About Health Satisfaction Two Point Oh!

The past year has seen some leaps and bounds in the way me and my team can rapidly handle publicly reportable data and get it onto Web sites. The two underpinnings of this are CLAIRE, the Claire Lightweight Agile IPRO Reporting Environment; and Pellucid, the health care transparency database system. CLAIRE is a software framework built on CakePHP that allows the dev team to grab up Pellucid data and quickly deploy Web applications. Pellucid is a MySQL data warehouse we built to house every single publicly reportable value we know of or can calculate in house. More on both of these technologies later.

So last week I initiated a test. I gave the dev team a week to come up with a complete rewrite of our Hospital Satisfaction Web site, and lo and behold they did it! You can go visit AboutHealthSatisfaction.org and review patient surveys of nearly every hospital in the US! Why are you still here? Click the link already.‎ Full story...

Why Not The Second Best?

'Tis the season to work all night every night for a couple of weeks. The newly updated WhyNotTheBest.org went live this weekend, with a spiffy new look and four gajillion new rows of data.

Well, truth be told it's about six million rows. But it's still a lot. WhyNotTheBest is a Web property funded by the Commonwealth Fund that is geared toward health care providers and policy makers, the basic intent being to identify the top performers for a range of measures and allow anyone to compare (benchmark) themselves against these top performers.

The new design is thanks to Digital Wave who laboured over a very functional search engine that allows any user to add as many hospitals to a comparison list as they want.

The new site contains a bunch of new data, notably the readmission and mortality rates published by CMS for several conditions, and we included average Medicare reimbursements for the same conditions.

In addition we added a whole slew of new filters, so it is now possible to create groups of hospital by Dartmouth HRR (Hospital Referral Region), by ownership, by health system and a whole lot more.

As always the data drives the user to improvement tools and intervention material that will help improve quality of care for the measures being published.

Please go check it out and comment here if you have some feedback!‎ Full story...

No Ma'am, We're Statisticians

Yes, it's true. I wanted to build the Illinois Health Care Report Card just so I could finally write a blog post laden with Blues Brother quotes. You could say I was on a mission from God. Our Lady of Blessed Web Site Acceleration don't fail us now.

Jokes aside, the IPRO eServices team has never worked this hard. Incidentally, the work allowed me to visit Chicago a few times and I have to say it is a surprisingly fun place to be, even if you can't find the Cook County Assessor's Office. We had just a few short months to get Illinois up and running, and by today's numbers I think we did a great job.

We launched early this morning and traffic started flooding in like I've never seen. Let's have a look at what's in it.

Quality

Quality data leads the tabs, and we populated it with both process and outcomes measures. We took the process of care measures from hospitalcompare.gov and rolled them up into three neat aggregate scores for Heart Attack, Heart Failure and Pneumonia. Following that are six mortality measures using AHRQ Inpatient Quality Indicators. Unfortunately due to some complex issues surrounding the measures, we couldn't risk adjust the data this quarter so the data are observed rates for now, we'll fix that for the New Year. We round off the tab with some utilisation data including the C-section rate.

Safety

For safety we published a range of Surgical Care Improvement measures, then we get the much awaited Hospital-Acquired Infection data. Illinois is out in front with collecting this data, and we had some good stories to tell, but we are looking forward to hospital-level MRSA rates next year. For now you can review central line-associated bloodstream infection rates. The last module on the safety tab shows a selection of the Patient Safety Indicators from AHRQ including accidental puncture/laceration and foreign body left after procedure.

Satisfaction

I've been vocal that patient satisfaction is the necessary final leg on the barstool of health care reporting to round out the usual quality and cost data, and I was extremely glad to include the HCAHPS data in this report. Ten measures of patient experience after an inpatient stay populate this tab.

Services

The services tab shows the number of patients, the median length of stay and the undiscounted charge for a range of procedures and conditions, depending on whether you're viewing hospitals or surgery centers.

Staffing

The final tab shows two interesting proportion measures; the first is the ratio of full time nurses compared to contract staff, the second is the proportion of registered nurses, licensed practical nurses, and certified nurse assistants. I'd like to change this up to a pie chart next quarter. Also, on this page you can see the kind of beds this facility is authorised to operate.

Next Up

We're immediately looking at the nurse staffing data to get some more granular numbers based on various service areas, we'd like to add more procedures and conditions, and maybe bring in the rest of the process data. Regardless, Illinois hosted over 10,000 visitors today so there's no shortage of interest in these data, and we look forward to growing the site over the next year. First though, whynotthebest 2.0 - it's a busy season.

It's 106 hours to Monday, we got a full tank of coffee, half a pack of cigarettes, it's dark and we're wearing sunglasses. WhyNotTheBest.org will be updated in a few weeks with the most data I've ever worked with in one fell swoop, and will feature the most flexible search engine into our millions of rows of quality performance data yet.

‎ 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...

