Patient Unfriendly Environments

Bridget Duffy is the "Chief Experience Officer" for the Cleveland Clinic and gave a presentation at the first "Gel" conference looking at the patient experience from a personal standpoint when she broke a leg and as she described "became invisible". You can see the presentation here (it is 25 minutes long but worth the time from a provider perspective as well as the patient perspective)

Bridget Duffy at Gel Health 2009 from Gel Conference on Vimeo.

And if that does not work click this link here. Fascinating insight that I can only echo from recent experiences that start long before any interaction with the hospital. Dealing with insurance coverage is an excruciatingly painful experience. When I called my local, friendly and most importantly the pediatric orthopedist who I knew and knew my family I discovered he no longer accepted . There a whole side bar here on why he would stop accepting an insurance but who wants to bet that it has something to do with the pain and agony his office has in getting reimbursed for care and the rates he is forced to accept with those patients.

So now the patient choice is to pay "out of network" or find another provider who you don't know and does not know you (and unless you are religious about collecting your medical records and imaging studies won't have the slightest idea of your medical history). Electing to save money means navigating through the the voice navigation system designed in hell for your insurance company to reach a human being to ask who in the nearby area takes their insurance. Does this feel like rolling the dice in Vegas to anyone else? I spend more time researching the hard drive upgrade for my PC than I have and can spend on where to go for my care. Imagine if you were buying a hard drive but although you liked the Geek Squad at Best Buy could not go there because they did not take your credit card - frustrating. But then again perhaps Best Buy would not want your business if when you bought the hard drive worth $100 but your credit card company actually only paid them $35....

Back to the orthopedic referral - now you have to call the office and spend 15 minutes redialing as the number is constantly engaged! I thought that problem had disappeared along with my Vinyl records! Finally you get through and must finish strong persuading the receptionist that you do need an appointment today. Not unreasonable having placed your 11 year old patient in a painful holding pattern over the weekend because you knew that marching off to the local ER was a gargantuan waste of time and resources and nothing would be done over the weekend anyway. This step alone saved the insurance company hundreds of unnecessary dollars of spending but will never be taken account of.

Does any of this seem broken to you - it does to me and as Dr Duffy explains some of these things are not difficult to fix. If the first things I heard when I attended a medical facility was concern for me and how I appeared to them vs the typical first interaction that is composed of data and financial gathering I'd already feel better treated.

What insurance do you have
or
What is your Patient ID

Hello.....!
Sadly few facilities are likely to find the money or resources to allocate to a CEO (that's a Chief Experience Officer) for their facility or being able to run a Code Lavender that delivers Spiritual Care, Counseling, and arrange of other holistic type support services to departments and staff alike but you can bet that they all need one. There are few I have visited that have the slightest inkling of the challenge patients face every day dealing with their organization. To be clear this is not so much an individual criticism as an institutional one.

Ask yourself this question

Can you facility pass the Mother Test: can you drop your mother at the door of your hospital and leave her there for a few days and know that she has been treated with compassion, care and understanding and will emerge happy and contented at the end of it

If you can answer yes - please tell use where this is so we can direct people to this facility. If the answer is no what can you do to fix this and what would make you feel comfortable with a facility that it would pass your mother test?

I Can't See My Patients Because I'm At A Screen Entering Data

As with so many services the world is getting flatter (per Thomas Friedman: The World is Flat - A Brief History of the Twenty-first Century) and medical services and in particular medical care is no exception. Everyone must run faster just to stay in place even the health care profession. We are seeing increasing interest and uptake of "Medical Tourism" (this term seems wrong to me - it reminds me of "Friendly Fire") and a recent posting on the Wharton Site on Health Economics: Bangkok's Bumrungrad Hospital: Expanding the Footprint of Offshore Health Care (Props to HISTalk). As with many of the offshore medical facility there are questions regarding safety and oversight (see this web site regarding Jim Goldberg's 23 year old son who died there and he is convinced there is a cover up and conspiracy).

