November 25th, 2009

U.S. health IT money going to community colleges

Posted by Dana Blankenhorn @ 8:58 am

Categories: General, Government, Hospital IT, Medical IT, Medical Office IT, Medical Records, Physician Information, U.S.

Tags: Information Technology, Health Care, Training, Workforce Management, Vertical Industries, Training And Certification, Benefits, Healthcare, Human Resources, Dana Blankenhorn

National Coordinator for Health Information Technology (NCHIT) David Blumenthal has launched his own blog, where he announced this week $80 million in grants for health IT training, mainly to community colleges.

The money was authorized as part of the Obama stimulus, specifically the $19.2 billion HITECH Act.

Administrators can apply for a total of $70 million in community college grants, which would go into programs aiming to train health IT professionals. The hope is that 10,500 people can be trained annually in the use of health IT systems through the program.

These are not programming jobs. Among the “exciting job opportunities” the money hopes to create are:

• Practice workflow and information management redesign specialists;
• Clinician/practitioner consultants;
• Implementation support specialists;
• Implementation managers;
• Technical/software support staff;
• Trainers

This follows common medical practice, where a hospital or medical practice has a number of people trained at different levels of depth to perform different roles.

In addition to the training money, there’s $10 million available to create the training materials for these programs.

It will be interesting to find out just what is going to be taught, given the wide differences among all the various EHR systems now on the market.

Will Community Colleges align themselves with specific vendors in order to stretch their dollars, thereby giving those products market advantages? Or will the curriculum be more general, based on technical standards and legal requirements?

Stay tuned to Blumenthal’s blog for more. We’ve put it on our blogroll.

November 24th, 2009

What open source can teach medical practice

Posted by Dana Blankenhorn @ 7:34 am

Categories: Consumer Information, Ethics, General, IT Management, Internet, Medical Office IT, Medical Records, Networking, Open Source, Research

Tags: Gender And Diversity, E-health, Open Source, Human Resources, Healthcare, Dana Blankenhorn

It is frustrating whenever personal medical questions become political questions.

This happens all the time. Example A, ripped from the headlines, is the kerfluffle over mammograms.

Women, doctors and politicians who hate having to go through the procedure are now screaming bloody murder over the non-existent “threat” to halt access to it.

Let’s go back to where this started. It was a population study, done on behalf of the U.S. Preventive Services Task Force,  which concluded that the risk of unnecessary treatment exceeds the risk of death from annual screenings for the disease.

It was a science paper, and it was complicated, couched in the words scientists use to describe their work with precision.

Every profession has its version of this language. Engineers do, lawyers do, even software developers do. Learning the language gives a journalist entree into these professional worlds, but it’s not an exercise most of us will, or should, go through.

Thus this study, like so many, was filtered through the lens of journalism. A flood of words failed to answer the questions women wanted answered

• What are the chances I will die from a late diagnosis?
• What are the chances I will suffer from over-diagnosis and over-treatment?

Calculate the threat to me so I can make a rational choice.

This is where technology comes into play. An Electronic Health Record (EHRs) can show you your own history, we can take your family history, we can analyze your genetic history, and we can estimate based on that.

If, that is, we have access to the larger pool of data. That’s our baseline. It’s what we need to compare your own data to before we can give you the answer you seek.

In scientific studies like this one we don’t have access. The data is locked away somewhere. Mass adoption of EHRs is going to unleash a firehose of data, and the question should occur, very soon, what to do with it.

I’m not talking here about your record. I’m talking about the gross data, this warehouse of numbers describing everyone’s condition, what is being done for us, and what the results are.

An open source attitude toward that data, within the realm of science and throughout the medical community, can help patients gain access to the benefits of that data and answer the question they ask — what should I do?

Unfortunately medicine, health IT, and medical data all suffer from a proprietary attitude born of paranoia, the fear that you may be identified in this data mountain, that your needle will appear in this haystack, and that giving everyone access to data means giving them access to you.

A database, stripped of personal information, consisting of millions of records, is safe for use by software code. The data, and the code, are what we need to provide real answers.

We are collecting the data. We need to unlock it. We are writing the code. We need to share it.

This is what open source can teach the practice of medicine.