Free Guide to Health Pricing

I'm working very long hours right now, but I want to take a minute to point out a new site I was asked to look at. It's an expansive price guide to fair and reasonable prices for hospital visits, physician visits, dental, cosmetic surgery and more.

http://healthcarebluebook.com allows you to tap in your ZIP code and browse based on regional pricing. It's not evident, you'll need to put your ZIP code in *after* you start browsing, but once it's in it's remembered for each category.

The site nicely separates out procedures from hospital charges, so for example if you review Carpal Tunnel, you'll see the surgeon's price, the anesthetist's price, and the hospital bill. These rates are intended to reflect the amount a decent health insurer would pay, or more precisely, the amount these individuals will happily accept from an insurer.

As I've railed about before, if you have high deductibles or are self pay, you will be billed at a nonsensical sticker price that has no business or financial reason for existing outside of having a random number that once, many years ago, meant to reflect the full cost of something, but over the years has simply grown by 4% a year regardless of actual cost.

So, while the sticker price for carpal tunnel release may be $12,000 or so, Healthcare Blue Book lets me know that on average, people are getting paid about $5500 in my ZIP code.

I can then use that to negotiate with my provider.

Navigation is pretty intuitive, you can browse by condition or procedure for example, and a free form search allows you to search for words like "appendix" and get the appendectomy prices on the site.

In addition, there is a very informative "How to negotiate prices with doctors and hospitals" page, well worth the visit. All that's really missing is an "understanding your bill" page, because that's when the price issue usually hits home, when you get an unreadable bill covered in codes and numbers that are completely indecipherable.

Overall the site is extremely easy to use, is light on methodology, I'm not entirely sure where these prices are coming from, but it's clean and easy to use, so go check it out.

‎ Full story...

2008 Health Accountability Health Care Report

So here's why I haven't been posting too much lately...

I've been working on two major projects and this is one of them. I finally got the Health Accountability Report Card out today, it covers all hospitals and HMOs in NY, NJ, CT, VT and RI.

It's huge, but my other project - due in December - is even more exciting, stay tuned.

The report card started off as a printed HMO report in 1999, I first put it online in 2002 I think.

I've been slowly adding more and more to it, three years ago I added hospitals and last year I included NJ. Here's a brief, OK, not brief summary of what's in it.

The team that puts this together is large, all in all about 25 people contributed their expertise to the report. The short story is that it's a public data gumbo, it collects up about 20 data sources from which we extract roughly 250 measures. For each measure, if we can find a standard comparator we run a variance analysis to find out if the HMO or hospital deviates significantly from the state average. We then simply paste a red, yellow or green circle onto the data to give you a really quick idea of just how well the HMO or hospital you're looking at is doing.

On the HMO side you can review quality of care data from NCQA HEDIS scores. This covers stuff like getting the correct medicines, asthma and diabetes care, vaccinations and that sort of thing. Also for HMOs we have a customer satisfaction survey results from CAHPS surveys. We then scoop up retail premium rates for standardised plans.

Unfortunately states differ slightly in how they measure HMOs, so we can't make a national comparison across the board, so in this report you're seeing either a comparison to a state average or a regional average.

On the hospital side it gets way more complicated. HHS puts out the Hospital Compare data for download, so we grab that and crunch some additional measures to derive composite topical scores from the appropriateness of care measures. This year we also got to add patient satisfaction score and Medicare reimbursement rates.

The real fun part was requesting discharge data from five states. I actually requested data from every state that borders New York, plus Canada, and I went with the four I got back. That data is a full set of every single hospital discharge in each state, deidentified. In it you can see primary diagnoses, age, gender, enough to make some serious measurements. So, we have the AHRQ Inpatient Quality Indicators as well as new this year some Patient Safety Indicators, recently endorsed by the National Quality Forum. These include mortality rates and adverse events.

I did have to lose Caesarean section rates, but I'll keep hunting for an NQF endorsed measure for this.

In addition, we calculate number of cases, average length of stay and average hospital charges. Besides that there's the now-recurring Leapfrog patient safety measures. Cardiac surgery mortality came out this year for the most part, but it'll be back next year.

Here's a full list of all the measures.

Go check out the report and please, please, please send me your feedback.

Now I'm going to sleep.‎ Full story...

USA Hospital Patient Satisfaction Report

It's not widely known, but Medicare began collecting survey responses recently that asked patients a number of questions about their recent hospital stay. CMS has not restricted this to Medicare patients only, they call anyone who is eligible, regardless of payer. My boss was kind enough to give me the opportunity to take the data from Medicare and make a consumer-oriented report card that is easy and quick to use.

The site is AboutHealthSatisfaction.org and is completely free to use, no registration required, and does not contain ads. The source data is available on the Hospital Compare Web site put out by CMS, but it's hard to get to, hard to read, and restricts you to only a handful of hospitals to compare at a time. However, CMS makes the data freely available for download, so this is what I came up with.

