The Health Care Blog

Open access scheduling at the doctor's office

By DAVID E. WILLIAMS

I’m quoted in the Boston Globe today (A new practice: The doctor will see you today) on open access scheduling. (I’m all the way down at the bottom of the article.)

Open access is one of my favorite innovations because it improves customer service and quality levels. As we add patients to the system open access provides a way to preserve or improve access to the physician. It’s better—in my view—than other solutions such as using more mid-level practitioners and trying to boost the total number of doctors.

Open access means seeing today’s patients today rather than forcing them into a slot far in the future or trying to squeeze them in to a crammed schedule. The example given in the Globe article is a more extreme version than what I’m used to. I’m not sure such a radical shift to open access is optimal. It might be best to preserve a lower percentage of slots for same-day access rather than forcing folks in today who’d prefer to wait a bit!

What’s required to make open access work?

• Working overtime to chip away at the existing backlog (otherwise there’s no free time to offer up)
• Varying number of hours worked per day to accommodate fluctuating demand
• Having the right sized patient panel—something that’s somewhat hard to assess in advance, since the true demand is unknown (offices usually just know how far out they are scheduling)

Why does it work?

• There’s a high no-show rate from appointments made weeks or months in advance

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Introduction to ONC Initiatives

By Matthew Holt

SUBTEXT: At the start of  the Health 2.0 Goes to Washington Conference, Matthew Holt and Indu Subaiya welcomed all of the conference attendees. Wil Yu, Director of Innovation at the Office of the National Coordinator for Health IT (ONC), gave the opening remarks and spoke about health innovators and initiatives.

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A Reply to the Cato Institute

By MAGGIE MAHAR

This week, the Cato Institute released a 52-page report on health care reform titled: Bad Medicine: A Guide to the Real Costs and Consequences of the New Health Care Law.

The tract was written by Michael Tanner, a senior fellow at the Institute, and it rests on the thesis that the Patient Protection and Affordable Care Act (ACA) is both Unaffordable and Unfair. Inevitably, Tanner’s claims about affordability are shaky; in truth no one can project how much reform will cost over ten years—and how much it will save. There are too many variables involved. Nevertheless, Tanner seems sure: the legislation will add to the deficit, he asserts, and force insurance premiums higher. Moreover, he stamps the legislation “unjust”: it would turn private insurance companies into regulated “public utilities,” forcing them to insure sick people, while “redistributing income” from families earning “over $348,000” to families earning “$18,000 to $55,000.”  Ultimately, he argues, reform represents yet another step toward turning the U.S. into a “Nanny State.”

Why a 52-page report on health care reform now? Tanner makes his purpose clear in the Introduction where he suggests that conservatives will make the new health care legislation the “centerpiece of Republican campaigns this fall,” as they lobby for repealing the Affordable Care Act, or at the very least, replacing it. Bad Medicine is meant to serve as a playbook for those who hope to kill reform.

With that in mind, The Century Foundation decided that the document deserves scrutiny. In the weeks ahead, I will be analyzing and rebutting the report’s many arguments against individual and employer mandates, insurance regulation, subsidies, reductions in Medicare spending, and the CLASS Act, a much-needed national long-term care program.

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So I'm on TV, unfortunately in piece of crappy reporting

By Matthew Holt

So last month the nice people from KTVU (the local Fox affiliate in SF) came by to interview me and last night it aired. They’d been over at web-based EMR vendor Practice Fusion and had found out about EMRs. Then they came to interview me. I should probably have got the hint when reporter John Fowler kept on asking me about privacy concerns. I spent 20 minutes giving a balanced nuanced view about the advantages and problems of adopting medical records which is not exactly represented by the 6 second soundbite I get.

Unfortunately—despite the producer’s stated desire to use Bay Area people—Texan nutjob Deborah Peel gets almost half the piece including almost all the interview content. (Apparently Deven McGraw couldn’t be tracked down? Maybe DC is too far away) And what does Deb Peel say? Well you know what she says…

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How to Ration Health Care

By JOHN C. GOODMAN

Suppose you were in a triage situation and you had to choose between two patients, deciding who lives and who dies. Are there any principles you could rely on to make your choice?

