 2 (2006): 566)

No matter what position one takes on these issues, the need to address fundamental informatics and health information technology issues must be addressed now.

Personal Health Records

A Google search for "personal health records" on August 31 returned over 450,000 links. Something is going on. Clearly the notion of a record focused on and maintained in participation with the individual is a critical factor in better health care. But beneath the obvious value of such a future lie the traditional technical challenges, financial issues, technical concerns, and, frankly, struggles for power. Who will really "own" the record? Who will be the steward of such an effort? To what extent does stewardship or support enhance the market power of those who support it? What is the best way to achieve this. Does a stand-alone health system-based PHR make sense? A plan-based PHR? A consumer-driven open market PHR? There are many unanswered questions.

This posting will try to provide links to some of the efforts that may provide answers and lead to better care in the years to come. They are provided without endorsement or opinion.

Position Papers

• AHIMA/AMIA value statement and position paper (July 2006)
• Personal Health Group Final Report, 2003 . This somewhat dated Markle Foundation document provides references for consumer-centric concerns and is a preface to their current efforts
• AHIC/HHS documents
• RWJ position papers
• Consumer grou position papers

Some PHR Initiatives

• CMS pilots
• RWJ Initiatives
• Aetna - http://www.aetna.com/news/2006/pr_20061003.htm

Wellpoint's Consumer-Driven Health Initiatives

Wellpoint and its subsidiary Lumenos on August 22, 2006 announced that it will make its new consumer-driven health plan (CDHP) products and services available in all states and to all markets, from the largest national employer to an individual member, beginning Jan. 1, 2007. Previously, these products were offered only to national employers' members.

• Follow this link for the press release
• Follow this link for the Lumenos site
• Follow this link for Dr. Michael Parkinson's May 10, 2006 Joint Economic Committee Hearing for Health Information for Consumers

Pay-for-Performance

• Follow this link for an interview concerning WellPoint's P4P vision

The Executive Order of August 22, 2006

On August 22, the President delivered an address arguing for greater transparpency in health care and signed an executive order with far-reaching implications.

Follow this link for the executive order

Quoting portions of the order:

It is the purpose of this order to ensure that health care programs administered or sponsored by the Federal Government promote quality and efficient delivery of health care through the use of health information technology, transparency regarding health care quality and price, and better incentives for program beneficiaries, enrollees, and providers. It is the further purpose of this order to make relevant information available to these beneficiaries, enrollees, and providers in a readily useable manner and in collaboration with similar initiatives in the private sector and non-Federal public sector. Consistent with the purpose of improving the quality and efficiency of health care, the actions and steps taken by Federal Government agencies should not incur additional costs for the Federal Government.

Where health care technology is concerned:

• As each agency implements, acquires, or upgrades health information technology systems used for the direct exchange of health information between agencies and with non-Federal entities, it shall utilize, where available, health information technology systems and products that meet recognized interoperability standards.
• Each agency shall require in contracts or agreements with health care providers, health plans, or health insurance issuers that as each provider, plan, or issuer implements, acquires, or upgrades health information technology systems, it shall utilize, where available, health information technology systems and products that meet recognized interoperability standards.
  

Where quality measurements are concerned:

• Each agency shall implement programs measuring the quality of services supplied by health care providers to the beneficiaries or enrollees of a Federal health care program.
• Such programs shall be based upon standards established by multi-stakeholder entities identified by the Secretary or by another agency subject to this order. Each agency shall develop its quality measurements in collaboration with similar initiatives in the private and non-Federal public sectors.
• An agency satisfies the requirements of this subsection if it participates in the aggregation of claims and other appropriate data for the purposes of quality measurement. Such aggregation shall be based upon standards established by multi-stakeholder entities identified by the Secretary or by another agency subject to this order.
• Each agency shall make available (or provide for the availability) to the beneficiaries or enrollees of a Federal health care program (and, at the option of the agency, to the public) the prices that it, its health insurance issuers, or its health insurance plans pay for procedures to providers in the health care program with which the agency, issuer, or plan contracts.
• Each agency shall also, in collaboration with multi-stakeholder groups such as those described in subsection (b)(1), participate in the development of information regarding the overall costs of services for common episodes of care and the treatment of common chronic diseases.
• Each agency shall develop and identify, for beneficiaries, enrollees, and providers, approaches that encourage and facilitate the provision and receipt of high-quality and efficient health care. Such approaches may include pay-for-performance models of reimbursement consistent with current law. ..... Agencies shall comply with the requirements of this order by January 1, 2007.
  

There is both promise and peril in this executive order. If it is viewed as a path to careful, deliberate public discussion and evolution to a common consensus, it will be transformational. If instead, federal agencies and other groups rush to "ossify" the definitions and attempt to define explicitly the definition of "transparancy" and "quality" in advance of public buy-in and broad participation, such a premature imposition could lead to a further distortion of the true costs and benefits of our current health care system. The challenge is not in the vision or the executive order, but in the open, cautious, and thoughtful execution of intent.

HIT Consensus-building Among State Governments

A June 13 posting by HHS presents signs of increasing momentum in coordinating the health information activities of state government. Quoting from the announcement, HHS is proposing that the National Governors Association Center for Best Practices "develop and establish a consensus-based executive-level advisory body where states will be able to: identify, assess and through the formation of consensus solutions, map ways to resolve state-level health information technology (health IT) issues that affect multiple states and pose challenges to interoperable electronic health information exchange; provide a forum in which states may collaborate so as to increase the efficiency and effectiveness of the health IT initiatives that they develop. "

• Follow this link for the announcement

The Description section taken from this document is as follows:

The Department of Health and Human Services intends to negotiate with the National Governors Association, Center for Best Practices, 444 North Capitol Street, Suite 267, Washington, DC 20001, on a sole source basis under the authority of FAR 6.302.1. The cost reimbursement contract will be awarded for a base year with two 12-month option years.

The Contractor shall develop and establish a consensus-based executive-level advisory body where states will be able to: identify, assess and through the formation of consensus solutions, map ways to resolve state-level health information technology (health IT) issues that affect multiple states and pose challenges to interoperable electronic health information exchange; provide a forum in which states may collaborate so as to increase the efficiency and effectiveness of the health IT initiatives that they develop.

The Government is seeking to establish a sustainable consensus-building body that must cross political affiliations to address issues, form consensus solutions and implement plans at a state level. As such, the contractor that establishes this body must be a politically neutral entity that has the expertise, audience acceptance, experience and ability to respond to the Office of the

National Coordinator's (ONC) need to identify, assess and broker consensus solutions to resolve state level health information technology (health IT) issues that affect multiple states and pose challenges to interoperable electronic health information exchange.
The contractor needs to be a not for profit 501(c)(3) entity. Furthermore, the contractor needs to work with state level entities that have sufficient authority and breadth of duties as to be able to consider and implement a variety of policy solutions that could come in the form of regulations, reimbursement policies, financing models, coverage, and technology. ONC believes that Governors meet these authority and breadth of duty concepts.

Taking all of this into account, ONC believes that the National Governors Association (NGA), Center for Best Practices is the only known organization in the United States that has the requisite experience, state audience acceptance and successful operational platform to work directly with state governors to successfully broker significant multi-state consensus building activities that lead to workable solutions. The NGA is the collective voice of the Nation's Governors. The association provides governors and their senior staff members with services including developing policy reports on innovative state programs and hosting networking seminars for state government executive branch officials.

The NGA's Center for Best Practices focuses on state innovations and best practices on issues that range from education and health to technology, welfare reform and the environment. NGA also provides management and technical assistance to both new and incumbent governors. The purpose of this synopsis is to determine whether there may be other sources with the requisite qualifications to perform the work described above.

Any organization capable of performing the work should submit a statement of capabilities with documentation supporting its ability to meet the Government's requirement as described above. No solicitation document is available. Capability statements should be submitted within 45 days of the publication of this synopsis to the contact point and address given above. See note 22.

The High Cost of Rapid Transformation

AHRQ / OMB Request

Efforts to develop consensus and seek public input are costly and time-consuming. Some data on one ambitious program has this summer been presented and the results of the ongoing analysis may do much to help states understand the time and effort required to advance health care agenda more broadly.

