The future of Meaningful Use?

Thrill is gone as meaningful use strains
'I’m telling you, it’s really, really hard out here.'
Dana Manos, WASHINGTON | May 9, 2014

It seems just about everybody has a gripe or two concerning the meaningful use program: software vendors that make electronic health records systems, hospital CIOs, the very people charting the related committees and, of course, physicians.

Whether that means it’s time to trim the EHR program’s sails, turn the boat around, or abandon ship entirely is becoming a matter of increasingly winded debate...

Is meaningful use driving eligible providers off course?
Kyle Murphy, PhD,  May 12, 2014

The concept of meaningful use has many supporters. Its execution, however, has its fair share of detractors. Even the most ardent proponents of meaningful use recognize the deficiencies present in the certified EHR technology required by the EHR Incentive Programs...

Meaningful use involves a big amount of money: billions in incentives to eligible providers, more so to the EHR vendors whose systems they had adopted. As the industry shifts toward a value-based approach to care delivery, patients will more and more assume the role of consumers which in turn will require providers to be more discriminating in how they treat their customers.

“If reimbursement is going down, we have to always vet our decisions about how they provide value and we can recover that cost. There’s a very serious value proposition we’re having to make, and that’s good. It should be that way — we should be good stewards anyway,” says Reid.

Meaningful use is only in its second phase, but early results from Stage 2 are underwhelming. Could it be the case for providers that the meaningful use journey is already.

4 hospitals, 50 EPs have attested to Stage 2 Meaningful Use
Jennifer Bresnick, May 7, 2014

Only four eligible hospitals (EHs) and fifty eligible providers (EPs) have attested to Stage 2 of Meaningful Use so far, said Beth Myers on behalf of CMS during the latest Health IT Policy Committee meeting this week.  While Myers stressed that the “slim amount of data” is too little to form an opinion about the success of Stage 2 so far, she was optimistic about the outlook for the second stage of the EHR Incentive Programs despite ONC Acting Director, Office of Economic Analysis, Evaluation, and Modeling, Jennifer King, noting that small rural and critical access hospitals (CAHs) are significantly lagging behind their peers in adopting EHR technologies ready for the new challenges ahead...

I have never really liked the phrase "Meaningful Use." Too easy to mock. Meaningful to whom? The clinicians who have to use the technology, or the payers and policy wonks?

We need Effective Use of health IT by those who must use it. That assertion implies a ton, obviously, and it goes way beyond capturing a relative handful of measures in "structured data" formats.

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Oh, yeah, btw...

EHR Hardship Exception Deadline Is July 1
By Christine Kern

CMS provides update on EHR Hardship exceptions for eligible professionals who haven’t applied yet.

Those eligible professionals within the Medicare EHR Incentive Program who did not successfully meet meaningful use in 2013 may still submit a hardship exception application for payment year 2015, according to the Centers for Medicare and Medicaid Services.

As HealthData Management reports, the CMS deadline for eligible professionals to apply for 2013 reporting year-2015 payment adjustment year hardship exceptions is July 1. To date, 600 eligible professionals have applied for hardship exceptions, according to a CMS official who made a presentation during the Health IT Policy Committee's May 6 meeting.

Elisabeth Myers, policy and outreach lead for the CMS Office of E-Health Standards and Services, told the committee that "We have received a number of hardship exemption applications. I know that that's been a big question of how those are going."

Acceptable conditions for applying for the hardship exemptions include EHR vendor issues, lack of infrastructure and unforeseen/uncontrollable circumstances, "lack of control over the availability of Certified EHR Technology" and "lack of Face-to-Face Interaction." Hardship exceptions are valid for one payment year only; new applications must be submitted each year to continue a hardship exception claim for the following payment year...

See the relevant CMS site here.
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UPDATE

From NBC News. Who owns your health data?

 

I posted on health data ownership back in 2011. Here as well.

apropos...

Hospitals overcharge med records by $7M
Lawsuit alleges three New York hospitals and business associate overcharging up to $0.50 per page
Erin McCann, May 5, 2014

A triad of big name hospitals have come under fire recently for allegedly overcharging patients for copies of their medical records.

Back in March, New York-based Mount Sinai Hospital, Montefiore Medical Group, Beth Israel Medical Center and release of information service company HealthPort Technologies were slapped with a class action lawsuit for reportedly violating New York State's public health law regarding medical record request fees.

