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If you are a student studying echocardiography, or a department chair trying to develop colleagues' familiarity with cardiac echoes, you may want to check out EchoJournal. Curated by David E. Winchester, MD, a Cardiology Fellow at the University of Florida, EchoJournal is a free video resource for watching and discussing echocardiography clips. The video collection has been steadily growing to become a comprehensive database of diagnosed conditions. Registered members can create their own groups and video collections from the public library as well as to add their own uploads. Anyone able to use YouTube should find himself comfortable working with the EchoJournal interface. Whether you are a health care strategist, doctor, nurse, patient, or just a citizen concerned with the state of medicine and its future, Medpolitics is the place for you to bring up debates, offer solutions, announce events, organize groups, and establish professional contacts. In other words, Medpolitics is a social network for health care politics. Medpolitics allows anyone to blog, post videos from YouTube, and create discussion forums by topic. Check it out today!...
Michael
Read more [Medgadget]
Sikker Concept Baby Monitor Connects Parent and Child Via Bracelet
It's only a concept but the Sikker (Danish for safety) baby monitor is a great idea by designers Jessica Mendoza and Henoc Monte that we think would have both parents and babies alike going gaga. The bracelets, charged on a docking station during the day, would allow two way communication between mother and child, as well as the ability for the mother to monitor the babies temperature and heart rate. It would also allow the mother to play .mp3 lullabies to the baby If built, they'd probably have to ditch the idea of monitoring temperature since any readings at the wrist would be poor indicators of core body temperature, but connecting parent and child via bracelet is a good idea that has promise and it'd be great to see this built. More from Yanko Design: Sikker is for Safety...
Sean Duffy
www.medgadget.com
Read more [Medgadget]
Life Coach Mountain View
Life Coach Mountain ViewRead more: Life Coach Mountain View, Life Coaching Mountain View
Life Coaching Mountain View tries help you by approaching coaching from a NVP method. We will sit down with you and talk over what it is you actually want and need. In this way, we will extract the most value from life coaching.
Read more [Medical Informatics Blog]
Paying the Bill
In June of last year, Dr. Pat Santy, writing in her blog, Doctor Sanity , declared her disgust with the healthcare bill, which now seems to be placed firmly about our necks. I can't say it any better than she does below:
I'm done.
My entire professional life as a physician and psychiatrist I have been exceptionally vocal about the prospect of government medicine here in the US. I have given impassioned speeches (when I was younger); written essays in medical journals and elsewhere; and talked until I am blue in the face to anyone and everyone about the horrors of socialized medicine and government interference in the health care system of this country. Once it would have seemed impossible that I would ever want to quit medicine; to stop practicing psychiatry.I have watched with dismay as every year we have inched closer and closer to the Democrats and the left's goals; goals which I firmly believe will completely destroy American medicine. I have watched up close and personal the utter soul-destroying consequences to both patients and doctors alike, of the pervasive cultural collectivist and looter thinking in my specialty. Every time this madness is killed, it just doesn't stay dead. Like some kind of putrefying zombie, the left just keeps resurrecting it. Logic doesn't matter. Facts don't matter.
Let's face it. To the zombies of the left, reality doesn't matter. With President Postmodern in office, aided and abetted by zombie hordes in Congress; why should I pretend anymore that it does?This time around, I JUST DON'T CARE ANYMORE. If that's what people want, so be it. I'm done. If Congress passes Obama's destructive zombie health plan in any form, I quit.I will simply not practice medicine anymore. I will take my psychiatry books and my years of experience and do something else. I used to wait tables when I was in college. It's an honest living and Obama isn't interested for the time being in nationalizing restaurants--yet.=Let me be clear. I don't believe that people have a "right" to health care; because, what advocating such a "right" basically means is that you believe you have a "right" to my mind; you have a "right" to my professional competence; i.e., you have a "right" to enslave me.
Having chosen to work primarily in the public sector most of my life, I have watched this entitlement and victimhood mentality grow to incredible proportions in parallel with number of laws, regulations, administrators, and oversight agencies. I have watched the decline of personal responsibility and the rise of endless demands and impossible clinical and psychosocial conundrums that I am expected to solve, even if my patient has no desire to change. I have been demoted to the near-mindless activity of pushing pills to the point that I understand why my collegues see every clinical situation as a biological malfunction--the old adage that says, to a hammer everything looks like a nail, comes to mind. Psychiatrists are the mental health profession's hammer; and drugs are the nail. And, the same powers that tell me to prescribe drugs, warn me against the evil of working too closely with any of the drug companies, for fear I might be corrupted, God forbid, by the dastardly profit motive.I have watched as the quality of care has inevitably deteriorated even as spending went up. I have watched the system abuse patients and doctors alike--to the point that the frustration level just keeps going up and is simply not worth it anymore.I quit my memberships in the AMA and APA some years back when I realized that they were not really in it to make things better for doctors or patients. Perhaps at one time they were real advocates for both, but now they are like most of those supposedly "capitalist" businesses--like AIG and all the others-- who willingly feed at the government trough and can't get enough of that yummy government pork. They sold themselves long ago--in both areas of clinical and research medicine-- in order to have a place at Big Government's table....We will all see what happens when and if the zombies take over health care in this country and make it all like Medicare and Medicaid....and GM and Fannie Mae and etc. etc. I expect a Zombie Health Czar (Barney Frank would be perfect) will be appointed any day now. Someone who will have control over doctors' compensation and drug company profits. Someone who won't have to answer to the public who can control implementation of any aspect of the zombie plan that needs to bypass intelligent scrutiny.Even with the vote, it isn't quite over yet. Many state Attorneys General (including ours here in South Carolina) plan to fight this monstrosity on the basis of Constitutionality. It is felt that the Federal Government does not have the right to force citizens to purchase a product, any product. We will see.
Read more [Dalai's PACS Blog]
The Biomarkers Consortium Launches I-SPY 2 Breast Cancer Clinical Trial
THE BIOMARKERS CONSORTIUM LAUNCHES I-SPY 2 BREAST CANCER CLINICAL TRIAL
Highly Anticipated Multi-Agent Trial Opens at Major U.S. Medical Sites
Groundbreaking Public-Private Collaboration Combines Personalized Medicine and Novel Trial Design to Develop Potentially Life Saving New Breast Cancer Drugs
BETHESDA, MD – March 17, 2010 – The Biomarkers Consortium, a unique public-private partnership [...]
Read more [GooMedic.com]
John Glaser, CIO of Partners Health Care, speaks with David Harlow about health IT and meaningful use in a $7.9 billion health system
What does a large health system CIO worry about if his system is already fully up to speed in the day-to-day use of EHRs? Using them in ways that improve communication of information across a diverse group of clinicians, and that enable the integration of additional interesting and useful data as time goes on -- such as the integration of genetic testing data into the diagnostic and treatment logic built into the EHR. John Glaser explains how Partners uses its EHR system to leverage knowledge for the benefit of patients, and describes some of the ways in which decision support systems are being used today and may be used in the future. Tools in place at Partners now: [T]here is
for example a monthly report put out on dozens and dozens of quality
measures and they are coded red, yellow, green depending where we are
relative to the national benchmarks and that . . . allows us to focus
on areas that do need some attention. In addition to that you can use
the systems like CPOE or the EHR to introduce logic at the time of
care, so to make sure that an order is a safe order or that an overdue
health maintenance activity has been noted and followup is occurring. ... [L]argely at this point focused on cancer . . . we do have
decision support that says before you order this chemotherapeutic agent
you should run this genetic test because that will tell you whether the
agent will or will not be successful. We do have a piece of software
called the patient genome explorer which sits right beside the results
viewer for chemistry results, and this allows you to look up genetic
test results and understand the ramifications for the patient you are
treating. Glaser acknowledges the difficulties that may be faced by smaller provider organizations in gearing up to meet the meaningful use criteria related to EHR implementation, but notes that for him, there is no separate ROI calculation for implementation of these tools, saying I mean,
what’s the ROI of email? Beats me but, nonetheless, few of us could get
through a day without it. At other times the ROI is quite tangible
because you could say golly, we are cutting real costs here or making
real revenue. At times the outcome is tangible - it may not always be
expressible in terms of dollars. You can, but that’s not the point. . . . So I think we will see a
return broadly speaking . . . . I think at the end of the day it is one of those
things which you say listen, this is a given. It is hard to imagine
that we would sit here today and say if ten years from now we ran our
health care system on paper that would be okay or a good thing. The Partners team has the luxury of being able to spend significant time on R&D, and Glaser says that we do have
some people who are looking at different techniques to be applied to
putting a layer of logic on top of complex and idiosyncratic data
coming in, and teasing out that sort of data. So, for example, if you
know that there are, let’s say, 200 notes [in a patient's EHR, entered by a variety of clinicians] and that the patient is being
seen by a cardiologist, you just have the system be able to identify
that subset of notes that appear to have a bearing on the consultation
in question and being able to categorize those notes for the doctor, so
that he or she can say jeez, of the 200, there are five that are
related to prior cardiac events, there are four that are related to
what appear to be cardiac procedures . . . to help to filter
through and surface that subset of note, or other data, which appears
to be the most salient. So we are learning. We are trying a bunch
of different techniques to figure out how to do that. The audio file of my interview with John Glaser (about 25 minutes long) is available for download/podcast. A full transcript is at the end of this post (and in the linked John Glaser, CIO, Partners Health Care, HealthBlawg interview transcript).
