Worldwide Flandemic

Once in a while, I post a funny. This is one of those times.

For those of you who clicked through, here's a bonus extra.‎ Full story...

Physician Performance Assessment

A bit of a departure from my usual transparency efforts, but this week we launched our Clinical Data Portal, a Web-based portal that allows physicians to upload clinical data directly from the chart of from an electronic medical record software and be assessed instantly on their clinical performance. Physicians who score high enough automatically start receiving bonus checks from the Bridges to Excellence program. Pretty neat stuff.

We have started with Diabetes and Cardiac Care, but we'll be rapidly adding more topics for physicians to measure themselves with. Physicians are free to become recognised for any of the topics, but if they fall under a BTE program area, they are eligible for real reward dollars. Next up we'll be processing batch files of data from EMR vendors. Exciting stuff.‎ Full story...

Why I'm Not Camping

Ahh, my poor blog languishes. As I have nothing interesting to say here's a list of what I'm working on, which may explain why my blog is so sparse these days.

Pay for Performance: Physicians are eligible for many programs that will pay them bonuses for delivering care at defined levels. For example, there are strict measures of evidence-based care that should be delivered to a diabetic patient. Starting this month, physicians will be able to enter data into a new clinical data portal that will instantly or near enough instantly score their performance and - if the physician achieves the correct performance level - be identified to these programs. We'll be kicking off with diabetes and cardiac care. Down the road,we'll also process data directly from EHR systems. Go live mid June, 2009.

Transparency: Illinois has elected to use my team to produce their state's hospital report card, we'll be publishing everything you never wanted to know about Illinois' hospitals. Go live Octoberish, 2009.

Transparency: This year's Regional Health Care Report Card is underway, and will split HMOs from hospitals, making it easier to review one or the other. Additionally, this year's hospital report will be the juiciest report card you've ever seen. Go live end August 2009.

Quality Improvement: Phase two of the WhyNotTheBest.org Web site is coalescing, more data, more benchmarks, more quality improvement resources. User interface is being reworked for a smoother, faster onramp to the content by a very cool team, and we're following behind loading up the new data. Go live November 2009?

Transparency: Pellucid is my new project to collate every ounce of publicly reportable data that exists. As you can imagine, that one's keeping me up nights. Go live of yesterday or never, depending on when you ask me.

All that, plus my youth rugby team made it to the semis in the Annual NYC Mayor's Cup. Busy year...

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Uninsured and Charges

Two items caught my eye today that neatly juxtapose. One is from California, which discusses the publication of hospital charges (retail sticker price) for surgeries, and the hospital's insistence that these prices are meaningless. The other is from a Families USA study counting how many people were without health insurance for some period in 2008.

"That database is meaningless," said Jim Lott of the Hospital Association of Southern California. "There’s no relationship between the price on that list and what your insurance company has negotiated."

OK, fair enough. So how many people *didn't* have insurance, and thereby didn't have the benefit of a negotiated rate?

Turns out in California, during 2007 and 2008, 37.4% of the population under 65 spent some time without health insurance. Of these, 76.9% were without health insurance for six months or more.

80.2% of all people who went without health insurance were members of working families, i.e., someone at the house has a job. i.e., employment does not mean health insurance.

Most interestingly, 26.2% of uninsured people have incomes at or above 200% of the federal poverty level. I would hazard a guess that these folks are not rushing to claim bankruptcy to avoid the bill.

And of course, *all* these people are subject to the meaningless numbers. They all are charged sticker price. Maybe they don't pay them, but someone does, either through direct write-offs which impact us at the local tax level (we pay it for them) or indirectly through these folks becoming indigent.

Sticker prices hurt all of us. They are not meaningless. I myself have been charged them, even with my PPO in place.

I, like many other folk in public reporting, would prefer to report the cost of care - how much it costs a hospital to perform a given procedure - but this data is still hidden from us.