The group of plaintiffs representing some 100 members alleged the three hospitals and HealthPort Technologies, the company responsible for handling the record requests, overcharged patients and clients by up to $0.50 per page. New York Public Health Law stipulates fees for medical records are not to exceed $0.75 per page and that fees are not to exceed the actual costs incurred by the provider.

[See also: Charging for data: What is too much?]

According to the lawsuit, clients were charged around $0.75 per page when the incurred costs only calculated to $0.25 per page...

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More to come...

The Blog turns 4

With the REC initiative winding down -- heading quietly off the national health IT stage in "no-cost extension" mode, and given that I have retired from the program, it is time to finally execute a name change. I will continue to use the old URL while I lock down the explicit URL custom domain, but the re-direction URL "Blog.KHIT.org" will get you here. I've been mirroring these posts at KHITblog.blogspot.com, but that seems like a duplicative waste of effort and bandwidth, so I may soon quit doing that. Too much hassle to migrate everything in my right-hand Links column.

I originally registered both "RegionalExtensionCenter.blogspot.com" and "RegionalExtensionCenters.blogspot.com" (I use the free Blogger.com), with the latter simply "squatted" to prevent someone else from getting it and causing confusion with my active REC blog work. My masthead title was "The HHS Regional Extension Center Blog," but I always noted that it was not a HHS project, but was a in fact private, independent undertaking. This is what the marketing peeps call "positioning." Today, the simple phrase "REC blog" entered into a Google search (even absent the quotes) returns this blog as the first search result. Didn't pay a penny for that. Meta-tags, baby (among other SEO things).
I launched this effort four years ago today. My initial post was entitled Opportunity for collaboration? ASQ and the RECs. I have to admit to disappointment that I never got any traction with the collaboration. I am a senior member of ASQ and continue to believe it could bring a lot to the healthcare and health IT tables. ASQ Healthcare Division Chair Dr. Joe Fortuna agreed, and invited me into the Division Leadership Council, and we made repeated proposals for pro bono collaboration with ONC.

ONC, though, exuded a "not-invented-here,-not-interested-here" indifference, and the various relevant ASQ Divisions seemed equally uninterested. In fact, the only feedback I got early on after pitching the idea around the Society was a that of being admonished by some dope in the Software Quality Division for "using the ASQ logo without permission"  on my blog.

Seriously, bro'? That the best you can do?

We see how far that got him.

I attended seven major healthcare and Health IT conferences and events in 2013 for the blog (HIMSS13, Health 2.0 Refactored, California State HIT Day, Lean Healthcare Summit, Health 2.0 2013 Annual, NYeC 2013, and the IHI 25th Forum). I was apparently the only ASQ member at any of them. Sigh...

The other weird thing that went down at the launch of this blog was the upshot of my mistake in having had the impolitic temerity of directly contacting my CEO, Marc Bennett with the good news of Dr. Fortuna's interest in helping the REC initiative. I got immediately and publicly upbraided within HealthInsight by our then-REC Executive Director for "exceeding your scope." The soap opera Uproar was pretty lame.

I thought I was gonna get fired after only two months into the job. It was stressful. It sucked. I was blindsided. My relationship with Marc went back to the early '90's, when the Utah Peer Review and Nevada Peer Review were merged to form the bi-state HealthInsight. Marc was on the Communications team and I was an analyst. Way antedated the tenure of this particular ED. I was unaware that I was now not to directly approach His Most Serene High CEO-ness.

Cooler heads prevailed, though, and she never brought it up again. The Big Emergency Inquisition Meeting never happened. 314 posts later I am still blogging, still supporting the now-mostly moribund REC program, and still trying to add content and perspectives of value to the healthcare and Health It spaces. My interests, as regular readers of this blog know full well, go way beyond just IT to process improvement and rational healthcare and Health IT policy.

I don't get paid for any of this. I do it because it's important. I'm "retired" now, and have been joyfully catching up with life with my awesome wife after five years of difficult work separation (and dealing with some of the inevitable chronic health issues that come with my age). I'm behind on some of my prospective KHIT work, but I will catch up. I have two books to finish writing, and more reading to do than I can possible ever keep up with.  Some KHIT stuff remains under wraps 'til I get them done.

Spending some quality time with my guitars, too. And, last night I exercised my live performance photographer chops by attending a benefit performance in Mill Valley at the Throckmorton Theater for the "3 Still Standing" documentary project. I'll be dumping, triaging, and posting my shots from last night to my Facebook page and another of my blogs as soon as I finish here.