The Harlow Group LLC
Health Care Law and Consulting
Interview of John Glaser, CIO of Partners Health Care
March 3, 2010
David Harlow: This is David Harlow at HealthBlawg, and I have with me today John Glaser, the CIO at Partners Health Care in Boston. Hello John, thank you for joining us.
John Glaser: It’s a pleasure, David.
David Harlow: So Partners Health Care - for those of you who are not familiar with it - is an organization that includes ten hospitals, 7000 physicians, 45000 employees. Have I got that right, John, more or less?
John Glaser: Yes, you do.
David Harlow: And John has been the CIO at Partners for quite some time. He’s also been acting as an advisor to the ONC on implementation of the HITECH Act since last spring. We’ll try to steer clear of government-related issues today and focus on issues at Partners. So John, moving beyond the numbers, how would you describe Partners Health Care and what it means to be CIO of Partners?
John Glaser: Well, Partners Health Care has got a couple of attributes. One is it’s large, so we’ve got another number to put in there, it’s about 7.9 billion in revenue and in addition to its hospitals and extensive array of outpatient clinics, physician practices and 90 key facilities, it’s a very large, very complex organization. It’s also quite academic given its two founders [Massachusetts General Hospital and Brigham and Women’s Hospital, both of which are major teaching affiliates of Harvard Medical School]. So it has tremendous resources, tremendous talent, some world class organizations, and using those assets it can be a challenge at times to line everybody up and have the organization move in a concerted direction. I guess that’s true of all large organizations, although we certainly feel that at Partners. And while that can be difficult at times, the fact that there is such talent, and there is such a commitment to the mission of care, research and education makes it worthwhile and enables us to accomplish - from time to time - some very remarkable things.
David Harlow: Would you say that things have gotten easier as the association has lasted longer, or more complex as it’s grown larger? You’ve been with the organization quite some time now and I was wondering how things have changed over the years.
John Glaser: Well I have been for quite some time. I’ve been the CIO since 1995 and so that’s a little over 15 years. And prior to that, CIO at the Brigham for another seven years, so 22 plus years in the family as a whole.
So I think it’s very clear that as the organization has matured and has begun to understand how to work together, that it is more effective at working together, bringing together very disparate organizations, large AMC’s, small community hospitals, for example, bringing together people who may or may not have a track record of working together. So it is better at moving as an integrated system than it has been in years past.
On the other hand, the challenges it has to address have become more significant so there are greater cost pressures today than there were ten years ago and there are greater quality pressures than there were ten years ago.
The pace of medical innovation and events are more significant. As our community of clinicians and others have become more experienced with the technology, they also become more demanding and more sophisticated. So the demands and the expectations are higher and have been paralleled by a growing ability to work together as a collective.
David Harlow: So going back to a couple of things that you said specifically, I’m wondering if you could tell us, how does the health information technology function within Partners help to enable the organization to deal with some of these issues - whether it’s adherence to quality measures; whether it’s dealing with payment issues - and, how does your function, your part of the organization’s function integrate with the clinical function?
John Glaser: Well, there are a number of ways in which we try – and, at times, succeed - in helping Partners address these challenges. At times we take processes and make them more efficient and save money in addition to having those processes work faster, be less error-prone, etc.
By providing data that comes out of the EHR, the organization’s in a much better position to look at variations in care practices and identify those practices that are more efficient than others, that are of better quality than others. I actually have the data to assess quality and to then deal with that variation in whatever manner it chooses to do so. So the fact that you have clinical data, and data that also brings along the cost component of that clinical data, allows us to look at where we need to do some work, where we don’t.
So there is for example a monthly report put out on dozens and dozens of quality measures and they are coded red, yellow, green depending where we are relative to the national benchmarks and that again allows us to focus on areas that do need some attention. In addition to that you can use the systems like CPOE or the EHR to introduce logic at the time of care, so to make sure that an order is a safe order or that an overdue health maintenance activity has been noted and followup is occurring.
So through the transactions systems one has the ability to carry out a lot of the guidance and recommended care that comes out of the data activities. So there is a series of analysis capabilities and transaction capabilities that help address this complicated mixture of cost, quality and safety. But also in addition to that is the ability to adapt. So for example it’s fairly clear in the next several years - 3 to 5 for example - genetic testing will be increasingly a lager component of health care because of our greater understanding of your genetic makeup and how it guides treatment decisions, or what disease you really have.
And so the ability of systems to adapt and to capitalize on advances in medical care, to capitalize on advances in care models such as the medical home or accountable care organizations, and also capitalize on the gains that new technology can bring - that we are trying to make sure that our infrastructure and applications are able to move as the collective environment moves.
David Harlow: Now I understand a few years back you established together, Partners established together with Harvard Medical School a center for genetics and genomics and is this what you are talking about, is this informing some of the care management, is there genetic testing data that’s included in patient profiles that can be used to guide clinical services?
John Glaser: Yeah, we formed several years ago what is now called the Partners Center for Personalized Genetic Medicine, and it has two major roles. One is to facilitate research into the genomic basis of disease or treatment variability. So for example if you are clinically depressed and given an SSRI, it works well a third of the time, medium well a third of the time and not at all a third of the time, and so helping investigators determine whether there’s a genetic underpinning to that.
So we’ve learned a lot and this will help accelerate research into how genes contribute to our disease and our treatment success for example. In addition to that, that is also not only because of the advances themselves but the knowledge of how do you store genetic test results and what does genetic decision support look like, how do you present genetic test results to the clinician. It’s begun to make its way into the clinical systems, largely at this point focused on cancer, but we do have decision support that says before you order this chemotherapeutic agent you should run this genetic test because that will tell you whether the agent will or will not be successful. We do have a piece of software called the patient genome explorer which sits right beside the results viewer for chemistry results, and this allows you to look up genetic test results and understand the ramifications for the patient you are treating.
David Harlow: Is there an overlay now with the GINA legislation on top of HIPAA in terms of privacy requirements and protection requirements, encryption, others, relating to genetic information that’s on the system or does HIPAA deal with that sufficiently?
John Glaser: Well, there are clear genetic privacy ramifications for all of this and it gets complicated. I will give you two examples. If a genetic test were to say that you or I were at great risk of a debilitating form of dementia, one would say, well, I ought to keep that private, because of – for lots of different reasons.
On the other hand, a genetic test result that says you will be a slow metabolizer of sulfa drugs, you might say -- jeez, I’m less worried about loss of job or loss of insurance based on that. But I do want my doctor to know because I do want to make sure they don’t inadvertently overdose me on a particular drug. So genetic test results actually span the gamut of those which are highly sensitive to those which I think most people regard as no more sensitive than a blood potassium reading.
And given that, nonetheless, what we have decided to do is to treat any genetic test result as being in the same category as the most sensitive data and so this is HIV data, this is mental health data - we treat that and provide both the policy procedure the consenting processes for example but also the IT controls over that type of data that we would - I think perhaps society may evolve to the point where it categorizes genetic data into different forms or buckets of sensitivity. But until that’s the case, we will treat it as the most sensitive.
David Harlow: So you’re not looking to get patient consent to disclose certain types of genetic information like for example the way you would…
John Glaser: Yeah just as you would on any sort of highly sensitive set of data.
David Harlow: Okay. One area of interest at Partners is the electronic health record and the use of electronic health records over time, which, I understand, is a home grown system. Is that right?
John Glaser: Yes - the bulk of our, we have approximately 4200 physician users of our outpatient EHR, 85% use the homegrown version and 15% use a mix of GE and a couple of other systems that have been in place for quite a while.
David Harlow: And what would you recommend, having had the experience with both? What words of wisdom would you have for other providers who are looking at implementing EHR systems in this era of HITECH incentives?
John Glaser: Well I think these systems, whether you build them yourself or you buy them from the market - and most people buy them from the market, and most people should buy them from the market - these are a challenge to get in place. They are very invasive to the workflow and so a physician, or a nurse practitioner or any other health care professional who now is documenting on them, writing orders on them, reviewing results, - it’s very invasive. It’s not something that is kind of off to the side.
And as a result there is a great deal of demand for systems that have a lot of strong features, functions, but also are very usable and quick. It requires that workflow be understood, changed if necessary and that includes where do you place printers and things like that. It requires a good deal of training and some strong support, and I think practices who undergo this should be prepared for several months - and it seems to vary at least in our practices, sometimes it’s as long as six months, sometimes it’s short as two months - where there is a form of disruption and people just getting their feet wet and getting oriented to this. So there are a lot of demands on the systems, there are a lot of demands on the implementation process and the workflow change process and there are a lot of demands on support, and obviously there are a lot of demands on the practice who goes through this. Nonetheless once you get through that we have never had any clinician of any form say I wish I could go back to paper.
They clearly see that the care is better, that there have been some efficiencies gained, there’s been some challenges. Sometimes it takes longer to do certain tasks. But nonetheless it is a journey that is - both from the care perspective and the cost of care overall but also the ability of the providers to say I’m practicing good medicine, must be able to say that. So I think it is a hard journey but it is a worthwhile journey that the federal government incentives recognize the importance of us collectively moving in that direction.
David Harlow: Part of the issue is the interoperability, the opportunity for free exhange of data from one provider’s electronic health record to another, to be able to follow a patient across care settings. Given the size and the scope of the Partners network, I’m wondering how important the development of RHIOs and health information exchanges are to Partners? Are patients who are seen within the Partners’ network receiving all of their care within the network?