Alex Tabarrok had an interesting post the other day at Marginal Revolution in which he asked readers to imagine standing behind a Rawlsian veil of ignorance. This is a thought experiment in which you are about to be born into a world, but you don’t know which person in that world you will be (e.g., you could be born smart, dumb; rich, poor; black, white; etc.). You can decide the rules governing the world you are about to be born into, but you must make your choice “position blind.”

What decision rules would you choose?

For his part, Tabarrok focuses on how to allocate kidneys among transplant prospects and his own solution is: allocate scarce organs so as to maximize remaining years of life:

In the current system, a 60-year-old patient can be given a 20-year-old kidney — that's a waste because the life expectancy of the kidney is longer than that of the patient; it's like putting a new clutch in a car that is rusting away.  If we had 20-year-old kidneys to spare, this wouldn't be a big problem.  But we don't have 20-year-old kidneys to spare, so we also give 20-year-old patients 60-year-old kidneys which means the kidney is likely to die early, taking the patient along with it.  If we want to maximize total life expectancy, younger people should get younger kidneys.

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Fantastic job: HHS ONC subject matter expert on consumer e-health

By Matthew Holt

Josh Seidman has written from ONC telling us about a fantastic job opportunity. You get to work with the brilliant folks at ONC on fun stuff regarding consumer e-Health. What does that mean? From the posting.

• Forge alliances with consumer organizations, technology and care delivery innovators and consumer advocates to further the consumer e-health agenda.
• Develop consumer oriented strategies across the Office of the National Coordinator for Health Information Technology (ONC).
• Serve as Project Officer providing project management oversight for contracts, including designing, developing and coordinating project management plans for policy initiatives in conjunction with the Division Director and the Office of Policy and Planning Director.

We’ve been very impressed by everything we’ve seen about ONC’s commitment to patient communication—not least the “sneaking-in” to the meaningful use requirements in Phase 1 of patient education materials (what Don Kemper calls Christmas in July). I can’t think of a more fascinating job for anyone who cares about online health.

So if you’re interested here’s the link to apply. 

Christmas in July: Meaningful Use as a Gift for the Consumer

By DON KEMPER

Everyone was expecting the new meaningful use rules to include some important, but relatively basic advances for the consumer—and it did. However few of us expected meaningful use would include a real consumer gift: the requirement that EMRs help doctors deliver information prescriptions to each patient. That addition is a game changer for advancing the patient’s role in a patient-centered health care system.

Page 225 of the rules includes this Stage I Measure for demonstrating the “meaningful use” needed to qualify for the federal subsidy for EMR investments:

More than 10% of all unique patients seen by the provider are provided patient-specific education resources.

That simple requirement represents a sea-change in use of the EMR as a tool to advance the role of the patient. It will bring into mainstream American medicine a recognition that medical care is of high quality only if it includes relevant information to help the patient do appropriate self-care and better participate in treatment decisions.

The requirement gives mainstream life to the decade-old concept called “information therapy” or Ix for short. Ix promotes the need to prescribe the right information to the right patient at the right time as part of the process of care. The new rule promotes the exact same thing.

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My EMR Reality

By ROB LAMBERTS

OK, I am an EMR fan-boy, I will admit it.  I seem real “rah rah” in my approach to computers in the exam room, and to many I seem to have my head in the clouds; I seem to be out of touch with reality.  In response to posts I have written on the subject, comments have been thus:

“I couldn’t see as many patients if I had an EMR.  It would slow me down too much.”

“Using an EMR makes doctors ignore their patients and focus too much on the computer screen.”

“EMR is too expensive for the small practice or primary-care physician.  It will reduce their income in a time when it’s hard enough to function as a PCP.”

Yeah, yeah, yeah.  This is very familiar to me.  It’s also wrong.

True, there is a start-up period of getting used to the EMR in which you can’t see as many patients, but that goes away.  True, there is a time when you are uncomfortable with the computer in the exam room, but once you get used to it, it becomes as natural as having a paper chart.  True, EMR start-up expense is high enough to make doctors, especially PCP’s, wonder if they can afford the cost in this time of austerity.