That aside the interview with Mack Banner CEO of Bumrungrad makes for interesting reading especially when it comes to the implementation of their Electronic Medical Record system (in this case Microsoft's Amalga) and their move towards a totally digital hospital. This is interesting not least of all because Microsoft is exploring this vertical in another country and developing a solution that we will likely see being rolled out in this country once they have worked out all the issues and filled in feature/functionality gaps. But from a documentation standpoint as Kenneth Mays (the Hospital's Director of Marketing) points out:

We talk to our colleagues in the States and they're all facing the same challenge of getting doctors to enter things into computers. It's wonderful in theory. It makes your system more efficient. It makes it faster. It takes out a big source of errors. But it requires doctors to type in these things and it's not easy to get doctors to do that. It could also take something away from the doctor-patient interaction if the doctor has his head buried in a computer rather than looking at the patient and having a dialogue with the patient.... Hospitals, not just our hospital but I think hospitals everywhere, are facing this challenge.

This challenge is significant and one that remains unanswered in the limited roll out of EMR's. In fact a recent Washington Post article: "Electronic medical Records not seen as a cure-all" Alexi Msotrous makes the point that while everyone appears to agree that American Medicine needs to go digital (it is probably broader than that and I would suggest worldwide medicine needs to go Digital) the results are less than stellar and in some cases

suggest that computer systems can increase errors, add hours to doctors' workloads and compromise patient care

Yikes! The Senate Finance Committee has sent a letter to 10 major vendors demanding to know what steps have been taken to safe guard patient data - I expect the responses will be made public which should make for interesting reading. Meanwhile David Bluementhal rightly points out that

the critical question is whether, on balance, care is better than before and he (David Blumenthal) said. "I think the answer is yes"

I agree - we cannot continue the paper based record and we need data to feed these systems to make them useful. But to get this data in creates a data entry challenge that one physician said

I can't see my patients because I'm at a screen entering data

AND

his department found that physicians spent nearly five of every 10 hours on a computer, he said. "I sit down and log on to a computer 60 times every shift. Physician productivity and satisfaction have fallen off a cliff"

And my own daughter (as a patient) from her experience interacting with a physician office said "I wish the doctor would look at me as much as she looked at her computer" (See Doctor Please Look at Me not Your EMR).

The answer lies in using the current methodologies for capturing information - dictation, forms, and other tools that are blended to provide the easiest and most facile way to capture the data for clinicians. Making the data capture part of the clinical interaction without taking it over is essential. Clinicians talk faster than they can type - capturing that information and making this narrative tagged with semantically interoperable data that is usable by the EMR is possible today. Technology, standards and resources exist that allow for this today.

What would you rather be doing - typing at a screen or talking to your patients?

Myths and Lies in Healthcare Debate

The British Medical Journal published a letter to Senator Kerry that was from more than 100 National Health Service (NHS) health service professionals and patients that addresses some of the criticism leveled at the UK's NHS service. Titled "Setting the Record Straight about the NHS" it is worth reading in its entirety. I'm not here to suggest that we need the NHS in the US but having experienced the service as both a provider and consumer I can attest to the high level of service and the feelings of security that arise from a true catch all service that does not require the production of your money for service.

My own personal experience, coming from the fortunate position of having health insurance and good personal health and a family with few medical problems is a fear of approaching any medical facility or health care provider. It remains a mystery, much like the single sock in my dresser that never finds its pair, what the charge will be I end up paying. The idea of health insurance, given the extraordinary amount of money deducted from my pay each month would be that accessing care would cost me little over and above what I already pay in premiums. But this is almost never the case. Following the billing process and managing Explanation of Benefit statements, insurance, medical savings accounts and all the other associated tasks is almost a full time activity and is always a fight. In the tax system you need to reach a minimum outgoing of 7.5% of your Adjusted Gross Income (AGI). That might seem like a lot but each year I am often close and frequently pass this hurdle to be able to deduct anything in excess of the 7.5% of my AGI. This by the way is over and above my insurance premiums. And I consider myself lucky. I wonder how my British friends and colleagues would perceive this state of affairs. At any point in time when I do dig into the details or end up chasing a payment that has not been made I have to organize conference calls to get the insurance agent and the providers billing office on one call to agree what is missing and who needs to fix it. The Providers office does not see it as their problem - hence every time you enter their office they demand you sign a document saying you are responsible for all the costs and as a courtesy they will attempt to bill insurance on your behalf. The insurers for their part fails to deal with the provider except with your forcing the issue and any payments go through their Delay Department that seems designed to make life as difficult for everyone involved as possible. Recently I made a tactical error and agreed to pay the whole cost up front to the provider to get a discount. Suddenly the billing office had no incentive to follow up the billing to get me my insurance payment and the insurance company would not accept any "bill" or claim form me - it had to come from the provider. Heaven forbid I had a serious condition or required extended treatment or clinical visits?