Lots of important stuff to continue to write about. And, if you would like to write for/cross-post with the KHIT blog, just let me know. My traffic numbers are pretty decent; you'll get good exposure.

Thank you for your continued interest.

- BobbyG

UPDATE:

Some of my shots from last night, uploaded to my Facebook site.

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More to come...

ICD-9: E922.9, E955.4, E956, E970, Health IT, public health, and the Second Amendment

Imagine coming across an EHR Social History sub-template like this:

Preposterous. First of all, notwithstanding the potential public health data mining utility of such information, it's illegal for a clinician to ask a patient about firearms possession and usage. The gun lobby made sure to have such a proscription inserted in the PPACA. to wit:

PPACA, consolidated:

SEC. 2717 [42 U.S.C. 300gg–17] ENSURING THE QUALITY OF CARE.

(b) WELLNESS AND PREVENTION PROGRAMS -- For purposes of subsection (a)(1)(D), wellness and health promotion activities may include personalized wellness and prevention services, which are coordinated, maintained or delivered by a health care provider, a wellness and prevention plan manager, or a health, wellness or prevention services organization that conducts health risk assessments or offers ongoing face-to-face, telephonic or web-based intervention efforts for each of the program’s participants, and which may include the following wellness and prevention efforts:

(1) Smoking cessation.
(2) Weight management.
(3) Stress management.
(4) Physical fitness.
(5) Nutrition.
(6) Heart disease prevention.
(7) Healthy lifestyle support.
(8) Diabetes prevention.

PROTECTION OF SECOND AMENDMENT GUN RIGHTS -- As added by section 10101(e)(2)

(1) WELLNESS AND PRIVENTION PROGRAMS -- A wellness and health promotion activity implemented under subsection (a)(1)(D) may not require the disclosure or collection of any information relating to—

(A) the presence or storage of a lawfully-possessed firearm or ammunition in the residence or on the property of an individual; or
(B) the lawful use, possession, or storage of a firearm or ammunition by an individual.

(2) LIMITATION ON DATA COLLECTION -- None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used for the collection of any information relating to

(A) the lawful ownership or possession of a firearm or ammunition;
(B) the lawful use of a firearm or ammunition; or
(C) the lawful storage of a firearm or ammunition.

(3) LIMITATION ON DATABASES OR DATABANKS -- None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used to maintain records of individual ownership or possession of a firearm or ammunition.

(4) LIMITATION ON DETERMINATION OF PREMIUM RATES OR ELIGIBILITY FOR HEALTH INSURANCE

A premium rate may not be increased, health insurance coverage may not be denied, and a discount, rebate, or reward offered for participation in a wellness program may not be reduced or withheld under any health benefit plan issued pursuant to or in accordance with the Patient Protection and Affordable Care Act or an amendment made by that Act on the basis of, or on reliance upon—

(A) the lawful ownership or possession of a firearm or ammunition; or
(B) the lawful use or storage of a firearm or ammunition.

(5) LIMITATION ON DATA COLLECTIONS REQUIREMENTS FOR INDIVIDUALS -- No individual shall be required to disclose any information under any data collection activity authorized under the Patient Protection and Affordable Care Act or an amendment made by that Act relating to—

(A) the lawful ownership or possession of a firearm or ammunition; or
(B) the lawful use, possession, or storage of a firearm or ammunition.

[Emphases mine}

Moreover, in today's acrimonious 2nd Amendment climate, irrespective of the foregoing PPACA clauses, any EHR vendor providing such a template would likely get death threats. I've gotten them simply for posting this (below) online in weapons rights-related article comments sections and advocating for repeal of the 2nd Amendment, which I view as a dangerous anachronism -- a relic of a distant and very different time, one whose benefits are nil and lethal risks are empirically incontrovertible and legion.

Not kidding. One Keyboard Commando comedian warned me that "you'll change your attitude after we come and kick your front door down" and sent me URL links to jpegs showing automatic weapons and ammo caches. Another wrote "We'll be over to Antioch soon. Until then, sleep tight."