November 23rd, 2009

The medical home is reform without objections, so far

Posted by Dana Blankenhorn @ 10:13 am

Categories: Aging, Ethics, Finance, General, Government, Home Health Care, Hospital IT, IT Management, Internet, Medical IT, Medical Office IT, Medical Records, Wellness

Tags: Team, Patient, Health Care, Home, Doctors, Team Management, Management, Dana Blankenhorn

There is one type of health reform that, so far, has received little publicity and no political objections.

It’s called the medical home. (Picture from the American Academy of Family Physicians.)

Physicians have been talking up the concept since the 1960s, and at its heart it is pretty simple. Charge for wellness and create a team, headed by a physician, that can deliver it.

When people like Larry Green, who heads the American Board of Family Medicine, talk about moving toward a “blended payment” model he’s advocating for this team approach to care.

Many doctors’ groups support the medical home, but getting from here to there is not easy. Doctors are basically being asked to create a new business, with a new set of employees, and to do this they need start-up capital.

The AAFP magazine Family Practice Management published an article last month with 10 suggested steps for getting that capital.

These start with using existing medical codes to generate more revenue from each patient visit, hiring more nurses and medical assistants, then using these people to increase the number of patients you “see” each day. Wash, rinse, repeat.

If this sounds like gaming the system to generate revenue, it reads like this to me, too. But this revenue has a purpose. The article suggests that capital go into an Electronic Health Record (EHR) system, a “patient portal” through which customers access health data, and links to other helpful electronic resources.

One idea of the $19.2 billion HITECH stimulus cash is that it helps doctors pay for these computer resources so they don’t need to game the system to get the money. But they still have to build scaled businesses.

Only after doctors have their office and systems right should they focus on high-cost patients, the article continues. A lot of alligators need to be slain before you drain this swamp.

From the patient point of view, you’re going to be given a lot more control over your care, you’re going to have a lot more appointments with people other than the doctor, but you’re going to get more face time with people trained to help you.

It’s that face time that can end disputes like the present one over pap smears and other tests. You will have people you can discuss these issues with, people who have access to your medical records, people who will have the time to listen to you as well as talk.

Now that you know the good news, here is the bad news:

1. The financial success of a medical home is based on nagging. You get the data, you get access to the people, but money is only saved when you take the advice.
2. It takes money and business transformation to get from here to there. Running a team takes money and organization. Either doctors become businessmen or go to work for people who are. Either they buy and build systems they need or they associate with others who have them.

A health policy based on the medical home is going to be a lot more intrusive than the present fee-for-service model. The team will know if you smoke, how much you drink, what you eat, even what you’re likely to die of, based on a whole lot of data.

If the medical home is to save money, and lives, that team will need power to enforce what’s good for you. It could come from an adjusted insurance rating, based on your observed lifestyle, with the higher fee going to your medical home.

Or the medical home needs the power to force you out for non-compliance.

The medical home, in the end, offers the promise of lower costs and personal attention, in exchange for your willingness to be bound by your doctor’s advice on what’s good for you.

Do you still like the medical home?

November 20th, 2009

Paying for what does not work remains popular

Posted by Dana Blankenhorn @ 9:36 am

Categories: Consumer Information, Ethics, General, Home Health Care, Internet, Research, Wellness, genetics

Tags: Women, Cancer, Pap, Gender And Diversity, Human Resources, Dana Blankenhorn

Another Day, Another Recommendation to Relax Screening for Women.

That’s the ABC headline on today’s story that young women can avoid cervical cancer just as easily getting pap smears once every two years as every year.

This is good news. Pap smears are a hassle. If you’re a woman, or know any, you know this.

So why the pushback? Why the accusation that the Administration wants to ration necessary tests?

One reason is that women continue to die from cancer, including famous women like Stephanie Spielman (right), wife of former football star Chris Spielman. She first discovered her cancer in a self-exam 12 years ago. It took her life on its fifth recurrence.

But not all cancers kill. If you are diagnosed with prostate cancer and told it has a low Gleason score, you may be told to do nothing — watchful waiting, it’s called. Similarly not all breast cancers are invasively aggressive. Research is ongoing to find better ways to distinguish breast tumors.

