Healthcare Informatics Technology

There's No Such Thing As a Free Lunch

noreply@blogger.com (R. Kay) — Wed, 16 Nov 2011 03:53:00 +0000

The White House on Monday announced it would free up as much as $1 billion in grants to help groups, doctors, and communities hire and train health care workers as a way both to create jobs and improve health care. (Quinton, 2011) Okay, on the face of it this looks like good news. I mean, a “grant” means to “transfer or convey” (Dictionary.com, 2011). If I “grant” you $1 billion, then I am transferring to you the sum of $1 billion. That is not the way the government sees it – trust me, I worked there for 28 years, and I know how they think.

A “grant” from the Federal government means, “the government is going to convey a sum of money to you with certain conditions, codicils, and provisos. In this case, the “grant” is to “hire and train health care workers “ (Quinton, 2011) for the purpose of lowering the cost of healthcare. Now let me see if I have this straight. If I hire and train more healthcare workers with “grant” money, then when the money runs out I still have to pay these workers, which I have to charge the patients for, or I have to lay off the new healthcare workers which increases the unemployment rolls.

“Today’s grants can be a catalyst for the kind of innovation we need,” Health and Human Services Secretary Kathleen Sebelius said at a news conference. (Quinton, 2011). Excuse me? I always thought necessity was the Mother of invention.

“When I visit communities across the country, I continually see innovative solutions at the very ground level—a large health system working with community partners to decrease the risk of diabetes with nutrition programs or a church group that sends volunteers to help home bound seniors so they can live at home,” Centers for Medicare and Medicaid Services Administrator Dr. Donald Berwick said in a statement. (Quinton, 2011)

To which Secretary Sebelius added, “By bringing national attention to these projects, we can help them spread to other communities,” (Quinton, 2011). Bring attention to them, yes. Laud them and get Congress to award Medals of Freedom to their instigators and innovators, yes. Throw money at them, no.

Look, there is no such thing as a free lunch. When the Feds give you a grant, there are always strings attached; and when the grant is done, the cost of maintaining the level of service you started is on you, and your patients.

Works Cited

Dictionary.com. (2011). Dictionary.com. Retrieved November 15, 2011, from Dictionary.com: http://dictionary.reference.com/browse/grant

Quinton, S. (2011, November 14). Yahoo News. Retrieved November 15, 2011, from White House Announces $1 Billion in Health Care Grants: http://news.yahoo.com/white-house-announces-1-billion-health-care-grants-114848156.html

The Question of Maturity?

noreply@blogger.com (R. Kay) — Mon, 14 Nov 2011 01:37:00 +0000

So the question becomes have we really matured when it comes to healthcare information technology? The initial talk about healthcare IT was about reducing cost and providing better care. I believe we have put to rest the notion that healthcare IT is going to save anyone money. At the same time, we have not quite solidified the notion of better care through IT. News services such as the Huffington Post Investigative Fund have discovered disparities in healthcare IT. Some of these have led to serious errors in health care and shown that a total reliance on IT can result in serious complications or even death.

When it comes to the abundance of information concerning healthcare IT there is certainly no lack of availability. A search on YouTube for Healthcare Information Technology gives over 7,700 hits running the gamut from testimonials, to sales pitches, to infomercials. A similar search on Google results in over 21 million hits. While the increase of information and exposure of information technology in healthcare is certainly welcome, has it led to a process of maturation, or merely a process of oversight?

President Reagan said, “The most terrifying words in the English language are: I'm from the government and I'm here to help”. With the advent of government oversight on healthcare information technology, can a process of maturation take place? Without government oversight, would the advances of information technology in healthcare be safe?

The resultant debate should center on how to use information technology to commoditize healthcare. Only then can we truly lower the cost of healthcare for the American, or the World consumer. We have seen this in recent years, but have not recognized it as such, or have not touted it as such. The availability of flu shots at your local pharmacy, over the counter pregnancy tests, home glucometers and even automated blood pressure monitors are all advances that have been made by making a trusted medical procedure into a commodity. This has given the trained medical professionals the ability to work on those cases where there is no standard answer, no standard diagnosis, and to use the education for which they strived and paid. The use of information technology in healthcare should be focused on more access to healthcare – more commoditized healthcare – not more government oversight which will only stifle innovation and stagnate commoditization.

Works Cited

Reagan, R. (2011). Ronald Reagan Quotes. Retrieved November 13, 2011, from Brainy Quotes: http://www.brainyquote.com/quotes/authors/r/ronald_reagan_4.html

Disrupting Medical Education

noreply@blogger.com (R. Kay) — Sun, 15 May 2011 21:37:00 +0000

One of the things that we need to tackle as a nation is what to do about healthcare. The last big grab bag by Congress was not what many Americans wanted; while a lot said, it was better than nothing. There is truth to both sides. The problem is, there is no such thing as a “quick fix” when it comes to healthcare reform. If reform is going to be lasting and sustainable, then it must be disruptive. We do not pretend to have all the answers, but we do have some ideas, and that is where this whole blog got started in the first place.

People know we are a big fan of Clayton Christensen, so we want to merge a couple of his books, in the broadest sense, to provide some fodder for the ideas arena on disruptive measures concerning healthcare. To that end, we want to look at Disrupting Class and The Innovator's Prescription. There is a joke, which is quite true, if not humorous that goes, “What do you call the guy who graduates medical school with a D?” The answer is, “Doctor”. Hopefully, and most probably, this is the person who gets weeded out during the rigorous internship process. But what about the educational process that allowed him to graduate in the first place?

In Disrupting Class, Christensen brings up two different training techniques comparing one of the Big Three in Detroit and the Toyota plant in Canada. We will not belabor the points here, but the Toyota plant training was to start with Step 1. When you had mastered Step 1, you were granted the privilege of going on to Step 2 and so forth. If Step 1 took you one minute, then in one minute you would move on to Step 2. If Step 1 took you a day, then tomorrow you would move on the Step 2. The attitude here is that it does no good to teach you step two, if you have not mastered step one. Any yet, the American education system continues to move people through Steps (Grades) 3, 4, 5, and on before they have mastered the current level of work.