From a Salon.com article this morning:

Imagine you’re sitting in a restaurant and a loud group of armed men come through the door. They are ostentatiously displaying their weapons, making sure that everyone notices them. Would you feel safe or would you feel in danger? Would you feel comfortable confronting them? If you owned the restaurant could you ask them to leave? These are questions that are facing more and more Americans in their everyday lives as “open carry” enthusiasts descend on public places ostensibly for the sole purpose of exercising their constitutional right to do it. It just makes them feel good, apparently.

For instance, in the wake of the new Georgia law that pretty much makes it legal to carry deadly weapons at all times in all places, parents were alarmed when an armed man showed up at the park where their kids were playing little league baseball and waved his gun around shouting, “Look at my gun!” and “There’s nothing you can do about it.” The police were called and when they arrived they found the man had broken no laws and was perfectly within his rights to do what he did. That was small consolation to the parents, however. Common sense tells anyone that a man waving a gun around in public is dangerous so the parents had no choice but to leave the park.  Freedom for the man with the gun trumps freedom for the parents of kids who feel endangered by him.

After the Sandy Hook elementary school massacre, open carry advocates decided it was a good idea to descend upon Starbucks stores around the country, even in  Newtown where a couple dozen armed demonstrators showed up, to make their political point. There were no incidents.  Why would there be? When an armed citizen decides to exercise his right to bear arms, it would be reckless to exercise your right to free speech if you disagreed with them. But it did cause the CEO of Starbucks to ask very politely if these gun proliferation supporters would kindly not use his stores as the site of their future “statements.” He didn’t ban them from the practice, however. His reason? He didn’t want to put his employees in the position of having to confront armed customers to tell them to leave. Sure, Starbucks might have the “right” to ban guns on private property in theory, but in practice no boss can tell his workers that they must try to evict someone who is carrying a deadly weapon...

Anyone recall Nevada's absurd "Second Amendment Remedies" Senate candidate Sharron Angle? And more recently, we have the maudlin spectacle of the scofflaw Bunkerville Nevada rancher Cliven Bundy, the bumbling, inarticulate hero to a throng of fractious, equally delusional self-appointed "militia" irregulars?

"The second amendment in effect prevents the national government from destroying the militias of the states and preserves a personal right that is centuries old. Joel Barlow, the Connecticut wit and writer, in 1792 sagely declared that a tyrant disarms his subjects to "degrade and oppress" them, knowing that to be unarmed "palsies the hand and brutalizes the mind," with the result that people "lose the power of protecting themselves." But arms privately held can be dangerous to society. President George Washington once reminded Congress that "a free people ought not only be armed but disciplined." He meant that the militias of his time had to be under military authority or, in the frequently used phrase, should be "a well-regulated" militia. However, we no longer depend on militias, a fact that in some respects makes the right to keep and bear arms anachronistic. An armed public is not the means of keeping a democratic government responsible and sensitive to the needs of the people. As the Supreme Court said in 1951, in Dennis v. United States: "That it is within the power of Congress to protect the government of the United States from armed rebellion is a proposition which requires little discussion." Whatever hypothetical value there might be, the Court said, in the notion that a "right" against revolution exists against dictatorial government "is without force where the existing structure of the government provides for peaceful and orderly change." The Court added, "We reject any principle of government helplessness in the face of preparations for revolution, which principle, carried to its logical conclusion, must lead to anarchy."

The right to keep and bear arms still enables citizens to protect themselves against law breakers, but it is a feckless means of opposing a legitimate government. The so-called militias of today that consist of small private armies of self-styled superpatriots are entitled to their firearms but deceive themselves in thinking they can withstand the United States Army. The Second Amendment as they interpret it feeds their dangerous illusions. Even so, the origins of the amendment show that the right to keep and bear arms has an illustrious history connected with freedom even if it is a right that must be regulated."

Professor Leonard W. Levy. Origins of the Bill of Rights (pp. 148-149). Kindle Edition.

From my blog post Force Majeure?

We routinely capture and risk-analyze all manner of "lifestyle" data: smoking, alcohol, drug use, motorcycle-riding, skydiving, etc. I would add firearms possession and use to the EHR SHx templates.

I won't be holding my breath, though. In fact, I'll likely be threatened yet again for even suggesting it. Meanwhile, ICD-9 dx codes E922.9, E955.4, E956, E970 and their kin will continue to populate U.S. hospital EHRs post hoc at a rate of several hundred per day.

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More to come...

Meaningful Use: who's making bank here?