Meanwhile, thousands of women are losing their breasts each year to unnecessary surgery or risking death from chemotherapy. And millions of women (as well as men) aren’t doing the first thing to prevent this disaster — losing weight.

We imagine a simple formula. Get tested and if there is cancer get treated. But what scientists are trying to tell us is there is a different formula. Get healthy and seek appropriate treatment based on how dangerous your particular cancer is.

This is just what men have been told about prostate cancer for years. It’s the refusal of some people to accept this fact that’s dangerous.

Many also refuse to accept the fact that you can do everything right and, like Stephanie Spielman, die anyway. It’s tragic, but it’s true. There is still much more to learn about cancer before it is beaten.

The bottom line is this. We know a lot about how to cut health care costs. Stay healthy. Eat right, exercise, don’t get obese. Don’t smoke. But too many think this advice is an infringement on their freedom, that magic tests and magic treatments will save us from ourselves.

They won’t. Do what works, meaning take care of yourself, and you will be less likely to rely on what does not work, frequent testing and over-treatment.

Of course, this advice can be refined if we know your genetic background, what you are most susceptible to, what is most dangerous to you. But in the end predictive medicine is just a refinement, and the advice you will get from it is similar to what doctors are saying now.

You have the best chance of staying healthy if you take care of yourself, and rely on yourself, rather than the magic of medicine, to keep you well. That is what works.

Sorry if you think this violates your freedom. You remain free to eat that brownie, to smoke that cigarette, to have that fifth beer, to overwork and to ignore your doctor.

But at some point your neighbors, who are paying for your excess, whether in the form of insurance or in the form of taxes, are going to start asking these hard questions, like why do you feel free to drink deeply from the well of cures if you’re not doing what it takes to stay well?

November 18th, 2009

Practice Fusion in PHR game

Posted by Dana Blankenhorn @ 11:36 am

Categories: Consumer Information, General, Home Health Care, Internet, Medical IT, Medical Office IT, Wellness

Tags: Game, Electronic Health Record, Personal Health Record, PracticeFusion, E-health, Healthcare, Dana Blankenhorn

Practice Fusion is a well-known SaaS vendor of electronic health record (EHR) software to doctors and hospitals, working inside the Salesforce.com cloud.

(Shown is part of the new product’s medications screen, from PracticeFusion.)

Their base product is ad-supported, so while larger vendors are hustling hospitals for multi-million dollar contracts, Practice Fusion is able to get small practices online for zero dollars. Priceless.

So it is natural Practice Fusion would get into the Personal Health Record (PHR) game.

The difference between an EHR and a PHR is that, while the EHR belongs to the doctor or hospital who creates it, the PHR belongs to you. Also, while disclosure of EHR data is subject to HIPAA rules, you control what is released from your PHR, and to whom.

So PracticeFusion is highlighting Salesforce’s annual Dreamforce conference this week with the announcement of PatientFusion.

It’s a PHR built and delivered on the same platform as the EHR offering. Multiplying the number of doctors using its service by their rough patient counts PracticeFusion says it is offering this service to 1 million people at launch.

Any PracticeFusion practice, which may be paying nothing for its service, can thus offer a PHR to their patients, who also pay nothing.  This is not as large a benefit as what Microsoft HealthVault and Google Health offer, but wait, there’s more.

Since the EHR and PHR are in the same cloud, populating your PHR, and managing the permissions needed to keep the data flowing, is easy. Security is also simplified, since once you order your EHR a bunch of data isn’t flowing between systems, but within a single cloud.

When PracticeFusion’s PR shop pitched this to me, they compared it with Kaiser Permanente’s EPIC-based system, myHealth Manager. One can argue that’s unfair, since Kaiser spent billions to build a scaled EHR-PHR system early in this decade, while PracticeFusion has been growing its smaller SaaS operation organically.

But if the feature sets are nearly identical, and the delivery mechanisms are similar, how different are they? Time will tell. As more people get PHRs we’re going to get into a feature war, with all vendors looking to connect a range of devices and analysis to their offerings.

Should be fun.

November 18th, 2009

Why electronic health records have far to go

Posted by Dana Blankenhorn @ 7:30 am

Categories: Finance, General, Government, Hospital IT, IT Management, Internet, Medical IT, Medical Office IT, Medical Records, Physician Information, U.S.