I understand these things better than most people give me credit for, because I have lived through each of these troublesome sides of EMR personally.  Here is my EMR story:

I started thinking about using an EMR in 1995, when I saw how difficult it was for me to keep track of information in the record.  This came to a head in 1996 when the result of a test was missed, causing harm to a patient.  The problem wasn’t in the thought-process or in the intelligence of the doctor; the problem was from flaws inherent in a paper medical record.

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Keas Opens API for Health 2.0 Developer Challenge!

The fifth challenge for the Health 2.0 Developer Challenge has just been announced. Keas, the health and wellness data-driven platform, has opened up their API and a development environment to anyone who wants to author a "social Care Plan." In a fun play on a "Challenge to design a Challenge," teams will have access to tools and a robust engine to test new ideas that incorporate social motivation in health and behavior change through the sharing of health data and health results.

The winning team gets to discuss their work over dinner with Web 2.0 pioneer CEO Adam Bosworth, $3,000 cash prize, and the opportunity to feature the winning app at the Health 2.0 Conference in October. To find out more and sign up to compete, see the Keas' Challenge here.

Patrick Soon-Shiong – Role in a World of “Data Liberacion”

By Matthew Holt

Subtext: In the DC panel debate on the Role of "Data Liberacion" Executive Chairman of Abraxis Health, Patrick Soon-Shiong, commented on how coordination and exchange of health data can improve healthcare and have a direct impact on individuals. He also talked about how his "realizing of the American Dream" enabled him to  contributes to this through the non-profit organization the Health Transformation Institute.

Big Day in HIT

By DAVID HARTZBAND

Today was a big day in health care information technology (HIT). There are so many acronyms in HIT that I probably should publish a list, not today though. The Office of the National Coordinator of HIT (ONC) of the Department of Health and Human Services (HHS) issued its final rule on meaningful use criteria. As we know, these are the requirements that 'providers' (mainly physicians) have to meet to receive incentive payments from the Centers for Medicare & Medicaid Services (CMS) for the use of electronic health records (EHR) and other specific information technology (such as electronic ordering, electronic prescribing & exchanging of health information). The incentive payments start as early as this year for Medicaid providers, the rub is that after 2015, if you haven't qualified, you will receive smaller Medicare or Medicaid payments (you can only qualify for one). These criteria were first published early last year & have been in comment periods or under revision ever since.

Despite this long period of evolution (over 2000 comments were evaluated), the question for providers continues to be "Is it worth it to me or my practice to even try to qualify?" The incentives are supposed to be based on the cost to acquire & adopt the necessary technology, but the total incentive (paid over as much as five years) is well under $100K for Medicaid providers. This may be close to the actual cost of the technology, but that does not take into account the disruption in practice caused by training, workflow changes & differences in usage caused by the technology. Providers who have been used to talking to their patients (even in the small amounts of time that modern clinical workflows allow) must now also do data entry (into the EHR) & spend part of their time filling out electronic order & prescription forms. This disrupts the clinical visit for both the provider & the patient. I have had not a few people (it's people who are patients after all) tell me that they refuse to allow their doctor to enter data & consult "the computer" during their visit. They feel it's disrespectful, regardless of how productive it may potentially be.

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New and Improved Meaningful Use

By MARGALIT GUR-ARIE

The long anticipated final rule on Meaningful Use was unveiled yesterday with much pomp and circumstance in a rather unusual ceremony which, interestingly, also marked the first public appearance of Dr. Berwick as CMS Administrator. The Final Rule is contained in an 846 page document. Accompanying the CMS ruling is the 228 pages final EHR certification rule issued simultaneously by ONC. Fortunately for all of us scrambling to figure out what has changed, Dr. Blumenthal released a synopsis in NEJM (recommended). Already many articles and dissertations have appeared and indubitably many, many more will be written in the next few days and weeks analyzing every change and every nuance of the new, and now binding, Meaningful Use. For those who don’t care much about nuances, preferring a bigger and lower resolution picture, here are the major changes to the old version of Meaningful Use.