In the meantime, and even if I were to have cost data in hand, I would still publish charges, because charges most certainly do mean something, and they mean something to an ever-growing portion of the population.‎ Full story...

National Health Care Reform – and Its Potential Impacts in New York

Please join us for a major forum about:

* the urgent problems in health care (escalating costs, increasing numbers of people with no coverage, disparities in access, and unsafe care),
* the increasingly intense debate about options for national health care reform, and
* the potential impacts of national reform in New York

To address these issues, the non-partisan National Coalition on Health Care has invited an extraordinary panel of experts to share their insights about how national reform could affect patients, health care providers, employers, employees, and communities in New York.

Registration: http://www.nchc.org/registrations/?id=12E0D163-D762-488E-B0CD-D47B7599DB41

And we have invited a wide range of leaders and stakeholders – from many organizations and vantage points – to attend and participate.


The future of health care – in the United States and here in New York – could be changed fundamentally by decisions made in the next few months. The stakes – for the health and well-being of all of us, for the growth and competitiveness of our economy, and for our living standards – are enormous.

We hope that you will join us for an important, informative program -- and a vigorous debate of these issues.

Speakers will include (in alphabetical order):

* Ana Abraido-Lanza, Ph.D., Associate Professor of Socio-medical Sciences, Mailman School of Public Health, Columbia University
* David Dobbins, Chief Operating Officer, American Legacy Foundation
* Ben Geyerhahn, New York Project Director, Small Business Majority
* Sherry Glied, Ph.D., Department Chair, Health Policy and Management, and Professor of Health Policy and Management, Mailman School of Public Health, Columbia University
* Mark Goldberg, Executive Vice President, National Coalition on Health Care
* Atul Grover, M.D., Ph.D., Chief Advocacy Officer, Association of American Medical Colleges
* Lori Heim, M.D., President-Elect, American Academy of Family Physicians
* Sue Klug, Assistant in Health Benefits, Program Services, New York State United Teachers
* Joann Lamphere, Dr.P.H., Director, State Government Relations, Health and Long Term Care, AARP
* Susan Lerner, Executive Director, Common Cause/ New York
* Joel E. Miller, Senior Vice President for Operations, National Coalition on Health Care
* Margaret K. Offermann, M.D., Ph.D., Deputy National Vice President for Research, American Cancer Society
* Vivian Riefberg, Principal, McKinsey & Co.
* Anthony Shih, M.D., M.P.H., Chief Quality Officer and Vice President of Strategic Planning, IPRO
* Hugh Waters, Ph.D., Associate Professor, Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University

The National Coalition on Health Care is the nation’s largest and most broadly representative alliance of organizations working for system-wide health care reform. Its 78 member organizations include major businesses and business associations, unions, medical societies, health and pension funds, insurers, faith organizations, patient advocacy and medical research groups, and higher education councils. Its honorary co-chairs are former Presidents George H.W. Bush and Jimmy Carter. Together, the organizations that belong to the Coalition represent – as employees, volunteers, members, and congregants – more than 150 million Americans.

The Coalition is grateful to the W.K. Kellogg Foundation for its financial support of this forum.

Registration: http://www.nchc.org/registrations/?id=12E0D163-D762-488E-B0CD-D47B7599DB41

If you have any questions about the forum, contact either Mark Goldberg (goldberg@nchc.org) or Joel Miller (jmiller@nchc.org) at the National Coalition on Health Care. We hope to see you on May 27.‎ Full story...

Guest Blog: Collective Clinical Wisdom by Heather Leslie

I'd like to invite and encourage all clinicians to register for the openEHR Foundation's new Clinical Knowledge Manager (CKM) - found online at www.openehr.org/knowledge.

CKM is an international repository for openEHR archetypes and has two primary purposes - that of archetype publication and archetype governance. It is a real opportunity for clinicians to collaborate and agree on clinical content definitions for publication and use in our electronic health records.

openEHR archetypes are open source, computable specifications that define clinical information about a single and discrete clinical concept. For example there are separate archetypes defining a 'symptom', 'diagnosis', 'blood pressure', 'medication order', and 'risk of disease based on family history'.