In The Innovator's Prescription, Christensen talks about the training of doctors and other medical professionals, and brings in some of the main points, and that is what we want to concentrate hereupon. How can we implement student-centric education, first with our nurses (LPN, RN, etc.) and then with our physicians? I do not think there is anything that will substitute for the hands-on clinical experience that each class of professionals go through at the end of their classroom education. So let's focus on the classroom education.

This needs to be student-centric; and by that, I mean the student should control the pace, the place, and the time. Even with “distance learning” from today's educational institutions, there is still a time-line that has to be met. You have the option of doing your classwork around your schedule, but it still has to be done in the allotted amount of time. For the purpose of argument, what would happen if each healthcare student who arrived for internship had mastered every class in every field they had taken? Would not, then, the internship process be much more profound and rewarding for both the budding professional and the patient alike?

Student-centric learning, with the latest technology, whereby a student does not move on to Step 2 until they have mastered Step 1, is the disruptive step we need in medical education. This will promote higher quality, less critical shortages, and eventually lower prices.

Electronic Medical Records

noreply@blogger.com (R. Kay) — Sat, 07 May 2011 17:48:00 +0000

The buzz about electronic medical records may have calmed down, but the push to implement has not. Consequently, EMRs have fallen in to about three broad categories, which we will discuss, in brief, here today.

The first, and the one that a lot of us based our future and our fortunes on, was the self-contained version installed at each hospital. While this promised to be a big profit maker for many people, it was not except in the larger hospitals for the larger companies who could afford to put out a lot of “up front” money. The problem with this scenario is the hospital and the company involved must commit to long-term relationships. These systems are not “plug and play” sometimes taking years to implement.

Which brings us to the second model – the “build your own” system. The Cleveland Clinic is one such hospital that went this route (http://huffpostfund.org/stories/2009/12/can-cleveland-clinic-be-model-digital-medicine). Over a period of ten years, at a cost of nearly $100 million, the Cleveland Clinic did not see any cost savings by going with an EMR system. What they did see was a quantum leap in the quality of healthcare. C. Martin Harris, a physician who has overseen the digital transition at the hospital, has been quoted as saying, “Buying a computer is not going to suddenly cause your operating cost to drop." However, building your own system does give you incredible control over what you end up with in the end.

Finally, there is the “new” model that a lot of us felt was going to be the way to go for smaller clinics and “one doc” shops – the subscription service. Companies like Dell are getting into the subscription service platform in a big way. The benefit to the clinic is the freedom from the technical background that goes with any automation system. The provider takes care of all the backups, the patches, the security, the personnel. It is perhaps “cloud” computing as it was meant to be. A system that provides good service and helps the health care professionals deliver the best quality health care.

The bottom line is that automation in health care does not save money; it costs money. But, it does provide a big boost in productivity and quality of health care. That will make the extra cost worth the price. We need to look at other innovative ideas to bring down the cost of health care.

Budget Cuts

noreply@blogger.com (R. Kay) — Wed, 15 Dec 2010 04:23:00 +0000

I never intended this to be a political blog - we have plenty of those, but it seems to have turned out that way. The elections this year have sent a clear message to Congress to cut the budget, but no one is wanting to take the hit in the back of the head that is needed to get the job done. It seems to always be "cut the other guys benefits, not mine". I guess we have lost sight of the fact they are benefits, not entitlements, not rights. During the push for health care reform last year the mantra seemed to be that everyone in the US had a "right" to adequate health care. Well, no, we don't. We have the best (and most expensive) medical system in the world, which gives the impression that if you can afford it, then you can get it.

We have the technology to do amazing things, but we do not have the national will to make fundamental changes in the way we do business. Until we learn how to harness the technology, and garner the will to make change, then we are going to continue to move backwards instead of forwards.

Before I was born, one of my Grandmother's died of renal failure. There was no such thing as kidney transplants, or even dialysis in those days. When your kidneys failed, for whatever reason, it was a death sentence. Now we are telling people, "Yes, a liver transplant will save your life, but you can't afford it and the government is no longer paying for it, so get your affairs in order." There has to be some type of sanity to be gained from all this madness.

New Digital Networks

noreply@blogger.com (R. Kay) — Mon, 19 Jul 2010 23:13:00 +0000

There is a lot of tax-payer money being thrown at electronic medical records lately. While the new emphasis on EHR's is certainly welcome, some caution needs to be exercised. The subject news article from my friends at the Huffington Post Investigative Fund is talking about a new EHR in the delta of Mississippi, but then goes on to describe a telemedicine application to the EHR, and not the EHR itself.

The article states the hope that by incorporating EHR systems the cost of medical care will be reduced. Understand plainly that electronic medical records do not cut cost, they increase it. With the increase in cost comes a quantum improvement in the quality of health care. Now this improvement in quality (which also means better communication between provider and patient even when they are not co-located) can reduce the number of office visits, and the number of hospital stays, by making the patient more aware of how to take care of themselves. The best way to cut medical bills is to stay healthy, and that can be the real benefit to EHRs and their telemedicine applications.

Another bit of caution is as old as time - buyer beware! When you publicly state you are about to throw billions of dollars at any widget, then every widget in the world will appear. Some will work, some will partly work, and some just won't work at all. This was a problem before the "stimulus" which has sky-rocketed the deficit, and it is, and will continue to be, a major problem in the near future. Electronic medical records are NOT plug-and-play, and can take decades to get right. In an earlier post I pointed to another Huffington Post article on a hospital in Cleveland that took over ten years to get their EHR right. And the only way they were sure of what they were getting was to build it themselves.

EHRs are great things - when they work, and when your staff has been properly trained on their use, and when you don't have to wait two years to get a "fix" to something that doesn't work just quite right for your particular location. A little Teddy Roosevelt would be good here - "Walk softly and carry a big stick."