John Glaser: No and I think that some networks are more closed than others; the VA, Kaiser, are more closed than others. For example, almost 50% of our referrals – remembering we’re academic at our core - come from physicians outside of Partners. So we have extensive movement of people in and out of Partners, some stay within the Partners community but a lot don’t.
So I think this notion of exchanging data is critical, and it runs a sort of a gamut, it runs a gamut of giving the referring physician access to the core institutional systems, to the gamut of the movement of a structured transaction - maybe it’s an operative note, maybe it’s a set of chemistry results - from one system to the other. At times we have clinical affiliations which are very strong and we wind up with shared scheduling systems, shared email systems and much more extensive integration and interoperability.
So I think the basic rubric of putting out standards and encouraging the exchange is a very important set of activities. It creates parallel issues, it creates issues of making sure that the privacy and the security steps necessary are put in place, because we now have different privacy and security challenges when this occurs. It also places a challenge on the providers who now may be going into their EHR and seeing lots and lots of data from lots and lots of other providers and saying holy smokes, I have a brief period of time with this patient, but I have 200 notes and 180 of them are not mine. How do I wade through these and determine which ones are the most important? So a knowledge management function, and a decision support function, and a set of guidance using all of the above, might help the physician zero in on the most clinically relevant - becomes a challenge. So there is, there is great gain to be had. It does bring some parallel challenges that we still need to address.
David Harlow: Have you seen some movement in the direction of being able to wade through those kinds of notes, the kind of volume of notes there might be from outside providers, any sort of knowledge management systems that you are using or that is on the market today?
John Glaser: Well, I don’t know about on the market. We are, as an IS group, unusually academic in our approach - about 15% of our staff are funded by federal grants or through industry partnerships to explore leading-edge topics in healthcare IT and they run the gamut from what is known as telemedicine, to genetic medicine, to knowledge management – things like that.
But we do have some people who are looking at different techniques to be applied to putting a layer of logic on top of complex and idiosyncratic data coming in, and teasing out that sort of data. So, for example, if you know that there are, let’s say, 200 notes and that the patient is being seen by a cardiologist, you just have the system be able to identify that subset of notes that appear to have a bearing on the consultation in question and being able to categorize those notes for the doctor, so that he or she can say jeez, of the 200, there are five that are related to prior cardiac events, there are four that are related to what appear to be cardiac procedures. So anyway to help to filter through and surface that subset of note, or other data, which appears to be the most salient. So we are learning. We are trying a bunch of different techniques to figure out how to do that.
David Harlow: On a related note, some of the tools and products that have been on display at HIMMS this week or announced at HIMMS this week down in Atlanta – I’m wondering whether there are categories or particular types of tools coming out of that conference and from the exhibitors there that are of particular interest to you, something that catches your interest?
John Glaser: Well, I was at HIMSS for only a day and I was only briefly on the exhibit floor so I didn’t get a chance to see what was going on. I think in general obviously the major topic is the federal stimulus funds and how to address those. So I think tools that invariably help providers to meet those meaningful use requirements or the standards and particularly help the smaller physician practice, the smaller hospital, which have very low adoption rates and have in general, not entirely but in general, not been as well served by the market as the larger organizations as technologies that are directed there are of great interest. Anyway I didn’t have a chance to personally see a whole lot of the exhibit floor.
David Harlow: Fair enough. What would you identify now as areas of opportunities as well as areas of challenge in adopting not only EHRs but also other health information technology tools across the health care spectrum? Maybe speaking from your experience within Partners but also as you mentioned looking at some of the smaller providers which is where I think collectively we’re hoping there will be greater adoption.
John Glaser: Well I think broadly, and across the country, we still have the challenge of getting higher adoption rates and now meaningful use of those technologies so those of you folks listening to this know the rates as well as I – but they’re low. So that challenge which has been with us for a while, it’s still with us, and perhaps we’ll have a series of factors that will cause us to pursue it more aggressively and I think in particular, as has been mentioned before, it’s the smaller provider organizations which need the most innovative approaches to the delivery of these systems in helping those patients, and remembering that two-thirds of all of outpatient visits occur in physician practices of three or fewer docs. That’s where the bulk of care occurs in the US. So there is - that challenge is going to be with us for quite some time - several years. And all that implies - the difficult work of implementation and some of the comments mentioned earlier. In addition to that it is also clear that there are some opportunities emerging or at least will be different as result of broad adoption of interoperable electronic health records. One is itself the management of interoperability at scale, protection of privacy, the assurance of standards, helping docs deal with large volumes of information. And so there will be a series of things we’ll have to do and understand this is when you have interoperability at scale, what gain really occurs but also what challenges are present or revealed that we still need to develop tactics and tools to deal with.
The other is that there is a clearly going to happen or beginning to happen now, large accumulations of data about patients which can be used for comparative effectiveness research, clinical research, post-market surveillance of medications and devices, public health surveillance, etc. And I think we have a lot to learn about how to manage that data, not only the protection of privacy but also how to distill patterns out of data which is often conflicting, noisy or incomplete.
The third area - we still have a lot of ground to cover - is how best to engage patients; we use the technology to engage patients - personal health records, personally-controlled health records, a lot of targeted applications where you can measure your blood sugar or your blood oxygen saturation, or whatever it might happen to be - people with chronic disease; we have a lot to learn there.
So lots of promise there but still relatively small levels of adoption and very limited understanding of how much of a contribution this will make to the management, let’s say, of a chronic disease, or the gradual improvement of health. So there are a couple of big areas.
I guess one other big area is - if we have large bases of knowledge or decision support across wide ranges of systems - is managing this knowledge base. A knowledge base of rules or order sets or templates, it is now quite sizable, which changes from time to time. And I think one of the factors of our growing knowledge of the relationship between the genome and our health is whatever volume of decision support rules you think there are now – it’s going to go off the charts as that becomes increasingly incorporated into medical practice, so how best to manage that knowledge base and to ensure that it’s effective remains a daunting challenge.
So, as we address the core one, getting these systems in place and used well, and broadly looking at a series of challenges coming up that will result from the broad use of interoperable electronic health records.
David Harlow: Do you see a direct correlation between the advances in the systems and the return on investment, if you will, or is this just part of the infrastructure that has to be in place in the future? Is this just like you need to have a telephone, you need to have this…
John Glaser: Well I think it’s a combination of things. One is technology at the end of the day is a tool and, per se, guarantees no ROI and you see that in some of the studies they’ve done or sometimes great gains in patient safety have occurred, sometimes they haven’t, and sometimes the organization runs more efficiently and sometimes it doesn’t.
So we have very variable outcomes and partly because it’s not the tool that delivers the outcome, it’s the way that it is implemented and how effective it is. So we will continue to see that because again it is at the mercy of the skill of change management and leadership and a wide variety of other things so, given that, we also recognize that that the nature of the return is really diverse, at times it is very intangible - I mean, what’s the ROI of email? Beats me but, nonetheless, few of us could get through a day without it. At other times the ROI is quite tangible because you could say golly, we are cutting real costs here or making real revenue. At times the outcome is tangible - it may not always be expressible in terms of dollars. You can, but that’s not the point. So if you are, if you deliver safer care, you can certainly measure the dollars there but those aren’t really the measures that people are focused on - or improved service.
So I think we will see a return broadly speaking - realizing how tangible or intangible, how dollarizable or not dollarizable it is, to the sort of settings in which it’s delivered. I think at the end of the day it is one of those things which you say listen, this is a given. It is hard to imagine that we would sit here today and say if ten years from now we ran our health care system on paper that would be okay or a good thing.
I think there are very few people who would stand up and try to carry that argument forward - at a face validity level, and at an empirical level, it just doesn’t make sense. So I think the basic idea that if we really want to make extraordinary gains in the care in this country you have to have this foundation in place. The foundation doesn’t guarantee it but it’s hard to imagine that you would accomplish it without it.
David Harlow: Well, thank you very much.
John Glaser: My pleasure. I hope this is interesting and informative, and I appreciate the time.
David Harlow: It certainly is. I’ve been speaking with John Glaser, Chief Information Officer at Partners Health Care in Boston on implementation of health information technology and the improvement of health care. Thanks again, John.
John Glaser: All right. Thank you, David.Related articles by Zemanta
Read more [HealthBlawg - David Harlow's Health Care Law Blog]
Overdose
Overdose
[copied from half way through]
To cut the story short, after a day on the treatment, it was decided that this poor bloke needed a liver transplant as the liver was failing. An organ your body cannot do without and, unlike the kidneys with dialysis, there is no artificial support method for a damaged liver. Either he will get a liver transplant in time, or he will die. Pretty shocking news for his family.
A couple of days after seeing this patient, myself and the other 5 students on my firm were discussing some of the patients we had seen that week. Most of us had met the same patients, but had all spent varying time with each one, so talking about the patients with each other lets us learn more. I was talking to my colleges about the patient who had come in with a paracetamol overdose, and the fact that he will now need a new liver. One of my colleges, a nice friendly girl, usually with a smile on her face, goes and drops a bombshell of a reply.
"Why give him a new liver? He destroyed his old one. What a waste!"
You are joking, right? All those years of boring ethics lectures and you can pop out a comment like that?
No, she wasn't joking. She genuinely and honestly thought that because this patient had damaged himself and destroyed his own liver he shouldn't be allowed a new liver and should instead be left to die. What about ex-alcoholics who need new livers? What about people involved in car accidents where they were exceeding the speed limit? What about people who decide to smoke and end up with lung cancer? What about people who eat too much, get fat and end up having a heart attack? Nope! They don't deserve our treatment because they did this to themselves!