Please go check it out, and let me know your thoughts and feedback here. I plan on updating the site every three months when the fresh data comes out. Right now I have three editions of the data, so you can even track numbers from quarter to quarter. Go have a look, and check back here to let me know what you think.‎ Full story...

Blame Canada

This will be a very short post, but I think it's worth mentioning...

Whenever the conversation turns to a national health care system in the USA, the detractors invariably point at Canada and say "Canada's system sucks" and use that as the be all and end all of why national health care can never work.

The thing is, Canada's health system *does* suck.

Shock! Horror! Did he really just say that?

Yes, yes he did.

But listen carefully. Canada is not the only system to compare against.

In fact, in the Euro-Canada Health Consumer Index report published this very year, comparing Canada to 29 European health systems, Canada came in 23rd.

Canada is not the system to aspire to. They are working on their system, and their problems do not have to be the USA's problems.

This week we saw the release of the first annual Canada Health Consumer Index, spring-boarding off the afore-mentioned report. From that self-examining report:
· Access to healthcare varies widely from province to province, whether in terms of availability of family doctors and midwives, the affordability and timely approval of new drugs or the waiting time to see a specialist.
· Even the best-performing provinces do not provide the standard of care that is commonplace in Western Europe.
· Canada lacks a culture of accountability and transparency in healthcare, and it still puts providers and bureaucrats ahead of consumers.

So, my point is, stop pointing at Canada and declaring universal health care to be universally bad. Saying no to universal health care because Canada's is not great is like saying no to democratic elections because Iraq doesn't do them very well.

Pick the best performers and compare to *them*.

‎ Full story...

Up and Over Down Under

The Australian Capital Territory, Australia's answer to Washington D.C., publishes a very detailed quarterly report on it's health care services.

Australia, like all, sorry, most, sorry, everyone except the USA, provides health insurance for all as part of the government's duty to it's citizens. The reports, which have been published starting in 2005, are easy to read, easy to understand, and provide a wealth of useful information while delivering a highly honest and transparent report on the taxpayer service. Some nice examples are wait times for surgery, often thrown out as the number one reason to avoid universal health care. For patients who needed surgery with 30 days, the median time to surgery was 14 days (down from 16 the year before).

Also of interest is the measure "unplanned return to operating theatre within an episode of care". This is a measure we can never follow in the US, as we have no episodic record, the patient bounces between a half dozen, unconnected providers. Under universal health, the system knows the patient all the way through an episode of care.

Hospital acquire bloodstream infection rates are freely posted, and even dental services are reported on.

All in all, a concise, readable report that shows us the way things should, and could be done.‎ Full story...

More Chartered Value Exchanges

Eleven more communities will join the fourteen already designated by Leavitt as Chartered Value Exchanges - collaborations focused on improving care and transparency.

The new Chartered Value Exchanges are:

* Aligning Forces for Quality, based in York, Pa.;
* the California Chartered Value Exchange, in San Francisco;
* the Colorado Chartered Value Exchange in Denver;
* eHealth Connecticut, Inc., of Middletown, Conn.;
* the Greater Louisville Value Exchange Partnership in Louisville, Ky. ;
* the Health Improvement Collaborative of Greater Cincinnati and HealthBridge, in Cincinnati, Ohio;
* the Kansas City Quality Improvement Consortium, in Kansas City, Mo. ;
* Michigan Health Information Alliance, in Mt. Pleasant, Mich.;
* the Nevada Partnership for Value-driven Health Care, in Las Vegas,;
* the Quality Health First program, managed by the Indiana Health Information Exchange of Indianapolis, Ind.;
* and the Virginia Health Care Alliance of Glen Allen, Va.
‎ Full story...

New York Acquired Infections Report... For Dummies

I've been following the progress of New York State's Hospital Acquired Infection reporting initiative since the law was first passed. NY was given a year to pilot the reporting, and to provide a public report in aggregate the first year, moving to hospital-specific reporting the next.

I've read the report, and while it's certainly a great move forward for transparency it's hardly easy to read. Weighing in at 115 glorious pages, it makes it hard to figure out exactly what it's saying. Therefore, I give you NY HAI For Dummies!

The report covers three topics: central line-associated blood stream infections in critical care unit patients, and surgical site infections associated with colon and coronary artery bypass graft procedures. CABG reports on both the chest incision and the secondary (leg) incision. Further, patients are given a risk factor ranging from zero to four, four implying plenty of risk for infection (long surgery time, dirty incision site etc.)

For each topic and risk factor, NY has an opportunity to be statistically significantly better, the same, or worse than (older) national rates provided by the CDC. One huge caveat: the "national rates" against which NY is compared are from data spanning 1992 to 2004, so I'm not sure they honestly comparable, but at this point in time it's all anyone's got.