In the Wednesday, June 7 Federal Register (v. 71, n. 109, p 32964) AHRQ requested the OMB for information collection as part of an AHRQ contract for "Privacy and Security Solutions for Interoperable Electronic Health Information Exchange"). The Document states that the process would involve 12,759 stakeholders each taking three hours for a total burden of 38,250 hours.

Comments on the AHRQ information collection were requested with regard to any of the following:

• Whether the proposed collection of information is necessary for the proper performance of functions of AHRQ, including whether the information will have practical utility
• the accuracy of the AHRQ's estimate of burden (including hours and cost) ofthe proposed collection of information; and
• ways to enhance the quality, utility and clarity of the information to be collected; and
• ways to minimize the burden of the collection of information upon the respondents, including the use of automated collection techniques of other forms of information technology.
  
  
• Follow this link for the AHRQ RFP
• Follow this link for the request for review
• Dr. Carolyn Clancey's broader testimony to a senate subcommittee. June 21, 2006
• What is Earned Value Management? Section 300.4 of OMB Circular A-11
• Capital Programming Guide Supplement to Part 7 of Circular A-11 (PDF Version)
• DoD Earned Value Management Web Resource
• November 14, 2001 Memo from OMB concerning compliance with the Paperwork Reduction Act

The answers to these questions will have implications for all state efforts to effect change and may cause additional review into the ways to improve the federal contracting process.

Transparency and Efficiency in Government Processes

Along with the rapid pace of action at state and federal levels has come a collection of appeals and concerns raised by individuals and organizations over authority, transparency, and process. Some of these appeals are from outside of government and some actions come from inside of government through application of laws like the paperwork reduction act.

The enclosed links are added for reference without comment.


AAPS v HHS

• American Association of Physicians and Surgeons (AAPS) v, HHS (US District Court, District of Columbia) - from the AAPS Web site

Stark and Safe Harbor Exceptions Published for Comment

On August 1, 2006, the Secretary of HHS announced the final rules for the Federal anti-kickback statute (AKS) and the physician self-referral law (the "Stark Law). The former rules are from CMS and the latter from the Office of the Inspector General.
The following notes are my personal interpretation and should not be construed as legal advice or in any other way authoritative.

• Follow this link to the 33-page PDF document from the August 8 Federal Register
• Follow this link to the 29-page OIG document from the august 8 Federal Register
• Follow this link to the PDF pages requesting comment from the August 9 Federal Register

AKS "Safe Harbor"

The anti-kickback statute defines criminal penalties for individuals or entities that pay or receive remuneration to foster business referrals under federal health care programs. These regulations are similar to many state laws but do not pre-empt these state laws. The definitions were extremely vague and some believe created sufficient concern that entities like hospitals or health plans could not provide legitimate services to enhance the care of individuals out of fear of prosecution under the AKS regulations. Some exceptions have been declared by the OIG, but uncertainty remains. In the current publication, the OIG states: "this final rule creates a separate new safe harbor for certain arrangements involving the provision of non-monetary remuneration in the form of electronic health records software or information technology and training services necessary and used predominantly to create, maintain, transmit, or receive electronic health records."

There are two basic types of AKS safe harbor regulations:

Electronic prescribing safe harbor and exceptions:

• Authority under the Medicare Modernization act
• Applies to necessary items used only for e-prescribing, including hardware, connectivity, support, training, other services
• In my view, the definition of e-Rx is broad and includes many other data items required for safe and effective e-prescribing - labs, allergies, decision-support; but the e-Rx rule did not include labs and related data but the EHR rule did
• Any amount of such goods and services can be provided 100% by appropriate donors, including hospitals providing services to their medical staffs, prescription drug plans and pharmacies, group practices
• Donors cannot select recipients in ways that directly or indirectly take into account volume or value of services of referrals. From my non-lawyer perspective, this means one can make contributions based on volume of Rx but not on where the Rx re filled.
• Commercial messaging does not appear to be allowed.
• This rule has no sunset date

Electronic health records safe harbor and exceptions

• Authority through the Safe Harbor section of the Social security act - 1128(b)(3)(E) to the OIG and 1887(b)(4) to CMS
• Applies broadly to software used for electronic health records but must include an electronic prescribing component. Includes billing and administrative functions, services, and others.
• Unlike the pure e-Rx safe harbor, hardware and software cannot be contributed
• Systems must meet HHS standards for interoperability as defined by a certification process
• Recipient must pay 15% of the donor's cost for the donation. This cost may not be financed or loaned to the recipient by the donor
• Covers those people and organizations providing covered services, health plans, and related individuals
• Protected recipients are physicians
• Donors cannot make their donations on the basis of recipient behavior that directly is related to volume or value of referrals to the donor or other related business relationships.
• This rule sunsets at the end of 2013.
  

Stark
Compliance with the Stark Law is mandatory. (Compliance with the AKS is voluntary). It refers specifically to referrals by and to physicians. (AKS is much broader and refers to multiple parties).

California Health Care Foundation Releases More Information on Chronic Disease Management

Quoting from the press release:

Chronic disease management systems (CDMS) focus specifically on managing chronic disease and preventive care, while the more comprehensive electronic medical record (EMR) documents the entire patient encounter and provides real-time patient information. A new report, IT Tools for Chronic Disease Management: How Do They Measure Up?, examines the comparative value of these two systems. The report finds that CDMSs scored higher in product function and are significantly less expensive. EMRs received higher ratings based on vendor services and technology, while the two shared similar scores for corporate qualifications.

The new report, entitled "IT Tools for chronic disease management: How do they measure up?" is authored by Laura Jantos and Michelle Holmes of ECG Management Consultants. They interviewed vendors, examined their products, and created a scoring system.

• Follow this link for the background
• Follow this link for the report

HR 4157 Ways and Means status

The House Ways and Means Subcommittee on Health on Wednesday voted 8-5 to approve a bill (HR 4157) that would promote the use of health care IT and establish national standards on privacy and implementation of electronic health records, CQ Today reports. The legislation, sponsored by subcommittee Chair Nancy Johnson (R-Conn.) and Rep. Nathan Deal (R-Ga.), would codify the Office of the National Coordinator for Health IT within HHS and would establish a committee to make recommendations on national standards for medical data storage and develop a permanent structure to govern national interoperability standards.

• Follow this link for the Thomas record of this legislative proposal
• Follow this link for HR 4157 (Johnson Bill)

New York State Awards

On May 24, Governor Pataki announced that 26 regional health care networks across the state were provided $52.9 million in grant awards as part of New York's Health Information Technology (HIT) initiative. These projects will help expand the use of technology in New York's health care system and improve the quality of care for patients.

• Follow this link to the press release and a listing of the awards

Among the New York City Area initiatives are: The Bronx Regional Health Information Organization, Inc./ ($4 m); New York Clinical Information Exchange ($2 m); and the NYC Department of Health and Mental Hygiene/ Community Health Exchange Project ($3.1 m)

New York State Awards

New York State Awards

Google Health

ZD Net mentions a blog that claims to have identified an internal "Google Health" server that somehow got out of their securtiy zones. Snapshots of the alleged offering are at:

• Follow this link to the blog

If this is to believed, Google Health will build on its strengths to provide highly customized and refined views of health information tailored to an individuals needs and preferences. Naturally, this requires the Google engine to "know" a lot about the individual asking the question. This may be problmatic to some and in principle, certainly the integration of these data with finance and other personal information (from one's Gmail account, say), will raise concern. But it also appears that for many individuals, such services are worth the price and trusted. It is also true that one could anonymize one's queries, but this is actually harder to do than one would think.

Increasingly, Google will have to become even more transparent on what it does with personal information. The real currency of Google is trust, and, frankly, the founders are among the most altrustic people in the industry. I would suspect personal information is in safe and good hands, since the company IS based on principles and the erosion of trust runs counter to even the most mercenary business interests.