Its quite simple. Mental illness is a disease, just like having a broken leg or a stroke. With the right management, care, and support into turning his life around this person will not remain suicidal for the rest of his life. Just because he was ill enough to think that suicide was the only way out of the situation he was in, does that mean you just want to go and kill him for it?
Anyway, I will not rant for too long on this case. It was just amazing to see someone who seemed like a nicely balanced, friendly person with a decent ethical education rain down judgement on someone whose life was so different from hers that she must have no idea of how he felt. How can you look down on someone who decided to take their life after all of these bad things happen if you haven't had them happen to you? How does this medical student know that if half these things had happened to her she wouldn't have gotten upset and tried something similar. And then how would she like to be told, once she was in a better place mentally, that she would be left to die because she had done this to herself. It is beyond belief. Anyway - I really hope that the next few years bring this eduction to those who need it on the course. I hope there are not that many third year medical students and upwards who would think like this.
Anyway, I wasn't that outspokenly offended by her - I showed by distaste (I think I might have used disappointment rather than distaste) in her views, but I have to spend time with her and don't want her to think that I am a massive morally righteous douche-bag so I kept it calm, but kind of regret that now.
[Blog continued at http://internal-optimist.blogspot.com/ ] if you want to read the full start/end etc!
Have a good week!
Read more [Medical Informatics Blog]
HIMSS 2010 Attendance Numbers
I always find the attendance numbers for a conference interesting. Ok, I pretty much find any statistics interesting. Just ask me about the statistics for my various websites and I can tell you them up and down. I’m a stats addict. So, it seems fitting that I share the HIMSS attendance stats: Here’s a nice graph of the numbers comparing HIMSS 2009 and HIMSS 2010: It really is quite amazing that the attendance at this conference was up despite this current economic recessions we’re experiencing. I guess government money will bring people out of the wood works. I wish that they would have shared percentage of clinical staff that attended. Yes, I’m talking about doctors, nurses, practice managers, etc. I actually saw quite a few in the sessions that were targeted at them. However, those sessions were generally poorly attended compared to many of the other sessions about policy or stimulus money. Also, if you look at the CEO, CIO and CTO’s that attended the percentages break out to about 6000 people. I wish I knew how many CEO, CIO and CTO’s there are in the healthcare space so I knew if 6000 was a large percentage or small. I also wish they would have broken out the CEO, CIO and CTO’s and told us how many hospital ones were at the show. I could have easily put down CEO of EMR and HIPAA, but that’s not the same as the CEO of a hospital. I think I know which one is better. Related posts:
Registration: 27,855, compared to 27,627 at HIMSS09, healthcare industry experts learning about the latest solutions for improving healthcare through IT.
Read more [EMR and HIPAA Blog]
links for 2010-03-19
Read more [FutureHIT]
EMR/EHR vs. PHR, ad nauseam
Mainstream media still don't get it. Personal health records and electronic health records/electronic medical records are not the same thing. Yet, on the agenda for next month's annual Association of Health Care Journalists conference is a panel entitled "Personal electronic medical records: What will consumers need to know?"
The meeting is here in Chicago next month, but I already have plans to be out of town. I'm debating whether to change those plans to attend this meeting, because there are some sessions that could be of value to me. I may want to go just to be a voice for reporting on health IT. The lack of focus on health IT was what made me quit AHCJ four years ago.
Every time I see the phrase, "electronic personal health records," my blood boils. Last time was this Dec. 2, 2009, article in something called eSecurity Planet that erroneously said the federal stimulus was paying for "electronic personal health records." I used this story as an example for a yet-to-be published piece I've written for Reporting on Health, a project of the USC Annenberg School and California Endowment Health Journalism Fellowship.
For the record, I define an EHR as, at least in theory, a comprehensive digital collection of information about an individual’s health and medical status that encompasses multiple care settings. EMR means a record tied to a single facility or organization. The two phrases often are used interchangeably, and I think that's OK for now.
A PHR, to me, is a record that patients can view, update and control access to. It is a subset of an EHR, not a synonym.
Read more [Neil Versel's Healthcare IT Blog]
BrainLab Takes iPhone-like Digital Lightbox to Next Logical Step
We have previously mentioned that BrainLab's Digital Lightbox reminds us of a giant iPhone. Clearly agreeing with our way of thinking, last week at the American Academy of Orthopedic Surgeons we saw BrainLab demonstrate an implementation of their knee navigation software that simply uses an iPhone/iPod Touch, coupled with a passive tracking attachment and iPhone App. The iPhone, with attached markers, is used to identify bony landmarks on the knee, which are then fed into the BrainLab software for 3-D guidance of knee surgery. The iPhone screen is used as the display, both for marker placement prompting and leg-alignment indicators during the procedure. Using the motion tracking sensor and the iPhone as an input and display, rather than the other solutions BrainLab supports (shown below), reduces the footprint needed in the OR. There is no mention of the iPhone version of their imaging suite on the BrainLab website, but the FDA 510(K) clearance given for its Uni-Knee software does not define the display technology used, seemingly allowing this configuration. uni-knee product page... FDA 510K Summary......
Michael
Read more [Medgadget]
Webinar on Certification Programs for HIT NPRM March 25, 2010 4:00 – 5:00 p.m. EDT
This came from the nice folks at ONC this morning: On March 25, 2010 from 4:00 – 5:00 p.m. EDT, The Office of the National Coordinator for Health Information Technology (ONC), with the National Institute of Standards and Technology (NIST), will present a webinar on the recently released Certification Programs for HIT Notice of Proposed Rulemaking (NPRM). Public comments on the NPRM are now being accepted. The temporary certification program’s comment period ends April 9 and the permanent certification program’s comment period ends May 10. Because this NPRM is currently in the comment period phase, this webinar will be solely informational and seeks to help listeners better understand the proposals included in the NPRM. Background Learn more about the NPRM at http://healthit.hhs.gov/CertificationNPRM To Participate Join the meeting (click this on the 25th before 4:00 PM) Audio Information First Time Users: Troubleshooting
Eligible professionals and eligible hospitals who seek to qualify for incentive payments under the Medicare and Medicaid EHR Incentive Programs are required by statute to use Certified EHR Technology. This webinar will discuss the proposals included in the NPRM that would enable eligible professionals and eligible hospitals to adopt health IT that meets the definition of Certified EHR Technology.
There is limited space on this webinar. For those unable to join, there will be a transcript posted to the ONC website, http://healthit.hhs.gov, by March 29, 2010.
Dial-In: 1-888-673-9805
Participant Passcode: 9033671
To save time before the meeting, check your system to make sure it is ready to use Microsoft Office Live Meeting.
Unable to join the meeting? Follow these steps:
Read more [The Healthcare IT Guy]
Hitachi Offers Its Own Take on Ultrasound Elastography
Major ultrasound companies Siemens, GE, and Philips have all offered differing flavors of ultrasound elastography, and now Hitachi has entered the market with Hitachi Real-Time Tissue Elastography (HiRTE). Elastography is a technology that uses ultrasound to tell clinicians about the relative tissue hardness, approved in Europe for identifying firmer, possibly cancerous, regions of soft tissues such as liver, breast, and prostate. It uses the visualization of the propagation of mechanical waves through the tissue to derive either a shear wave velocity or a Young's modulus as a measure of tissues stiffness. Hitachi's claim about the measurement being real-time is in comparison to other providers of elastography which require post-processing of static images either at another workstation or after the image is taken. The Hitachi application will be part of its compact platform Hi Vision Avius. From Diagnostic Imaging: Hitachi Medical Systems has been a pioneer in the clinical development of elastography and is offering its own version of this technology, Hitachi Real-Time Tissue Elastography (HiRTE), as a key application on its new compact ultrasound platform, Hi Vision Avius, which follows last year's launch of the Hi Vision Preirus. The application is part of a package of advanced product features on the new machine, including established technologies such as Hi Rez+ (tissue adaptive filtering), HdTHI (high-definition dynamic tissue harmonic imaging) and Hi Com (frequency and spatial compounding), as well as new features such as RVS (real-time virtual sonography). The latter is a software application that uses magnetic tracking sensors on the ultrasound transducer to display real-time freehand ultrasound images alongside synchronous other images. Elastography may also have applications in cases of rectal cancer. More from Diagnostic Imaging: Elastography advances feature prominently among ultrasound exhibits... Product page: Hitachi Real-time Tissue Elastography (HI-RTE)...
Michael
Read more [Medgadget]
Sneak Preview of Dr Nano X Game for iPhone
Mission Critical Studios, makers of DR Nano iPhone game that we covered previously, is about to release the next version of the nanomedicine inspired video game. Here's what a company rep tells us about the new version: Dr Nano was basically a tunnel game in one environment. We took a different approach when creating Dr Nano X we treated as though we were creating a console game. Dr Nano X has new characters, new worlds to explore in the Nano Verse on foot, sub and swimming. New weapons... even a jetpack. Dr Nano X is all about the mission. Using the Nano Shrink Ray and the Mysterious Osmotic Effect move through the NanoVerse on a mission to save your patients (s). Battle defective Nanobots, Parasites, Viruses and more. Link: Mission Critical Studios... Flashback: Dr. Nano Nanomedicine Video Game Comes to iPhone...