So is this system working for you - I doubt it. But maybe if you started in a system where this was the norm you might not sense that this is an additional unnecessary burden and stress. For all the faults and challenges in the NHS I never feared walking into a physician office for care, treatment or preventative healthcare and screening - never!

Health insurance i nothing more than a commercial operation designed to manage the flow of money with an extra set of mouths to feed adding what some estimates put at 10 - 30% of total cost of healthcare. Is this value for money. While we are at lets crush one misconception here - dental insurance is not insurance. It's does not provide even the most basic of coverage adn the out of pocket expenses are huge even for the most basic of dental care.

With that all said moving the existing healthcare system to a new format is not going to happen. The challenge of "Getting from There to Here" was eloquently detailed by Atul Gawande in his New Yorker piece. The NHS was established on July 5, 1948 but what is lost in the mists of time is the sequence of events to reach that point:

Instead, the N.H.S. was a pragmatic outgrowth of circumstances peculiar to Britain immediately after the Second World War. The single most important moment that determined what Britain’s health-care system would look like was not any policymaker’s meeting in 1945 but the country’s declaration of war on Germany, on September 3, 1939.

The sequence of events and war time necessity created "a national Emergency Medical Service to supplement the local services" which expanded to cover essential services necessary to the population remaining int he country and dispersed by the war time bombing of cities and the returning veterans injured in the line of duty. For many groups providing free care was a necessity of the "war effort" and engaging the private system to supplement the rapidly assembled government system was an obvious step. The system was expected to be temporary but status quo had been destroyed and not least of all because the population, despite the war, had seen an improvement in the health of the population.

The medical and social services had reduced infant and adult mortality rates. Even the dental care was better. By the end of 1944, when the wartime medical service began to demobilize, the country’s citizens did not want to see it go. The private hospitals didn’t, either; they had come to depend on those government payments.

So in 1945 the concept of the NHS was really nothing more than extension of what had been created through necessity of the war.

By 1945, when the National Health Service was proposed, it had become evident that a national system of health coverage was not only necessary but also largely already in place—with nationally run hospitals, salaried doctors, and free care for everyone. So, while the ideal of universal coverage was spurred by those horror stories, the particular system that emerged in Britain was not the product of socialist ideology or a deliberate policy process in which all the theoretical options were weighed. It was, instead, an almost conservative creation: a program that built on a tested, practical means of providing adequate health care for everyone, while protecting the existing services that people depended upon every day. No other major country has adopted the British system—not because it didn’t work but because other countries came to universalize health care under entirely different circumstances.

So whatever we end up with in the US it won't be an NHS. It might take some of the elements of the NHS and it will be based on our countries experience and system drivers. But within the discussion lets focus on facts rather than anecdotal stories and fears (as seen here in the Scientific American article on "Anecdotal Evidence undermining Scientific Results":

Thinking anecdotally comes naturally. Thinking Scientifically does not

So please start thinking scientifically and base discussion on science and facts and help move this reform forward.

Agreement on Healthcare Reform

The healthcare debate continues front and center with every last group weighing in on what needs to change, what needs to stay the same. In fact I'd be willing to bet that for every position in favor of change or status quo you can find the opposing view from another group.