The Asheville Project - Pharmacy and Disease Management

The Asheville Project was established in 1997 under the leadership of the North Carolina Center for Pharmacy Care and the Mission St. Joseph's Health System. The City of Asheville became the first employer to support the program. In 1997, 24 pharmacists began training to provide diabetes disease management services in their retail pharmacies. It has since expanded to the management of asthma for several hundred individuals. It is a model for complementing disease management through retail pharmacy.

• Follow this link to the North Carolina Association of Pharmacists Asheville Project site
• Follow this link to a 1998 supplement to the journal Pharmacy Times

Pandemicflu.gov

The federal government has an informative site addressing concerns over potential influenza pandemics.

• Follow this link for the site
• Follow this link to the National Strategy for Pandemic Influenza site
• Follow this link for an article summarizing criticism of the project

The plan emphasizes real time surveillance - see Chapter 6.

CMS Long Term Care Regulations Published

In the first week of May, CMS published its most recent regulations for the management of long-term care hospitals. These regulations are - even by health care delivery standards - among the most complex this reader has ever seen. One gets the sense of game theory gone awry - so much anticipation of abuse that leads to further regulations. One gets the sense that the unusual nature of long term care facilities - particularly those in close alliance with acute care facilities - must juggle both the short-term stay PPS rules and the long-term stay PPS rules.

• Follow this link to the CMS Long Term Care PPS Home Page

In the middle of all of this are the patients. It is not widely appreciated that many patients come from the community and for many an extended stay at a long-term care hospital leads to improved health care. But the very nature of these patients suggests that their needs are extraordinary even by the traditional health care financing calculus. They are often ventilator dependent or suffering from severe trauma. But they can get better, and the quality delivered to their care has an enormous financial impact.

Long term care hospitals are part of the often neglected underbelly of our health care system. They are not nursing homes, they are not hospices. They are unique facilities with a unique mission. It is indeed unfortunate that so much time and effort seems to be focused on reimbursement when it could be spent on care. As Peter Drucker said, the purpose of a business is to take ideas from the outside, transform them inside, and return greater value to the outside. To take these ideas to heart in long term care hospitals, all of the apparently necessary debate on pricing comes at the expense of adding real value to patient care. One hopes the trade-off is at least in the best long term interests of our citizens.

ComputerWorld and Life Post-Brailer

A May 1 Computerworld article quoted me concerning Dr. Brailer's replacement.

• Follow this link to the article

Quoting:

Mark Frisse,..... said Brailer brought a human face to what were intangible issues. Through that effort, he said, "the health care IT horse is out of the barn, and sufficient consensus exists that rapid acceleration is possible."

Frisse, who is working to develop a regional health information organization in Tennessee, suggested that the next coordinator work to foster stronger collaboration among federal agencies.

"People want a coherent view of the federal government and a sense that agencies are working together," he said. "States are going to be critical in the next stage of evolution, and collaboration on state initiatives is important."

Frisse also said the new leader must continue Brailer's work on building a national health information network and on creating EMR technology standards.

J. David Liss, vice president of government relations and strategic initiatives at New York-Presbyterian Healthcare System in New York, made a particularly insightful comment that we agree with. You cannot combine patient-focused data exchange with "report-cards" or other quality measures without additional debate. Skepticism over the validity of these report card approaches is valid. Although they are evolving a great deal and in this writer's view will be transformative to care and quality, it is early in the game.

Quoting from the article (and Liss):

Brailer's successor must also ensure that the effort doesn't focus on the use of metrics to grade physicians' work or involve calculating payments based on such a grade, Liss said.

The coordinator should instead work to streamline the health record process, he noted.
"Clinicians may view health IT more negatively if they perceive the technology's main function as aggregating and reporting data from their practices," he said. "This does not make the doctor's work easier; it merely supports another regulatory burden."

Commonwealth Fund Identifies Growing Gaps in Insurance

The Commonwealth Fund Biennial Health Insurance Survey, a nationally representative survey of 4,350 adults age 19 and older was released in April of 2006. It presents new information on the health insurance coverage of Americans and the health and financial consequences families face when they experience breaks in insurance. It finds that while the lowest-income families have always been most at risk of not having insurance coverage, more moderate- and middle-income earners and their families are also in jeopardy. The survey found that 41 percent of nonelderly American adults with incomes between $20,000 and $40,000 a year were without health insurance for all or part of 2005. An increase of 28 percent from 2001.

In addition, one of five of all adults under age 65 is currently paying off debt from medical bills incurred in the past. Those who lack insurance are particularly affected by this burden. The survey also finds that uninsured people with chronic health conditions like diabetes and asthma are much more likely to skip medications for their conditions and go to an emergency room or hospital than are those who are insured.

Follow this link for the Commonwealth Fund Report Home Page

Responding to this work, the New York Times columnist Paul Krugman on May 1 wrote a piece entitled "Death by Insurance." Quoting from his work:

What would happen if Medicare was expanded to cover everyone? You might think that the nation would spend more on health care, since this would mean covering 46 million Americans who are currently uninsured. But the uninsured already receive some medical care at public expense — for example, treatment in emergency rooms that would have been both cheaper and more effective if provided in doctors' offices.

And Medicare manages to spend much more of its funds on medicine, as opposed to other things, than private insurers. If you do the math, it becomes clear that covering everyone under Medicare would actually be significantly cheaper than our current system.

And this calculation doesn't even take into account the costs our fragmented system imposes on doctors and hospitals. Benjamin Brewer, a doctor who writes an online column for The Wall Street Journal, recently commented on the excess expenses he incurs trying to deal with 301 different private insurance plans. According to Dr. Brewer, he currently employs two full-time staff members for billing, and his two secretaries spend half their time collecting insurance information. "I suspect," he wrote, "I could go from four people in the paper chase to one with a single-payer system."

Krugman cuts to the chase, closing:

So here we are. Our current health care system is unraveling. Older Americans are already covered by a national health insurance system; extending that system to cover everyone would save money, reduce financial anxiety and save thousands of American lives every year. Why don't we just do it?

Revolution Health

The May 1 iHealthBeat quotes an April 27 Washington Business Journal article listing the addition of five additional health care executives to their team. This extends a powerful group of executives with some key components enabling a consumer-driven health care system

• Follow this link for Revolution Health
• Follow this link for the Washington Business Journal Site (link is erratic)

The members are:

• Jim Bramson, former chief counsel for intellectual property, products and technology at AOL - general counsel;
• Robert Goodman, former president, CEO and chair of Informed Medical Communications- president of content and commerce;
• Jeffery Gruen, former senior executive at UnitedHealth Group- president of care;
• Michael Singer, former chief technical officer at Microsoft - senior vice president of corporate development
• Anna Slomovic, former chief privacy officer and senior privacy strategist at SRA International, - chief privacy officer

GAO Report on Health Information Technology - March 15, 2006

The GAO has released a 21-page report outlining some of the federal expenditures and efforts for HIT. It is a brief and concise summary emphasizing the role of ONC but also mentioning in some detail roles played by CMS, AHRQ, and other agencies.

• Follow this link for the report

UK HIT: Anatomy of a Failure?

The April 16 Sunday London Times has a brief article outlining the problems and risks associated with the United Kingdom's NHS computer initiative led by Richard Granger. It is not favorable.

• Follow this link for the article
• Follow this link for the UK Connecting for Health home page
• Follow this link for the U.S. Connecting for Health Common Framework

Addressing the same problems of large-scale IT implementations, the article also raises some generic issues critical to the implementation of large scale health information exchange.

Specifically, the distrust of a large centralized database with unclear privacy policies seems quite predictably to lead individuals to "opt out" of the system, negating its enormous potential. In this writer's view, this experience argues all the more for an approach similar to that employed by the U.S Connecting for Health Framework.

Quotes from the article:

It envisaged a new NHS computer system designed from the top down to hold the records of 50m patients on one huge database.