The feds just released a huge dataset comprised of Meaningful Use attestations by EHR vendor to date. The dictionary:

552,406 data rows in the main sheet. You can grind these sixteen ways to Sunday for useful substrata. Here's my quick Excel tally of the aggregate ranks to date, all years, all programs (EPs, EHs, Medicare, Medicaid), top 25:

An "EPIC situation," no? While their relative share has decreased as the program has matured, they still rule, far and away.

Note that the top 10 comprise ~2/3rds of the attestation action and the top 25 nearly 80%. Interesting that the freebie Practice Fusion is ranked 9th (beating out even Jonathan Bush's anti-REC athenahealth).

I wonder how much of the $22.9 billion MU money paid out to date [1] passed through to the vendors, and [2] cycled back around in taxes? To the latter question, were it, say, ~20%, you'd have a bit more than $5 billion coming back to the Treasury.

I'd also like to know how much the Meaningful Use program has cost the taxpayers in total, net (incentive payments, RECs, administrative costs at ONC and CMS, etc).

HIMSS ON THE REC FUTURE

Just out (pdf).

In August of 2013, the Office of the National Coordinator for Health Information Technology (ONC) announced the opportunity for a no-cost extension of the remaining funds available through the American Recovery and Reinvestment Act of 2009 (ARRA).

In order to assess how Regional Extension Centers (RECs) are going to prepare for a future in which funding was uncertain, HIMSS developed a study to evaluate organizations’ preparedness to sustain operations in the future. This survey assesses a number of factors including key information technology (IT) priorities, the business issues impacting RECs, and the types of strategic relationships organizations are creating to sustain viability...

By all accounts, the REC program has been extremely successful to date. Over 147,000 providers are currently enrolled with a REC. Of these, more than 124,000 are now live on an EHR and more than 70,000 have demonstrated Meaningful Use. Additionally, 872 Critical Access Hospitals (CRHs)/SRHs have been paid for MU1. Yet, as the ARRA funding winds down, there are questions around the financial sustainability of these organizations.

Findings from the 2014 HIMSS Regional Extension Center Study suggest executives are optimistic about the future of RECs. For example, 85 percent of executives responding to the survey indicated they did not expect to close their doors, despite the fact that 28 percent of the 36 executives responding to the 2014 HIMSS Regional Extension Center Study indicated that their funding ran out prior to the end of February 2014.

Indeed, RECs are moving forward with a number of strategies in which to ensure they can continue to fulfill their mission. Approximately three-quarters (72 percent) had applied for a no-cost extension of their ONC funding. Nearly half are creating strategic partnerships with other organizations in their service area. Finally, approximately half reported that they have received state funding to maintain operations...

...[A] handful of the RECs responding to this study noted that they have already been generating revenue streams to sustain operations going forward. One respondent noted that they are earning money from “provider membership fees, consulting services, selling IT resources and IP to other RECs and government entities”. This is not an easy model to achieve, and not all respondents believed that this model will yield full-blown sustainability. One respondent suggested that “the level of interest remains high among providers to continue with Stage 2 and embark in PCMH (patient centered medical home) recognition; the revenue generation from such activities is insufficient to maintain full-blown REC services”. Another noted that many organizations, including “RECs are not accustomed to looking for sustainability models nor have the infrastructure to operate as a for-profit entity. This has been the biggest concern with being a REC”. Finally, a respondent commented that “their organization will not commit to building a sustainable model”.

I continue to bemoan the short-sightedness of HHS not infusing the RECs with funding sufficient to get them and their clients through Stage 2.

A NEW BOOK ON ORDER

From the Thedacare Center for Healthcare Value.

If the history of revolution around the globe has taught us one thing, it is this: leadership succeeds only when it learns to evolve. No matter how necessary and just the rebellion, when the dust clears, the leaders need to govern, to make systems work in order to keep a country or an organization running. And that requires an ongoing willingness to change and adapt.

For nearly a decade, the lean revolution in healthcare centered on improving quality and reducing costs in advance of the huge systemic changes we all knew were coming.With healthcare bills bankrupting families and threatening to do the same to the United States, major hospitals and health-system leaders began experimenting with various improvement methods. A healthy percentage of those organizations embraced lean thinking and adopted tools and methods from the Toyota Production System...

It turns out that revolutionary change is necessary, but it is not sufficient.