Michael
Read more [Medgadget]
Study Claims First In-Vivo Gene Delivery
While gene therapy has seemed always just on the verge of being right around the corner, the limitation has always been delivery of the gene. How do you get the new gene to the right cells and activated? An in-vivo mice study in PNAS may take us closer to a usable delivery system. Rui Maeda-Mamiya of the University of Tokyo and others were able to get diabetic mice to increase their insulin levels after delivery of a insulin 2 gene by a water-soluble fullerene. From the study abstract: Water-soluble fullerenes are molecules with great potential for biological use because they can endow unique characteristics of amphipathic property and form a self-assembled structure by chemical modification. Effective gene delivery in vitro with tetra(piperazino)fullerene epoxide (TPFE) and its superiority to Lipofectin have been described in a previous report. For this study, we evaluated the efficacy of in vivo gene delivery by TPFE. Delivery of enhanced green fluorescent protein gene (EGFP) by TPFE on pregnant female ICR mice showed distinct organ selectivity compared with Lipofectin; moreover, higher gene expression by TPFE was found in liver and spleen, but not in the lung. No acute toxicity of TPFE was found for the liver and kidney, although Lipofectin significantly increased liver enzymes and blood urea nitrogen. In fetal tissues, neither TPFE nor Lipofectin induced EGFP gene expression. Delivery of insulin 2 gene to female C57/BL6 mice increased plasma insulin levels and reduced blood glucose concentrations, indicating the potential of TPFE-based gene delivery for clinical application. In conclusion, this study demonstrated effective gene delivery in vivo for the first time using a water-soluble fullerene. PNAS Article Abstract: In vivo gene delivery by cationic tetraamino fullerene Image from PDF of article....
Dan Buckland
Read more [Medgadget]
Envoy Esteem: First Totally Implantable Hearing System Gains FDA Approval
The FDA has given approval for Envoy Medical's Esteem hearing system, the first totally implantable prosthetic for moderate to severe sensorineural hearing loss. The system detects vibrations at the eardrum, processes the signal digitally, then applies physical vibrations directly to the cochlea. Clinical studies showed that 56% had improved hearing with the Envoy Esteem compared to their pre-implant hearing aids. However, 7% experienced facial paralysis and 42% experienced taste disturbance as a result of the surgical implantation of the device. Envoy will follow up with a new study of 120 subjects to further evaluate post-implantation complications and device effectiveness. Video of how the Esteem works... Press release: FDA APPROVES FIRST OF ITS KIND, FULLY IMPLANTABLE (SURGICALLY), INVISIBLE, PROSTHETIC HEARING RESTORATION DEVICE... Product page: Envoy Esteem... Flashbacks: Esteem Totally Implantable Hearing Device Under Consideration for Approval in US; Esteem Totally Implantable Hearing Device On Track for US Approval...
Michael
Read more [Medgadget]
Cell Levitation to Build 3D Matrix Structures
Jokes about needing special glasses aside, Nature Nanotechnology published a letter on March 14, 2010 describing progress in three dimensional cell culture technology from Glauco Souza, et. al. at the Texas M.D. Anderson Cancer Center. According to the research team, prior attempts at 3-D culture have included “protein based gel environments or rotational/agitation-based bioreactors” and yet “broad, practical application of such methods has not been achieved.” The novel method they describe uses magnetic fields to manipulate cells which have endocytosed “gold-hydrogels” which incorporate magnetic iron oxide. Once the cells have taken up the iron in the hydrogel, a magnetic field is applied which levitates the cells, allowing them to grow in a three dimensional architecture as opposed to the standard two dimensional fashion. One benefit of this technology as reported in the letter is the flexibility of the cell culture medium. Current products available use a fixed chemical environment in their scaffolding to support three dimensional growth of cells. Because certain cell populations have specific metabolic requirements which must be met by the culture medium, the fixed chemical environment of existing 3-D culture techniques may preclude specific cell populations from being used. However, because this technology does not rely on a chemical environment, cell lines are not limited by the medium they grow in but rather the ability to take in the iron laced hydrogel. The researchers state the potential applications of their work include “biotechnology, drug discovery, stem cell research, or regenerative medicine.” They go on to say, “Indeed, a potential long-term goal is the possibility of accomplishing the ‘engineering’ of normal tissues or complex organs.” The technology has been licensed to n3D Biosciences out of Houston, Texas. M. D. Anderson press release: 3-D Cell Culture: Making Cells Feel Right at Home Abstract in Nature Nanotechnology: Three-dimensional tissue culture based on magnetic cell levitation Link: n3D Biosciences......
Michael
Read more [Medgadget]
Missouri State Senator Wants Docs to Invade Patients’ Privacy
Meet Tom Dempsey, a threat to the privacy of women in Missouri. State Senator Dempsey recently introduced a bill, SB 792, that would have doctors invade their patients’ privacy and require doctors to try to give patients information that supports his religious agenda even if the patients do not want it. Emphasis added by [...]
Read more [Personal Health Information Privacy]
Information Superhighway Through Your Arm
Scientists at Korea University in Seoul have demonstrated a prototype of a new biomonitoring system that transmits data through the body, replacing wires and minimizing the need for batteries. The device is 300 micrometres thick and in a test, using a metal electrode coated with a flexible silicon-rich polymer, the researchers transmitted data at a rate of 10 megabits per second through a person's arm. The device was tested for skin safety after continuous wearing and the data was transmitted via low-frequency electromagnetic waves through the skin. The technology may have implications for diagnostics, as it can be used to detect electric fluctuations as is currently done by ECG and EEG machines. Read on at New Scientist: Human arm transmits broadband... Abstract in Journal of Micromechanics and Microengineering: Wearable polyimide-PDMS electrodes for intrabody communication...
Michael
Read more [Medgadget]
Unruly Customers
There is a nasty old limerick that begins, "I have no aversions to mergin's with. . ." which is all I can repeat on this family-friendly blog. Well, I do have some aversion to, well, really fear of, AMICAS mergin' with Merge. As a loyal and vocal customer of AMICAS, I need to hear that the AMICAS product line will continue unscathed, which means that the majority of the development team and management will be kept on as well.
No doubt AMICAS never discussed my presence in the Blogosphere with Merge. That might have scuttled the deal right then and there. Just ask GE and Agfa if they enjoy basking in my reflected glory and attention. But its up to the buyer to perform due dilligence and discover these little glitches, and certainly the financiers at Morgan Stanley had the same obligation. I wasn't hiding anywhere, guys!
Merge has returned to viability, if not yet profitability, under the stewardship of Michael W. Ferro, Jr., Chairman and CEO, Merrick Ventures, LLC, owner of Merge, as well as Justin C. Dearborn, CEO of Merge itself. These are smart, successful guys. How smart and successful the lenders at Morgan Stanley are remains to be seen, but one would think they wouldn't release $250 Million without some chance of getting it back with interest. (Of course, this nation just experienced an economic meltdown due to the government forcing lending institutions to give out cash to people that couldn't possibly pay it back, but I digress. . .)
According to DOTmed.com, AMICAS has 250 installations at over 500 facilities. Centricity PACS is installed globally, with over 1000 sites (although none to my knowledge are running the IntegradWeb product purchased several years ago). Fusion RIS/PACS has 200 installs, and Agfa IMPAX has more than 400 sites worldwide. For those who weren't aware, Fusion is the descendant (and I don't know how much it has been changed since then) of the old eMed Matrix PACS.
Historically speaking, Merge bought eFilm in 2002, then RIS Logic in 2003, creating their first integrated RIS/PACS. Meanwhile, Cedara bought eMed in 2004, and then merged with Merge in 2005. From 2006 through 2008, Merge experienced "corporate reorganizations and restatements", and then "returned to profitability" when Merrick invested in it in 2008. This is a reasonable pedegree, not all that different from AMICAS as outlined here. But today, we have Merge with a smaller PACS base and significantly less capitalization buying up its larger competitor courtesy of a very large loan.
Potential PACS buyers, at least those who do their due diligence, often stumble on this blog looking for ideas as to what to buy or what not to buy. I don't have any illusions about my ability to influence anyone, but as the lone radiologist PACS blogger, I do get some minor degree of attention. As such, and as a customer and user of AMICAS PACS since 2004, I have strongly favored and advised its purchase. But, with the current state of affairs, I have to put that ON HOLD for the moment. We MUST hear something about the new owners' intentions toward their new acquisition.
If Mr. Ferro or Mr. Dearborn should feel so inclined to comment, this is what I would like to hear:
I realize this whole merger business was borne of a desire to maximize stock-prices, and as an avowed Capitalist, I must approve. However, as physician using AMICAS PACS, I have to get up on my bully pulpit (which is definately full of bully) and make these statements/requests/demands on behalf of all of us AMICAS customers.
Now we see why the AMICAS Board of Directors failed to include me in their portfolio. Nothing worse than an unruly customer with a blog.