But there are some core principles that I think some level of agreement:

• Elimination of Waste
• Improve Patient Care
• Care for Everyone (Life sustaining not lifestyle sustaining)
• No one should be bankrupt paying for Care

Based on a totally unscientific poll with friends and colleagues who represent from both sides of the aisle there was agreement with the above principles. No doubt the devil is in the detail but if we can agree on some basic principles and start with agreement rather than disagreement perhaps there is some hope for much needed reform of our healthcare.

Each of these issues is complex and as I wrote in my other blog on a recent incident involving abuse of services for a bee sting it may seem obvious in this case but the problems arise when you look at cases that are not so obvious. The level of waste is staggering - based on this report from Price Waterhouse Coopers:

more than half of the $2.1 trillion spent on healthcare every year is

This is spread across many areas and reasons why but as they point out in looking at one large facility - John Hopkins which is representative of the complexities facing the other 4,500 hospitals around the US:

About 700 different organizations, health plans, and employers pay the bills at Johns Hopkins Health System in Baltimore. Each one has different rules about what’s eligible for payment, how much to pay and when to pay....Reducing the redundancies could save the hospital more than $40 million annually, and that’s only “numbers we could identify if we could just get computers talking to each other”

This is basic stuff and these savings alone could go along way to help pay for some of the proposed reforms that, on principle, we agree are desirable such as care for all. In the words of one reporter in the UK: US Healthcare - the Biggest waste of Money in the World. I might not go that far but the idea we are getting any degree of value for money. What is interesting in the breakdown shown is the public/private split of payment


Interesting since in this view it would appear that the number in the US is skewed so high in excess cost because of the Private Costs. Maybe focusing on fixing the excess cost int eh private system might be a place to start on cutting waste.

I look forward to hearing the President's address and hope he can focus on the areas we agree on and set a framework that unites people to overhaul the system for the benefit of everyone.

What do you think - can you agree on the principles above or are these even subject to disagreement?

Standards and Interoperability

It has been an interesting week of rhetoric and emotional outbursts for and against healthcare reform. In amongst the many articles I found this post from David Kibbe on the Healthcare Blog: Why Standards Matter - the True Meaning of Interoperability; a word that he believes that the American people are skeptical of.

You only have to take a quick visit to one of the personal health record systems Google Health or Microsoft HealthVault) to understand why when he says:

interoperability is a hugely important word in the context of today's ongoing debate about the use of EHR technology by physicians, hospitals, and patients too

It is not just an important work, it is an essential component of any future innovation in healthcare. At a recent meeting of the HIT committee several of the members acknowledged that

didn't really know" what interoperability means

Yikes! Frightening if the advisers don;'t have a good handle on what this should mean. He is right that there is complexity in a precise meaning of interoperability since there are many levels and the post contains some good descriptions on the various levels and elements of interoperability - for instance data, words, formats, layout etc. But as he rightly points out capturing medical information in PDF format does not make it truly interoperable and in the example h cites of loading his living will into Google Health this is simply an online version of the Amazon Kindle. Interesting and may be useful to have but not really interoperable.For it to be interoperable the information contained in the files should be in a standard format and the example here is XML (the underlying basis of web pages that you are reading this blog on). XML is an open standard and has a lot of flexibility (as we have seen with the advent of even more creative web pages and Web 2.0 type applications)

The essence here is the need for standards that are the industry and users of the information need to agree on the standard. We need to move past the VHS/BetaMax or BluRay/HDDVD debate and to a set of standards that everyone can use.

At this point standards have not been agreed and there are still some competing standards but XML does seem to be an underlying technology format of choice and is in use Healthstory. Based on Clinical Document Architecture (CDA) that uses XML this format allows for the capture of free form narrative linked to encoded content such that the Diabetes in the note can be identified by a computer systems as ICD9 Code of 255.0 - Diabetes Mellitus). Already some systems will import medical information encoded using XML type standards and this is likely to increase. As you think about your health record you should be looking for providers and technology that will export your information in a meaningful format that can be reused in other systems and applications. Start looking for your records in interoperable format - and insist on the full story not just extracts or sub sets of the data.