Colon Procedure Surgical Site Infections

SSI Risk 0: 4.5% Same
SSI Risk 1: 6.3% Worse
SSI Risk 2: 7.6% Same
SSI Risk 3: 9.4% Same

1,082 reported infections of which MRSA (the "superbug") accounted for 110 cases or 10.2% and was the third most occurring organism.

Coronary Artery Bypass Graft with Chest and Donor Site Incisions

Leg SSI Risk 0: 0.0% Same
Leg SSI Risk 1: 0.8% Better
Leg SSI Risk 2: 1.6% Better
Leg SSI Risk 3: 0.0% Same

Chest SSI Risk 0: 0.0% Same
Chest SSI Risk 1: 2.2% Same
Chest SSI Risk 2: 3.2% Same
Chest SSI Risk 3: 5.3% Same

Coronary Artery Bypass Graft with Chest Incision Only

Chest SSI Risk 0: 20% (1 of 5 procedures) Same
Chest SSI Risk 1: 0.9% Better
Chest SSI Risk 2 & 3: 4.0% Same

503 total infections reported, of which MRSA accounted for 76 or 15.1%.

Central Line-Associated Blood Stream Infection (CLABSI) Rates

Coronary ICU: 2.2 Better
Cardiothoracic Surgical ICU: 2.0 Same
Medical ICU: 3.2 Same
Med Surg - Major Teaching: 2.4 Same
Med Surg - All others: 2.3 Same
Pediatric ICU: 4.0 Better
Neurosurgical ICU: 3.1 Same
Surgical ICU: 3.7 Worse

A central line infection rate is calculated by dividing the number of actual infections by the length in days all the lines are in and multiplying by 1,000. So if a patient has a central line inserted for 24 hours that's one "surgical line day".

Interestingly, when the report compares upstate NY to New York City, it stands out that NYC is the same across the board, whereas upstate stands out as being the offenders bringing the state average worse. I help out a little with the CLAB infection collaborative initiative run by UHF and GNYHA over on Jeny, so I know there's a bunch of hospitals more city than not who are actively working on reducing CLAB infections. I have no idea if that's attributable or not, but sure is interesting.

(Edit: on second reading I noticed on p.39 the author references the collaborative as a potential factor in the lower numbers.)

1,348 infections reported, MRSA counting 83, or 6.2%

That's the easy-to-read and way-too-simplified summary, there's a wealth more data in the report including CLAB bundle compliance and NICU numbers and much more, I urge you to download it. If nothing else, let's show the Department of Health we're interested in their reports.

‎ Full story...

Transparency For All

The health care transparency movement has mostly been concerned with increasing consumerism in health care purchases, but the industry as a whole is shrouded in all kinds of complexities. This carries over to the providers themselves, for example the payment policies and business practices of the major insurers.

The American Medical Association released a report this week that grades major insurers on topics ranging from prompt payment to adherence to the contracted amount to the most common reasons for denying a claim.

I think this is great news that yet more business practices are being reported on, and the AMA has done a fine job of explaining their metrics.

Of course, this is the same week the very same AMA is getting concerned over medical tourism, which leaves them in the dubious position of asking for foreign docs info to be publicly available to US consumers while staying antsy about US doctors info being available too freely.

And it's the same AMA that can be pretty loud if insurers release a report without showing it to the docs first, yet the AMA did not see fit to show this report to the insurers first.

And the same AMA that this week railed against the use of secret shoppers working to measure the customer service standards of physicians.

Still, any data is better than no data, and even if the AMA is not the Consumer's Union, anything that pours more sunlight on claims and payments is a Good Thing.‎ Full story...

Data Data Everywhere, Nor Any Drop To Drink

A lot of people think the data for publicly reporting the quality and cost of a physician visit doesn't exist.

Which is, of course, nonsense.

Doctors are service professionals who for 95% of their clients bill a third-party. It might be Medicare, Medicaid, a private health insurance company like HIP or CIGNA, or others. Very, very few people - in the USA - pay their own bill.

So?

So we have these huge databases of things doctors billed for. It's called billing data, or administrative data. Health providers use the term in direct reference to this data not being clinical data. As in, it must then be useless data. In the industry, billing data is mud, clinical data is sacred.

The way it works is this: your doctor writes stuff down that will become your chart, your medical record. Someone else then abstracts from that things that can be billed for, and creates a second set of data that tries to describe what the doctor did so a bill can be sent. Your clinical data is not sent to anyone for billing purposes.

In public reporting, as it stands right now, we can get our hands on billing data pretty easily, clinical data is nigh impossible.

People like me involved in the public reporting of health care data hear a lot of providers scorn our use of billing data.

And like I always say, as soon as you give me the clinical data, I'll start using it.

So what's in this unusable billing data?

Office visits. Prescribing antibiotics. Breast exams. Diabetes care. Removing surgical staples.

So?