'In the system they are building, errors can get spread and copied across the network and nobody can do anything about it,' said Ross Anderson, professor of security engineering at Cambridge University and one of the 23 academics calling for an independent review of the project. 'What they are proposing is a recipe for chaos and disaster.' Helen Wilkinson-Makey, a 40-year-old manager from High Wycombe, Buckinghamshire, says that her experiences highlight the pitfalls. She discovered that an inputting error had led to her being wrongly logged as having received treatment at an alcohol dependency unit in 1998. The computerised record had been distributed to her strategic health authority, primary care trust and a local 'shared care agency'.

'The only way you can stop data being given out to third parties is by opting out of NHS care altogether, and that is what I have done, but they still have not destroyed the record,' she said.'I find it very worrying indeed and I think people should know about this.' Doctors have similar concerns — and if they refuse to put patient records on the database it will undermine the whole purpose of the system.

The implementation issues have been raised for years. Paul Strassmann is among the authors who have written extensively about such initiatives and their governance. (Like Peter Drucker, Strassmann's books - some over a decade old - still work.)

Ironically, this UK inititative is called Connecting for Health. Not to be confused with the Markle and RWJ initiative of the same title, the initiative none-the-less would benefit greatly from the principles and framework recently published by this US effort.

Physician-Based Connectivity Efforts - an Effective "Stealth" Technology

While the large organizations and technology companies have been mired in the politics of health information exchange, a growing number of physician-based networks are evolving from quite different principles. Based primarily on the need for point-to-point negotiations for managed care contracts, some groups recognized that the same technologies used to coordinate managed care contracts could be used to coordinate care itself. As a result, a growing number of physician organizations are adoping networks they own and they are charging clinical labs, hospitals, and plans to connect to these powerful communications media in ways that offset their costs.

One of the most intersting new arrivals in this arena can be found in Portland.

• Follow this link to Portland's ConnectIQ site

This writer surmises that this is similar to the work by Kryptiq in the same area. Other vendors include Axolotl and RMD Networks. Links are provided below without endorsement or comment.

• Kryptiq
• Axolotl
• RMD Networks

AHRQ Issues New RFA for Patient Safety and Simulation

The Agency for Healthcare Research and Quality (AHRQ) has recently released RFA–HS-06-030 entitled "Improving Patient Safety through Simulation Research."

• Follow this link for the RFA

The goal of the effort is to support research and evaluation of simulation and the roles it can play in improving the safe delivery of health care. Simulation is described as a strategy – not a technology – to mirror, anticipate, or amplify real situations with guided experiences in a fully interactive way. Simulation can complement other organizational change methods to facilitate adoption and implementation of best practices and new technologies. In these projects, AHRQ is interested in the use of and/or adaptation of simulation tools in diverse health care settings and the evaluation of its impact on improving patient safety.

AHRQ anticipates 8-10 grants. The total amount of funds available are $2.4 million.

The deadlines are tight:

Letters of Intent Receipt Date(s): April 28, 2006
Application Receipt Dates(s): May 22, 2006
Peer Review Date(s): July 2006
Earliest Anticipated Start Date: September 2006
Expiration Date: May 23, 2006

Intuit Partners with Ingenix to Advance Consumer Access

The San Jose Mercury News published on April 12, 2006 and AP Newswire story describing Intuit's further advances into consumer based health care products. Partnering with Ingenix, a United HealthCare subsidiary known for episoding and claims management, Intuit said "the first of the Quicken-branded products, slated for release next year, will allow millions of people to view and organize information such as medical bills and insurance data from a variety of health care sources."

• Follow this link for the Mercury News Article

quoting from the article:

"Americans spend more than $350 billion in out-of-pocket medical expenses each year," said Steve Bennett, president and chief executive officer of Intuit. "One of the ways we can help is to equip consumers with tools that enable them to easily navigate through their health care information and decide what's right for them."

Several medical insurers and human resources companies, serving up to 40 million Americans, have already committed to participate in the new health care initiative launched by Intuit and Ingenix Inc., a subsidiary of Minneapolis-based UnitedHealth Group. They include: UnitedHealthcare; Hewitt Associates Inc.; and Optima Health, a unit of Sentara Healthcare.

HIMSS - 2006

A copy of my HIMSS talk may be found through the following link.

• http://www.volunteer-ehealth.org/frisse/02-13-06-HIMSS-frisse.pdf

I hope to post other relevant links and findings in the future in this entry.

Pharmacy Informatics

America's hospital pharmacists have been the bedrock of patient safety initiatives focused on meddication administration. In my view, CPOE, while a valuable term, does not imply this critical role (nor does it adeqautely represent the critical role of nursing and others involved in the medication administration process.

The American Society of Health-System Pharmacists has recently issued a draft paper on the role of pharmacists in broader, hospital-based initiatives. This draft - along with several others - can be find on their web site. See:

http://www.ashp.org/bestpractices/draft_guidance.cfm

Of special interest is the mention of the critical role for informatics education in the pharmacy curriculum. This is especially critical in the case of professionals who choose a career in retail pharmacy. In this writer's view, retail pharmacists are going to play a far larger role in health maintenance than they do today. To do this, they will need better training, better technologies, and far more thinking about the value of pharmacists in community settings.

The Health Information Security and Privacy Collaboration

HHS / AHRQ have awarded a contract to Research Triangle institute to form an Health Information Security and Privacy Collaboration. One phrase to describe the scope is: privacy and security laws and business practices impacting on the exchange of interoperable electronic health care information.

The tasks included in this effort include the assessment of variations, identification of practical solutions, collaboration with other states, regions, and both NGA and RTI, and detailed plans to implement solutions

• Follow this link to the RTI contract site
• Follow this link for information about the other related initiatives

Some Comments from Health Affairs

In a November 29 Web Exclusive, Vicky Gregg, CEO of Blue Cross Blue Shield of Tennessee delivers a comprehensive and enlightening perspective on the promising directions her organization is taking.

• Follow this link for an abstract of the entire interview

Included in the interview are some comments about the Shared Health Initiative that may dispel the concerns of some critics. Posssible copyright issues prohibit full relase, but portions of the interview between Vicky Gregg and James C. Robinson are included below:

Robinson: And so right now, individual physicians treating an individual TennCare patient could, through the Internet, look up a person's record, including drug use and lab values?

Gregg: It shows the lab tests they've had, the lab values, and the norms. Because today there's no standardization out there between labs, interestingly. It shows the physicians whom the patient has seen over time, their diagnoses, any procedures they’ve had, and their prescription drug use history. The drug history has been by far the best tool in terms of a physician looking at a new patient and trying to understand what's going on.

Robinson: And for the enrollees in the other health plans, are equivalent data fed into the Shared Health system?

Gregg: Yes.

Robinson: So if an enrollee were to switch from BCBST to one of the other health plans, or vice versa, the data would follow, so to speak?

Gregg: Yes. It's one of the things that can't be owned by any one entity. You've got to be able to follow that patient over time. If the patients move between managed care organizations, if they move between clinicians, all the data need to follow.

Robinson: How would that principle translate into the commercially insured population, where you’re competing against other health plans and where enrollees do frequently switch health plans? How would the data be aggregated, where would they be aggregated, and who would have access to them?

Gregg: Our sense is that ultimately we're going to need state oversight. I don’t know if it’s a commission, but there’s going to have to be an understanding of who controls the data and how, and who has access to them and how.

Peter F. Drucker, 1909 - 2005

Across the world, obituaries marking the passing of Peter F. Drucker describe his remarkable career and the many insights that propelled him beyond the ranks of simple management theorists and into the pantheon of 20th century thinkers. Indeed, since his early work in the 1930, extending through his examination of GM culture in the 40s to his ongoing and equally radical notions towards government and the role of voluntary work, there are few areas where Drucker's efforts have not left a mark on us all.

Some selected resources:

• NY Times Obituary
• The Business World According to Peter Drucker
• The Leader to Leader Foundation (formerly the Peter F. Drucker Foundation for Nonprofit Management)

Fleeing Nazi Germany in the 30s and working first in London and later at a number of educational institutions in the United States, Drucker was years ahead of most in his formulations concerning the importance of people in the organization, the rise of Asian economies, and his emphasis on a term he coined - the "knowledge worker."