So where are we going with health care?

noreply@blogger.com (R. Kay) — Fri, 11 Jun 2010 04:20:00 +0000

So where are we going with health care? Today it is hard to get through the hype and hyperbole to find some modicum of truth. We passed the health care bill so we could see what it said, and depending on whom you listen to, it is either the greatest boon or the greatest bane to the American scene. So let us look at some facts:

• nHealth is a small Virginia company that specializes in high-deductible insurance policies couples with Health Savings Accounts (HSAs). HSAs are the fastest growing sector of the insurance industry because they provide a consumer-driven plan where people choose which health care options they pursue. If I know I have a high deductible, then I am going to do my best to stay healthy and seek the best alternatives. I will not be running to the doctor for every little sniffle and sneeze. In 2008, nHealth was one of the “Greater Richmond Companies to Watch”. nHealth has announced they are closing their doors after stringent new Federal regulations and future uncertainty, both a part of the new health care law.

• According to the insurance research firm Dowling and Partners some of the major players (Aetna, Assurant, Mega Life and United Health) plan to bail out of the individual market, at least in some states. This will leave an additional two million Americans without coverage.
(Nix)

Looking at the other side of the coin, we find:

• It makes insurance more affordable by providing the largest middle class tax cut for health care in history, reducing premium costs for tens of millions of families and small business owners who are priced out of coverage today. This helps 32 million Americans afford health care who do not get it today – and makes coverage more affordable for many more. Under the plan, 95% of Americans will be insured.

• It sets up a new competitive health insurance market giving millions of Americans the same choices of insurance that members of Congress will have.

• It brings greater accountability to health care by laying out commonsense rules of the road to keep premiums down and prevent insurance industry abuses and denial of care.

• It will end discrimination against Americans with pre-existing conditions.

• It puts our budget and economy on a more stable path by reducing the deficit by more than $100 billion over the next ten years – and more than $1 trillion over the second decade – by cutting government overspending and reining in waste, fraud and abuse.

(The White House)

So now the question becomes, “Who do you believe?” This is largely going to be a story of individuals and for every individual that you find with a success story you will also be able to find one, or more, with a nightmare. It is also going to be a story of budget and who gets to pay for all of this. You only have to look at the cradle of democracy, Greece, to see the effect of spending without regard to reconciliation.

Works Cited

Nix, Kathryn. Side Effects: Like Your HSA? Enjoy it While You Can. 9 June 2010. 10 June 2010 .

The White House. Health Care | The White House. 2010. 10 June 2010 .

Where Do We Go Now...

noreply@blogger.com (R. Kay) — Mon, 03 May 2010 03:08:00 +0000

The healthcare reform bill has been signed into law, and the iron triangle is hard at work formulating the regulations that will be put in place to enforce the law.

Already several states are joining in a class-action suit against the Federal goverment on the grounds that forcing people to purchase health insurance has nothing to do with interstate commerce and so exceeds the authority of the Federal government. Personally, I agree with the governors, but it will be an interesting court case, none the less.

So where do we go now? I still believe that market forces, the forces of disruption are the key to making health care more affordable for everyone. We need drastic changes in how we manage clinical trials and in how we diagnose desease. We know now that what we used to call "breast cancer" is actually over twenty different types of cancer. It isn't that we don't have good medicine, it is that we don't have the best diagnosis. A bad diagnosis will ruin a clinical trial faster than a fatality.

On top of that, the charlatans have hit the streets pawning off "electronic medical records" the way peddlers use to hawk "snake oil" out of the back of wagons. What a lot of people in the medical profession haven't learned is that nothing comes for free and it takes years or decades to implement a truly successful electronic medical system.

So now we have errors cropping up where there should be no errors and it is costing people their lives. That means the Federal government is scrambling to come up with a system of checks and counter-checks to make sure the EMR you purchase is the best.

This has good points and bad points. On the good side it makes sure some of the charlatans are caught and dealt with. On the bad side it makes those who are not charlatans jump through additional, costly hoops to get their product to market.

Make no mistake - EMR's do not save money, but when implemented correctly, they save lives and improve the efficiency of health care. The biggest thing they do is provide the clinician with the information they need to correctly diagnose a problem. That correct diagnosis, when it happens often enough, allows the care and treatment of that disorder to be passed down to a technical based care solution, such as a PA or an RN - this saves you money, and it frees up the time for the MD to do what he does best - find answers to questions that haven't been asked before.

Case in point - what used to take a trained medical professional to diagnose (a pregnancy) is now the venue of an over-the-counter $15 test you do at home. If you still want to pay $75 for an office visit you can, and the doctor is going to hand you one of those sticks and tell you to visit the bathroom; or they will get the RN to do it, and still charge you for the office visit.

Flu shots are another example. What used to take a trip to the doctor is now being done in most pharmacies across the country. And in-house clinics at chain pharmacies are set up to see a specific type of ailment for a specific cost structure. This is the future of medicine and the answer to the high cost of healthcare. It isn't forcing everyone to buy health insurance, any more than forcing people to purchase life insurance will guarantee their families won't grieve when they pass away.

I want to recommend two books as I have in numerous places. "The Innovator's Prescription" by Clayton Christensen; and "The Healing of America" by T.R. Reid. I think both of these should be "must reads" for anyone sitting in Congress, or who desires to sit there.

CPOE Errors

noreply@blogger.com (R. Kay) — Mon, 26 Apr 2010 18:32:00 +0000

As Doctors Shift to Electronic Health Systems, Signs of Harm Emerge

Reports Link System Malfunctions to Injuries, Deaths

By Fred Schulte and Emma Schwartz
Huffington Post Investigative Fund

One day in March 2009, hospital workers misread small print on a computer screen, causing them to dispense 10 times the prescribed dose of a drug. Result: The patient has a heart attack.

Another time, a computer fails to alert doctors and nurses when a patient is moved from intensive care to their ward. Left unattended during the night, the patient suffers seizures for hours.

In December 2009, there’s a report of a software glitch that delays a patient’s medical treatment, causing a disabling injury. “Breakdowns of this magnitude endanger hundreds of patients simultaneously,” warns a report on the incident.

Scores of reports on file with the Food and Drug Administration detail consequences to patients when an electronic medical record system fails. Those reports, reviewed by the Huffington Post Investigative Fund, show that a central function of the record systems, known as computerized provider order entry, or CPOE, has been linked to instances in which patients died or suffered serious injuries.