The Good

• By far the biggest relaxation was to divide the original 25 measures (23 for hospitals) into two groups – 15 mandatory measures and 10 optional measures of which only 5 need to be fulfilled, per provider choice. This is in effect a 20% reduction of the Meaningful Use burden.
• They added back a requirement for hospitals to record advanced directives. It is listed in the optional group, which means that some hospitals could choose not to implement it, but one must be grateful for having it back on the list.

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Josh Sommer – A Patient Looking for a World of “Data Liberacion”

By Matthew Holt

In this part of the panel debate on the Role in a World of "Data Liberacion" founder of Chordoma Foundation Josh Sommer tells the story about how he was diagnosed with Chordoma and how he funded the Chordoma Foundation with his mother as a reaction to the lack of treatments available. Josh is working to help coordinate data sharing between different researchers.

Interview: Blumenthal talks meaningful use

By Matthew Holt

Absolutely hot off the recorder, here's my interview with David Blumenthal, the Obama administration's National Coordinator for Health IT.

David and I discuss patient communication, why the percentages of certain criteria were reduced, and how to get the two Reginas on Oprah. Well, he didn't have many ideas about that! ...

David Blumenthal on Meaningful Use, 13 July 2010

Meaningful use, and cats & dogs

By Matthew Holt

More than a year or so of squabbling is (sort of) over and today HHS announced its criteria for the first phase of meaningful use. Essentially the 25 criteria for qualifying for “meaningful use” (in other words who qualifies for the money) have been changed to 15 with a further 5 from a menu of 10. The details are here, and it looks like most of the percentages needed to qualify have been relaxed but not eliminated. The Dogs have clearly had a minor victory in that there are patient communication requirements in both the mandatory and optional criteria.

The most impressive part of the announcement (you can see it here) which included HHS Sec Sebelius, CMS head Berwick (not wearing his Che Guevara T Shirt) & ONC Director Blumenthal, was the two Reginas. First, Surgeon General Regina Benjamin explained how thrice her clinic was destroyed by nature, and how the second time she realized that while she had thought she couldn’t afford electronic records for her patients, she then realized that she couldn’t afford not to have them.

The other Regina was our friend Regina Holiday who made (to me) a surprise appearance and told the 73 Cents story in a heartfelt and powerful way. She’s really become the poster child for why access to health data matters to ordinary people, and we need to get her from the world of webinars, Health 2.0 Conferences and HHS announcements onto Oprah and the 6 O’Clock News right now.

And I’ll be suggesting that when I interview David Blumenthal in a little under 30 minutes.

And here's the 3mins audio of Regina Holiday at MU announcement

What Could Don Do?

By PAUL LEVY

What is the important thing Don Berwick could do as head of CMS to improve quality and reduce the cost of health care?  Let's face it, as head of a humongous agency, it is hard to make changes.  You have to pick your battles carefully, for every cause has a constituency and an opponent.  Gridlock is a fact of life in Washington, DC:  The system is designed for that result.

Let's just say, though, that you had a chance to adopt one innovative regulation or proposal, one where even opponents would have little moral ground on which to get traction.

Here's mine:

Announce that you are going to create a website in which each hospital is invited to input two or three real-time metrics with regard to reducing harm. Let's start with central line infections.  There is a common definition provided by the CDC.  Many hospitals keep track of their rate of infection.

Provide a password-protected template and give each hospital CEO (yes, CEO!) the opportunity to send in his or her hospital's quarterly figure for the world to see.  Set up the web page so the accumulated sequence of numbers is translated in a trend line, so anyone can watch a given hospital's progress over time.

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Jamie Heywood Challenges Health 2.0

By Matthew Holt

 

SUBTEXT: Jamie Heywood, Co-Founder and Chairman of PatientsLikeMe, spoke  at the recent Health 2.0 DC conference. While on stage, Heywood issued a challenge to federal agencies to "change what we pay for."

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Op Ed: Dr. No to Run CMS

By JOHN GOODMAN 
President and CEO, National Center for Policy Analysis

 Let’s do a thought experiment. Suppose you were a U.S. Senator and the President’s nominee to head CMS appeared at his confirmation hearing:

• Wearing a Che Guevera t-shirt, sporting the image of a psychopath who apparently enjoyed killing people, or
• Fondly clutching a copy of Quotations from Chairman Mao, written by a man who presided over the genocidal murder of more people than any other person in the history of the world.