The kinds of change that come from rapid process improvements are essential but are only the first steps of a lean journey.The core work of the transformation is changing the culture—changing how we respond to problems, how we think about patients, how we interact with each other. This is an issue not only in healthcare organizations; we have also seen manufacturing, service companies, retailers, and government agencies all struggle with the same issues.When lean thinking goes only skin deep and management does not change, improvements cannot be sustained, and savings never quite hit the bottom line...

We are finally moving beyond the age of heroes chasing exceptions and are looking forward to innovations in management that will move us even further ahead.The faster we can implement these ideas, the better it will be for all of us—patients, physicians, nurses, managers, and everyone who pays for healthcare.

—John Toussaint, MD Founder and CEO,ThedaCare Center for Healthcare Value, January 2014

Not available in eBook format. Yet.
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OFF-TOPIC ERRATUM ON "MAKING BANK"

I recently finished Nomi Prins excellent, best-selling history of the modern U.S. financial system, "All the Presidents' Bankers."

Read my Amazon review here. Highly recommended. I have some personal history with the often slimy FIRE Sector (Finance, Insurance, and Real Estate).

Playing off the phrase "making bank," I've been bugging Ms. Prins and her agent with this idea.

My quickie Photoshop. A no-brainer, this one. She is utterly gracious to put up with (and respond to) my emails.

I can't help it; I just have ideas all the time. I mostly just give them away, e.g., see this one. And this old one.
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MU INFOGRAPHIC

nuemd.com

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More to come...

$22.9 billion in MU payments through March 2014

Data just released. Billions with a "B":

Notice the aggregated registrant counts for 2011 and 2012, after which they only give monthly registrations for 2013. Hmmm... 123,648 Medicare EPs in 2011, and 113,658 in 2012, for example. Maybe they just don't want you to easily see the dramatic fall-off in 2013 registrants. There were only 54,062 Medicare docs registered for MU in 2013, less than half, relative to 2012.

In fairness, there's been an uptick thus far in 2014: 19,237 through Q1. Last Chance for Romance, I guess.

Below, another interesting graphic, this one from a HITPC presentation.

Early adopter attrition. Pretty severe, I would think. Twenty five percent of 2011 Attesters bailed in 2012 after picking up their Yeah 1 Stage 1 money? What cannot be clear at this point is how many of the 2011 cohort who made it through 2013 will stick around for the relative chump change of Stage 2 Year 1.

Also unclear form the above is the Medicare vs Medicaid mix of the dropouts. Are a significant proportion of them the Free Money "A/I/U" registrants? On the Medicaid side, recall, an EP or EH can take "a year off."

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More to come...

You want some cheese with that whine?

Continuing with a recent theme  (re: my April 25th, April 22nd, and April 15th posts).

Is it time to “damn the mandates” and forget meaningful use?
Jennifer Bresnick, April 29, 2014

Even as the healthcare industry marches dutifully into Stage 2 of Meaningful Use, there are still plenty of physicians that have not yet accepted the requirements put forth by CMS in the EHR Incentive Programs.  Dr.  Daniel F. Craviotto Jr., an orthopedic surgeon in Santa Barbara, California, took to the Wall Street Journal this week to protest the restrictive chains of EHR adoption, quality penalties, shrinking Medicare reimbursements, and bureaucratic red tape that prevent a physician from focusing on what’s really important: engaging with and treating patients.

“In my 23 years as a practicing physician, I’ve learned that the only thing that matters is the doctor-patient relationship,” Craviotto writes. “I acknowledge that there is a problem with the rising cost of health care, but there is also a problem when the individual physician in the trenches does not have a voice in the debate and is being told what to do and how to do it. When do we say damn the mandates and requirements from bureaucrats who are not in the healing profession? When do we stand up and say we are not going to take it anymore?”

Aaron Carroll has a beaut of a response in The Incidental Economist.

Once more unto the breach...
April 29, 2014 at 10:15 am  Aaron Carroll

Austin has been working on his trolling skills. He’s alerted me to another op-ed in the WSJ written by an orthopedic surgeon threatening to walk away from it all.

Look, I’m not suggesting that we limit anyone’s free speech in any way. I’m not suggesting that we shouldn’t hear from unhappy doctors. But I’m going to offer them a bit of (unsolicited) advice. You’re starting to be the docs who cried wolf.

In the interest of providing some media strategy, I’m going to go through this bit by bit. Let’s begin:

In my 23 years as a practicing physician, I’ve learned that the only thing that matters is the doctor-patient relationship. How we interact and treat our patients is the practice of medicine. I acknowledge that there is a problem with the rising cost of health care, but there is also a problem when the individual physician in the trenches does not have a voice in the debate and is being told what to do and how to do it.

