Should Paul Levy be More Transparent?

As many of you already know, health care transparency evangelist Paul Levy, CEO of BIDMC in Boston, is having a bit of of trouble with his professional life apparently colliding with his personal life. Details are unknown, but include an inappropriate relationship with a subordinate. Mr Levy apologised to his staff via e-mail for his lapse in judgement, and little else is known.

The Boston Herald has run a few pieces about this, and sent a reporter down to Ohio where Mr Levy was speaking about health care transparency at a conference. The Herald is having a grand old time asking a transparency leader to be transparent about this particular incident, basically flogging the story as "Mr Transparency has something to hide" while Mr Levy ducks the reporter and tells everyone at the conference not to talk to the media.

So the question is probably a valid one. If you are a thought leader and public speaker on transparency in the hitherto opaque world of health care business and outcomes, shouldn't you tell us all who you're having sex with and when?

Hmm, now that I say it out loud, it doesn't sound so valid. But let's examine it a little more.

What is health care transparency, and why do so many of us give a damn about it? For me, it's a question of fair trade. I am expected to participate in an allegedly free market but I cannot know the price of goods and services before consenting to the purchase. I am expected to participate in an alleged free market but I cannot acquire adequate data to compare providers of goods and services on their quality, efficiency, or ability to render the services required.

Transparent Deck Repair

My new house has a deck that is falling apart, and I need to repair or replace it. If my deck were my appendix, I would dial a number, a dispatcher would send a contractor and his crew to my house, I would flash an insurance card that he will gladly accept. Later, I will find out that two of his staff do not actually accept my deck insurance, and I will have to pay retail for the railings. Later still I may find out that this particular deck builder has had three decks fall down after he left, but the previous owners were forbidden to tell anyone. I will call the department of housing asking why they can't tell me this, and they will say I am unable to adequately use the information without drawing potentially wrong conclusions.

Later still, I will get a bill that includes a bunch of vague billing codes but the words "wood" and "nails" will be nowhere on there. I will realise I can't afford the portions that my insurance didn't cover, and I will sell my house to pay for my deck.

Obviously, this is absurd, but it is the current state of play in health care. So that gives us the common sense reason. So why should I be in a position to demand transparency? It's a free market, right?

Wrong. Taxpayers prop up the system in a number of ways, and by dint of anyone taking public funds, we immediately expect accountability. Seeing as we're talking hospitals, let's take a look.

Most hospitals operate as non-profits, thereby evading huge property tax bills. That's money out of our public pocket. Yet many of these non-profits pay multi-million dollar executive salaries. The oft-quoted argument is that "we need to pay competitively to keep these execs out of the private sector and in our non-profit", but of course the bulk of the market is non-profit so that argument doesn't truly hold.

Then we pay taxes to reimburse these non-profits when they come across someone who (shock, horror) can't pay. The hospitals go begging at the state kitty and we pay again.

And of course, about half of all the money in health care comes directly from the government via Medicare and Medicaid payments.

So, we want accountability. We don't have it, so we demand transparency in order to hold people accountable.

Accountability is not Universal

Now, Paul Levy has done something for which he needs to be held accountable. To whom is he accountable? The Boston Herald? Me? Who?

Seems to me that while, yes, he could have made mention on his blog and twitter feed and the rest of it that something was going on, the details are not ours to know. He is accountable to the board of directors. There is talk of some severance package for the female staffer in question, and if this be the case then there is the added accountability of misuse of funds. But it is the board whose job it is to be transparent here. Transparency is not about knowing everything about everyone at all times. And those of us who preach transparency in health care have no additional requirement to confess our personal sins in the newspaper.

Over at one of my other blogs, abouthealthtransparency.org, I have received an e-mail from a business editor named Frank Quaratiello at the Boston Herald with the title "Interesting Story" and a copy of the Herald piece. I don't know Mr Quaratiello, but I assume he believes the story has something to add value to the health care transparency debate.

I will not be posting it on abouthealthtransparency.org as it is not about health transparency.

Is there a newsworthy story there? Yes, a major CEO and public figure has proven himself to have had a lapse in judgement, requiring his Board to take action. That is news. Should he resign? Maybe, that's between him and his Board. Do I or anyone else not involved with running that hospital have a right to know the who, what, when and where of the story?

Not at all.