Tags: Electronic Health Record, Training, Health Internet, Moore, E-health, Healthcare, Dana Blankenhorn

It’s easy to seize on word that electronic health records (EHR) are not yet saving money and call everything the Obama Administration is doing in health care bogus.

That would be unfair to the technology.

Ashish Jha of the Harvard School of Public Health offered the report this week as a scene-setter for the school’s Public Health and Technology (PHAT) conference, whose speakers’ list is a who’s who of EHR advocates. (Picture from Dr. Ashish Jah’s home page at Harvard.)

Rather than being a hit piece at the current Administration’s aims, the report focuses on the best practices of groups like Kaiser Permanente and the Cleveland Clinic, which have spent years adapting their work to the technology. Do these things and you can make things work, as proven in areas like heart care, he writes.

Rather than focusing on paying for the computers and software, he says, emphasis should be placed on training people, and adapting practices to take advantage of what the data can do. As in any business a failure to adapt means you’re wasting money.

Dr. Jha made this point in the School of Public Health’s in-house publication last month. Speaking at a University-sponsored public forum in September, he said this:

The money in the stimulus bill is going to help a lot in terms of getting systems adopted. You’re going to see this entire field change dramatically in the next several years. You’re going to see new vendors getting into this field who haven’t been there before. I’m hopeful this will mean better products that will require less training. There’s no doubt in my mind that five years from now, we are going to have far more widespread use of electronic health records.

Whether we are going to get to 90% as President Obama has said he wants, I’m not sure. But the bottom line is that this train has left the station. We’re moving towards electronic records. The only question is whether we can do it well. The big challenge for us is to make sure we adopt these systems effectively, that we remember the prize is not electronic records; the prize is higher quality at lower cost. And that’s only going to happen if we really think through how to adopt these systems in a more organized and effective way.

Those are the words of an EHR enthusiast, not a skeptic, and certainly not a cynic.

Fact is the EHR revolution has barely begun. The Health Internet is still being implemented. Barely one hospital in 10 has a functioning EHR system. Moore’s Law of Training (there is no Moore’s Law of Training, we learn as fast as we learn) has barely kicked in.

The health IT revolution will not happen like the turning on of a light switch, as people in every other industry that has been touched by computers, including journalism, will tell you.

It’s a long-term process.

November 17th, 2009

Keep your genes to yourself after this weekend

Posted by Dana Blankenhorn @ 9:03 am

Categories: Curioisities, Ethics, General, Government, IT Management, Medical Records, U.S., genetics

Tags: Insurance Company, Health Care, Genetic Information Nondiscrimination Act, Family History, Insurance, Vertical Industries, Healthcare, Benefits, Business Operations, Corporate Insurance

The Genetic Information Nondiscrimination Act (GINA) goes into force this weekend, and the regulations will impact more than the mere collection of genomes.

The Act was passed last year and signed by then-President Bush.

It makes it illegal to base insurance eligibility or even rates on genetic data, including family histories. Some insurers had been giving discounts to people who completed family history questionnaires. No more.

Employers are already complaining. Some say common health risk assessments will no longer be legitimate. Some complain that wellness programs will be hurt.

Some employer groups and insurers wanted the law’s implementation delayed. Lawyers are already going ka-ching. People who don’t like lawyers are wringing their hands.

The American Medical Association has told its members that physicians should no longer participate with insurers on genetic testing, and even limit disclosures of genetic data to law enforcement.

Basically the new law puts your family history, including your genetic make-up, under requirements similar to those of HIPAA. Just as doctors can’t share your medical data with outsiders, they can’t share your family history either. This may require changes to Electronic Health Record (EHR) software, especially on the server side.

The New York Times says the law will have some unintended consequences. If a CEO’s father and grandfather died of heart attacks at age 50, and the board refuses to promote him to the top chair at age 49, he could have a tort.

Some data can still be collected. There’s a “water cooler” exception, so if you tell the boss about your mom’s breast cancer they can hear that. Or if they later read her obituary in the paper. Or if they ask why you took family leave and you say it’s because your dad has pancreatic cancer.

GINA may be impacting you right now, because many companies are engaged in “open enrollment programs” for next year’s health insurance. There are no longer discounts for giving the insurer data. Some analysts think the new law is America’s definitive statement that they don’t want insurers playing their present expansive role in the health care system.