More is Not Better

It is customary to believe that more is better. Higher availability and more access = better care...right? Wrong! A recent interaction at the pediatricians office amplified the point and the influence that the patient can have. In a case of extended week long general malaise some level of investigation and therapy was warranted and we agreed on some basic blood work. But in the conversation with the pediatrician she explained that many of her patients were insisting on "Lyme Titre's" based on local reporting of "huge increases in Lyme disease". Nationally the incidence runs around 0.04% and is considered "rare". I could have insisted but logically it made no sense - there had been no possible instance of exposure to risk factors (tick bites) so what would that test bring. But my choice was clearly not the norm.

It is this excess utilization driven by the system that is detailed in in Atul Gawande article penned a another insightful piece in the New Yorker that shreds the notion that we are getting better care just based on higher access. "The Cost Conundrum" is the talk of the town and rightly so.

In his tale of two cites - 800 miles apart in Texas the data available on healthcare costs and results shows that McAllen, Texas is spending approximately twice the cost (~ $15,000 per enrollee). Currently Medicare income per capita is $12,000....! In El Paso - some 800 miles away the costs are half as much running at around $7,504 per enrollee. Similar mix of demographics and public health statistics.

His discussions with local residents and providers was revealing in the wide variation of possible causes:

• McAllen is providing unusually good care (it's not)
• Better technology availability (it's not)
• More doctors (no difference)
• The service is better
• Malpractice is a bigger problem (not based on the recent Texas law capping malpractice claims)

In Fact on the quality metrics published by Medicare:

Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s.

Not only is the cost troubling but the outcomes show that the population is not getting value for their expenditure. As is so often the case if you follow the money" the answer becomes evident. Our system incentivise use not results. As the cardiologists put it when asked about a hypothetical patient with chest pain that goes away and has no associated family history or other clinical indicators to suggest heart disease...

“Oh, she’s definitely getting a cath,” the internist said, laughing grimly.

And for many patients this would be a great outcome. They got the test they needed and ruled out heart disease. Not so for the sub group who are unfortunate to suffer complications some minor and transient and some major and permanent (you can get a good overview of the procedure and complications here):

The1-2% of people who get major complications from the procedure, the 0.08% who die from the procedure, the 0.03% who have a myocardial infarction precipitated by the procedure, the 0.06% who have a devastating stroke or the 0.62% or 0.06% depending on the approach Hospital Acquired Infection, the 1% who have an allergic reaction to one of the many agents used, the 1% who may go on to develop renal dysfunction....still feeling good about the investigation?

In McAllen the analysis of the Medicare data revealed some troubling variation compared to El Paso:

Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits.

As Atul Gawande put it:

The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

The good news is that just having the technology does not necessarily translate into over use. The Mayo clinic in Rochester has some of the highest levels of technological availability but one of the lower rates of Medicare spending (in the lowest 15% of the country at $6,688).

At the core of this story is data - the lack of insight and availability of data was troubling:

It was a depressing conversation—not because I thought the executives were being evasive but because they weren’t being evasive. The data on McAllen’s costs were clearly new to them. They were defending McAllen reflexively. But they really didn’t know the big picture of what was happening.

The most expensive piece of equipment in the hospital is a doctor's pen. But this tool has been heavily influenced by knowledge and availability of best practices. Where best practices are well defined there is close alignment in the clinical choices. Where the science is unclear the variations arise from high levels of investigation (in areas of low cost healthcare delivery) to low levels and conservative treatment (in areas of low cost healthcare delivery). Overall the intent is not to over charge or provide more care but the underlying drivers change behavior for clinicians who try to cope with a complex and overwhelming system that they have little training to deal with.