Hot Dog Never Events

If a surgeon made a mistake on the operating table and cut off the wrong leg, are we immediately entitled to know everything he's ever done in and out of the hospital? Should we expect him to rush to update his Facebook feed "just chopped off the wrong leg, brb, chopping off the other one"? Maybe one time he put mustard on his hot dog instead of ketchup. Surely this should have bearing on his ability to perform surgery? At the least shouldn't I know he can't tell his condiments apart?

No, the transparency is in the knowledge of the event, and the efforts made to avoid it happening again. Transparency is about good, useful data that fosters better, more informed decision making.

It is my opinion, and my opinion only, that a figure with as much publicity as Mr Levy should not avoid the fact entirely on his many outlets, especially given his use of his blog as a glimpse in to his personal as well as his professional life. The modern world and its modern communications channels necessitate that we bloggers and tweeters and users of the Web cannot but give up much of our privacy, and separating personal from professional has never been harder now that we are all profiled and LinkedIn'ed.

I myself have been at the wrong end of making poor judgement in a professional setting. When your work is your play, when you are passionate about your work and your goals it can be hard to separate professional from private. Hell, most people I know who are as dedicated and hard-working as I think I am don't have time to have a personal life, and it's easy to fall into the trap of allowing your professional life to substitute for a private one at times. Been there, done that.

But I have no interest in knowing any medical provider's personal intimacies, and neither should anyone be particularly holier-than-thou when talking about Paul Levy.

I don't defend what he did, we all make mistakes and we all have to pay for them. If his Board thinks his judgement lapsed enough to warrant them losing confidence in his executive leadership, so be it. But this pious outpouring that he should be fully documenting his tribulation for all of us to benefit from his transparency is nothing but sanctimonious codswallop.

‎ Full story...

I Bet They Ain't Moving to Canada

ATLANTA, Georgia, March 19, 2010 (LifeSiteNews.com) - A new poll reveals that President Barack Obama’s health care reform may push as many as a third of the nation’s practicing doctors into shuttering their offices and getting out of the medical business entirely.

In other words, the doctor may not be in to see you shortly.

According to a survey conducted by The Medicus Firm, a nationally retained physician search firm, “nearly one-third of physicians responding to the survey indicated that they will want to leave medical practice after health reform is implemented.”

Sounds like a quick fix for bringing down the national spend. Would less doctors per capita be a good thing?

Dennis Cauchon, USA TODAY -Others worry that more physicians will drive up the cost of medical care, not make it cheaper and more accessible. Physicians will order more tests, more procedures and more drugs — without improving the nation's health, they say.

"Doctors create their own demand," says physician Don Detmer, co-chairman of an Institute of Medicine committee that, in 1996, recommended cuts in funding for medical residents. "If we produce an abundance of doctors, there's little incentive for the system to become more efficient." The Institute of Medicine is an independent group created by Congress for advice on medical issues.‎ Full story...

Field Trips are Fun! Random Op-Ed is Fun Too!

I received a link this morning to a cutesy video wherein Doctor Marshall advocates for Congress to come visit a hospital on a field trip and truly learn what's broken in health care. Obviously, a day late for me, but nonetheless it sparked a few thoughts which I've jotted down below.

Doctor John L. Marshall of Georgetown University is a very respected and highly regarded oncologist leading the charge against cancer. I'm sure the guy is a wonderful doctor, and has contributed enormously to his field.

But.

I watched the video, and those of you with a Medscape login can too, it's here: http://www.medscape.com/viewarticle/716038

After watching it, I got just a tiny bit annoyed about how simplistically the argument was made with no actual proposals, solutions or advice given, just this grumbling about congress-doesnt-know-jack-about-my-problems rhetoric I've heard time and time again. So I decided to pick apart the arguments a little, my response after the jump.

1. About not having Congressional representation: DC has three electoral votes for Presidential elections, and a delegate in the House who can vote on House committees and many other procedures, just not on the floor of the House. DC of course has no-one in the Senate, because last time I checked DC was not a state that had ratified the Constitution. Just like Puerto Rico. If you want Senate votes, stop whining and become a state. Or rejoin Maryland. In the meantime, here's a record of Congresswoman Eleanor Norton's work as DC delegate including the bills she has introduced: http://www.norton.house.gov/

I also find it oddly contradictory that someone not overly-happy with government interference in his chosen profession then implies he wants more government in the form of diluting State's rights by giving votes to a federal district. Again, with no proposed solution or desire, just a complaint that he doesn't have representation.