When I was at Columbia University, my fellow students did these sorts of things. I soon learned they were not evil. They simply could not think clearly about moral issues involving collectivism. I view Don Berwick in much the same way.

President Obama took advantage of a short Congressional recess to appoint him to run Medicare and Medicaid without even a hearing. Although the President blamed Republicans, even some Democrats were unhappy with his snubbing of normal Senate prerogatives — something Obama criticized George Bush for doing with the appointment of John Bolton as UN Ambassador.

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Wellcare, yes there's more even without(?) Regi

By Matthew Holt

A few weeks back we welcomed John Goodman as a contributor at THCB. His first column was more than a tad critical of me for impugning the ethics of Harvard Business School Prof Regina Herzlinger. Herzlinger, you may recall made a boatload of money off her position on the board of directors of Wellcare. Wellcare was operating a Medicaid and Medicare HMO in Florida, while basically using that not-too-sacred trust as an excuse to defraud the taxpayer.

Due to the demands of reality cutting into my work-life, my blow-by-blow analysis of Wellcare’s bad behavior has waned a little, but here I instead commend to you the consistently great work of Roy Poses over at Health Care Renewal. Earlier this month Roy took a look at the latest chapter in the tawdry tale. I encourage you to read his article for the full tale, but essentially even despite the settling of the criminal and civil charges for theft of around $46m, there’s a brand new set of charges from the same period—this time theft is alleged of up to $600 million. This new set of allegations were collected by (FBI informant & Wellcare financial analyst) Sean Hellein who wore a wire for more than a year, and probably stands to make a packet in the qui tam suit.

And not that I’d further besmirch the reputation of Prof. Herzlinger, but the time period all this happened was while she was still on the board, and none of these were given as her expressed reasons for leaving. Then it struck me, is Regi in on the qui tam suit too? That would be the way to make serious money out of her insider knowledge.

PPACA: The Individual Mandate

By ROGER COLLIER

The individual mandate is the single most controversial feature of the Patient Protection and Affordable Care Act. Everyone who can afford coverage—unless an undocumented immigrant or exempted on religious grounds—is required to have it or pay a penalty of $695 or 2.5 percent of income.

The rationale is straightforward: without a mandate, many people would wait until they needed care before buying insurance, driving up premiums for those with ongoing coverage, and potentially creating an “insurance death spiral” as the higher premiums lead to increasing numbers simply dropping their coverage. (This last part is basically what we have today, but will be magnified by PPACA’s ban on preexisting condition exclusions.)

The individual mandate was preferred for obvious reasons over the alternative of a general tax offset by credits for premiums paid. Democratic lawmakers had no wish to be blamed for imposition of a new tax—no matter how reasonable the arguments in its favor. In fact, as President Obama made clear in an ABC television interview “I absolutely reject that notion [that the penalty is a tax].”

The individual mandate has now become the centerpiece in Republicans’ legal fight against reform. Suits challenging PPACA have been filed by the attorneys general of twenty states (with the first, in Virginia, already being argued), with the constitutionality of the mandate a key issue in every case.

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KP Innovation Workshop

At the Sidney R. Garfield Innovation Center, Kaiser Permanente's patients, doctors, nurses, architects and engineers use elements of human-centered design to improve and to innovate physical spaces, technologies and clinical operations in a unique, “movie-set”-style warehouse. Many of these innovations have been spread throughout Kaiser Permanente as well as to organizations nationally and internationally.  

As a result, an inaugural workshop has been developed workshop to share the Kaiser Permanente methodology and some best practices. On August 3rd and 4th, a variety of health care providers, biotech and pharmaceutical companies, policy researchers, architects and more will get together in a hands-on session to explore and experience first-hand how Kaiser Permanente understands it’s users’ needs and ideate and prototype new processes, spaces and technologies. Participants will work in the same space where Kaiser Permanente employees and patients conduct deep-dives and collaborate on new idea generation.

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