As with everything, there are unintended consequences. Some baseball teams have used genetic tests to identify (and set the age for) players from Latin America. One basketball team refused to re-sign a player without a genetic test. Perhaps, as Roberto Duran once said, no mas.

One more thing. The blog Queerty notes that if they ever find the the “gay gene” employers can’t test for it, nor discriminate against you based on it. They’ll have to rely on finding your two tickets to “Gypsy”, or meeting your companion at the company picnic. (Hey, I love “Gypsy.”)

November 16th, 2009

Niacin best for raising good cholesterol

Posted by Dana Blankenhorn @ 5:42 am

Categories: Aging, Consumer Information, Drugs, Finance, General, Home Health Care, Medical Equipment, Research, Wellness

Tags: Cholesterol, Dana Blankenhorn

Want more of that good HDL cholesterol?

(Picture from Costco.com.)

Try a timed-release niacin, and be skeptical if your doctor gives the sales pitch for Zetia or Vytorin.

The authority for this is a study dubbed ARBITER-6, which was stopped suddenly this summer, with the study’s authors insisting safety had nothing to do with it.

It was a question of efficacy.

The results, described in the New England Journal of Medicine, make clear that niacin does better at the main job, keeping arteries open.

“The use of extended-release niacin causes a significant regression of carotid intima–media thickness when combined with a statin and that niacin is superior to ezetimibe.”

Ezetimibe is the generic name for the active ingredient in Zetia, while Vytorin combines the same drug with a generic statin, simvastatin.

This does not mean ezetimibe is worthless. It works. It just doesn’t work as well as niacin.

This has important implications for anyone who, like me, has a family history of hypertension and high cholesterol. But if you want to save some serious money, look further.

The ARBITER-6 study compared ezetimibe with Niaspan, a drug form of timed-release niacin. But you can get similar dosages, for a lot less, with a supplement containing the same stuff. I use something called Slo-Niacin.

On most insurance plans you’ll pay $10/month for a generic statin and $30/month for Niaspan, or $30 for Zetia, “saving” $10 by using Vytorin (which contains the statin).

But Costco offers 150 Slo-Niacins for about $10, so even if you double your dosage to 1 gram (as many doctors recommend, taking one in the morning and one at night to prevent flushing), that’s $14/month for simvastatin and niacin, or $30/month for Vytorin.

Last time I got checked out, my combination of simvastatin and 1 gram of SloNiacin per day was working like a champ. Total cholesterol under 150 and a ratio of bad to good that had my doctor putting exclamation marks on my chart.

The paragraphs above, combined with the results of ARBITER-6, represent the heart of comparative effectiveness, and the way we old-timers can interpret those results to stay healthy for less.

As health IT begins collecting hundreds of millions of health records over the next several years studies like this will become easier to do, and they will be more accurate, given the larger number of records being studied.

But this is bad news for drug-makers. You not only have to prove safety, not only prove that your drug does what it claims, not only prove you’re better than a placebo, but you now have to prove you’re better than alternatives before you’re going to get the big money.

Bad for drug companies, good for patients. That’s what comparative effectiveness studies are all about.

November 13th, 2009

I'm in a nanny state state of mind

Posted by Dana Blankenhorn @ 8:45 am

Categories: Consumer Information, Curioisities, General, Government, Home Health Care, Internet, U.S., Wellness, state government

Tags: State, Tobacco Company, Rates, Taxes, Free Trade, Financial Planning, Finance, Dana Blankenhorn

The headline is that the U.S. smoking rate has stalled at over 20%, but the news is those places that have the strongest “nanny state” policies against smoking and smokers are still making progress, while those that don’t are not.

In other words, the nanny state works.

The government broke out its numbers by age, race and education, as well as by state.

Rates are highest among native Americans (more than one-third), among those with limited education (nearly half of those with a Graduate Equivalency Diploma (GED) smoke), and in coal country (rates are highest in Kentucky and West Virginia).

Rates are lowest where elements of social control are strong (Utah leads at 11%), and where policies aggressively fight smoking (California is second at 14%). The rate in New York, where the state tax for each pack of cigarettes is now $2.75, dropped from 18.3% in 2007 to 16.8% in 2008.