2. About changing or picking a health insurance plan: Elected representatives are not born that way. While they have a decent health plan as members of the House or Senate, they (assumedly) had health care insurance *before* they were elected. His argument that all Congresspersons are ignorant of the ins and outs of acquiring health care insurance is misguided. Each of these people held jobs prior to holding office, and experienced the American life and system alongside everyone else. Many of them as self-employed professionals or small business owners.

3. About being on hold waiting for someone who doesn't know what you do day-to-day to judge your performance: I believe for an elected representative they are called "constituents" and "elections".

4. About being audited on their procedures and activities: Elected representatives are under constant scrutiny, myriad rules; are subject to ethics committees; are audited by the Government Accountability Office; furthermore they are then judged by hundreds of lobby groups who pore over each representative's and senator's voting record. The accountability of your average elected official in the federal government far exceeds that of a medical doctor, and comes with the added bonus of having to do a decent job to get re-elected.

5. About getting paid for good documentation: http://clerk.house.gov/legislative/legvotes.html, http://www.senate.gov/pagelayout/legislative/, http://www.gpoaccess.gov/, http://www.fedworld.gov/, http://www.loc.gov/index.html - I would like to see how fast this or any other oncologist can pull up records for a given patient he saw ten, twenty years ago. All other shortcomings aside, you can't possibly fault the government for it's record-keeping nor it's accessibility to same.

6. About pay-for-performance: (a) the federal government has *zero* pay-for-performance affecting doctors, there are a few pilots going on but no doctor in the USA is subject to pay-for-performance involuntarily and none at all from the feds. (b) Elected representative are very much paid by performance. Don't perform? Don't get re-elected. Doctors can lose their license and simply pick up and go practice in another state. Yay freedom. (c) The only thing the feds have done is told hospitals they, and by they I mean Medicare, will no longer pay for avoidable errors. Prior to the rule, a doctor could cut off the wrong leg, bill for it, then cut off the correct leg and bill for that too. Not anymore. Boo-hoo.

7. About being told what you as a doctor are allowed to do for your patient: No insurance company tells you what you are allowed to do. They tell you what you are allowed to bill for. Correction, you can bill for whatever you want, but an insurance company tells you what they will pay you for. The most current data on health insurance denials are 2.36 percent (AHIP) and 2.65 percent to 6.8 percent (AMA). AHIP has an interest in the number being low, AMA has an interest in the number being high, so cut that down the middle however you like.

Total denials for non-covered services were 1.2 percent. The number for denials in the raw is much higher, but much of this is simply billing the wrong insurer - which counts as a technical denial but some other insurer then gets the bill and pays up - or having to resubmit and getting paid the second time. Not perfect, but not denial of service either.

8. About Congress not having a clue what is wrong with health care: Congress has 16 doctors right now, plus two dentists, three nurses, a psychologist, an optometrist, a clinical dietician, and a pharmacist which by my math (25/535) is just under five percent of Congress. Seems to me the medical community is well represented in Congress.

The implication that the legislative branch of the United States federal government is tackling this problem with too little background, understanding and general knowledge of the problem is - in my not very humble opinion - a disservice to the viewers of the video. There is plenty wrong with Congress. And plenty wrong with hospitals. But the easy target of "the government is a bunch of morons" seems a particularly poor choice for such a learned gentleman.

9. About taking a field trip to a hospital to fully understand what's broken: Hospitals are not the universe of health care, an issue I see at way too many hospitals who forget they only account for under one third of health care in the USA. Hospital care is 31% of health care expenditures in the USA. Health insurance, of course, reaches all aspects of health care.

In summary: for sure, there are plenty of things wrong in all parts of health care, including hospitals. The notion that Congress should have taken some time to explore the issue before writing and passing legislation is of course, sound. Hmm. I wonder if any of them did? Do you think any of them ever spent time in side a hospital? Hmm.

http://www.google.com/search?hl=en&safe=off&q=congressman+congresswoman+senator+visit+hospital‎ Full story...

Good Driver Discount

Seems to me the health insurance companies go on and on about how it should be more like auto insurance, everyone needs to be in the pool. I'm in favour, generally, although I wish it were a single-payer pool, but that aside... if we are all going to be in the pool, how about some good driver discounts? If I quit smoking, I don't get my premium lowered last time I checked. For auto insurance I can take a defensive driving course and knock 10% off the bill. How about reducing my premium for attending wellness sessions?