Among his less well-read articles was an April 8, 1996 Forbes article on leadership entitled: "Not Enough Generals Were Killed." As this title suggests, Drucker's works were through-provoking and invaluable.

His works will endure. He will be missed.

Kaiser Family Foundation Reports on Hurricane Katrina

The Henry J. Kaiser Family Foundation issued a report on October 10 that describes some efforts at the national and state level to provide additional health care coverage to those affected by Hurricane Katrina. The report covers the major components of the September 15, 2005 Senate bill, the Administration’s waiver initiative, and the Texas waiver. It also provides greater detail on the Texas waiver.

• Follow this link to the October 10 PDF report
• Follow this link for a comprehensive listing of Kaiser reports on the topic

Kristof on Health Care in Katrina-Affected Areas

In a September 25 Op-Ed piece in the NY Times entitled "A Health Care Disaster," Nicholas D. Kristof describes the social implication of health care disruption within the areas affected by Hurricane Katrina. He points out that access to appropriate pharmacy information is just the beginning. Armed with this information, patients must still pay for medications that they can ill afford under the best of circumstances. Among Kristof's claims and observations:

• "An....one study suggests that more than 18,000 Americans will die this year as a consequence of not having health insurance."
• "Nearly every medical worker I spoke to warned that there would be a surge in deaths from heart disease, strokes and other ailments, concentrated among the poor, because of the interruption in medicines. "
• "In both Mississippi and Louisiana, infant mortality is worse (for every 1,000 babies born, 10 die in their first year of life) than in Costa Rica (8 die per 1,000). For black babies in either state, the picture is still more horrifying: 15 die per 1,000. In poor, war-torn Sri Lanka, where per capita medical spending is only $131, babies have better odds, with 13 dying per 1,000."
• "So let's rebuild the levees, but let's also construct a health care system that works. A dozen years after the last, failed attempt to reform health care, the system is more broken than ever. "

This sentiment is confirmed by recent survey data. Lammot DuPont's notes of the September 19 KatrinaHealth.org describes how the Washington Post, the Kaiser Family Foundation, and the Harvard School of Public Health conducted a face-to-face survey of evacuees in shelters in the Houston area September 10-12. Their findings were:

• 52% report having no health insurance coverage at the time of the hurricane.
• Of those with coverage, 34% say it is through Medicaid and 16% through Medicare.
• Before the hurricane 66% of the people evacuated to Houston shelters used hospitals or clinics as their main source of care and of those, a majority (54%) used Charity Hospital of New Orleans, substantially more than the second most common care site (University Hospital of New Orleans, at 8%)
• 41% report chronic health conditions such as heart disease, hypertension, diabetes and asthma.
• 43% say they are supposed to be taking prescription medications
• and of those, 29% percent report having problems getting the prescription drugs they need.

Department of Homeland Security's National Response Plan

The Department of Homeland Security released a National Response Plan in December of 2004. This plan will be re-examined in light of the health issues surrounding care of hurricane evacuees. The plan has numerous references to health care and infrastructure, particularly with regard to the Joint Field Office (JFO).

• Follow this link for the 426-page report in PDF format

Katrina - a Response from the Informatics Community

In previous postings on the volunteer-ehealth Web site, I have raised some issues about how informatics tools can address the Hurricane Katrina crisis. There is nothing novel in these postings; such matters have been raised by a number of individuals and organizations, but it does seem appropriate to develop a framework for a response. How can informatics tools enable better health care for the region affected by this catastrophe, and as a by-product, build momentum for a more effective national health information infrastructure?

There are several major challenges:

• TASK 1. Unambiguous identification of individuals for health reasons that would be used by all facilities responding to the needs of those who are no longer receiving care from their traditional sources (e.g., an emergency person identifier)
• TASK 2. Identifying specific care provider facilities who can access information securely without fear of privacy violation (see the HHS HIPAA directive)
• TASK 3. Addressing immediate needs for transfer of medical information for the acutely ill Obtaining basic medication, allergy, and medical problem lists for the chronically ill (i.e. the spectrum from dialysis and transplant patients to asthmatics)
• TASK 4. Addressing the immediate needs of patients who are at risk for fatal withdrawal from medications (e.g., insulin, phenobarbital, corticosteroids)
• TASK 5. Maintaining a record of what care is being delivered in acute medicine, chronic illness management, and disease prevention arena at mobile sites
• TASK 6. Ensuring that the record of care so compiled is available across care sites and ultimately is placed in the hands of primary caregivers when individuals find some permanency of residence.

A lot of information is resident in digital format but it it not readily available

• Pharmacy data. Pharmacy data is available through RxHub for some commercially insured and Medicaid patients. It is available through some national chains. Information is also available (claims data) from health plans. The majority of individuals, however, do not have an easily accessible medication history because the Nation lacks a national prescription drug history database.
• Medical claims data. Medicaid and commercially insured patient have plans who maintain claims databases. Although these are not ideal for clinical care, they do give some idea of medications and general illnesses.
• Medicare data. CMS, through its various quality reporting initiatives, may have claims data relevant to acute and chronic care of the displaced.
• Health care systems data. Many patients receive care from health care systems with a multi-state or national presence. Examples include HCA, Tenet, and Baptist Health Care. In some instances, these systems may have data that would be valuable in supporting care.

There are a number of immediate sources where information can be made available in a secure form to address acute needs.

• Military and National Guard facilities have access to strong heatlth care technology infrastructures that should be able to access some information from the major sources
• Large health care systems. The same larger health care systems that have data can also access data if sufficient resources were brought to bear. As only one example, Our Lady of the Lakes Health System in Baton Rouge, with its extensive technology suites, may benefit from additional information
• Retail pharmacies. Retail pharmacies may be able to obtain claims histories in some settings. Much coordination would be required
• Designated care settings. As patients are triaged and their identity is established, a limited number of health care information access facilities could be created where trained professionals (nurses, for example) can validate identy and provide patients with a print-out that represents the best guess of a patient's past medical history and medications.

The Missing Link - Coordination

• State agencies in Louisiana and Mississippi have given consideration to health information infrastructures but were only in the early stages of planning. Still, they have the resources to understand what is required. However, they are too focused on more immediate needs and will need much support and assitance from their neighbors
• Federal agencies, still reacting to adverse public perception, may overcompensate by accelerating independent initiatives rather than coordinating their efforts more effectively and focusing on key "leverage points" like the medication and allergy history. These groups should be working just as hard to record what care is delivered as they do what information can be obtained about patients in need of care. These activities may best be led by the States in conjunction with FEMA and the Secretary of HHS.
• Knowledge. Many professional organizations are seeking ways of providing assistance. These include the American Medical Informatics Association, AHIMA, the eHealth Initiative, the the many groups who have worked diligently to advance a public health and disaster prepardness agenda for the country. These latter individuals should be contactted immediately and their reports quickly distributed and assimilated by those who can implement their recommendations
• The private sector. The private sector must be called on to assist with information technology as they have with utilities and other vital infrastructure projects. History tells us that such efforts are often a combination of altruism and, rarely, greed. The public must be assured that these groups are not profiteering or establishing advantages that are against the long-term evolution of healthy markets. Private sector contributions should be made to fix the problem now but in a way that provides maximum choices down the road. Indeed, one could argue that the various health care and technology concerns that are most readily available to do more have not done so because such approaches would have required a degree of cooperation and open standards that would have threatened their profits in a pre-Katrina world.
• Neighbors. Individuals in the State of Tennessee, Arkansas, and other regions are ready to do more than welcome patients and families into their communities and health care facilities. They want to apply their considerable information technology expertise to ensure that more lives are saved. To achieve this aim, they must learn and seek guidance so that their efforts contribute to the solution and not to the problem.

