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 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 12th, 2009

Watch BPA get taken seriously now

Posted by Dana Blankenhorn @ 7:15 am

Categories: Curioisities, General, Research, Wellness

Tags: China, Exposure, Study, Industry, Worker, BPA, Strategy, Management, Dana Blankenhorn

The warnings about Bisphenol-A (BPA), which we began covering here some time ago, have mainly gone unheeded. (Picture from China’s Peoples Daily of a chemical explosion in Jilin, China.)

It’s hard to take the flexibility out of plastic. It’s hard to create something new in quantity. It might be expensive to spray something other than BPA into metal food cans. And then what about liability?

And what’s it hurting anyway? Mood and memory? Is it making you fat? Is it making girls mean?

Big deal.

How much you want to bet that changes now that China has discovered male workers exposed to BPA had a high incidence of erectile dysfunction.

The Chinese study, in the British journal Human Reproduction, leaves a lot of questions unanswered. Just how high was the exposure of these workers? Are exposures of American chemical industry workers comparable? What level of BPA exposure causes harm, and at what level of exposure do we find what types of harm?

There’s going to be a boom market in medical studies aimed at answering these questions.

BPA has been in common use for over 30 years. It’s probably in you right now, probably more of it than you think.

The chemical industry is going to fight any attempt to limit its use or (later) to take legal responsibility for the consequences. Here is how the American Chemistry Council has responded to the most recent news:

• The Chinese study has limited relevance to consumers.
• Last year’s study by Consumer Reports is inconsistent with what regulators say.
• Other studies have limitations and unclear conclusions.
• Exposure levels in baby bottles are very, very low.

Wash, rinse, repeat. And don’t forget to put out a Web site that claims to be unbiased but is in fact an industry front.

Asbestos makers could be isolated from the rest of the industry and allowed to run down. The makers of BPA are a who’s who of America’s chemical industry. Bayer, Dow, GE, Sunoco. BPA is part of the green energy push.

But if it’s going to make our little soldiers go limp, I’m sure we can find a way to get rid of it.

November 12th, 2009

What Intel wants in health care

Posted by Dana Blankenhorn @ 6:10 am

Categories: Aging, Assistive Technology, Gadgets, General, Home Health Care, Home Health Care Equipment, Medical Equipment, Rehabilitation

Tags: Health Care, Intel Corp., Venturebeat, Vertical Industries, Benefits, Healthcare, Sales Strategy, Human Resources, Sales, Dana Blankenhorn

Our Tom Foremski is shocked, shocked that Intel is launching a camera that reads.

What’s going on, he asks? Intel is terrible at consumer products. (Picture from Intel.)

But the Intel Digital Health Group is as serious as a heart attack, and the Intel Reader is part of it. The device is actually a specialized computer, combining a camera, optical character recognition, and a voice chip.

I have a stake in this, because my daughter is dyslexic and my mother blind. I appreciate the hard work that went into this. The $1,500 price tag is off-putting, but Moore’s Law tells me that in time it should come down.

And therein hangs our tale.

Intel produces what is now a commodity. It is the dominant supplier of chips but margins are thin. It needs higher margins to thrive.

Health care offers those higher margins. Health care and assistive technologies offer humongous margins because production runs are often small and sales channels thin. Venturebeat says the Intel Reader, for instance, will be going to CTL, Don Johnston, GTSI, Howard Technology Solutions and Human Ware.

None are exactly Best Buy. These are specialty resellers. Johnston, for instance, specializes in technology for dyslexic and autistic kids.

Still, these are growing markets. The Intel Health Guide, for instance, is aimed at the business of aging in place. There are 76 million of us baby boomers and we’re not getting any younger — ka-ching.

And let’s look again at the Reader. Products for the blind, for the autistic, and for the dyslexic are traditionally seen as separate markets. Here we have one product that addresses all of them. That means more sales which can drive down costs. In this business that’s an innovation.

So there is potential here for the perfect marketing storm. A company that can drive down costs enters a market with enormous margins. It can get fat on slimmer margins than those it finds in the market. As it drives down prices it expands the market — I might get that Reader for my daughter when it comes in at $400 (and in time it will).

This can truly be a win-win-win. The assistive technology and health care markets want lower prices, which Intel can deliver. Lower prices will expand the reach of things like aging in place technologies and readers for the dyslexic. Intel can build a highly-profitable business that in time delivers top line growth as well as bottom line growth.

Sure, there are specialty channels to figure out. Sure there are new marketing skills here Intel has not yet mastered. But price can cover that up while those skills are learned. This is the lesson Japanese and Chinese producers have been teaching us for decades.

And if they want to offer a review unit, I’ve got some good testers coming in for Christmas.

November 5th, 2009

What the Google Privacy Dashboard can mean for health

Posted by Dana Blankenhorn @ 8:34 am

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

Tags: Google Inc., Privacy, Dashboard, Health Care, Personal Health Record, Vertical Industries, Benefits, Healthcare, Human Resources, Dana Blankenhorn

If you have checked out the Google Privacy Dashboard, you may not have noticed that it covers all Google products.