The difference between auto insurance and health insurance is that it's not a definite that you're going to have a car accident. You are most definitely going to get old and die. If you take good measures along the way to reduce your level of sickness, shouldn't you get a discount? Insurance companies wishing to adopt my proposal can do so free of charge, but I wouldn't mind a carton of cigarettes and a bottle of scotch as a nice thank you. INCENT ME!‎ Full story...

Save MySQL

Sign The Petition.‎ Full story...

$1300 Nose Bleed

I received the following E-mail this morning on another blog:

"Where is Wyoming on your list. It is a state in the USA. Our local
hospital, Wyoming Medical Center here in Casper Wyoming, is so greedy
about their charges and will not tell you what they charg before
you have your visit. Emergency care for a simple nose bleed wes $1,300.00
Why are they allowed to get away with this.
How do you make the greedy companies tell you what their charges are
BEFORE you agree to have care when it is not a life or death situation. If
I had been informed how much it was going to cost I would have refused the service.
HELP"

The sender did not leave an E-mail address to reply, so I thought I'd reply here.

First things first: $1300 for a "simple nosebleed" is outrageous.

Second things first: going to the emergency room for "a simple nose bleed" is outrageous.

What to do? Call the billing department, make them an offer. But bear in mind you elected to use highly specialised services of a very expensive health care facility.

I had a lot of nose bleeds as a kid. Spontaneous ones, they would just start happening. The remedy cost less than a cent and involved tearing one tissue into two, plugging my nostrils and tilting my head back. Occasionally, I would pinch the bridge of my nose (as instructed) but it didn't really seem to do anything.

When did it become acceptable to go to the ER for a nose bleed? This is half the problem, this is what drives costs up. I don't have nearly enough information to figure out how serious the author thought the situation was, maybe it was the first time it had ever happened and he or she thought their brains were going to fall out, but I'm going to go out on a limb and say no, it was a simple nose bleed.

I feel really bad for the author that they are now stuck with a ridiculous bill. I would absolutely call the hospital and offer them $500 and a payment plan. I agree wholeheartedly that pricing needs to be more upfront. In the absence of hospitals doing this, we're working as hard as we can to publicise as many prices as we can. You can browse pricing at OutOfPocket.com where you'll notice I have a similarly-priced ER visit, for which the insurance paid less than $500.

But I would also counsel that next time you have a nosebleed, tilt your head back lean your head forward (1970s Welsh national health advice aside, apparently the thing to do is lean *forward*, thanks Kenneth!). Visiting the ER for a nosebleed is like going to the car dealer for a flat tire. They'll do pretty much the same thing as the guy on the corner, but charge you ten times as much.

As long as this country refuses to have a public option, you are consuming health care in a free market economy, with all the trappings that come with that. The ER is not your local clinic. But as long as you treat it like one, they will be happy to bill you.‎ Full story...

Netflix Winner Announced

Health transparency wise we have three great new projects each due to go live in the next 60 days or so, hence the lack of posts, just too much going on. However, I do like to talk about technology that isn't health care-related once in a while. Netflix started an open contest three years ago offering a million dollars to anyone who could improve their movie recommendation engine. The contest is finally over, whittled down from over 50,000 contestants to two teams who came in at the last minute just a few minutes apart. The full story is at Wired, go to http://www.wired.com/epicenter/2009/09/bellkors-pragmatic-chaos-wins-1-million-netflix-prize/ and enjoy the read.

I think it's a great example of both using the collective consciousness and open software principles.‎ Full story...

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...

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...

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.

--

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?
‎ Full story...

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...

Why Not The Best? A New Web Site for Quality Improvement Professionals

Over the past six years I've been building consumer-oriented report health care cards pretty much non-stop. The field is young and short on evidence, but it's interesting work with noticeable impact. However, the truth is that the largest portion of readers of these report cards are not consumers, but providers.

To that end, I have long been wanting to build a report card for providers, not only to report their data but also to link directly to freely available improvement tools and knowledge directly from the report. My goal being, not only identify poor performance but right there, in the data, link to relevant interventions to impact that data in a positive way.

Well, it's done.



I met with the Commonwealth Fund earlier this year and they were looking to build something around their Why Not The Best? National Scorecard on U.S. Health System Performance. The Fund was looking for a vehicle to deliver their high performer cases studies, wherein hospitals identified as being high performers in a given set of measures were interviewed and the resultant wisdom distilled into case studies for other hospitals to learn from.

After many, many sleepless nights, I'm hugely proud to announce the launch of www.WhyNotTheBest.org - a quality improvement resource for providers from the Commonwealth Fund. A ton of very talented people have been working on this and we are all very, very excited to see how the site is received.