As structured and standardised definitions of clinical content, archetypes are increasingly being recognised as fundamental building blocks of electronic health records, especially when integrated with clinical terminologies such as SNOMED CT. If we all start to record information based on the same archetype, then we can meaningfully and unambiguously share health information between systems, and we start to query that information across systems.

A primary goal of CKM is to encourage a broad range of clinician input to make sure that the clinical content in each archetype is correct. Absolutely no openEHR experience is necessary to participate in CKM, although we anticipate you will learn about openEHR as part of the journey. All participation is purely on a volunteer basis, and you can opt out at any point.

Whilst CKM is still in its relatively early days, we are already seeing the benefits that contributions by grassroots clinicians are bringing to the archetypes currently undergoing team review. Technically oriented openEHR experts support the review process to provide guidance on design and implementation issues, so there are no unrealistic expectations of the clinicians. Contributions of clinical and technical nature are equally and gratefully received;-)
By design, each archetype contains all the relevant information about the specific clinical concept - a maximal dataset which can be used in all clinical scenarios. So, for each archetype we are seeking a range of views from a variety of:

- professions - including every type of clinicial expert;
- geographical locations - to make sure we can capture diverse clinical and cultural practice; and
- knowledge domains - from general healthcare to all specialist areas.

Please actively 'adopt' the archetypes that you would like to be involved in. This will ensure that you will be invited to participate in the review of archetypes that are of interest to you. At other times you may also be invited to participate in a review where we consider that your expertise might provide balance out the current team of reviewers.

While we will strive to achieve maximal datasets for each archetype, we are pragmatic and know that we won't get it 100% right - certainly not at first try. However, I suggest that a small group of 3-4 clinicians with complementary skills and appropriate expertise can create and develop a draft archetype to approximately 80-85% complete. Further review within CKM by a team of clinicians from a range of professions, countries, institutions, research, and health domains will contribute and refine the archetype further - maybe this still will only get it to 90% complete; but maybe much more. Our experience to date shows that maximal datasets are much easier to agree on than minimal datasets!!

Over time it will be interesting to see how the models evolve - no doubt a good research topic!

Obtaining agreement on clinical content within archetypes in this manner is a significant achievement, even if in retrospect we find they are not 100% complete at the start. The flow-on benefits that come from sharing a standardised set of clinical specifications for EHRs can potentially transform some eHealth initiatives and is a necessary foundation for the truly sharable electronic health record.

So, all clinicians are welcome to get involved in CKM - we will certainly set you to work very quickly! We expect that by contributing domain expertise and insights, clinicians will also benefit personally by gradually developing openEHR understanding and expertise as part of the experience.

And then of course, there is also the contribution to the good of mankind... ;-)


[Instructions for registering can be found at: www.openehr.org/wiki/display/healthmod/Registration+in+CKM]‎ Full story...

Tan While You Work

It's only vaguely health-related, but I wonder what the evidence says about tanning online? www.computertan.com offers you a five minute free trial and includes a mobile app for your iPhone. I have no idea if this is less or more likely to cause skin damage, but it will help me look good and feel less pasty.

Can't be healthy, can it?‎ Full story...

You Gotta Spend Money to Spend Money

"HHS is establishing a new Office of Recovery Act Coordination within the Office of the Secretary to ensure successful implementation of the American Recovery and Reinvestment Act (ARRA) throughout HHS. This Office will be led by a new Deputy Assistant Secretary for Recovery Act Coordination."

Starting on Tuesday March 3rd, and on each Tuesday thereafter through May 12th, agencies receiving Recovery Act funds will be submitting weekly cumulative reports detailing their latest recovery activities. These reports give regular updates to government officials, Congress, and the public on how much is being spent and on what, and list out the agency's major actions.