This includes Google Health, the company’s Personal Health Record (PHR).

The media focus here has been on what Google knows about you, and the oh noes that Google will use that data against you.

But with the Dashboard’s access to Google Health, it occurs there might be another use for it.

What if you could find out where all your health data is? What if you could learn just which doctors, which hospitals, which insurers have what types of electronic data on you?

Knowing what’s out there, and knowing the rules for releasing that data, you can have full control of your privacy as we move from paper records to electronic records.

Given the trend within health IT toward more open standards, and more standards generally, it should not be too hard to provide support for this capability within, say, the NHIN-Connect system, which the Administration now calls the Health Internet.

There are lots of ways for this to go down, but the most efficient might be for the Health Internet to support a spidering technology that lets service providers offer a full health dashboard to consumers. Where within the NHIN system are what types of data on you. Not the specific data, but who has stuff, which is information we should all be entitled to.

I’ll bet that would be an incredibly valuable service, because it’s something we don’t have right now. The availability of such a service might even drive consumer acceptance of the Health Internet itself.

Take my case, for instance. In addition to my regular doctor, I have an eye doctor, I’ve seen an orthopedist, I have an insurance company, and a guy who did my colonoscopy. I also have a pharmacist. All that data, in time, is supposed to feed my Personal Health Record, along with data I might create, like my workout data.

Knowing who has what puts me in charge. Computers can tell me that. This encourages me to embrace computers, and powers the movement toward PHRs.

Did I mention Google Health is a PHR?

November 4th, 2009

How fast can remote monitoring move?

Posted by Dana Blankenhorn @ 12:07 pm

Categories: Aging, Always On, Assistive Technology, General, Government, Home Health Care, Home Health Care Equipment, Internet, Medical Equipment

Tags: Monitoring, Standards, Approval, MedApps, Quality, Business Operations, Dana Blankenhorn

Remote medical monitoring, the use of sensors and networks to detect changes in patients and deliver alerts to caregivers, has been growing throughout this century. (Picture from Abledata.)

This week’s approval of an Alcatel-Lucent TeleHealth Manager by the FDA is just the latest 510(c) approval in a long line.

• RODA got approval for remote heart monitoring in 2002.
• St. Jude’s Medical has been getting remote monitors approved since 2004.
• Medic4All got approval on its VMS-01 telemedicine system in 2006.
• Medtronic has had heart monitors that can be pinged remotely for over three years.
• MedApps has been selling a remote diabetes monitoring system over the counter since 2007.
• ExpressMD got approval for its Electronic House Call system in April.

Not everything is rosy in this business, and not all the fault lies with government. Insurers are reluctant to reimburse, which makes no sense since these systems save enormous amounts of money. BIOTRONIK’s remote heart monitors have been approved to replace doctors’ visits.

Where Intel (and its new partner GE) can provide a service to the whole industry is by helping to streamline these approvals, from both industry and the FDA.

Electronics are insanely reliable. The links available between devices, base stations, and caregivers, via the Internet, are also improving thanks to Moore’s Law. You can even get remote health monitoring through WiFi.

What the industry needs to get past the analysts’ hockey stick graphs are standards. Technical standards, payment standards, approval standards. This is no longer rocket science, it’s not experimental.

Make it part of the technology mainstream, let remote monitoring benefit from Moore’s Law economics, and medicine will be truly transformed, in Internet time.

November 3rd, 2009

Kidneys do not like those chip and diet soda lunches

Posted by Dana Blankenhorn @ 7:11 am

Categories: Consumer Information, General, Research, Wellness

Tags: Correlation, Soda, Chip, Games, Corporate Communications, Semiconductors, Network Technology, Personal Technology, Marketing, Hardware

It’s hard to eat at your desk.

Chained to your computer by a job that must be done, the traditional snack of the programmer is some chips and a diet soda. It gets you through the day.

It may not get you through the night, however, and may hasten that long, long night to come.

Yes, we’re talking about your kidneys.

Julie Lin (right) of Brigham and Women’s in Boston looked at data in the famous Nurses Health Study, going through 3,000 records, collected over time, for evidence on kidney health, matching that data to the consumption of sodas and sodium.

Linn and Gary Curhan published two separate studies, one of which found a correlation between high sodium intake and kidney function decline (that’s the chips), the other of which found a correlation between artificial sweetener intake and kidney function loss (that’s the diet soda.)

There was no such correlation between regular sugar and kidney function (although there was a separate study from Colorado linking fructose and hypertension — modern American sodas are sweetened with high fructose corn syrup).

All this was offered at the annual Renal Week event in San Diego, run by the American Society of Nephrology.

There is a difference between the correlation found here and the headline “diet soda drinkers suffer kidney problems.” A correlation is not a certainty. And all they were studying were aging nurses. They weren’t studying male computer programmers who like Sarah Palin, or young video game players — it’s not a general population study.

But Lin and Curhan did account for extraneous factors within the study, like age, smoking, obesity, and heart disease, before coming to their conclusion.

I’d say take it with a grain of salt, but that might be bad for you.