The site includes all clinical quality and patient satisfaction data ever released on CMS' Hospital Compare. This means 24 clinical measures and 10 satisfaction measures. In addition, we created 5 summary scores, 4 being topical and one overall composite quality measure.

Users can register for a profile that will remember all their choices for the next visit. This is important as there are many ways to personalise this site.

Profiles are a basic three step process, you choose hospitals that you wish to compare yourself to, then choose measures you wish to track, then choose benchmarks of care you wish to compare against.

We have every hospital in the US that bills Medicare. This is about 4500 hospitals. We have collected the quality and satisfaction data since the launch of the public dataset.

Using this data, we can calculate state and national averages, as well as top percentiles. Commonwealth then asked us to identify just those hospitals that reported all measures and had at least 30 patients in each of four topics, and using that subset we further stratified the population to ascertain the high performing hospitals.

This means that for any measure, you can load the current top 1% of hospitals for each measure.

Choosing A Hospital

You can choose a hospital to add to your profile in three ways. First, you can simply start typing a name and the database will let you know if we have a match.



Another interesting way to build a group of hospitals would be to find facilities that are like your own. Users can choose from a variety of characteristics to whittle down the list to a useful set of comparator hospitals. In the example below I've asked for all teaching hospitals in New York with 400 or more beds.



Finally, users can simply browse a map and grab hospitals of interest.



We don't limit the number of hospitals you can save to your profile, but if you add more than 50 the site will start to look a bit busy. Theoretically, you could store all hospitals in the country, but don't call me when it takes half an hour to load.

You can then choose any or all of the measures and benchmarks, these will then be available to you in any charts you choose to generate, and this is where things get interesting.

User-Generated Charts

We have implemented a dynamic charting application that will build charts on the fly based on your choices and your profile.

This means that for any chart you choose to load, it will populate dynamically based on the hospitals, measures and benchmarks you selected.

Here are a few examples:





Pretty nifty huh?

You can see in the example that we even calculated each hospital's rank in the nation for a given measure.

Each chart is followed by an array of options:



Among other things, you can download a comma separated file of the data used to create the chart, save the chart as an image to use in Powerpoint or similar, and click through to browse related case studies and intervention tools.



There are a wealth of additional features, please stop by and kick the tires! The site is www.WhyNotTheBest.org - enjoy! And please feel free to leave me your comments.
‎ Full story...

Change Dot Gov - Copyright 2008

Although most of my posts on this blog are health care-oriented, it also covers Internet technology, freedom of information and related matters from time to time. Today is one of those days.

I was surprised to see Senator Obama standing behind a podium adorned with the Great Seal of the United States of America this morning, and further surprised to learn of the apparent existence of the Office of the President Elect. For one thing, he's not the President Elect. Yet.

You Did Not Vote For President

The Electoral College, which lives at archives.gov (National Archives), meets on the first Monday after the second Wednesday in December. This year that will be December 15th. On that day, the electors (most of whom were elected on November 4th in a political party election process that most people think is a presidential vote) - on that day, December 15th, the electors will elect the President.

This is basic US Constitutional stuff. The country votes for electors, electors meet a month later and vote for President. These electors are not legally bound to follow the popular vote. In the USA, the People popularly elect members of Congress, the Executive are elected through indirect election.

One more time, to be clear:

On November 4th, the US people elected a slate of electors.

On December 15th, these electors will meet and vote for President and Vice President. After this vote, one can say that there is a President elect.

On January 6th, Congress assembles and counts those votes in the House of Representatives. If a majority winner (270 of the 538 votes) is found the President and Vice President are declared and the Senators leave the House Chamber. If there is no majority winner the House votes for President and the Senate votes for VP.

But, I digress.

When is .gov not .gov?

Change.gov is a Web site that appears to represent an official government entity. Dot gov addresses are hard to come by, and are strictly regulated. It is with concern and curiosity then that I see change.gov to proclaim itself to be the Web site of the official-sounding Office of the President Elect.

However, this entity is in fact a private 501c(4) organisation, not a government office. I heartily salute Senator Obama's evident direction to bring greater transparency to the government through the use of Internet technologies, and I also look forward to the inclusivity promised through the use of blogs and similar modern concepts. However, what I do not ever want to see is a copyright notice on a dot gov Web site.