Read more [Dalai's PACS Blog]
EMR Backups
My favorite part of HIMSS is meeting all sorts of interesting people. One of those people I met was Lyndsey Coates from Nuesoft. I have a soft spot in my heart for Nuesoft since they were the company that trained me on my first EMR. I still remember the 3 day intense training in their office. Lyndsey and I had interacted a few times before the conference and so it was nice to meet her in person. It was just too bad that we didn’t get to spend more time together. What does this have to do with EMR backups? Well, Lyndsey and I didn’t have much time together at the conference, but she sent me a nice bloggers “love note” in the form of a blog post about offsite EMR backup systems after meeting me at the conference. She even sent me a friendly tweet to let me know about the post. I was a little busy with HIMSS and all, but I’m always happy to share in a little blog sparring. So, Lyndsey, here we go. I’m really glad to hear you respect my opinion, but I’m a little surprised that you didn’t like my post about offsite EMR backup services. I guess I could have imagined that a SaaS EMR vendor might have a different view. In fact, you make a nice case in your blog post about the challenges of backup with the client server model. Definitely a number of good points for doctors to consider when selecting their EMR. However, somehow your post left out some of the problems related to backups with a SaaS EMR. No worries though, I’ll be happy to share;-) First and foremost, I can’t believe you think that doctors will trust an EMR vendor to back up their EMR appropriately. I mean seriously, we’re talking about my whole clinical practice stored on your servers and trusting that your IT staff are doing my backups? I don’t think so. I barely trust my own staff to do backups, so why would I trust my EMR vendor’s staff to do something as important as the backups of my EMR? No, I’m definitely not trusting you and your IT staff to backup my EMR. Maybe there are a lot of doctors that don’t do backups properly, but there are a lot of large vendors that don’t do backups properly either. Yes, even the all powerful Google lost some data because they didn’t have the right backups. Plus, if you’re doing my backups that means that you establish the policy and time frame that the backups are done. If I do them in house, I get to schedule the backups, verify the backups and see the reports and logs about when backups are done. I get to choose when and how often those backups are done. With you, I just have to hope that you’re doing them. Plus, there’s just something that doesn’t feel right about you having the backup of all my data. Maybe you don’t remember that the data stored in the EMR is my life. Not my literal life, but the life of my practice. Maybe you feel comfortable with my life being stored in your redundant data centers across redundant servers who mirror the data and all sorts of other cool backup processes. Personally, I feel comfortable knowing I have a backup of my life in my office with me. I can see it, touch it, pet it and know that it’s safe in my loving arms. Finally, let’s not call out my previous post about Offsite Backup Service for EMR for “missing the mark a bit.” While SaaS EMR are doing very well, there’s still a VERY large number of people who will select a client server EMR. Better to help them get their client server backup services right than to just tell them that they should have bought a SaaS EMR. Plus, maybe Nuesoft and other SaaS based EHR should consider partnering with one of these offsite backup solutions. I imagine a lot of doctors would love to have their SaaS EHR backed up to an offsite backup provider like the ones I mentioned in that post. Basically, a location that the doctor can access and control. Could be an interesting service to offer your clients. Your turn Lyndsey! P.S. I personally don’t care either way. I think that the client server or SaaS model are legitimate EMR solutions. Long term SaaS EMR are likely to win the day, but that’s still a long ways away. I do enjoy playing devil’s advocate though. Related posts:
Read more [EMR and HIPAA Blog]
Virtobot Performs Virtual Autopsies
Virtobot is the name of a forensic robot used at the University of Bern's Institute of Forensic Medicine to perform virtual autopsies. In the futuristic Virtopsy laboratory, the robot scans the contours and texture of the human body by projecting light bars on it and acquiring high definition images. These data are combined with the CT images acquired by the scanner in the same room. A three dimensional image of the body is then reconstructed that can be used during forensic examinations and be preserved as long as necessary. Additionally, the robot can also perform CT guided biopsies. The US forces have already installed a Virtopsy laboratory at Dover Air Force Base in Delaware to assess the cause of death of soldiers sent back from Iraq and Afghanistan. Video of the Virtobot in action: Press release: Digital future heralded for forensic medicine... The Virtopsy Project on Youtube......
Wouter Stomp
Read more [Medgadget]
Massachusetts health care cost trends hearings yield data, stir heated debate
Tuesday's Boston Globe reported that Harvard Pilgrim Health Care (one of the Big Three not-for-profit insurers here) released hospital payment data confirming what the AG's office had previously reported (and what has been widely surmised or known for years) -- namely, that certain hospitals get paid substantially more for the same services and results as are provided by other hospitals, based on their market power -- whether that is based on "brand-name" status of certain downtown teaching hospitals, or local geographic market power of relatively isolated providers. The AG's final report (press release with link to report) confirms this bottom line. Update 3/19/10: See Paul Levy's post on the hearings at Running a Hospital. Local iconoclasts Alan Sager and Deborah Socolar, Directors of the Health Reform Program at the Boston University School of Public Health presented their health care cost trends report as well, and see the Commonwealth as heading over a cliff. (The graphic reproduced above is drawn from this report.) The Massachusetts Hospital Association questioned the conclusions they've drawn from the data presented. The former CEO of Harvard Pilgrim, Charlie Baker, is Gov. Patrick's GOP challenger; as I've noted before, Patrick is seeking to re-regulate rates (while Charlie was instrumental in their deregulation). Tim Cahill, running as an independent, has attacked the Massachusetts health reform law; the Globe, in an editorial, castigated him for his invective, calling it "irresponsible demagoguery" in the face of some rather serious problems: These nightmarish projections at yesterday’s UMass hearing came from Len Nichols, health care economist at George Mason University. “We can’t afford business as usual,’’ he warned. Let's hope that the Commonwealth can have the space to effectively work out cost control -- the second leg of the proverbial three-legged stool of health care reform. In any event, health wonks around these parts will be glued to their screens Thursday
and Friday, as these hearings are being livestreamed. Folks elsewhere in the country may also find this instructive, given the close relationship between the Massachusetts approach and the approach to health insurance reform found in the Congressional bills now under consideration. David Harlow
The Massachusetts Division of Health Care Finance and Policy and the Attorney General's Office are holding three days of hearings this week on health care cost trends. You may wish to get up to speed by taking a look at the HealthBlawger's earlier review of preliminary reports on Massachusetts health care cost trends and positioning by key participants. There is a comprehensive collection of preliminary reports and testimony on the Commonwealth's website.
The Harlow Group LLC
Health Care Law and Consulting
Read more [HealthBlawg - David Harlow's Health Care Law Blog]
Peter Neumann, Director, Tufts Center for the Evaluation of Value and Risk in Health, speaks with David Harlow about the role of cost-effectiveness research in health care policy
The national debate on health care reform is currently focused on health insurance reform -- coverage, one of the proverbial three legs of the health care reform stool: coverage, cost and quality. In order to bend the cost curve -- no matter what the approach to health care reform: be it federal legislation, state initiatives, federal pilots and demonstration projects, and/or private sector initiatives -- most would agree that we need a rational approach to cost-effectiveness research, or comparative effectiveness research that we can all rely upon. Anyone who embarks on a search for such an approach will soon find Peter Neumann's Center for the Evaluation of Value and Risk in Health at the Tufts University Medical Center and the CEVR's Cost-Effectiveness Analysis Registry. I spoke with Peter this week about the use of "quality-adjusted life years," or QALYs, as a tool in standardizing the measurement of benefit derived from different interventions (be they medical, surgical, pharmaceutical), so that results of cost-effectiveness research used in the health care policymaking sphere can be compared, apples-to-apples, when we need to make tough decisions about paying for certain interventions and not for others. The Registry may aid in making such choices, since its purpose is to provide standardized summaries of all studies using QALYs to quantify benefits of interventions, allowing for easier comparisons to be made across interventions and across conditions. The audio file of my interview with Peter Neumann (about 25 minutes long) is available for download/podcast. A full transcript is at the end of this post (and in the linked Peter Neumann, Tufts CEVR Director, HealthBlawg Interview transcript). We also touched on the ways in which cost-effectiveness research may be used by clinicians and policymakers in their decisionmaking as one of an array of factors; American exceptionalism; communications failures (as in the case of the mammography guidelines released a few months ago); and the prospects for cost-effectiveness research to inform development of clinical practice guidelines in the future. HealthBlawg :: David Harlow’s Health Care Law Blog
The Harlow Group LLC
Health Care Law and Consulting
Director, Center for the Evaluation of Value and Risk in Health
Tufts University Medical Center
March 16, 2010
David Harlow: This is David Harlow at HealthBlawg, and I have with me today Dr. Peter Neumann, who is the Director of the Center for the Evaluation of Value and Risk in Health at Tufts University Medical Center here in Boston. He is also a Professor of Medicine at the Tufts University School of Medicine. Hello, Peter, and thank you for joining us.
Peter Neumann: Thank you, David.
David Harlow: So I would like to ask if you could, just for starters, introduce us a little bit to the work of the Center for the Evaluation of Value and Risk in Health.
Peter Neumann: Sure, well thanks for inviting me; I’m pleased to be here. Our Center focuses on a variety of health economics issues and essentially we are a group of economists and other researchers who are trying to understand how we can better spend our health care dollars, and we do that by measuring the cost-effectiveness of the value of different health care interventions. So we’re looking at pharmaceuticals, devices, procedures, public health programs - a variety of different strategies in health and medicine and trying to understand, in a sense, the health gains for the dollars that we spend in different areas, and how we can deliver health care and to improve health most efficiently.
David Harlow: Yes, so you work with private industry as well as with governments, I understand, and I’m wondering whether you see an openness to this sort of approach in the midst of the national debate on health care reform here in the United States; or whether there’s a different sort of openness or resistance to the quantification of these matters in the public debate here versus elsewhere in the world or in other circumstances.