OK, right off the bat, you’re claiming that you have no voice in the debate as you are being published in one of the most read op-ed pages in the country. You know who doesn’t have a voice? The 300-plus million people who don’t get to have their thoughts heard in the WSJ...

Ouch. Read the whole thing. An utter smackdown.

Across the country, doctors waste precious time filling in unnecessary electronic-record fields just to satisfy a regulatory measure. I personally spend two hours a day dictating and documenting electronic health records just so I can be paid and not face a government audit. Is that the best use of time for a highly trained surgical specialist?

I’m totally with you here. I think this kind of thing sucks. But do you really think that the average American doesn’t spend a whole lot of time doing things at work that they don’t enjoy? Do you really think lawyers don’t hate billing? Do you really think educators don’t hate teaching to tests and grading essays? Do you really think that small businessmen don’t hate regulations? I think many, if not most Americans, will read this and say, “Wait a minute. You only have to do two hours of crap a day? Lucky ducky!”

Again, read all of it.
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UPDATE

Just in. Relating to the environmental factors of health:

Supreme Court Upholds Air Pollution Regulation

The Supreme Court has given the Environmental Protection Agency an important victory in its effort to reduce power plant pollution that contributes to unhealthy air in neighboring states.

The court's 6-2 decision Tuesday means that a rule adopted by EPA in 2011 to limit emissions from plants in more than two-dozen Midwestern and Southern states can take effect. The pollution drifts into the air above states along the Atlantic Coast and the EPA has struggled to devise a way to control it.

Power companies and several states sued to block the rule from taking effect, and a federal appeals court in Washington agreed with them in 2012.

Justice Ruth Bader Ginsburg wrote the court's majority opinion. Justices Antonin Scalia and Clarence Thomas dissented.

Wow. 6-2. That rarely happens at SCOTUS these days. The smell in the air today is that of climate-denier wingnut hair on fire.

ERRATA

Funny.

COMMONWEALTH FUND INTERACTIVE MAP:
STATES' HEALTH SYSTEM PERFORMANCE

"Interactive." Move your mouse, stylus, or finger around the map for state-by-state data.

DESIGN FLAW

I use the free open source FileZilla FTP upload utility. Very handy. But, twice now I have slipped with my mouse and inadvertently wiped out all of my logins and passwords. Those "clear" items should either be moved elsewhere or backed up with a yes/no "are you sure?" pop-up warning.
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More to come...

"TwittEHR?"

(Not a real logo, just an allusive BobbyG Photoshop quickie)

In light of my last couple of posts dealing with the continuing issues of EHR dissatisfaction, there's interesting post on THCB.

What an EMR Built on Twitter Would Look Like
by DAVID DO, MD

WILD PREDICTION: It won’t be long before every patient has a Twitter feed, and doctors subscribe to them for real-time updates.

This is a time when the demands of being a physician are changing, and we need to leverage technology to maintain awareness of a huge number of patients. There is also increasing need for handoffs and communication between providers.

Here’s the bottom line: how can we improve technology when doctors seem so resistant? They are not happy with their EMRs, and rightly so, because they were built to do too much for too many.

Current system is inefficient
The EMR has become essential for documentation, billing, medical reasoning, and communication, among other things. Currently, documentation is built on a system of daily progress notes. If I consult a cardiologist about a case, he needs to go through each note, containing narratives, laboratory values, vital signs, and physical exams.

A patient with a seven-day hospital stay may have twenty notes that need synthesis to put together the story–this can take hours per patient!

In an age where more providers are involved in a patient’s care (whether due to duty hour restrictions, or the increasing presence of specialists for every problem), this inefficiency is not acceptable...