So we also have huge databases of things doctors didn't bill for. Well, we don't really, but there's a lot of stuff that isn't in the billing data and it's educational.

If a doctor didn't bill for something, I'd say it's a safe bet it didn't get done.

More precisely, given a large enough dataset, where a pattern can be established we can determine staistically significant variations of care delivery.

I've seen a lot of doctor's bills, and they stack a bucketload of stuff in there. You go for one check up visit and look at the paperwork your insurance company sends you. There's at least half a dozen line items on there. It's a very inclusive bill.

Medicare, for example, knows each and every one of its "beneficiaries", let's call them "members". And each member is entitled to certain care from a doctor, who we'll call "service providers".

And each member who doesn't get that care should probably get a call from their service provider to come get their care. If you're my doctor and you don't give me my care, surely my payor (let's call them "payers") should nudge you?

And do you wonder why billing data is electronic but clinical isn't? I don't. Billing data pays the bills, gets the checks cut. Clinical data is good for little more than monitoring clinical services, which we all know no-one wants to do.

Right?

So we have huge amounts of billing data. Huge. Tons. We can tell if diabetes patients get billed for diabetes checkups. We can tell if women over 50 get their mammogram every two years. We can tell if little Joey got improperly-prescribed antibiotics for a cold. We can tell if people on antidepressant medication are being properly followed-up with.

We can tell because if these things are happening, someone, somewhere is going to get paid for it.

Surprised? You shouldn't be. This data is up and out there already, but we can't get people to look at it. This Web site lists literally hundreds of quality reports you can go look at. Go look at them. Here's another site chock full of public reports.

So why can't we use this data and hold our heads up high in the street? These are the kinds of things I hear:

"Billing data isn't accurate."

"My patients are sicker."

"My patients don't do what they're told."

"100% is unachievable."

Or, my all time favourite, the one that gets me really, really, super riled up:

"Consumers can't understand the data, or they'll understand it wrong."

Most physicians are doing an awesome job in the face of all kinds of adversity, they're dedicated professionals delivering quality health care. A small percentage are behind the curve. The argument here is how to identify them, and until we get better data that measures how we deliver care, not how we bill for care, we're stuck making highly complex, educated guesses.

Do me, and you, and the rest of us a favour. Use what we make. Go research your health care options. Use the links above and go learn about the hospitals in your region, the doctors in your neighbourhood. And tell them you're doing so.

Push for electronic clinical records. Demand that your health care information be as accessible and as accurate as your banking record or your credit record.

Because the sooner you start using the data we put out, the sooner we can get better data.

/rant‎ Full story...

Open Response To Leavitt's Call for Health "Travelocity"

The Gnome Will See You Now

The Memphis Business Journal has a piece on Health and Human Services secretary Michael Leavitt expressing his desire for a "Travelocity for health care"

I've seen Secretary Leavitt speak on more than one occasion, I dig the guy, and I like his attitude and I'm one of the people itching to build what he wants. The following are my thoughts on why I haven't done it yet.

Give Me The Data!

The main problem is simply that medical data is tied up in Doctor Smith's funky handwriting.

Health care currently consumes 16 out of every 100 dollars in the USA, but electronic health records are next to non-existent. The few that are in existence don't talk to any of the others.

If we ran banking like that we'd be... oh wait a minute, we did run banking like that. About a million years ago. Well, thirty anyway.

16% of the US economy runs on scrawly, handwritten notes.

Point is, we have these futuristic machines now, we call them ComPewters, and they can add, subtract, and do all kinds of whizzy things, like store my entire medical record, manage a million people's access to it, provide an audit trail and allow doctors anywhere in the world to know if I'm allergic to peanuts. (I'm not, by the way. I like peanuts. The honey-roasted kind are my favourite. Hint.)

16% of the US economy runs on scrawly, handwritten notes.

If I was the government, I would say "excuse me, stop that!" except I wouldn't be so polite.

I would say something like "hey newly minted doctor! Welcome to the world of health care, and the associated billing joy that is your income. If you would like to bill us, the government, representing roughly 40% of your revenue, please use any of the following software (insert CCHIT list) or, if you prefer, here is some absolutely free of charge software (openEHR springs to mind, or MirrorMed, or OpenEMR or FreeMed ) from the world of free and open source software that you will use if you want us to pay you. Oh, and feel free to use it for all your other billing and patients too, not just ours."

Being Medicare, I would instantly recognise that having these docs interact with and bill me using EHR data will help me contain costs and monitor (if not improve) quality on a massive scale, therefore I would pay for training the docs and their staff to use an EHR-based office system.

Later I would find a way to extort something or other from the other insurance companies for doing them such a big fat favour. Then I would sit back and revel at getting my country up to speed with the rest of the developed nations and making sure we all have an electronic health record.

Until this happens, we cannot build Healthpediaocitywiki.

Mr. Leavitt, tear down those (data) walls! Seriously, you can't mandate this stuff?‎ Full story...