Peter Neumann: Right, we do work with diverse groups; so we work on government grants, we work with foundation grants and we do work with private industry as well. So I think everyone recognizes we need to deliver care more efficiently and everyone recognizes that we have a cost problem and that formal analysis likely will help us understand what we are getting from what we are spending. That said there is a lot of sensitivity around using cost-effectiveness analysis openly. People are worried that it will result in rationing of care to people who need care, will result in denying care in ways that are unfair and so forth. So even while we recognize our cost problems, there is great concern that these techniques would be used inappropriately.
I think there’s more openness to using these techniques, broadly speaking, outside the US than inside the US. No one even overseas likes to deny care or ration or use cost- effectiveness analysis explicitly, perhaps. But I think there’s a greater willingness in many countries - certainly in many western European countries, in Canada, Australia, even countries in Asia – to set limits using cost-effectiveness information to inform health care choices, and that hasn’t been the case in the US to a large extent.
David Harlow: Yes, now one of the terms used in some of these analysis, including some of the analysis that you’ve written and participated in, is the term ‘the quality-adjusted life year’ which I think raises a lot of red flags for US-based listeners and readers; and I’m wondering whether you can help us understand how that term is used. What does that measure mean and how is it used explicitly or implicitly in the sorts of analysis that you and others are doing in this field?
Peter Neumann: Sure, so the quality-adjusted life year, or QALY, is a health metric, it’s a measure of health that combines morbidity and mortality into a single number. We often think about life expectancy as a metric that sort of helps us think about gains in health and we talk about people’s life expectancy, we might even talk about life expectancy gains with a new cancer therapy - say a new cancer drug may come along, and on average it increases one’s life expectancy for those with cancer say by one year.
All that a quality-adjusted life year is doing is adjusting that year of life gained with some information about the amount of impairment or disability lived in that life year. So you could imagine someone might gain a life year with cancer but they live that life in very poor health, so we would weight that life year by some amount. They would only get, say, a half of a quality-adjusted life year gained. So the quality has been…
David Harlow: Let me interrupt you for a moment; if I can like to interrupt you . . . Well, many patients or families would say well, I am happy to make that sort of assessment on my own, let me be the judge…
Peter Neumann: Sure.
David Harlow: Of whether a year in pain is worth half a year.
Peter Neumann: Sure.
David Harlow: Don’t let an economist make this decision for me.
Peter Neumann: Sure, there’s a lot of pushback to economists or - even worse - bureaucrats making these decisions that patients would like, and feel they should make on their own. So a QALY is really a population-based metric, in a way, it’s an average of sorts, averaging across different people in the population and we do that in all sorts of ways in health care. We average results from clinical trials into a single number, a new drug improves quality of life by so much and a new drug, a new program improves life expectancy by so much; and those are population-based metrics as well and they’re used as guides to clinical care, and maybe to policy.
So a QALY is not doing anything really that different. I think one of the red flags that your question suggests that is a little bit different as well: My being in pain is very different than my neighbor’s being in pain. I maybe don’t tolerate pain as well, so I have a different number and while that’s probably true or at least true that people all have different preferences around health states – again, all the QALY is trying to do is give a guide to roughly amount of life lived and the quality of that life lived.
And so the other thing I suppose I would add is, a physician treating a patient can look at a QALY and make his or her own informed decision along with the patient about whether it’s applicable for them in their particular circumstance.
But I think as your question rightly highlights, it is with some controversy. And people feel often that QALYs are not capturing what they care about, that’s another criticism of the QALY: that people may care deeply about aspects that are not captured by quality-adjusted life years gained. For example, we might want to give priority to certain populations, whether or not it’s the QALY-maximizing thing to do, we might want to give priority to vulnerable populations or children or people with rare diseases or people with cancer and people with - and on and on. Whether or not the QALY-maximizing strategy would lead us there and I think that’s a very real concern and again all the QALY is doing is giving a benchmark or a common metric to help us understand the gains for the spends.
David Harlow: Yes. So it’s a metric. And what you are saying is that a policymaker could add other adjusting factors when translating a result that’s in terms of QALYs into a policy decision.
Peter Neumann: Exactly. And the economist would say: well, resources are limited, whether we like that or not, we can’t do everything we want for everyone who is in need of care and we do make decisions and those decisions have implications. The QALY is simply a guide to helping us make those decisions more fairly and consistently and perhaps rationally.
David Harlow: You’ve written or spoken in the past about the notion of American exceptionalism and that’s a notion that a lot of folks have been speaking about in connection with the health care reform debate in recent months. My question to you is whether there is anything we can learn from the ways in which other countries in the world have resolved or attempted to resolve these issues of allocation of scarce resources in health care? What can we learn from the way this has been addressed elsewhere in the world? Is there a particular country or two that you think has addressed this particularly well?
Peter Neumann: Right, so there is this theme of American exceptionalism that is much broader than just in health care, but the basic idea, oversimplified somewhat, is that because of our unique history and culture, our strong inclinations towards personal economic freedom and the institutions we’ve set up that make it difficult to enact major change, and the culture’s sort of broad mistrust of government and big corporations that makes it very hard for us to enact policies, universal health care, it’s very hard for us to use cost-effectiveness analysis, and so forth.
So other countries also have their own unique history and systems and culture, and have addressed this in ways that I think offers some lessons to us. They’ve created institutions in places - the UK is a good example, Canada is another - where they have policy experts, often including stakeholders, citizens’ councils, physician groups and others, patient advocates perhaps, who are collectively trying to make these difficult decisions and using economic evaluation, cost-effectiveness analysis, to help make those decisions; and in many cases not covering new technologies that are very expensive but have small marginal gains. So the UK maybe most famously has an institute called the National Institute of Health and Clinical Excellence that sifts through the data, looks at the economics of new treatments and then decides whether or not to cover. And in some cases at least decides not to pay for new very expensive technologies that offer marginal benefits.
David Harlow: Do you think that there would be a change in approach or a change in decisionmaking about what should be covered, what should not be covered, if there were a change in the basic approach to reimbursement for health care services in this country? Would a change in those incentives drive a change in behavior of providers?
Peter Neumann: Well I’m a strong believer that it would. I think part of the issue that we’ve been talking about is the information itself and to what extent do we use that information in decisions. Another issue we haven’t to this point talked about is the incentives in the system, and I think the information would have a much bigger impact in an environment with different incentives. So if providers were under bundling arrangements where you have a global payment that follows a patient with a particular disease for example, particular diagnosis, I think the incentives change in ways that makes this information more relevant and more powerful. And there are other ways to change incentives to also make this information more relevant - it could be salaried physicians, it could be changing incentives to do more and getting paid more, it could be incentives that are different for patients where they face more cost sharing.
Now changing incentives in all those ways has some potential downsides too, of course, but I think in an environment where we really have a cost crisis, I think we are going to see changes in incentives and behavior will change accordingly. And I think this information that we’ve been talking about, cost-effectiveness analysis, may have a more important role in ways it doesn’t have today.
David Harlow: Speaking of incentives, on everybody’s mind these days are the incentives for the propagation of electronic health records systems in this country. I’m wondering whether you see an opportunity there for gathering of more data in an effective way through the deployment of electronic health records systems that would help inform some of the decisions that we are talking about.
Peter Neumann: Yeah, absolutely. I think giving people incentives is being widely discussed and maybe we are seeing some policies now to use electronic medical records should have an impact that in turn will generate lots of data with clinical detail we don’t have now; and that kind of information can feed into analyses that can help us better understand the impact of different treatment strategies - both safety and efficacy and cost- effectiveness.
So I think there is perhaps a data issue, data problem, infrastructure problem that exists today where I think we are not capturing the kind of information that would be possible if encounters led to more systematic data capture. So I think that would be an important part of moving forward.
David Harlow: Okay. Now one of the projects that I understand you’ve been working on - that your Center has been working on for a while - is a registry of cost-effectiveness studies, Cost-Effectiveness Analysis Registry and I wonder if you could speak a little about that, explain what that is, how you use it in your work.
Peter Neumann: Sure, it’s the Tufts Medical Center Cost-Effectiveness Analysis Registry which we refer to as the CEA registry. And it's essentially a database of published cost-effectiveness analyses, and these are studies that have appeared in the peer-reviewed Medline literature that my group, there is a formal protocol for the collection of data from each of these published studies.
We collect something like 35 or so variables on each cost-effectiveness analysis. We have two readers independently reading each study and then coming and meeting in consensus; their consensus meeting to enter data into a database. We enter data on the cost-effectiveness ratios that are produced by these studies as well as a lot of detail on how the studies were conducted. So with an online searchable database, and I would invite all of your listeners and readers to go on the site if they are interested it's www.cearegistry.org and you can plug in a word or phrase or an author’s name and so forth or type of intervention.
So for example if you were interested in what is cost-effective in the area of multiple sclerosis you can look and plug that term into the database and you’ll find published studies on the cost-effectiveness of interventions for MS and similarly for any other disease that you’d like.
I should emphasize all of these studies are in the form of cost per QALY studies so that is the currency or benchmark that we use. The great strength of that is that the results are comparable so you can compare a cost per QALY in a study on depression, to a study on cancer to a study on I don’t know some kind of new diagnostic technique to detect I don’t know, I’m making it up, heart disease.
So there’s lots more I can say about this database but we’ve always viewed it as a public resource and we plan to expand upon it in the future, and the goal of this exercise is really to try to understand society’s best opportunities for improving health efficiently. So we’ll keep it going in the future and again I invite everyone in and we’d love feedback if anyone has any.