Next Steps - what the informatics community can do

1. Review what is known. What are the major studies that have addressed informatics solutions to large-scale disasters from bioterrorism and natural events? The important studies are focused on what can be done and arguably not on suveillance (although this is important because of the infectious disease potentials associated with large-scale migrations)
2. Identify local experts who can plan and evaluate options both for the affected region and for the individuals from their own professions and communities who may be able to help.
3. Learn more about the sources of information that are technically available to meet the health care needs of the affected individuals
4. Raise awareness with individuals and organizations who have such data and urge them to work together to provide information where it is needed. Lobby political leaders as well.
5. Seek guidance from a coordinating agency. In the end, the best outcome will be realized if informatics efforts enhance the ongoing large-scale rescue efforts underway. Linking whatever person identifier information that is being obtained with health information may be a good start.
6. Be realistic. The central challenge for some is to differentiate between what is really important from what is merely interesting. A clear and focused agenda that starts with the basics of care and evolves must be developed and adhered to.
7. Express hope. Do what you can to help people understand that we must never be caught unprepared again. One can argue that 9-11 may have affected the public psyche profoundly and led to a long-term change in attitude towards security, but it did not create a climate in which millions of Americans are cut off from their homes and health care. Every year, around 20% of Americans move....this year..add to this number over 1 million who moved with very little of what they have. Let us work to do what we can so that this tragedy is not relegated to history because of even greate calamity.

Clinical Laboratories

A recent iHealthBeat report describes Quest Diagnostic's interest in expanding its physician portal to support additional clinical decision-support.

• Follow this link for the iHealthBeat posting

Clinical laboratories have to address the issue of laboratory data availability in a systematic way. Every data sharing initiative seeks connectivity through the larger clinical labs and these interfaces may both be costly and at times redundant (if the lab interface goes both to a primary provider and to a consolidator, then it is possible that a single lab report may appear as two separate lab reports from two institutions).

Clinical laboratories also have a critical interest in effective and timely communications with their customers and their reputation in this area is the result of many years of effort. But it seems unlikely that any one clinical laboratory or no one single source of data can ultimately serve a "primary" desktop but instead will have to participate with other groups to develop common approaches that are patient- and provider-centric in the generalized sense.

Some Reflections on RHIOs

Someone from the American Medical Informatics Association asked me to comment on RHIOs. Enclosed is the first draft of a response.

Question:
More than 100 regional health information organizations (RHIOs) have been formed to date. These grass roots organizations face the challenge of exchanging data effectively in an environment which lacks a national interoperability model. Given the lack of interoperability standards and the potential for insufficient or inadequate security arrangements, can a coherent public health infrastructure be created through a RHIO network? Is it possible for such a national networked system to evolve from grass roots efforts as they are evolving today? What are sustainable economic models for these organizations and could support for the public health infrastructure be a way to offer support for both security and some base of stable funding?

Answer:
It is not clear that more than 100 organizations are forming RHIOs, since the definition of RHIO is not clear. As intended by the Office of the Coordinator of Health Information Technology, RHIOs are identified as regional organizations that are somehow granted unique status to coordinate health information technology. In the absence of legislation, it is not clear that a systematic model for a RHIO will be forthcoming in the near future.

What is apparent is that many hundreds of communities are recognizing that extending their information services beyond the borders of their own enterprise is both necessary to accommodate consumer preference and vital to improve both the quality and efficiency of health care delivery in America. In late August, the eHealth Initiative released its latest survey on community data sharing in the United States. In a self-reported survey response submitted by 109 organizations, over one-half of the respondents said they were beyond initial discussions and into significant efforts to realize some degree of data exchange. All are facing common struggles of alignment of incentives, financing, organizational issues, legal barriers, and technology impediments.

In many instances, the hospitals and large clinics with the greatest desire to advance these efforts are so immersed in systems implementations for their own organizations that they can afford little time to contribute to community efforts. Plans are often uncertain as to the impact such efforts would have to their own business value and small practices cannot realize the full potential of such efforts until an infrastructure for secure and timely access to critical medication and clinical history information is available in a standardized way at little additional cost.

Whether one believes in a comprehensive notion of a RHIO or not, it is clear that we as a Nation must develop an ability to create a consumer-driven information system where information is centered on the individual rather than on the locus of care.

Change is in the air. Whether the fundamental "disruptive" technology emerges from a Google or an established health care vendor, consumer-driven systems will emerge and will require a more standard data-sharing infrastructure.

For example, the introduction of a medical bill management product by Intuit is a harbinger of change. (Intuit is the developer of Quicken home / business finance management and TurboTax tax preparation systems, and was funded by some of the same venture capitalists who also funded WebMD and other health care initiatives.)

If individuals can pay their bills through banks and migrate to high-deductible medical savings accounts, isn't it possible that banks will become HIPAA covered entities and begin to provide clinical data surrounding medical transactions? Such innovations will shift power in medical services in unpredictable ways.

Even if one takes a more conservative approach, several key informatics issues must be addressed to create a stronger health care infrastructure. These include the development of standard means of obtaining prescription drug histories (discussed by the Systemic Interoperability on their May 18 meeting), laboratory standards, regional master person indexes, authentication mechanisms, security infrastructures, and new means for individuals to manage the control of their information both through a prospective ability to "opt out" of data sharing initiatives as well as an ability to monitory who is accessing their medical information and for what. If the experience of Federal Express is any guide, the ability of those most affected by health care to more efficiently "track their own packages" will improve the quality of data an put on notice organizations that take a less than six-sigma approach to data quality and service.

Adequate financing is always raised as an impediment. In my own mind, this is not so much a matter of insufficient funds as it is in our inability to use the funding available in a more reasonable way. The overhead of office practices is extraordinarily high and the administrative costs are crippling. In an coherent industry or market, such opportunities for savings would serve as sufficient financial drivers, but where the small practice is concerned, the challenge is more the cost of re-engineering a practice while maintaining revenues. This is a process akin to repairing your automobile's engine while you are trying to drive your car down the road. At the regional level, the real issue is one of power.

The "inefficiencies" and "redundancies" in care so often mentioned are usually someone's livelihood. Intermediaries at the clerical, organizational, and clinical level are, more often than not, somewhat content with the status quo because, for many, it is profitable.

In my own mind, it is not conceivable that the American public will tolerate a "market" for health care where the cost and quality of services is not known and where a significant percentage of expenditures are absorbed by processes that have nothing to do with the direct provision of services.

The late 20th century brought a revolution in commerce and productivity by removing excess inventory, streamlining the delivery of goods and services, and creating innovative, consumer-driven financing systems. American health care is lagging these other industries, but the change is inevitable and will require a patient-focused view of patient care information that differs dramatically from the encounter-focused perspective taken by most health information technologists over the past decades.

The interest in RHIOs is not necessarily an expression that a RHIO mechanism is essential, but rather an acknowledgement that the system we are currently using cannot sustain the expectations that will be placed on it within the next decade.

How can one keep abreast of these issues and focus on the fundamental issues without being unduly distracted by the plethora of "hype" press releases? JAMIA will continue to publish in this area and fundamental technology issues have and will continue to be the focus of AMIA meetings. HIMSS and the eHealth Initiative are also active in this area. The Quality Improvement Organizations have a charge to address some of the "last mile" issues for physician practices so central to the process. The Markle Foundation is leading in technology and policy issues. The California Health Care Foundation has made fundamental contributions as have a number of other foundations. A Fall issue of the journal Health Affairs also promises to provide an overview of the field. Indeed, the number of valuable sources grows daily. For our work in Tennessee, we note some "headline stories" particularly relevant to our own work on our web site at: http://www.volunteer-ehealth.org/news/info/info.htm

Waiting in the Emergency Department

Gina Kolata of the NY Times published a very human description of the waste and inneficiency associated with long Emergency Room waits and the somewhat parallel confusion over waiting for the results of diagnostic tests. The article inclues an impressive graphic that is of value to demonstrate ED waiting times.

• Follow this link for the article
• Follow this link for the jpg illustration

The article has some very good personal quotes as well as some wise remarks from Dr. Gordon Moore and mention of the work of Steven Asch from RAND.

TheED problem has been well-described for many years. Among others, the Advisory Board has done a good job of describing how ED waits are often a function of throughput problems with hospital beds and not with the Emergency Department, per se. Still the overall degree of logistics challenges and delays due to lack of information about a patient's past disorders and treatments undoubtedly contributes to the delay.