Doctors, Plans, Doctors, Plans...

In an almost humourous move physicians today released a report card of their own: a report card ranking pay-for-performance plans in Minnesota. Coming from the very people who have been staunchly defending themselves against public reporting, this could seem a little tit-for-tat counter-intelligence style of guerrilla physician warfare, but the details are pretty cool.

The Minnesota Medical Association reviewed nine P4P programs and declared the system to be inconsistent, forcing docs to work to nine different tunes. Much of the problem lies in the fact that the health plans themselves don't have a standard way of measuring quality performance, which leads to docs having to chase their tails trying to meet performance objectives.

On a side note, I see again the concern that docs who treat "sicker" patients are unfairly measured as these populations should lead to risk adjustment for the physician.

I don't know about you, but if a medical society is willing to posit that Doctor A treats sicker people than Doctor B, I suggest that instead of grading Doctor A on a curve, we take the medical society at their word that Doctor A is not achieving good outcomes and get his "sicker" patients a better doctor who can actually handle the extra effort required.

If they're sicker, surely they should be getting better-than-standard care, not risk-adjusted average care? Call me crazy...‎ Full story...

New York Regional Health Care Report Card Goes Live

I know, I've been quiet. It's been a while since I posted, and here's why:

First and foremost, I have been buried in data all summer, getting this report card out. More on that in a minute.

Secondly, I determined to take some time to myself this year, so I've taken a slew of short camping trips to spend time with my son, do some fishing, sleep in a tent and generally get some of the city out of me.

Thirdly, I finally had my appendix out after my third and final bout with appendicitis.

So, now it's out. It's online at http://www.nyshaf.org/hcrc and I'd like to take this post to explain how I think it can be used, what purpose it serves, and talk about some of the data involved.

The report card is split into two main sections, HMO and Hospital. In both sections the report is split up by groups of measures that can viewed side by side, some quality, some patient experience, some cost.

One of the main problems with public report cards is that the health data is so complex and so arcane it's practically useless to the lay consumer. Sometimes a lower score is better. Sometimes a higher score is better. Sometimes the score is a percentage, sometimes a range. Sometimes it's a vague statistic definition, such as "not significantly worse that the national mean".

Another big problem is the tendency to predetermine what "good" is, and then try to communicate that top the viewer. Health care providers may say that high quality is paramount, cost is irrelevant. An HMO may say that the best care is given by better high quality, low cost providers. Some people think high volume is a good thing, other's don't. The list, and the permutations are endless.

Finally, the overarching goal is to present as many of these public reports as possible in a single space in a single format. For this year's report we've combined 25 publicly available reports which you'd normally have to obtain from 25 different sources.

So I set about trying to determine how to take all these kinds of different data and represent them in a singular fashion that would be easily and quickly comprehensible, without implying a judgement or a ranking. More than one reporter asked me "which hospital is the best?" My answer is always another question: best at what?

One hospital may be the world's best for cancer treatment; is that where I should go for a scheduled C-section?

There is no best hospital, there is no best doctor, no best surgeon, no best HMO. But there *are* providers that are better for you and your individual needs than others.

So, goals set: translate complex data analysis into visual nuggets of qualitative information, and allow the user to narrow down the qualities and measures that matter to them.


What you see above is one category of HMO data. More detailed information is available with a click or two, but at a glance you can see that for customer service one HMO stands out as being highly rated, three are more or less average, and one has some issues.

At least, I hope you can see that. If not, I just wasted a year.

So how can a consumer use this report card?

Example 1: Heart Attack

I have never heard of anyone having a heart attack and stopping to consult report cards on where they think they should go.

However, once you're in the hospital, your loved ones can consult the report to see how well the facility you ended up at is faring at providing quality treatment. If anything stands out as worrisome, bring it up with your doctor.

Further, several of the measures apply to the care you receive after your emergency treatment. Medications prescribed at discharge for example, including aspirin, as well as smoking cessation counselling.

Mortality rates for heart attack are relatively flat, everyone is going to be pretty much "as expected". If your hospital shows up red for mortality, bring this up with the hospital staff.

You may be looking at a co-pay or even worse, you're uninsured. Use the average charges bill to get an idea of how much the stay will cost you or your employer. You can also see the average length of stay for a heart attack patient, and if it's shorter or longer than you think is right, raise this with your physician.

The overall point is that the level and standard of care can and will vary from hospital to hospital, and nowhere is perfect. It pays to be informed, and remember you are your best advocate.

Example 2: Choosing an HMO

Some employers will offer you a choice of two HMOs. If you or your partner has an ongoing condition such as asthma, have a look at which of the two HMOs available seem to be more on the ball for that condition. Then check out the customer satisfaction ratings for that HMO.

If you don't have a choice and your HMO plan scores poorly, then use that as a reminder to make sure you get the care you need by advocating for yourself. Have a look at the care provided by other HMOs and demand that same care from your primary physician.