Spending data covers appropriations, obligations, and expenditures, by Treasury account, as recorded in the agency's financial system. Using the Treasury account code allows us to track the money by the specific program on which it is spent. For now, only appropriations and obligations are required, and expenditure data reporting is optional. After April 6th, all three types of data will be required.‎ Full story...

All Quiet on the Western Front?

You'd think with all the hubbub around transparency and EMRs that I'd be writing like a man possessed these days. While it's true that I've rarely been busier, I'm mostly sitting, watching, waiting. Something big is about to happen, that's for sure.


Stimulus money is already being spent, agencies are fervently plannign on where best to put the money once it starts flowing. I've been part of some very interesting discussions, and I've gotten to hear about som every interesting plans. I've also been part of some very odd discussions, with the requisite odder plans.

Myself, I'm working on several health care transparency projects right now, plus a P4P project which is extremely interesting, so I'm keeping busy for sure, but I am on tenterhooks, drooling with the thought of all the data that might start becoming available if any of this health reform movement actually gets it's steam up.

The problem is, you can't really mix health reform, which by definition means trying to attain lower costs, with stimulus spending, which by definition means spending like there's no tomorrow.

With the proposition that moeny will fall from the sky for physicians to buy EMR software, lots of companies are gearing up to offer their product to a much wider market. SoftwareAdvice.com has updated it's advice on EMR selection with a timely article update on "Should CCHIT Influence Your EHR Selection?"

Anyone thinking about buying an EMR package should read this. It succinctly explains what CCHIT is, and why you need to care what it is. For the uninitiated, CCHIT is the Certification Commission for Healthcare Information Technology, which simply means they say what an EMR has to do to pass muster.

If only it were that simple...

However, if you go on to read the related article on stimulus monies being used to reward adoption of EMR software, the larger picture starts coming in to focus. Roughly twenty billion dollars is sitting in a pot waiting to be given to physicians who become "meaningful users" of "qualified EHR" software.

"Meaningful" and "qualified" are where the rubber hits the road, and these two articles will help you sort through the NewSpeak.

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On a related note, I was forwarded this WP piece this morning: Bad Bet on Medical Records. Long story short, health care professionals (Stephen B. Soumerai and Sumit R. Majumdar) posit there's no clinical evidence that electronicization is a good thing.

"there is little evidence that currently available computerized systems will improve care."

Those of us in the common sense portion of the universe may want to point out that very, very few physicians use EMR, therefore there is, by definition, very little evidence.

Oh, wait.

"The latest national survey, published in the New England Journal of Medicine, shows that only 4 percent of doctors have fully functional electronic records that can provide any kind of clinical recommendations."

They did it for me.

How is this not the bleeding obvious? More worryingly, how is dragging the only industry on the planet currently NOT participating in the Information Age not a bleedingly obvious good thing to do?

Do we *really* need clinical evidence to prove that these new-fangled com-poo-ters are good tools?

As the authors suggest:

"Before moving ahead, the administration should first consider conducting well-controlled research on the cost-effectiveness of health IT in office practices, which are the bulk of the U.S. medical system."

I agree totally.

Lets start by PUTTING SOME SOFTWARE IN THE OFFICE PRACTICES.

I wonder how people so bent on evidence-based judgment for everything park their cars in the morning. I see no clinical evidence on the efficacy of E-mail. In fact, I see plenty of anecdotal and research-based evidence that E-mail can be harmful to efficient work processes. I hope the authors took that into account before sending in their article.

What else? Oh yeh, the system is corrupt.

"Moreover, personal financial ties have been found between some researchers and the companies that produce these systems, and as far back as 2005 studies have shown that health IT developers are about three times more likely to report "success" than evaluators who had no part in system development."

However, physicians who don't use said software and have their Medicare payments reduced but rail against the use of such software, that's not self-serving at all? Getting rid of these requirements directly impacts every physicians income.