Follow this link for the Rand site and access to Steven Asch's work

Framing the "RHIO" Rhetoric

The tone and rhetoric used in describing regional exchange meetings increasingly seems to veer towards the concept of competition. In a June, 2005 HealthIT News on-line column entitled "Blame it on RHIOs" the author emphasizes the competitive and highly uncertain nature of these efforts. This may have helped "sell" what turned out to be a very informative meeting but it may also be accurate. This author was quoted as saying:

“There is widespread consensus that the challenge is with people, organizations and incentives – not technology,” said Frisse, director of regional initiatives at the Vanderbilt Center for Better Health in Nashville. “Some efforts seem directed at consolidating the power of intermediaries rather than passing this power to consumers. Without a clear federal framework and strong state and local governance, it is difficult to see how the widespread enthusiasm for regional healthcare initiatives will play out in a way that is both self-sustaining and consistent with community expectations.”

A similar competitive tone is evoked in the title of an upcoming meeting sponsored by the Tennessee Hospital Association and HIMSS entitled "The Race for Data Exchange: How it Impacts You as a Provider." Included will be a talk from Linda Kloss (AHIMA CEO), Vicki Gregg (BCBST CEO), David Goetz (Commissioner of Finance and Administration of the State of Tennessee), and Bob Gordon (Batpist Health System and chair of the MidSouth eHealth Alliance.) In addition to the Memphis-based MidSouth eHealth Alliance, panelists from CareSpark (NE TN), Eastern TN Health Information Network, and SharedHealth will present and discuss their respective programs.

The rhetoric of the meeting titles is provocative. Perhaps it should be. In some respects, new enabling technologies offer new solutions and, in so doing, change the balance of power among consumers, providers, payors, and intermediaries. In this case, however, perhaps "blame" should be placedd on our current state of inequitable and poorly-controlled health care delivery system and the "race" should be for measurable improvement.

Patient Perceptions of Emergency Department Errors

The July 25 issue of the AHRQ Patient Safety e-Newsletter highlights some work on error reporting in academic medical centers published by Vicki Fraser, an extraordinary researcher who holds the J. William Campbell Chair at Washington Univerisity in St. Louis. Quoting directly from the report:

AHRQ patient safety researcher Victoria Fraser, M.D., of the Washington University School of Medicine in St. Louis, and a team of multidisciplinary investigators have been examining ways to improve the reporting of medical errors. With AHRQ's support, Dr. Fraser's research has been used to evaluate methods for analyzing medical error and safety event data, investigate optimal dissemination strategies for patient safety, and determine the best methods for informing patients about medical errors. Dr. Fraser and her colleagues have examined the attitudes of health care providers toward reporting medical errors and the cultural and technical barriers that make reporting difficult in hospitals. In a recent interview, she explained that although doctors and health care workers want to discuss and report medical errors, there are no resources in hospitals to fund these projects and collect, manage, and analyze the data in a timely fashion. Dr. Fraser and her colleagues are working on a survey expected to be released later this year that compares U.S. physician attitudes about reporting with those of their Canadian counterparts. To learn more about Dr. Fraser's research, go to the following recent article about safe medication prescribing; and an article about medical errors in emergency departments.

The Last Mile

Adding data to the obvious, the Center for Studying Health Systems Change on July 7 reported that most Medicare beneficiaries get their ambulatory care from practices with little clinical information technology. A summary points out that the primary determinants include practice size. In particular, a supplementary table points out the lower odds of specific clinical technologies as a function of practice size.

HSAs, Credit Cards, and Medical Financial Management

A July 16 New York Times article by Jennifer A. Kingston entitled "Health Care at the Swipe of a Card" describes the growing number of individuals who are creating health savings accounts and managing their medical expenses in conjunction with special credit cards. The article makes reference to the non-profit HSA Coalition as a source for additional information. The article also mentions J.P. Morgan Chase and Exante - a Utah-based bank chartered in 2002 by UnitedHealth Group.

Watch as well for the growth in the personal money management sector. After years of speculation, Intuit has weighed into the market with its Quicken Medical Expense Manager. (A demo is available at the site).

Linking a product from Intuit to regional data exchanges and other sources of data may play a major role in the evolution of a more consumer-driven health care system. Over the past decades, millions of people have used products like Intuit's TurboTax to navigate the complexities of our tax system. This success experiences the evolution of a parallel product line in the health sector with similar promising results.

Leavitt Announces Medicaid Commission

In a July 8 Press Release, Secretary Mike Leavitt named former Tennessee Governor Don Sundquist to chair a Medicaid advisory committee charged with "identifying reforms necessary to stabilize and strengthen Medicaid."

Facing a state of crisis, members from both sides of the Aisle are working together to address these pressing health care issues. But the appointment of the former Governor of Tennessee led to some relatively rare partisan comments over health care reform - prompted in part to the consequences of past Tennessee administrations to address the rising costs of one of the most comprehensive and ambitious state health care programs in the country. An article in the Nashville Tennessean reflects the differences of opinion over the history of TennCare.

Quoting from the Tennessean:

Bob Davis, chairman of the Tennessee Republican Party: Placed blame for TennCare's woes on former Gov. Ned McWherter, the Democrat who created the program, saying Sundquist inherited a "difficult situation." "Gov. Sundquist has some experience on this issue. I'm sure that's the reason he was appointed," he said.

Bob Tuke, chairman of the Tennessee Democratic Party: Said Sundquist is the wrong person to lead a national dialogue on Medicaid reform. "Our first thought was: 'This must be a joke.' Don Sundquist and the Republicans are the ones who drove TennCare into the ditch," he said. "If the White House is looking for an expert on how to make Medicaid reform a perfect disaster, they've found the right man. We just hope he doesn't do for Medicaid what he did to TennCare."

Tennessee remains a crucible for health care policy debate. Governor Phil Bredesen espoused his principles in a recent address on what he calls "Medicaid 2.0."

Harris Interactive: Public Lukewarm for P4P Tied to EMR Use

A May 24 2005 Harris Interactive Poll News Release on a poll of over 2000 individuals suggests:

the U.S. public is only modestly supportive of having health plans pay more to doctors if they have been shown to provide higher quality care to their patients. However, a sizable majority is interested in this type of plan if it helps to lower their health insurance coverage costs. The question remains: how should health plans measure quality? On the whole, the public is somewhat supportive of measures that are associated with prevention and promoting patient compliance while they are less supportive of plans that measure quality based on particular technology metrics.

Nearly two in five (38%) adults strongly or somewhat support having health insurance plans pay more to doctors if they have been shown to provide higher quality care to their patients. A further 17 percent oppose a pay-for-performance system and a third (32%) is indifferent, neither favoring nor opposing one. Interestingly, the more educated adults are, the more likely they are to favor a pay-for-performance system.

Public support for a pay-for-performance system increases dramatically if it helps to lower their costs. Two-thirds (67%) of adults are interested in a health insurance plan that provides access to fewer doctors, but certifies that those doctors provide higher quality care to their patients and charges consumers lower premium, deductible and co-payment charges.

Specific findings include:

• Strong support for preventive screening tests. e.g., Whether the doctor uses preventive tests like cancer screening and blood tests for high cholesterol (64%)

Less support was found for ED and technology issues:

• The frequency with which the doctor’s patients use the emergency room for medical problems that could have been treated in the office (30%)
• Whether the doctor uses reminder systems to prompt patients to refill their prescriptions when needed (28%)
• Whether the doctor uses electronic patient medical records (18%)
• Whether the doctor uses electronic systems to prescribe drugs to patients (15%)

From this poll, it appears that public support will not at present be a driver for technologic change unless it is associated with a financial impact to the patient.