If you have children, compare the two youth sections. In my county, only one HMO has all green for appropriate youth care.

Example 3: Appendicitis

I have a bit of personal experience here. I had the symptoms of acute appendicitis for a few days, and finally went to the ER after the symptoms didn't go away. i was a little atypical, and was in little danger of perforation, but nonetheless you may be able to do what I did.

I looked at the five hospitals nearest me, and compared the length of stay for an appendectomy, the surgical infection prevention score,a dn the price.

I'm price-sensitive even though I have good health insurance. The company where I work pays for the health care I receive, and the last two years have seen a steady increase in both the company cost as well as my family rate contribution to the plan. Further, all my co-pays went up significantly this last year.

Because health care is so often paid for with invisible dollars it can feel a bit like Monopoly money, you never see it, you never worry about it, you get a long, arcane bill that you never have to worry about. However, I know that if I can get an appendectomy at hospital A for $10,000 less than hospital B, I just saved the company money. Saving the company money puts more dollars in the kitty for my next pay raise. And being relatively young and by all accounts rather stoic, I'd rather have the cash up front than ploughed into a pool for a rapidly greying employee population.

In my county, appendectomy hospital bills range from $7,000 to $30,000.

Let me repeat that.

In my county, appendectomy hospital bills range from $7,000 to $30,000.

That's before the surgeon's and anaesthetist's bills.

I actually placed more importance on finding a hospital that had a low average length of stay with good surgical infection scores. I wanted somewhere under $15,000 with three or so days stay on average.

The hospital I chose actually had a poor score for timely antibiotics, so instead of choosing a different hospital, I questioned the staff when my first antibiotics were given and ensured I was less than an hour from surgery.

Example 4: Mother to be

Some women search for hospitals that are less inclined to perform a C-section. In my county, the C-section rate varies from 17% to 34%. That's double the rate. For primary caesareans, the rate goes as low as 11% at a hospital that also shows a high rate of vaginal births after C-sections, clearly a hospital that can help you have a natural birth.

Others may choose the scheduled C-section route, and look for a hospital that performs a good number of the procedure. You can compare the number of times the procedure was performed in a year at all your local hospitals, as well as the surgical infection prevention scores.

Looking to get home quickly after the surgery? Some hospitals have you stay for three days, others for five.

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In my next post I'll go into more detail about the different data sets including the different kinds of measures available, where we get the data from, and how accurate that data is.

In the meantime, I am very interested in hearing from anyone who has used a public report card similar to this one in a real life situation. Was it useful? Did it complicate things? Did you bring anything up with your doctor?

Finally, if you wish you had similar resources in your community, consult www.abouthealthtransparency.org/ and click your state. You can also check out www.consumerhealthratings.com/
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EBM vs CSBE

As the launch day of this year's health care report card draws near, I've been fighting the good fight on publishing volume data. Specifically, volume of procedures for low-volume surgeries such as esophageal and pancreatic resections. Working from billing data, I can find out how many times each procedure was performed in a given hospital for a given time period.

In some instances, I'm seeing a volume in certain areas that is under 10 for most facilities and then one hospital cleans up with 100 or 150. Is this qualitative data? Can anyone be reasonably expected to form a judgment from this information?

Sure, I can provide mortality rates, but at one death per year for most hospitals, what value is that? Surely if a hospital performs ten times as many procedures than the one next door, I can expect better outcomes?

In the normal world, of course the answer is yes. Midas will do a better job on my brakes, AAMCO will do a better job on my gearbox/transmission. In medicine however, it's not true until the literature says it's true. So until the community performs enough studies to validate the obvious, it's not defensible.

Even where literature exists showing better outcomes for certain procedures that are performed a certain minimum number of times, it's apparently not overwhelming enough to convince everyone.

This is the basis of evidence-based medicine, not to mention... science. Science is, after all, nothing but a bunch of measurements.

However, given that any practitioner will loudly declare medicine to be half science and half art, I hereby coin a term I've been using for quite some time:

Common sense-based evidence

Simply put, if Doctor A has done it once, and Doctor B has done it 200 times, Doctor B is more experienced. End of story. I don't need a $30,000 study performed to risk-adjust the patient mix.

Bolster the common sense with evidence, of course. I am the first person to say that no one measure stands alone. But failing to provide a complete picture is hurting the public and denying us the transparency we seek.

The report cards I work on I try to introduce enough data to allow the user to decide on the important factors and make an informed judgment. The medical community works exactly the opposite way: they want specialists to make the judgment and publish it in very expensive journals we can't afford to read.

I don't presume to know whether you care more about mortality rates, volume, or proximity to a Starbucks, but I'll continue to work as hard as possible to provide as much comparative data as I can get my hands on.

It is, after all, good common sense.‎ Full story...