One THCB commenter noted a company proposing to do this very thing. Medyear.com

From their FAQs:

1. Is Medyear secure?
   Yes, very. Medyear is HIPAA-compliant and would not be able to accept your clinical records in the first place if it did not meet strict government regulations (HIPAA) and standards (Blue Button) for handling healthcare data. Moreover, we apply very powerful database technologies that allow us to secure information at a granular level. No system is perfectly secure, but we obsess over security so you don't have to.
2. Is my information private?
   It depends on you. You can share your information however you want. You might share with a friend, a doctor, an insurer, a stranger, or with science. You might share just one small part of your health record, or the entire thing. You might share for one hour, or one year. Your privacy is your prerogative, and its up to you to decide.
3. What is the logo a snowflake?
   We are all unique as individuals, like snowflakes. So we know our body and our lives best. It is up to us to take charge of our healthcare destiny. Medyear is a people's movement to claim our uniqueness and let the healthcare system evolve around us, to suit our unique needs.
4. How is Medyear related to health reform?
   Many of the key changes in the law and regulations that now make Medyear possible did not exist a few years ago. The government has played an important role by implementing policies like HIPAA-HITECH, Blue Button, Meaningful Use, and Affordable Care Act. As such, we embrace government leadership.
5. What's in it for patients?
   Typically people will share health information for one of two reasons: to give help, or to get help. Perhaps your sharing can help a family member manage a chronic condition because you have had it yourself. Or perhaps you are the one who needs to share information frequently, in order to get the best medical care possible. Whatever the reason, empathy powers when we share to help, and empathy powers the help we might also someday receive.
6. What's in it for doctors?
   Medyear allows patients and healthcare professionals to collaborate directly and privately through Consults. The Consult works a lot like other types of encounters (phone calls, office visits, emails). But instead of recapping your health issues, fumbling with paper records, or expressing concerns in one sitting, you can simply share the information you've already collected. This makes everyone's life easier.
7. What's in it for scientists?
   Scientists working at the very bleeding edge of research need LOTS of data to make important discoveries that lead to the life-saving drugs or procedures of the future. But getting this valuable patient information is not easy, and often when data is obtained it is without patients knowing. With many people perhaps we should just let people share their data voluntarily.
8. Where can I get my records?
   In late February, the US Government has published a directory, known as Blue Button Connector of the healthcare organizations that currently adopt Blue Button. Over time, it is estimated that over 500 organizations - from small clinics, to lab companies, to large hospitals, to the largest insurers - will adopt Blue Button and be listed in the registry. If your healthcare provider is listed, you simply provide them with your Medyear address and your records are securely transmitted into you private Medyear account.

Intriguing stuff. You have to applaud people for attempting viable, disruptive, value-adding things. This is not materially different from the "Health Record Bank" idea I've written of before (scroll down in the linked page).

I just have a couple of concerns. As I noted in a comment (fixed my typos):

For both “Covered Entities” and (now with the Omnibus Rule) their “Business Associates,” EVERY time “protected health information” (PHI – specific legal definition) is, created, viewed, updated, transmitted, or deleted, there must be a date-time stamped transaction log of the event identifying the authorized person who “created, viewed, updated, transmitted, or deleted” the PHI.

Moreover, once an episode of care note is finished and “locked” for billing, it becomes a legal record, “updates” to which can only be done via appended addenda (and those too must be HIPAA-logged).

No small undertaking to make an app such as the one proffered here fully HIPAA-compliant. Yes, some of the PHI “tweets” are their own “transaction log entries,” but that is likely to not be the entire story. Anyone developing or using such an app had better have done their legal due diligence.

Medyear may claim to be "HIPAA compliant," but I'd want to review the gamut of their Business Associate 45.CFR.164.308 et seq documentation. The audit log requirements here would span multiple individuals and organizations. I don't just sanguinely assume that clinicians using a service like this would uniformly not be in violation of their own Covered Entities' HIPAA Policies (and, we must recall, "privacy" [164.5 et seq] is separate from "security" [164.3 et seq]. ePHI privacy is subject to the potential HIPAA-trumping laws and regulations of every state in the U.S. (not to mention the international privacy ramifications). 

Moreover, being able to connect and merge various individual time-sequential, subject-disparate medical "tweets" into efficient and necessary synthesized clinical "views" is likely to be a significant RDBMS challenge that is no different, really, than those at the heart of traditional EHRs. Anyone routinely using Twitter knows that tweets fly by at warp speed. Medyear clients (in particular, clinicians) will need near-instant access to reassembled "old" pertinent information "100-500 screen-scrolls down" at the point of care. Moreover, might there not be the equivalent of random "inbox overload" with medico-legal liability concerns? I'm just sure my Primary wants to be hammered 24/7 with "medical tweets" ranging from the consequential to the trivial.

Nonetheless. let's wish these folks well. Whatever helps.

I couldn't help one other THCB comment:

They appear to be privately held. Time for a VC-assisted IPO?
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More to come...