David Harlow: Terrific. What I’d like to ask a little bit more about there is - you’ve mentioned a moment ago about the notion of using QALYs as a standardized measure so you could look at issues across different diseases or treatments and I’m wondering, what would you be looking at exactly if you’re comparing effectiveness between a cardiac issue and a neuromuscular issue? What would be the outcome of that comparison?
Peter Neumann: Right, so the idea is we have limited resources to spend on health and we need some common measure that would allow us to say, “well, the money we have to improve health is better spent over here in a certain area, than it would be spent in a different area” so the way we standardize everything is through these cost per QALY ratios.
So for example if you have some kind of surgery for cardiac care a study might - someone might do a study and say the net cost per QALY gained for that type of surgery is say $10,000 per QALY and the neuromuscular condition let’s say an expensive new drug and the cost per QALY ratio in the study someone has reported is $200,000 per QALY. So the idea is if you’re trying to improve health it's much more efficient to spend that money on the cardiac care than it is on the neuromuscular drug in that case.
And while it's difficult to make direct comparisons across very diverse treatments this gives us a way of measuring value for different uses of resources to improve health. And what some countries are doing is saying we are not going to pay for the very expensive strategies, the $200,000 example, and we will pay for the less expensive more efficient better value strategies, the $10,000 for example.
David Harlow: If you had a crystal ball how would you predict this sort of information playing out into coverage decisions and policy decisions in this country?
Peter Neumann: Well, I think there will continue to be a lot of concern and sensitivity around doing cost-effectiveness analyses openly. I think it’s still fraught with a lot of political problems and mistrust and so forth. However, I think that we will slowly but steadily begin to use more of this information and we are beginning to see it - even in Medicare we are beginning to see it on the prevention side. So how frequently you screen for cancer is really an issue of the clinical and the cost-effectiveness information.
So you know at the extreme we could screen for cancer very frequently - every month - or we could screen much less frequently - every ten years - and what the right level of frequency is determined by the clinical outcomes of screening, it’s determined by false positive rates and by maybe some safety issue that would result from false positives. But it's also a cost issue and I think we will have cost-effectiveness information informing decisions like that; not only frequency of screening but we will have it likely for which subgroups get which types of prevention. Perhaps immunization schedules in the future will be informed by this and maybe even in certain cases, and I think this will come, treatment guidelines; failing cheaper therapies first before you get to the expensive one.
That’s a decision that can be informed by cost-effectiveness analysis. Even if you take the more expensive ones first and it gives you a little bit more clinical benefit, guidelines increasingly will dictate that patients try the cheaper drugs first or the cheaper treatments first and then get to the more expensive ones only if they can’t tolerate or they fail the others. And again I think cost-effectiveness analysis in the public sector and the private sector will inform those kinds of decisions.
David Harlow: Yes, well it certainly seems to make a lot of sense. The question is always how it is communicated. We’ve seen some stellar communications failures in the context of the mammography guidelines in recent months and changes in the way that’s been explained following a public relations disaster…
Peter Neumann: You’re right.
David Harlow: And it remains to be seen how those will actually be implemented by payors.
Peter Neumann: Yeah I think you’re absolutely right and the mammography episode shows how challenging this is going to be - but even there, there are limited resources, there are complex cost-risk-benefit trade-offs and we will see how it plays out. But I would argue even there, cost-effectiveness analysis could help us think through those issues, but it certainly will not be easy.
David Harlow: Yes, well, thank you very much. I have been speaking with Dr. Peter Neumann, Director of the Center for the Evaluation of Value and Risk in Health, Tufts University Medical Center. This is David Harlow on HealthBlawg, and thank you for listening.
Read more [HealthBlawg - David Harlow's Health Care Law Blog]
FDA Studying Approval of Drug Cocktails for Life-Threatening Diseases
In a major policy shift, the FDA is opening the door for the future approval of drug cocktails to treat life-threatening diseases such as tuberculosis in a more effective way (see: FDA Is Easing Way for Drug Cocktails; subscription required). Below is an excerpt from the article: This article mentions regulatory science, a term with which I was not familiar. It turns out that academic degrees are now being offered in this field. I am sure such graduates will be cordially welcomed by both the FDA and by the pharmaceutical companies on a much larger scale. One of the core competencies of such companies is the ability to maneuver through this complex bureaucratic pathway. Less time and effort to achieve drug approval equals less cost for them in bringing a drug to market. Knowing how difficult it is to gain FDA approval for new drugs, I can only imagine how complex a process it will be to study new compounds that are administered in combination with other agents. It's a bit of an understatement to say, as above: testing drugs together can make it more difficult to tease out which drugs or drug interactions cause certain side effects. I can't resist pointing out the analogy of between multi-drug cocktails and the development of panels of biomarkers interpreted by a computer algorithm that the FDA refers to as IVDMIAs. The attempt by the FDA to regulate them has been challenging for the agency. The second draft version of guidance dates back to July, 2007. In my mind, we are now facing a future with both therapeutic cocktails and diagnostic cocktails. This perhaps is a reflection of modern life and modern medicine whereby a single drug or a single biomarker no longer suffices. And the FDA is being forced to operate as a regulatory agency in this new environment. One of the gnarly issues associated with IVDMIAs has been proving diagnostic efficacy. Both efficacy and safety will be even a greater challenge on the drug side of this equation.
Read more [Lab Soft News]
Breaches of patients’ data raise questions on security methods
In the aftermath of the recent Wake Forest University Baptist Medical Center breach, John Hinton of the Winston-Salem Journal has this piece on hospitals allowing employees to remove patient data from their facilities and whether patients know that that might happen.
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Meaningful use for nursing. Six themes regarding the definition for meaningful use.
Forum: Nursing Informatics Journal Articles
Posted By: Nursing Informatics News
Post Time: 12-30-2009 at 04:26 AM
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Narrowing PubMed searches to nursing-related articles.
Forum: Nursing Informatics Journal Articles
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The new fundamentals in nursing: introducing beginning quality and safety education for nurses' comp
Forum: Nursing Informatics Journal Articles
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Health information literacy: hardwiring behavior through multilevels of instruction and application.
Forum: Nursing Informatics Journal Articles
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Implementation of standardized nomenclature in the electronic medical record.
Forum: Nursing Informatics Journal Articles
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[Promoting nursing competitiveness: introduction to the digital divide.]
Forum: Nursing Informatics Journal Articles
Posted By: Nursing Informatics News
Post Time: 02-04-2010 at 04:08 AM
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Adoption of a PDA-based home hospice care system for cancer patients.
Forum: Nursing Informatics Journal Articles
Posted By: Nursing Informatics News
Post Time: 01-29-2010 at 04:45 AM
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Technologies enable seniors to age in place.
Forum: Nursing Informatics Journal Articles
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IT Sales Executive - VeriScan
Forum: Recruiter Posted Informatics Jobs
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Clinical practice corner: health information technology.
Forum: Nursing Informatics Journal Articles
Posted By: Nursing Informatics News
Post Time: 02-03-2010 at 04:34 AM
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Cutting the cord. CIOs are leveraging wireless technologies to help nurses deliver patient care safe
Forum: Nursing Informatics Journal Articles
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Post Time: 03-03-2010 at 04:26 AM
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The Alliance for Nursing Informatics: A History.
Forum: Nursing Informatics Journal Articles
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Post Time: 02-26-2010 at 04:16 AM
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Manager of Nursing Informatics - iMethods - Jacksonville, FL
Forum: Recruiter Posted Informatics Jobs
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On the horizon: dialogues for the nursing academy.
Forum: Nursing Informatics Journal Articles
Posted By: Nursing Informatics News
Post Time: 01-27-2010 at 04:24 AM
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A quantitative analysis of the impact of a computerised information system on nurses' clinical pract
Forum: Nursing Informatics Journal Articles
Posted By: Nursing Informatics News
Post Time: 01-27-2010 at 04:24 AM
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Getting IT together.
Forum: Nursing Informatics Journal Articles
Posted By: Nursing Informatics News
Post Time: 01-27-2010 at 04:24 AM
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Evaluating your information system implementation.
Forum: Nursing Informatics Journal Articles
Posted By: Nursing Informatics News
Post Time: 01-13-2010 at 04:18 AM
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[Standardized nursing language: the bedrock of computerized nursing records]
Forum: Nursing Informatics Journal Articles
Posted By: Nursing Informatics News
Post Time: 01-13-2010 at 04:18 AM
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Collaborating to optimize nursing students' agency information technology use.
Forum: Nursing Informatics Journal Articles
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Instance testing of the family history ontology.
Forum: Nursing Informatics Journal Articles
Posted By: Nursing Informatics News
Post Time: 01-09-2010 at 04:35 AM
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Recording practices and satisfaction of hemophiliac patients using two different data entry systems.
Forum: Nursing Informatics Journal Articles
Posted By: Nursing Informatics News
Post Time: 01-29-2010 at 04:45 AM
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Description of inpatient medication management using cognitive work analysis.
Forum: Nursing Informatics Journal Articles
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Post Time: 01-29-2010 at 04:45 AM
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Applying PNDS to a standardized framework.
Forum: Nursing Informatics Journal Articles
Posted By: Nursing Informatics News
Post Time: 01-29-2010 at 04:45 AM
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IT Sales Executive - VeriScan - Denver, Colorado, 80012
Forum: Recruiter Posted Informatics Jobs
Posted By: carolfelsenthal
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