My Mechanic vs My Doctor

My mechanic is a great guy, I've been using the same guy for years now. Not only is he up front about what's needed, what's not, and how much it will all cost, but he drives the exact same car as me. This very morning, after hitting a pothole this weekend, I dropped my car off and described the excitingly new squeaking and clunking emanating from the left hand front wheel well. He calls me within the hour to confirm his suspicions: I broke a stabilizer rod, the very same thing happenend to him only two weeks ago and helped him diagnose my problem.

Listening to NPR this weekend, I was interested to hear my favourite finance news show cover the news about a doctor's group in California publishing the prices they charge for common office -based procedures such as EKGs, vaccinations etc. A brief point counter-point ensued wherein a pro-transparency lass made a statement about how great pricing transparency is and someone else who doesn't think so said so, stating:

"Shopping for a doctor is not shopping for procedures, it's shopping for a person, someone you can trust, who understands your priorities, someone you can develop a relationship with".

Hence, the logic seemed to be, price doesn't matter.

I got to thinking about my trusted mechanic. I didn't shop for him by price. He came highly recommended and I grew to trust him after a few visits. He may not be aware of it, but I'll drive the 20 miles from home to drop the car off for the day.

Nonetheless, once the trust has been established and the relationship built, what possible reason is there for him to say "now that you trust me, I have no need whatsoever to allow you to remain confident that I am not gouging you, that I am competitive with my rates, or at least you are only paying a small premium to continue a trusted relationship".

No, in fact, whenever I drop my car off, he calls me before commencing any work. Tells me what parts I'll need, how fast he can get them, how much they'll cost, how much the labour will be. I get a full and detailed price estimate before any work begins.

Of course, I don't have an automobile HMO. If I were as divorced from my car maintenance payments as I am from my medical bills, he might be extremely willing to perform as much work, necessary or otherwise, on my car, and file for reimbursement. But no, he knows full well I have limited means, I want the car to run but not be in tip top as-new condition, I'm about function over form and he has *never* offered to pull the dents out of the car.

I agree whole-heartedly; shopping for a doctor is not about price, it's about a personal relationship. And like any good relationship, I like to review all the costs; spiritual, emtional, ethical and fiscal. Doctors and health care are not above the money. If they were, we'd all be getting free health care and the docs would be in bread lines, but in fact they make an average six-figure salary and many grumble it's not enough, so quit with the line that it's not about the money. We all want to get paid, doctors and mechanics included.

As the US veers into shifting some of the cost burden back where it belongs - the customer - price transparency has to become the norm. Health care is a business much like any other, it's not so special. Sure, it's a calling. So is software development. So is ministering. We all get paid.

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I heard a story this weekend about a doc who offered to perform a muscular biopsy in the office for a nominal fee of roughly a hundred dollars. The patient called in for pre-authorization and the HMO responded that they would only cover it in a hospital. The patient duly made an appointment and received a bill for a couple of thousand dollars, the co-pay on a $20,000 bill.

The doc took it upon himself to call the HMO and call them out for being idiots, although who knows what actuarial rules were at play, but nonetheless, we need more docs like this looking out for both the patient *and* the bottom line; customer service and the price thereof are all part of doing business and private practice docs especially are - am0ng other things - small businessmen just like your local accountant or your local mechanic.

Bring the customers in, perform a good, quality service and charge a competitive rate. That's all we ask.

I can't speak to the accuracy of the numbers above, but this and similar events occur all the time, part of a system where the money is so divorced from the consumer it's like trying to dig up information on the Illuminati.

So, in short, I applaud the California doctors and I eagerly await news of more like-minded practices.

And if you have a crazy hospital bill story to share, please do.

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One final note, more of a note to self really.

Why do doctor's customers get called "patients"? I'm not his patient. Maybe if I'm in a hospital and I have to stay there then maybe I'm a patient, but a doctor I see maybe once a year? The only patient-ness I exhibit is the two hours waiting until 3pm for my 1pm appointment. Stop calling me a patient. Other professionals call me a client. Anyone else agree?
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50,000 Clinical Trials Go Public

GENEVA (Reuters) - The World Health Organization (WHO) said on Friday it was improving access online to data on clinical trials in the wake of high-profile cases of drugs being tested with possibly harmful side-effects.



A new Web site aims to help researchers, doctors and patients obtain reliable information on high-quality clinical trials, it said in a statement.

Currently a "significant proportion" of trial research is never published, meaning doctors can lack information about treatment options, according to the United Nations agency.

Initially, data from 50,000 clinical trials provided by three registers -- in Britain, Australia/New Zealand and the United States -- have been put on the WHO site, which is www.who.int/trialsearch.‎ Full story...

Tennessee Hospital Charges

The Tennessee Hospital Association today launched a Web site telling patients how much they'll pay.

Tennessee Hospitals Inform lists average prices for common procedures at the state's acute-care hospitals.
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