To borrow form the Six Sigma and Deming's "Plan-Do-Check-Act" Cycle Six Sigma attacks problems with DMAIC

• Define high-level project goals and the current process.
• Measure key aspects of the current process and collect relevant data.
• Analyze the data to verify cause-and-effect relationships. Determine what the relationships are, and attempt to ensure that all factors have been considered.
• Improve or optimize the process based upon data analysis using techniques like Design of experiments.
• Control to ensure that any deviations from target are corrected before they result in defects. Set up pilot runs to establish process capability, move on to production, set up control mechanisms and continuously monitor the process.

Rinse lather and repeat. Critical to this process is developing measures and collecting the data to measure. But healthcare has lived in a wilderness of data both clinical and financial. Everything about the current system is focused on increasing volume in part to offset the decreasing levels of reimbursement. Creating systems like the Mayo that deliver care where "the needs of the patient come first" is at the core of the changes necessary. What is interesting is that most here would love access to the Mayo care but in the political battlefield the concepts and ideas are tainted as rationing and limits to our supposedly great service.

Everyone likes to bash the NHS in the United Kingdom and roll out the legion of complainers who list the reasons why the system is not working while failing to acknowledge the integrated care and access helps deliver better care. While the NHS may not be the perfect system it does encompass elements that we should learn from. I know which care I'd prefer to receive - that of the Mayo style; balanced and high quality. I avoid the McAllen experience where possible recognizing that the "MD" at the end of my name can influence the clinical interaction positively or negatively. I can invariable force the investigation or test if I choose to but I elect to be far more conservative in my approach for me and my family. As I did with the Lyme Titre and do repeatedly - I remain conservative bucking the trend.

Do you? Would you have insisted on the Lyme Titre or just accepted it when it was mentioned simply because you had heard about Lyme disease, were worried and your physician had mentioned it? More is not always better. What's your experience?

Meaningful Use and the Missing Ultrasound

Imagine you show up for a follow up appointment with your physician to review the Ultrasound you had done 10 days ago. An ultrasound that was performed in the same hospital system as the one you are visiting that you fully expect to be available for your physician to review with you - but when you arrive they have no information, report or even knowledge of the study every being performed.....well you don't have to imagine this at all as I would bet it is happening on a routine basis in many facilities.

So it was for a recent visit in our family. Fortunately I had insisted on a digital copy of the Ultrasound delivered on a CD in DICOM format. A quick visit to download a free DICOM Viewer - in this case OsiriX and a potentially wasted visit turned into productive experience. But were it not for the standard of DICOM making these images available easily, and my mission of collecting all medical records personally it would have been a very different story. In my mind the facility woud not have passed the first hurdle of meaningful use - no one involved in care was getting meaningful use of the imaging study or the information from that exam.

Which brings me to the the HITECH act and Meaningful Use standard. Health and Human Services convened hearings on Meaningful use in April this year and issued a set of recommendations that were open to public comment up to June 26, 2009. It is an important question because the incentive funds are linked to implementation that fulfills "Meaningful Use". Naturally everyone is scrambling to determine if their product/solution will meet the requirements and for those on the purchasing or user side wanting to know what Meaningful Use means to them. The Association of Medical Directors of Information Systems (AMDIS) submitted their combined response - the result of discussion that took place at the cleverly nabbed domain www.meaningfuluse.org. The AMDIS response can be found here (pdf). AMDIS promotes Meaningful use based on broad high level themes that include

• Meaningful use should be from the patient’s eyes and in particular make the information available to them
• Clarification of the requirements to receive funding - what must be met to receive payouts
• Focus on data capture and sharing
• Defer reporting requirements of quality measures on the basis that this will become a natural byproduct of implementing systems that capture this information appropriately
• Defer requirements for CPOE implementation as this represents a huge technical and administrative challenge
• Support the criteria with certification of systems that ensure they can talk to other systems - sharing of the data

Great additions to the debate and ones that include a common theme of the patient and importantly easy access to their own records and clinical information.