The Obama campaign's attempt to communicate it's freedom-loving principles are exhibited through the use of a Copyleft statement, the copyright notice on this Web site references a Creative Commons license.

I use the Creative Commons license myself wherever and whenever I can, it freely allows people to use and copy certain content with limited restrictions. It's a great tool.

But not for government. See, the government can't copyright anything. Ever.

The government is us. Well, technically not me as I'm not a citizen, but it is composed entirely of US citizens, for US citizens. Everything the government produces that is not secret is in the public domain. Because it *is* the public domain.

A dot gov Web site with a copyright notice is bad bad bad, unless that copyright notice says something to the effect of "there is no copyright". The government cannot put documents in the public domain via a Creative Commons license.

Here's an example of what a dot gov copyright should say, this one coming from the US Department of State:

"Links to State Department sites are welcomed. Unless a copyright is indicated, information on the State Department’s main website is in the public domain and may be copied and distributed without permission. Citation of the U.S. State Department as source of the information is appreciated.

If a copyright is indicated on a photo, graphic, or other material, permission to copy these materials must be obtained from the original source. For photos without captions or with only partial captions, hold your cursor over the photo to view the "alt tag" for any copyright information. Please note that many photos used on this website are copyrighted."

According to 17 USC § 105, copyright protection

"is not available for any work of the United States Government, but the United States is not precluded from receiving and holding copyrights transferred to it by assignment, bequest, or otherwise".

Further, we've witnessed the dilution of Web domains such as the dot org and the dot net, whose meaning's have now become shrouded in pre-2000 history. But dot gov is supposed to be sacred. I work and have worked on federal and state gov Web sites, the rules are long, complicated and necessary.

They ensure that when you visit a dot gov address, you can trust it. It represents government. It is the word of government. It is accessible, publicly-funded and accountable to the people.

Not a private lobby group.

In fact, the GSA, which administers the .gov domain, explicitly states:

"No Political or Campaign Information: The Gov domain is for the operation of government, not the political, political party, or campaign environment. No campaigning can be done using Gov Internet domains. The Gov Internet domain websites may not be directly linked to or refer to websites created or operated by a campaign or any campaign entity or committee. No political sites or party names or acronyms can be used. Separate webites and e-mail on other top-level domains (TLDs), such as .org, will have to be used for political activity."

(See Dot Gov Eligibility)

Obama's transition team is funded by appropriations from government, true. But it is also funded by donors. Private donors. This is not a government entity. The one link on this Web site that leads to a truly governmental source is the link below the copyright to the GSA, you'll notice a "leaving the Web site" notice as well as no copyright notice on the actual government Web site you end up at.

The Obama transition team is budgeted at 12 million dollars, 5.2 million of which comes from public coffers. The rest is private donations (under $5,000 each).

Presidential Transition services are an accepted part of the General Services Administration function. That's why the GSA has a transition Web site.

Regarding the use of the Great Seal (which of course is not the same as the Presidential Seal he will get to use soon...)

Use of U.S. State Department Seal (the U.S. Great Seal) and Other Official Insignia
U.S. State Department seals (the U.S. Great Seal), logos and other official insignia may not be used or reproduced without written permission. Use of the Great Seal of the United States is governed by Public Law 91-651, Title 18 of the United States Code. This is a criminal statute with penal provisions, prohibiting certain uses of the Great Seal that would convey or reasonably be calculated to convey a false impression of sponsorship or approval by the Government of the United States or any department, agency, or instrumentality thereof."

Senator Obama is doing himself, and the Web, a disservice by misappropriating the dot gov domain and the Great Seal while he awaits his turn in office. He holds no federal power, he represents no executive office, and he should wait his turn.

Addendum:

Having looked at the privacy policy, I'm now even more curious. If this is a dot gov site, why is there a COPPA notice? Further, this site actively solicits contributed content from readers via "Your Story" and other similar links, are these readers sending information to the government or to a private organisation? If the former, there a re serious privacy issues to be considered. If the latter, I think it is vital and fair for these individuals to fully understand they are dealing with a private, non-governmental Web site.‎ Full story...

History of Health Care

Saw this on the ye olde interwebs today


2000 BC : "Eat this root"
1000 AD : "That root is heathen, say this prayer."
1500 AD : "That prayer is superstition, drink this elixir."
1800 AD : "That elixir is snake oil, take this pill."
1900 AD : "That pill is ineffective, take this antibiotic."
2000 AD : "That antibiotic is artificial, eat this root."
:)‎ Full story...