While the data obtained by the Investigative Fund affords only a small glimpse at problems with the system, it could suggest a much larger challenge as the nation’s medical establishment swiftly moves from paper medical files to digital ones.

The safety concerns raised by the reports “may represent the tip of the iceberg,” said Jeffrey Shuren, who directs the FDA's Center for Devices and Radiological Health. Shuren, who made the remark at a gathering of government officials and safety experts in late February, did not disclose details from the reports, which the Investigative Fund obtained through an FDA database.

The CPOE system is pivotal to the success of government plans for spending billions of dollars in economic stimulus money to entice doctors, clinics and hospitals to switch from paper medical files. Government officials and many safety specialists argue that the system will revolutionize medicine by minimizing errors, cutting costs and protecting patients.

But some of those same experts also worry that the prospect of stimulus funding – an estimated $5 million or more per hospital – encourages hospitals to install systems prematurely, possibly exposing patients to harm associated with software glitches and other system bugs.

DATABASE: Explore 'Adverse Event' Reports Submitted to the FDA »
The FDA’s Manufacturer and User Facility Device Experience (MAUDE) database is the nation's largest repository of adverse events related to medical devices. Using the system, the Huffington Post Investigative Fund identified 237 reports related to health information technology filed with the agency since January 2008.

Altogether, the Investigative Fund identified 237 reports of “adverse events” associated with health information technology reported to the FDA over the past two years. Most problems involved computerized medical ordering software or systems that supply the software with vital information, such as recommended doses of medicine or test results. Most of the adverse events recorded in FDA files were blamed on software malfunctions, user error or the system’s lack of user friendliness.

While the reports open a rare window into troubles involving computerized records, much is still not known. Locations, names of institutions and the identities of patients are redacted from FDA data obtained by the Investigative Fund. Many reports don’t say what ultimately happened to the patients and could not be independently verified by the Investigative Fund.

There’s no way to know how often these problems arise. Most reports to the FDA are submitted voluntarily by health professionals, so the reports provide only a random snapshot of the problem. Meanwhile, the FDA itself is largely in the dark; it lacks a reliable, systematic method of tracking the safety of health information technology.

Justin Starren, a physician who oversees technology at the Marshfield Clinic in Wisconsin, lays out the dilemma starkly: “Computers are strong medicine. Done well, they are wonderful; done poorly they can kill people,” he said.

David Blumenthal, who oversees stimulus payouts as the government’s national coordinator for health information technology, said that he hasn’t seen evidence that “merits a lesser commitment to implementing CPOE.”

He said the CPOE devices can greatly help doctors make better decisions in treating patients. Medical experts advising the government have been “virtually unanimous” in concluding that on balance CPOE “improves the safety of care,” Blumenthal told the Investigative Fund when asked about its findings.

Even so, he acknowledged concerns, saying, “We are looking at this issue closely.”

Since late December, 18 reports received by the FDA involved one manufacturer, Cerner Corp., which sells CPOE devices and other electronic record systems.

One patient died after an “unplanned hospital wide CPOE and electronic record breakdown,” which in turn resulted in late or missed doses of medicines, according to one report. “Considering the size of the institution, it is possible that other patients were adversely affected by comparable delays and omissions,” stated the report.

Most of the reports filed by physicians alleged malfunctions or poor designs of Cerner's CPOE equipment. One criticized “user unfriendly interfaces” and screens with a small font size and “extraneous and distractive” information that had led pharmacists to overlook changes in medication orders.

Another report described how health care personnel had trouble reading orders on the computer screen – causing a “life threatening acute asthma attack” in a patient given the wrong drug.

Gay Johannes, Cerner’s vice president and chief quality officer, said in a prepared statement that the company maintains an “internal process” for resolving complaints about its products. “We continue to follow this process that has been in place for many years and investigate all claims Cerner receives or are filed with the FDA.” [Click for the full statement.]

She said that Cerner also voluntarily reports incidents to the FDA because the company “believes such disclosures provide much-needed transparency into the successes and challenges of these types of systems.” The company did not respond to requests for comment on individual reports.

The FDA also wouldn’t discuss the reports or say what action agency officials or manufacturers took in response.

‘Systems Do Fail’

Taken as a whole, the FDA reports show that making the complex systems work properly involves far more than simply transferring paper records into a digital format.

Health professionals use CPOE to type in orders for prescription medicines, diagnostic tests and the patient’s treatment plan. The information then is shared electronically throughout the hospital. Drawing on computer databanks, the systems can warn doctors of harmful drug interactions and help guide their medical decisions—functions that Obama administration officials promise will significantly improve health care delivery.

Citing this potential, the Obama administration wants to spend as much as $27 billion in economic stimulus funds to help doctors and hospitals adopt the systems and create a digital medical record for every American by 2014. To qualify for the first phase of funding, which starts later this year, hospitals must install the CPOE systems and use them in at least one in every 10 transactions with patients.

But many health information technology experts say past experience at hospitals indicates a need to phase in the systems gradually. Without greater attention to safety, several experts said in interviews, the stimulus plan might backfire, eventually discouraging their use, as risks and costs eclipse advertised benefits.

“Simply pushing CPOE as an unalloyed good has a great potential to negatively influence quality and increase cost,” said Starren, of the Marshfield Clinic. Experts generally expect successful installation to take the average hospital several years. Three is “about the fastest CPOE can realistically be implemented effectively,” said Starren. “Most places take longer.”

Other experts said that many successful CPOE installations have been “home grown” by university hospitals and research institutions and perfected over many years of hard trial and error. Though they strongly believe that the electronic systems will prove far safer than relying on paper files, they worry that federal officials aren’t doing enough to keep tabs on hundreds of tech companies aggressively marketing new versions of the complex software.

“These systems have lots of potential to improve safety but if they aren’t implemented correctly they might worsen safety,” said David Classen, an informatics professor at the University of Utah School of Medicine.

Classen points to his recent research testing CPOE systems at 62 hospitals, which found that the systems caught medication errors only about half the time, including some that would have resulted in serious injuries and possible death. Systems from the same manufacturers performed better at some hospitals than others.

“These systems do fail,” he said.