Tennessee Consumer Notifications

Tennessee Senate Bill 2220, enacted into law and now applicable, ammends Tennessee Code Annotated, Title 47, Chapter 18, Part 21, to include additional notification of privacy violations. Provisions include:

• (b) Any information holder shall disclose any breach of the security of the system followingdiscovery or notification of the breach in the security of the data to any resident of Tennessee whoseunencrypted personal information was, or is reasonably believed to have been, acquired by anunauthorized person. The disclosure shall be made in the most expedient time possible and withoutunreasonable delay, consistent with the legitimate needs of law enforcement, as provided insubdivision (d), or any measures necessary to determine the scope of the breach and restore thereasonable integrity of the data system.
• (c) Any information holder that maintains computerized data that includes personalinformation that the information holder does not own shall notify the owner or licensee of theinformation of any breach of the security of the data immediately following discovery, if the personalinformation was, or is reasonably believed to have been, acquired by an unauthorized person.
• (d) The notification required by this section may be delayed if a law enforcement agencydetermines that the notification will impede a criminal investigation. The notification required by thissection shall be made after the law enforcement agency determines that it will not compromise theinvestigation.
• (g) In the event that a person discovers circumstances requiring notification pursuant tothis section of more than one thousand (1,000) persons at one time, the person shall also notify,without unreasonable delay, all consumer reporting agencies and credit bureaus that compile andmaintain files on consumers on a nationwide basis, as defined by 15 U.S.C. § 1681a, of the timing,distribution and content of the notices.
• (h) Any customer of an information holder who is a person or business entity, but who isnot an agency of the state or any political subdivision of the state, and who is injured by a violation ofthis section may institute a civil action to recover damages and to enjoin the person or business entityfrom further action in violation of this section. The rights and remedies available under this sectionare cumulative to each other and to any other rights and remedies available under law.

Florida

The next meeting of the Florida Health Information Advisory Board will be held on Thursday Nov. 30 at 2 pm ET. Dial-in information is available at: http://ahca.myflorida.com/dhit/work_group05.shtml .

The agenda is available at: http://ahca.myflorida.com/dhit/pdf/FHINAgenda06302005.pdf

A July 26 Tampa Bay Tribune article outlines Florida's proposal to HHS to create a four-community data exchange project linked using a record locator service.

• Florida Health Information Advisory Board Site Press Releases

South Carolina

The June 21 report from Kasiernetwork.org discusses a plan by the State of South Carolina to pursue health savings accounts as a part of a broader reform package for Medicaid. Quoting from this article:

"South Carolina Medicaid beneficiaries would use personal
health accounts to purchase health insurance from the state or private insurers.
Insurers would offer a range of coverage, from low-cost plans with limited
services to comprehensive HMO plans. Beneficiaries also would receive debit
accounts to cover additional out-of-pocket costs and copays, which would range
from $5 for a generic prescription drug to $100 for a hospital stay. The amount
the state would earmark for each debit account would be similar to the amount
state residents spend on private-sector health care and would be based on the
beneficiary's age, gender and health status."

The demonstration waiver is available at the site. (pdf)

Pay for Performance Sites - selected list

American Academy of Family Pysicians - http://www.aafp.org/x30308.xml
American College of Physicians - http://wwwlacponline.org/hpp/pospaper/index.html
American Medical Association - http://www.ama-assn.org/ama/pub/category/14416.html
American Medical Group Association - www.amga.org
Bridges to Excellence - physician site
CMS Physician Focused Quality Initiatives - http://www.cms.hhs.gov/quality/pfqi.asp
Leapfrog Group Compendium - pdf
Medical Group Management Association - html release and ftp document
MEDPAC Congressional Report - pdf
National Quality Forum - pdf

Cerner Acquires Bridge Medical

June 16. Cerner and Bridge Medical announce the latters purchase from Amerisource Bergen. Although the press release from Bridge Medical states that this purchase "is not expected to have a material impact on Cerner’s 2005 financial results," the tighter integration of this bar-code technology to the strong Cerner product line may simplify the realization of effective closed-loop medication management processes. Every clinical systems vendor has strong relationships and capabilities in these areas. The Cerner acquisition emphasizes just how important "the loop" is for patient safety, cost-effectiveness, and health care quality.

Additional Resources`

Government HealthIT has a valuable set of links under the study of "classics" in their Health IT Resources section. It's worth a look. The broader section includes IOM reports, Leapfrog, Legislation, and many other topics

Wyoming

The June 16 Government HealthIT issue includes an article describing a commission of the Wyoming Healthcare Commission charged with reviewing a list of draft recommendations made by the consulting firm of John Snow, inc. The commission studying this issue was mandated through legislation. Wyoming is characteristic of the challenges faced in states where population densitiy is light and services are widely distributed and provided primarily by smaller health care practices and care settings. Several common themes emerge from this insightful report:

• distrust of "centralized" databases or imposed solutions
• clear desire for guidance in selection and adoption
• a critical need for high-bandwidth networks (they exist, but currently the State's network is restricted to educational uses)
• A need for a broader base of technology support in rural settings
• A widespread need for greater understanding of how to transform ambulatory practice settings and adopt IT

West Virginia EHR Initiative

A wide range of publications made note of West Virginia Govenor Joe Manchin's appointment of Dr. Julian Bailes to oversee a statewide working group studying implementation of electronic medical records technology. According to a State Journal (West Virginia) article, Dr. Bailes "established one of the nation's largest specialty telemedicine networks while practicing in Pittsburgh, and he was the co-principal investigator and leader of the National Medical Practice Knowledge Bank project, a $52-million effort at computerization and dissemination of medical information. "

Is Public Health Being Left out of "RHIO" Initiatives?

A recent Federal Computing Week Article written by Nancy Ferris (June 9), reports on the eHealth Initiative's Connecing Community's for Better Health Meeting in late May. At this meeting, Quality Improvement Organizations and Public Health were dominant topics. One speaker termed public health as an "afterthought," another used the term "second class citizen," and still another said that public health "is not engaged right now."

Utah and Rhode Island were cited as examples where state government agencies are leading public/private inititiatives.

The State of Tennessee should be added to this list. The AHRQ contract to TN is awarded to the Commissioner of Finance and Administration. Although directed primarily at health care delivery, from the outset, the impact on public health was both described in the proposal and will be explored in great detail. (The proposal can be downloaded in pdf form from the Volunteer eHealth Initiative home page.) In recent weeks, several meetings with the Department of public health have been held and the overall architecture for the Volunteer eHealth Initiative has been represented in a manner that promises to both strengthen the value of public health resouces and improve the quality of data. Areas of emphasis include child care and immunizations. Indiana's project has show a significant impact as well.

The SharedHealth Initiative of Blue Cross Blue Shield of Tennessee is also directed at public health in its proposed effort to enhance EPSDT reporting.

Public health is far from an "afterthought" in Tennessee.

National Governors Association and Medicaid

Under Public Law 92-463, the Secretary of HHS is establishing a Medicaid Commission to advise the Secretary on ways to modernize this program so that it can "provide high-quality health care to its beneficiaries in a financially sustainable way." The commission will develop proposals that address:

• eligibility, benefits design and delivery
• expanding the number of individuals covered with quality care while recognizing budget constraints
• long-term care
• quality of care, choice, and beneficiary satisfaction
• program administration
• other topics that the Secretary may submit to the Commission

The charter of the Commission includes as voting members former or current governors.

The National Association of Governors is already far down the road on developing a bi-partisan proposal. In a June 1 Statement on Medicaid, the governors said:

"The Executive Committee also discussed the role of the Medicaid Commission established by the U.S. Secretary of Health and Human Services. The nation's governors are supportive of the commission and look forward to working with it to reform the Medicaid program. Given that the NGA Medicaid Working Group has completed much of its work and will be releasing its preliminary recommendations later this month, the members thought it would be most effective to continue their work as an independent bipartisan group. NGA will provide its recommendations to Congress and the commission as opposed to being part of the commission"

It is hard not to believe that the result of the NGA work will result in a stronger Commission report to the Secretary.

Additional Medicaid resources can be found at the NGA site.

Colorado Telemedicine Legislation Signed into Law

Colorado Gov. Bill Owens (R) signed into law addititional telemedicine legislation (SB 224). It authorizes the Executive Director of the Department of Regulatory Agencies, together with the State Board of Medical Examiners and the State Board of Nursing and in consultation with representatives of other relevant state entities "to negotiate one or more interstate compacts endorsingi model legislation to facilitate the efficient distribution of health care services across state lines."