And if you look to your IT developer for success stories, you probably believe everything your car dealer tells you, and I have a bridge I'd like to sell you.

To rephrase the above sentence, we could say that "studies have shown that people who make stuff are three times more likely to say the stuff they make is awesome."

Well, duh.

Let's take a closer look at self-serving protectionism. The authors clearly state that one way they can affirm a positive impact is in single payer systems. This article tells me that for true improvement, we need not only EMR but less players in the market. Do the authors examine the feasibility of a single payer in the US? Of course not, it's business as usual. We have too many players and payers, EMR will never work.

Bah.

But of course, you can't just stand up and complain, you have to think of the children.

"For many chronically ill and vulnerable patients, it does not matter much whether their health records are digital or their prescriptions typed. Without patient access to clinicians and adequate health insurance that includes affordable drug coverage, a $50 billion investment in health information technology won't do much for many Americans. These funds are needed elsewhere."

That old whine. Money is needed elsewhere, so it instantly becomes an either/or argument. This is a logical fallacy at best. Money is needed in LOTS of places. HIT is one of them.

NO-one who wants to spend money on HIT thinks it's the only problem.

It is 2009. We use computers now. We have begged the industry to figure it out, but they can't or won't.

Need clinical evidence that computers are a good thing?

Hmm...

I propose that the physician population start submitting hand-written bills to the insurance companies they work with. And insurance companies should start hand-writing checks to doctors. It'll slow things down a bit, but at least we'll be able to gauge the average physician's love or lack thereof of interconnected data systems.

YES to computerized billing systems so I get paid faster!

NO to electronically storing my patient's data!

Seriously?
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Medical Data Privacy: Consumers v Hackers

I just left the following as a comment over at THCB, but after I got done ranting it seemed like a mouthful so I'm reposting it here.

I enjoy the position of being involved in HIT, clinical and claims data, *and* being one of the afore-mentioned hackers. Please distinguish hacker from malicious hacker or "cracker". The term "hacker" has no negative connotation in the community.

That said, I'd like to promise you all this:

When we're done, your health information will be as private and secure as your credit card information.

It will flow across secured networks using portions of the public Internet. It will be covered by copious security policies, all well-intentioned, and few implemented fully.

It will be accessible to you, the patient, electronically. A vague audit trail will also be available.

People who have access to this data - doctors, nurses, covered entities, HMOs, government workers, will store it on their laptops. Their thumb drives. Some will have identifiable data. Some will have deidentified. Some will have patient-level data, some will have aggregated.

Some of them will have their laptop stolen, forget it at the airport, lose their thumb drive. Some will just take it because they can sell it to some guy in Romania.

Third parties will make decisions about you based on your unique profile. Some of these decision will help you, such as reminding you to go get that mammogram. Some will hurt you, because you, like me, have not yet fully quit smoking.

All the above is going to happen. You have no say in it. It's begun, it's overdue, and it will be as imperfect a system as the current one, but with more detailed history of its imperfections.

It will surface new ways to practice medicine, and many of them will be for the collective good. It will surface new ways to lower cost, and many of them will be for the collective good.

You will be as secure in the safety of your medical data as you currently are with your credit data. You all punch your PIN in to the supermarket checkout machine while 15 people watch you. Right?

The government does not have your credit history any more than I have your credit history. The government may have your health score, the same way it can access your credit score. Or your landlord, or your employer, or your private detective.

You will have no more and no less security than with any other confidential information you currently manage, such as your Web site password for your online broker or your online checking account, the credit card bill you throw away unshredded, your mother's maiden name.

I don't hear any of you cutting up your credit cards.

I am not a doctor, a health provider, nor a policy maker. I am merely a tech-savvy consumer who happens to build health report cards using what little data is available to me. If nothing else, I look forward to the day I can actively score the use of evidence based medicine using clinical data delivered deidentified. That and I'd like to know what my last test result were, even if they were a couple years ago.