Alerts are ‘a joke’

A number of studies have documented that CPOE can significantly reduce medication errors that stem from sloppy physician handwriting on prescriptions. Yet others have found that CPOE can also create new hazards. One of the earliest critical studies was done by Ross Koppel, a University of Pennsylvania professor, who reported in 2005 that the systems can introduce a litany of errors. Koppel also found CPOE systems often flood doctors with warning alerts that are of no consequence, leading many physicians to habitually ignore them – a syndrome so commonplace it even has a name: alert fatigue.

The automated warnings aren’t taken seriously. “They are a joke,” Koppel told the Investigative Fund. He blames manufacturers for producing systems that rely on what he called “not ready for prime time software.”

Others remain optimistic that the systems eventually will live up to their potential. Blumenthal said in an interview that CPOE alert and “decision support” features make doctors better, and he cited his own medical practice in Massachussetts. He said the computerized system helped him decide whether to order X-rays, and what type, based on a patient’s symptoms entered into the computer. In some cases, the computer was able to locate results of a previous test, sparing the patient needless exposure to radiation.

“The interaction between me and the computer is emblematic of what’s possible to accomplish,” Blumenthal said.

Government officials note that phasing in CPOE is vital to achieving broad health reform goals. That view is shared by an influential coalition of consumer groups and labor unions. The coalition, which includes the older Americans’ lobby AARP, argues that the systems promote safety and efficiency and will grant patients a greater say in their medical care.

Blumenthal said that CPOE is critical to the success of the electronic health records initiative. “We need to support it and make sure it happens,” he said. “How fast and in what form remains to be seen.”

Related Story » Amid Digital Surge, a Lack of Policing by FDA

As federal officials encourage the rapid expansion of electronic medical records to help doctors improve care and cut costs, they lack a reliable and systematic method for tracking the safety of these products, agency data and audits show.

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Healthcare Reform

noreply@blogger.com (R. Kay) — Fri, 26 Mar 2010 01:28:00 +0000

The founding fathers did not think it mutiny to rebel against a system of government which did not represent the best interests of the governed. That is why we have the United States today. Our constitution is remarkably short (shorter than any of the State constitutions) because our founding fathers intended it as a "framework" for how we would lead our lives down through history. They made it particularly hard to amend on purpose - as well they should have.

Now we have reached a historical watermark - that watermark is either a Waterloo or an Armageddon, depending on how you look at it - but it is a watermark. It is not a cause 'celeb re reason for armed rebellion. If you are really upset with this legislation, as I am, then your recourse, as is mine, lies in the ballot box and in the arena of ideas. It does not lie in veiled threats of violence or hostile actions.

This writer does not like the currently passed legislation, and I have made my feelings known to my legislatures and will actively support those candidates who run against the supporters of this legislation in the next election. But this writer decries as infantile and asinine those actions of violence that have either occurred or are being planned against our elected officials. If you think they erred, then check your local polling district and see how many people actually get out to make their feelings known. If you find (which I doubt) that the majority of people in your community have voted, then build a bridge and get over it. If you find they have not, then find out why not, and get behind a new candidate in the next election.

President Obama has told the Republican Party, "bring it on". If you are serious, then you can make him regret those words at the ballot box, not on the street.

And So It Starts...

noreply@blogger.com (R. Kay) — Fri, 12 Mar 2010 23:14:00 +0000

It looks like the Congress is going to get a healthcare reform package through the doors, finally, by resorting to budget reconciliation to match up the House bill with the Senate version. It looks close enough the President has postponed his trip to Asia in order to be around and sign the measure into law. This will happen, I am sure, within moments of it being passed by Congress.

And so it starts…

Next the bureaucrats will get their multiple copies to start figuring out just what is in the bill. No one in Congress is really positive about all the ins-and-outs of this behemoth after all the juggling and jostling and political wrangling that has been going on for the past twelve months or so. And the bureaucrats will start with the “big picture” and work their way down to who has to do what, where and when.

And so it starts…

In a few months the first regulations will start to surface based on the new law and we will hear about just what is in the bill. Oh, I don’t pretend to know exactly what is in the bill even though I read the first draft that was released – all of it. It did not make any sense then and I am sure the final version will not make any sense after it is signed into law. But the bureaucrats will interpret the law and make it make sense for all of us.

And so it starts…

The political wrangling to come for the next “mid-term” elections will be fascinating to watch. The Republicans will be running out all the horror stories with a “see, I told you so” attitude and the Democrats will be running out all the success stories with a “neener, neener, neener!” attitude. To be sure there will stories on both sides and it will be up to us to determine who was right and who was wrong.

And so it starts…

As with all industrialized nations which have adopted universal coverage, health care reform will continue to be a major campaign and legislative issue. Wonder when they will have time for anything else?

If There Is A Way To Make a Buck...

noreply@blogger.com (R. Kay) — Fri, 05 Mar 2010 22:26:00 +0000

If there is a way to make a quick buck, someone will find it and someone else will use it to their advantage. The old adage of “buyer beware” is alive and well, it would seem, in healthcare informatics. In the rush to the “digital age” in healthcare we have seen some people put out a product and then walk-away from the long-term commitment that product should have backing it up.

In an article published by the Huffington Post Investigative Fund called “Experts: Safety Oversight Needed as Patient Records Go Digital” we find several instances of vendors seeking upwards between $70-million and $100-million dollars for their systems.

It must be remembered that these systems are not plug-n-play. They take years, if not decades, to implement properly, and if you just throw one in and expect to use it you will get the type of results we have been seeing.

In another work by Koppel (Gumpper, K., Zellmer, W., Aarts, J., & Koppel, R.. (2009). Computerized Order Entry/Computerized Order Entry: The Authors Respond. Health Affairs, 28(4), 1231-1232. Retrieved March 5, 2010, from ProQuest Central. (Document ID: 1799972741) we see “The potential for harm is nearly equal in the prescribing and drug-administration steps.2 Thus, it is noteworthy that 24 percent of hospitals have invested in bar-code drug administration technology, and 56 percent of the rest plan to do so within three years.3 Computerized infusion pumps that check doses against preset limits are used by 44 percent of hospitals; 47 percent of the rest plan to acquire this technology within three years.”