Smoking is the leading cause of preventable death in the U.S., killing over 1,000 people each day, the CDC said, with 1 in 10 of those deaths being caused by second-hand smoke.

The real scandal, shown in the chart above, is that only 3% of the excise taxes and settlement dollars collected by states go to smoking cessation programs. While $24.9 billion is available, the states spend just $75 million. Tobacco companies spent $13 billion in advertising in 2006.

In other words, we’re being outgunned better than 13-1 even though we’re putting out twice as much money to fight smoking as the tobacco companies are laying out to keep it around. That’s Halliburton-like efficiency.

If you want to save money on health care, in other words, maybe you too need to get into a nanny state state of mind. Or just become a little more personally intolerant of having smokers around you, so you don’t wind up among the 100 non-smokers killed by cigarettes each day.

November 11th, 2009

CCHIT going on almost as if nothing happened

Posted by Dana Blankenhorn @ 8:53 am

Categories: General, Hospital IT, IT Management, Medical IT, Medical Office IT, Medical Records, Physician Information, U.S.

Tags: U.S. Department Of Health And Human Services, Electronic Health Record, Health Care, Standards, CCHIT, Blumenthal, E-health, Quality, Healthcare, Vertical Industries

One of the big controversies early this year was over the role CCHIT was playing, certifying vendors to sell Electronic Health Record (EHR) software.

CCHIT (Certification Commission for Health Information Technology) was formed in 2004 out of HIMSS (Healthcare Information and Management Systems Society), an industry group, and began certifying EHR systems in 2006. Until this year you entered the EHR market by first undergoing CCHIT certification.

Was their approach right, or was it too rigid? Was it really helping buyers, or just pointing them toward expensive solutions from members of the HIMSS industry group?

When we last left the story the good guys seemed to have won. The standards under which software will be approved for stimulus cash are functional, requiring meaningful use. They’re not programmatic. It’s not what the software does, but whether it’s used, and for what, that counts.

So what happened to CCHIT? They’re going along pretty much as before.

In an extended interview with Healthcare Informatics, CCHIT head Mark Leavitt (above) said the group has added a new Preliminary ARRA 2011 Certification to its suite of products.

“It doesn’t really matter” what the National Coordinator of Health IT, David Blumenthal, or his policy committee come up with, Leavitt told Anthony Guerra.  CCHIT’s “Get Certified” seminar in October drew an overflow crowd.

Blumenthal’s policy committee called its government standard “HHS certification.” Leavitt called the same set of criteria “Preliminary ARRA Certification” because the Department of Health and Human Services (HHS) may give it yet-another name, and because the rules on all this don’t go out until next month in any case.

Even after that there will be time for CCHIT and others to comment, and for those comments to be digested, before they are final. Then certifying authorities must be appointed, and CCHIT has applied to be one. Meanwhile hospitals and doctors are having to make decisions that may haunt them through their professional lifetimes.

In his interview, Leavitt called the ARRA rules “basic” and his own rules “comprehensive,” but in fact one is the government standard and the other CCHIT’s private one.

What has happened is that CCHIT has been forced to take a step back, from being the gatekeeper of market entry to being one of perhaps several groups looking to be certification authorities under the new rules.

This is not Leavitt’s spin on the matter:

We’ve heard from provider groups, we’ve heard from the specialties that the marketplace was not making adequate progress in making the products they needed with all the features they needed.

There’s more than just federal standards, there are other requirements they have as providers, such as supporting workflows and maintaining a legally adequate record. They really thought CCHIT was a way to have a community conversation and move the entire marketplace forward.

We’re not a gatekeeper. We’re a community conversation. The CCHIT “comprehensive” standards aren’t for the  “sophisticated CIO,” in Leavitt’s words, but for small hospitals, for small practices, the people who need help in making an informed choice.

Maybe, but these same customers also have the most constrained budgets, and fairly basic needs. Do they need something a private industry group has deemed meets “comprehensive” standards or not?

That is a question the market will have to decide. Will hospital administrators and practice managers insist on the comprehensive CCHIT-approved label, or will they accept any solution that brings them that sweet, sweet stimulus cash?