This is a non-conversation, and allowing the world and their mother to have a say in the indisputably inevitable is merely costing more money and wasting more time. HIPAA already covers who can see what when; properly implemented using standards-based EHR software is already happening, and will continue to happen.

The sooner we build it, the sooner we can start making it better day by day.‎ Full story...

Wow. Seriously Interesting.

http://recovery.gov/

That is all.‎ Full story...

Open Source Government Predictions

Open source software, for those of you who don't know, is software developed by the people, for the people. It is sometimes, if not almost always, free of cost. But more importantly, it is software that is easily inspected, changed and repurposed. The "free" we care most about is freedom; freedom to edit, freedom to review, freedom to share.

Some examples of open source software that you rely on everyday include the Apache Web server software, which runs most of the world's Web sites. The Firefox Web browser is open source. Linux is a famous example of an entire computer operating system that is free of cost and developed by volunteers yet seriously threatens the Microsoft Windows platform.

Government, in the USA anyway, has had trouble adopting or implementing open source software. I think this about to change in a huge way.

Many nations around the world have adopted open source software for a number of reasons, the two main ones being freedom from vendor lock-in and lower cost of ownership.

Many governments prefer open source file formats, as they do not restrict access to documents in the public domain. Another concern is security; software that cannot be inspected or peer reviewed cannot truly be deemed secure. And of course, there are usually much lower up front costs associated with open source software.

Barack Obama's campaign for president has been fueled by an army of Web volunteers, relying on open source Web technologies to dominate the space. The Obama team is quite obviously staffed with open source users and proponents, which leads me to ponder a few things.

Obama promises transparency, and open source delivers. No software is as transparent as open source. All code is open to review and change. All edits are documented and owned. Obama promises accountability. Open source promotes accountability, everyone knows who did what where and when. Everyone is able to ask questions, suggest changes, describe errors. Obama promotes accessibility. Open source software leads the way in designing accessible software not only for disabled users but abled users also.

Obama's Web team have signaled their intent at www.change.gov. Liberal use of copyleft statements, free-flowing communication, use of video and audio, blogs, you name it.

What makes this interesting, is that these folk will soon take over www.whitehouse.gov. I even got an invite this morning to join the new WhiteHouse.gov community.

Hence, I make the following predictions:

1. There will be an early and short lived battle between Obama Web and Gov Web. Gov will throw reams of documents, rules, specs and protocols at Obama Web and tell them to use approved software only. Obama Web will simply do what they want, with the explicit backing of Obama. This will be fun to watch.

2. There will be a slow but steady increase in the number of companies, state governments, and finally end users who use open source multimedia formats and officing software, due to the new WhiteHouse.gov publishing documents in open source formats only. This will be transformative.

3. WhiteHouse.gov will stop using Windows Media and move to Ogg or similar. iTunes will be involved somehow. This will be less cool than it sounds.

4. WhiteHouse.gov will have a discussion forum. This forum will be next to useless.

5. Senior cabinet members will have blogs. These will be fun at first, but will soon become next to useless.

6. Bills will be written using versioning software. OK, this one's a joke, but seriously, it could be a fun idea.

Overall, I think the new administration's Web team will have a subtle, but quietly forceful impact on the everyday lives of Americans as they will slowly but surely be introduced to open source philosophy and implementation. By the end of the Obama administration, I feel confident Microsoft Office will be next to dead or have moved to documented specs and standards and will be mostly free, if not entirely Web-based.

Expect to see a slew of documentation being posted to the White House Web site, with excellent search tools.

And most of all, expect to see the most partisan conversation you've ever witnessed at the soon-to-be-released White House Online Community. Apple fanboys have nothing on Obamaniacs. Legitimizing their tirades via a government-hosted community discussion site will be one of the more humourous things you've seen in a long while.‎ Full story...