So now we have the government seeming to work against itself (what else is new). We have Federal regulators looking at implementing safety oversight to slow down the implementation of digital records at the same time the administration and Congress are throwing billions of dollars of stimulus money at doctors and hospitals to get them to implement within the next five years.

Again quoting the article from the Huffington Post Investigative Fund – “
Under the stimulus law, doctors can receive up to $44,000 in extra Medicare payments if they purchase digital systems and take a number of steps to make “meaningful use” of them.”

So am I the only one who thinks this is a little skewed?

Safety Oversight for Electronic Medical Records

noreply@blogger.com (R. Kay) — Sat, 27 Feb 2010 20:53:00 +0000

As reported in the Huffington Post Investigative Fund (subject link) the Federal Government is looking at how best to provide oversight of electronic medical records as they prepare to spend billions on these systems. Doctors and hospitals will receive increased Medicare disbursements if they have these systems, and even more if they show how they are making "meaningful use" of them. In the rush to get the money out the door, someone is taking the time to raise their hand with the suggestion that in the rush to collect stimulus money, doctors and hospitals may not due sufficient due diligence on their purchase decisions. Ross Koppel, a sociology professor at the University of Pennsylvania is one such person raising his hand.

Personally, I think electronic medical records are the key to quality health care for the future. However, I know that whatever the Federal government invests in it will control, overtly or otherwise. While this has both good and bad points, it is not my intention to debate those in this forum. But I believe there is a fallacy in reasoning that bears mentioning and should be closely attended to.

I am speaking of the fallacy known as post hoc, ergo propter hoc, or the fallacy of a false cause. Specifically, Mr. Koppel was concerned (in part) about orders that were written by doctors that are "strangely transformed" in the electronic record. I would ask if the doctor typed in the order, if he used a "template" (that is common among EHR software products) without carefully reading the entire template, or if he actually wrote out the instructions and then had someone transcribe their interpretation of what he wrote into the patients record? These are valid questions, and reading a doctor's handwriting has often proved difficult even for the doctor in question if some time has elapsed between when he wrote and when he is asked to read what was written.

Of Mr. Koppel's comments I have to totally agree that hospitals may rush due diligence and end up with a $70 million- to $100 million-system and will be married to it for some years to come. Taking this into consideration I think it is wise to look to some good examples of good systems - the Veterans Administration and the Cleveland Clinic. Both systems were implemented over decades, not years. Both systems require extensive learning curves for clinical and ancillary staff alike. But both systems are phenominal in the advancement of quality care.

The bottom line, in this writer's humble opinion, is that the Obama Administration is, once again, setting themselves up for failure. The idea of advancing electronic medical records is great. The notion that you can push these out over the next five years without having one disaster after another is incredulous beyond belief. What they will be doing, if they do not back up and slow down, is giving the Republican party all sorts of ammunition to use in 2012. President Obama is liable to find history recalling him as the short pause between the first Regan era and the second.

New Health Care

noreply@blogger.com (R. Kay) — Mon, 22 Feb 2010 20:20:00 +0000

The President is putting forward a new "compromise" health care bill that is still going to cost over $1 trillion in the next ten years. Suddenly it seems we have to pass something to earn political points for re-election. How sad that something as important as health care reform is being relegated to the back-burner of politics. Instead, our government should be looking at ways to foster innovations and disruptions to the health care industry that would engender true growth, better quality, and lower prices. That is something only the industry itself can do and government can not even come close with more regulations and more spending.

It would seem that President Obama is heading down the same road as President Carter - a really good man who is certainly smart enough to know what to do, but who has gathered around him the wrong advisors and is listening to them intently.

The Cleveland Clinic

noreply@blogger.com (R. Kay) — Wed, 17 Feb 2010 21:57:00 +0000

The Cleveland Clinic is being touted as the model for American health care reform, and that’s fine. What the Cleveland Clinic has done is to discover the benefits of Fluxus Quo in developing their own medical records. President Obama wants to spend $45 billion of stimulus money to “export” Cleveland’s system to other hospitals around the nation. While promoting electronic medical records is a good thing, there are some real hurtles the President needs to be aware of.

1. Electronic medical records are not plug-n-play. The Cleveland Clinic, like the VA, has spent decades and millions of dollars getting there system where it is today. Dr. Martin Harris, who oversaw the Cleveland Clinic install states, “If you install the entire electronic medical record on day one, that can be a very dangerous model.” (Schwartz, Lagan, & Sieck, 2009)

2. Electronic medical records are not cheap. Cleveland Clinic had pockets deep enough, and determination strong enough to keep pursuing their dream through hundreds of millions of dollars; and it takes additional millions of dollars each year to keep improving and innovating the system.

3. Electronic medical records are not easy. Doctors and staff alike have to go through an enormous “learning curve” before they understand how to efficiently and effectively use the record to the patient’s advantage.

Given these faults, there are distinct advantages to EMR’s:

1. They do eliminate mistakes. In the first year the VA installed the Bar Code Medication Administration module of their medical record, medication errors virtually disappeared. We are not talking about a sharp drop; we are talking almost completely eradicated.

2. The do streamline and safeguard records. During the evacuation of the VA Hospital in New Orleans leading up to Hurricane Katrina, the patients were, for the most part, evacuated to the VA Hospital in Houston. Their medical records arrived in Houston ahead of them being transmitted over the VA network.

3. They do make health care better. The best diagnosis begins with the best information©-2003 HITS, Inc. is not only a saying, but a fact.

Given all this, how do we require hospitals to have an up-and-running EMR within the next five years? Realistically, you do not. You can require them to show evidence of their planning and programming for an electronic medical record, but you cannot take neither the VA system, nor the Cleveland System and export it to another hospital. There is a saying within the VA that goes, “When you have been to one VA hospital, you have been to one VA hospital.” That is not a criticism for lack of organization, but praise for the VA’s ability to flex and bent to better serve their patient population. Medicine changes to fast to use a Status Quo model of software or technology. We had better learn the lessons of Fluxus Quo, and learn them quickly.

Works Cited

Schwartz, E., Lagan, S., & Sieck, S. (2009, December 1). Video: How The Cleveland Clinic Went Digital. Cleveland, Ohio, USA.

Health Care Overhaul

noreply@blogger.com (R. Kay) — Sun, 14 Feb 2010 01:26:00 +0000

What looks like the end of the President's health care overhaul has some people shouting for joy, but it should not be that way. As Washington Senator Maria Cantwell noted even with no health care overhaul prices will go up, and they will. However, in the middle of the worst recession in recent history, with budget deficits already at figures most of us can not even comprehend, it is not time to put out a broad goal and then let Congress try to figure out how to make it work.

So here's an idea - why not put together a non-partisan task force that can show government how to foster an environment of disruptive innovation within the health care industry. A good candidate to lead that would be Dr. Clayton Christensen from Harvard ("The Innovators Prescription") who has done extensive work on disruptive innovation in several industries, including his latest work which looks at the health care industry and how disruption can work there.

If we provide the environment necessary for innovation to grow (and that should be the primary job of government anyway), then the innovative forces of the marketplace will solve the problem of cutting the cost of health care and go a long way toward universal coverage. Understand, this is not going to be a "one term" process, or even a "one President" process, but an ever on-going process that will keep re-shaping health care through the future and beyond.

Of course, once this environment is set in motion, then government (national, state, and local) should work on fostering the environment necessary for small businesses to flourish. If you want to solve unemployment, then small business is the way to go.

The State of Health Care

noreply@blogger.com (R. Kay) — Wed, 20 Jan 2010 20:10:00 +0000

The stunning victory of the Republican Party in Massachusetts yesterday sent a message loud and clear to the White House and Congress that the American people do not like the direction health care reform is taking. It did not send the message that health care reform is not needed, nor wanted. The White House and Congress should be clear on this issue - your motives and ideals are solid; your process leaves many questions unanswered and only an ever-increasing budget deficit.

The time is now to role up your sleeves and really get to work on a true reform of health care. One that utilizes what is best about America and does not seek to borrow the solutions (and problems) of other countries. Ask us to sacrifice and we will; ask us the help pay for it and we will; but tell us this is what you are going to cram down our throats whether we like it or not and you will learn what Lexington and Concord were all about. Of course, it is no coincidence that Lexington and Concord were in Massachusetts, don't you think?

Believe it or not, there does come a time when re-inventing the wheel is a good thing.

A Point of Ponderance

noreply@blogger.com (R. Kay) — Thu, 19 Nov 2009 05:37:00 +0000

As a point of ponderance tonight I did a couple of Google searches - the first was on "electronic medical records software" which netted the usual million or so hits, but of particular interest was the first page which was loaded down with different companies offering electronic medical records. After clicking on a couple of links (by no means an exhaustive research), I noticed what I took to be a glaring absense. I refined my search to "digital radiology" and was amazed that the third listing was for Wikipedia and not a company offering the latest advancement. Of more than particular interest was the fact that Siemens was present on both pages toward the top of the list.

I was trained in DICOM early on, so I am sure my knowledge is more or less dated, and I know Siemens to be a highly professional company, so I would trust their digital integration (especially with their EMR offering). But I found it odd, that the seemingly cornucopious listing of companies for EMR's did not replicate for digital radiology. Of the companies listed in the later, only Siemens was present in the former. Interesting...

I have worked on EMR software for many years being a programmer and systems analyst for VistA systems within the Veterans Health Administration (not Microsoft), and have even had a stint at running a small multinational which dealt with the open source version of VistA. It is my honest opinion that EMRs coupled with digital radiology are one of the best advanced in medicine to come along in a while. Oh, they aren't rocket science, nor are they the cure for cancer, but they provide information in abundance at the physicians fingertips. And I have always felt that the best diagnosis starts with the best information.

The Long Haul

noreply@blogger.com (R. Kay) — Thu, 12 Nov 2009 21:22:00 +0000

It has taken some time, but the raucous over heath care reform seems to be dying down. Does that mean the task is over, or does it just mean that Congress is not in the limelight right now? It means that Congress is not in the limelight right now. The H1N1 virus is taking a healthy share of the headlines, as are Afghanistan, and other world news, and that is okay.

Keep this in mind. It matters a lot what our Congress decides to do on health care, but whatever they decide, it does not end the discussion. If you read H. R. Reid’s “Healing of America” (2009, Penguin Press) then you understand that “health care reform” is a never-ending struggle. Those countries which have gone with a public option and those who have gone to a total “universal coverage” are constantly looking at reforming health care. It is a part of the national rhetoric and a large part of every political campaign.

So what is the point? The point is that we are constantly going to be talking about health care reform because it will never be “right”. Our system now provides the best coverage in the world, to those who can afford it, but it leaves too many uncovered. That was never the argument. The argument was how to cover those who need it without ruining the coverage of those who can afford it, or who “afford” it through their employers.

I am one of those under “universal” coverage because I am a disabled veteran of the US Army, and contrary to popular opinion, the VA is one of the best medical providers around. There are things it will not do for you because it is not necessary, and sometimes the drug your doctor wants to use is “not in the formulary”. The VA, though, is constantly being looked at, constantly being reviewed, and undergoing constant “reform”. So unless you are sticking your head in the proverbial sand and saying, “everything is fine, we don’t need reform”, best roll up your sleeves and get ready for the long haul.

Troubling Question

noreply@blogger.com (R. Kay) — Mon, 07 Sep 2009 00:34:00 +0000

As with most Americans I have approached the question of healthcare reform with an "us" or "them" attitude. As with most Americans I have not had to do without any form of insurance during my lifetime. I went from insurance with my employer to being in the US Army to begin covered by the VA to being covered by the VA and having insurance with my employer. I have chafed at the idea of "socialized medicine" and fought against it with everything I had - namely my vote.

Then a couple of gentlemen opened my eyes to the bigger problem. I am speaking of Clayton Christensen in his book "The Innovator's Prescription" and T. R. Reid in his book "The Healing of America". If you haven't read these books, I strongly recommend you do so - and quickly. Mr. Reid shows us that the question of health care in America is one of "How much inequality are we willing to tolerate?" and Mr. Christensen shows us that market forces can disrupt, and thereby reduce the cost of, healthcare.

First questions first - just how much inequality are we, as Americans, willing to tolerate? We have stated as a matter of public policy that we will not tolerate prejudice in the areas of race, color, creed, or gender. In some areas we have expanded that to include sexual orientation, but we have yet to say we will not tolerate prejudice in the area of income. We cling to the golden rule (he who has the gold makes the rules) like it is the last sacred cow of a dying race - but it is not.

So we are going to start asking these questions and exploring answers over the next several weeks, months, years. But the first question we have to answer as a people, as the American people, is, "Do we feel that when a person becomes sick they have the right to see a doctor?" - this is a "yes" or "no" response. Either you do or you don't believe that, in the United States, a person should have the right to see a doctor when they are sick.

Think about it...

A Departure of Sorts

noreply@blogger.com (R. Kay) — Sun, 30 Aug 2009 14:45:00 +0000

Let us depart from the tried and true (and often overworked) vision of VistA and take a new slant that will enhance our discussion of the software life cycle. Instead of looking at VistA as the EMR of a hospital, let us look at VistA as a potential candidate for a national Patient Health Record (PHR) which could be a building block of health care reform as it is currently being debated.

The difference between an EMR and a PHR is more political than technilogical. A patient health record is the property of the patient, not the property of the facility housing the record (for it is not housed in a facility), nor the property of the Federal Government (because it is not run as a government entity). A PHR must be started by a company, or companies, large enough to break off a small segment of their workforce and revenue to set up a totally different entity that could augment the standard EMR in any shape, form or fashion. For this job VistA is uniquely qualified, and run as open source on GT.M is uniquely capable.

Each patient who subscribes to the service (set up cost around $10 with a yearly maintenance fee of around $5) is provided with a subscription access code. This code can be printed on and imbedded in the magnetic strip of a credit card type prototype. Where the Federal Government would come in is that each facility that treats a patient would have to be required to supply the information for any subscribed patient to the facility. This can be done via HL7, or whatever the current method of communicating platform disparate information is at the time.

Each subscribed patient would have the ability to supply their access code to any physician they happen to visit, and the physician would then (via the access code and a web interface) have read-only access to the patient record. If a physician is given an access code, then he must supply his information to the system, with the access code being a part of the HL7 message to identify the patient. The interface for supplying information to the system would be supplied to each facility for free, as well as the web interface information.

Each physician would use their DEA number to access the medical information along with the patient access code. This would give the system knowledge of who accessed the system for which patient. Other things, such as IP address could also be captured to give an appoximate location.

Under this system, the patient information is immediately accessible to any provider in the US, or abroad should the decision be made to extend the system to those areas. Using GT.M with VistA would ensure scalability as well as performance and security by having multiple databases replicating nationally, or internationally as the case may necessitate.

Discussion?

Interesting Tidbit

noreply@blogger.com (R. Kay) — Sat, 29 Aug 2009 21:20:00 +0000

We have all seen the chart that shows the US is spending more for health care as a percentage of GDP than any other industrialized nation. The latest chart I have seen is in T. R. Reids book "The Healing of America" which shows the US led the pack (at 15.3%) in spending over countries where everyone is covered and yet we still have millions uninsured. It is a statistic to tug at your heartstrings, and it does. On a whim I looked around to see just how we calculate GDP and here is the equation I found Y=C+I+G+NX where Y is the total Gross Domestic Product, C is the amount of consumer spending, I is the amount of investment money spent, G is total government purchases, and NX is the dollar amount of net exports.

Wait a minute - I thought we were considered a "debtor" nation because we have been running negative numbers in net exports for years, meaning when you subtract imports from exports, we run in numbers below zero - we buy more than we sale. So if I am looking at a number as a percentage and I decrease the bottom number, that is going to make the percentage bigger.

So I went to the CIA World Factbook and did a little digging. It was interesting that we led the world in healthcare spending as a percentage of GDP when our net exports were running -$639 billion. The next closest nation, Switzerland, was running at +$40.1 billion and France was running at +$72 billion. No wonder their "percentage of GDP" looks better. Just goes to show you need to know what is going on behind the numbers before you believe what some people will try to tell you.

Long Piece

noreply@blogger.com (R. Kay) — Wed, 26 Aug 2009 04:40:00 +0000

I am working on a long piece entitled "Does Healthcare Have to be Nationalized to be Reformed?" and it will be a couple of weeks before I am done with the research. If you would like to help me with the research, fill out my survey here
Thanks.

The End of Congress

noreply@blogger.com (R. Kay) — Thu, 20 Aug 2009 20:36:00 +0000

So, according to Charles Babington of the Associated Press, President Obama has disbanded Congress and "guarantees" that health care overhaul will pass and will abide by his four "bullet points" of "...reduce rapidly rising costs, protect consumers from insurance abuses and provide affordable choices to the uninsured — while not adding to the federal deficit."

The only way a President could do that is to disband the Congress first.

Does he know something we don't???

Just For Grins

noreply@blogger.com (R. Kay) — Fri, 14 Aug 2009 04:39:00 +0000

Just for grins today I downloaded the 1018 pages of the House Resolution for health care reform from house.gov. No wonder no one really knows what is going on, but this much I did find out. It spells out in detail that only a bureaucrat can love, how the new reimbursement system will work. I bolded the word reimbursement for good reason. It is the current reimbursement system that has gotten us into the trouble we are in now. When you pay a doctor to treat you when you are sick, where is the benefit for them to help you stay well?

Try this - take a look through the CPT codes that are used to pay for medical care in the US. You will not find one code that pertains to wellness. They are all codes for illness. When you only pay people for treating you when you are sick, they are not going to help you get well.

Something else I found interesting, but haven't really had a chance to dig into yet was the section on reimbursing employers for what they have put out for an employees medical care. So where is the deal about, "If you like your current coverage, you can keep it", unless it just means that every insurance company and plan in the US will bill and be paid by the US government, instead of by employers and individuals.

This is sheer lunacy!