Not surprisingly the common theme of shareability of information is also evident in the Healthstory response which can be found here (Word Document). Healthstory focused on:

• Incentives to make information sharing a core component of any system and process
• Make the information shared available in "meaningful" form that includes structure and consistency
• Include additional codification of the data that makes it useful to both humans and electronic healthcare systems
• Create incentives for reporting of quality measures

The common thread is the ready sharing of information for the Personal Health Record. As presented in an organization chart that I remember from years back at ground breaking and innovative facility Health Care International Hospital (HCI) in Glasgow Scotland the patient is the king and appears at the top of the organization chart. So while the comment period has closed your ability to look for meaningful use and getting the full healthstory has not. Insist on receiving your information in usable form - it may save you and your physician a lot of time.

Have you had similar experiences - did you get your medical record in usable form or did you meet with full blown resistance. Let me know the good and the bad.

Reinvestment is not Just About Technology

There is lots of excitement or even frenzy over the wave of investment coming down the pipe towards healthcare technology but in this piece on the Huffington Post: Workforce Development Essential to Obama's Health Care IT Initiative Julian Alssid and Jonathan Leviss are quick to point out that there is an essential element that must be included - that of Human Capital. Healthcare is unique and transplanting technology from other industries is not a straightforward process

Hospitals are not banks, or insurance agencies, or hotels. Healthcare's unique workflows -- including many physicians and nurses sharing computers in a busy emergency room, the challenges of maintaining working hardware in an intensive care unit, and the vast realm of data accessed to care for a sick human being -- require novel technologies and processes that cannot be easily translated from other industries.

While I agree that some technologies have stalled many are being implemented and are delivering success today. Speech Recognition did suffer problems in noisy environments (that's why the early adopters of this technology are Radiologists who mostly work in quiet reading rooms). But newer Speech Understanding which is modelled on nature's success in speech understanding by not only using audio inputs but also getting information from the patent's previous history, demographics, prior reports and any other elements that will help in understanding what was said.

But that's not enough

Physicians, nurses, and other health care providers routinely learn new skills and adopt new technologies....What is missing, however, is a parallel training track for a sufficient workforce to develop, implement, manage, and support advanced information technologies in hospitals, doctors' offices, and other health care venues.

So providing the infrastructure is one thing but having the resources to support it is an essential part. This is especially true for the embattled medical transcription industry that has been fighting declining rates of pay as hospitals and healthcare providers continue to push for lower and lower line rates. All this is driven by the perception of the medical transcription is a cost, when in actual fact it is a value added service that frees up the clinical staff to focus on taking care of patients rather than the drudgery of data entry. There are lots of examples of systems trying to turn clinicians into data entry clerks and while there are instances where this methodology makes sense in many cases it does not. Technology will help (see above - Speech Understanding is moving speech into the 21st Century) but even with this technology there is still the requirement to provide support and expertise to facilitate the process of capturing information that is essential to the new age of data driven medicine. The Medical Transcriptionist is the knowledge worker who delivers the value add of helping turn clinical information into structured clinical data that includes the fine detail in the free form narrative that clinicians need and want to include while adding tagged structured data to deliver the full Healthstory for the patent's episode of care.

Jonathan Bush from Athena Health on Government Reforms

Great interview on CNN Fast Money program with Jonathan Bush commenting on the investment and reforms and how this might impact his company.

He makes some salient points and in particular the focus on delivering data and focusing on data rather than paying to implement a bunch of "legacy systems" is the way to effect real change. Not using the money to "buy toys with it".

Athena Health helps clinicians get paid more money faster. They deal with the payment back end of health care. As opposed to building your own claim activity or use someone else who specializes like Visa does for retailers. So I guess Athena is the Visa of Health care. They offer Software Enabled Services rather than "shrink wrapped toys". In his word the key process starts with:

Step 1: Crap Removal

They claim to have one of the most sophisticated back ends in the business and they deal with 23,000lbs of paper for their customers each week! How they extract data from this is beyond me if this is coming in in paper form....

Follow this with a program not so much focused on the amount of investment but rather the execution that:

Pay for data and pay for results

Then stop using these legacy devices and start working towards capturing this as data as part of the process. Here he is singing my song and the need to capture the information in computer interpretable form (I have to believe that some portion of the 23,000 lbs of paper is being processed by an army of folks to digitize and extract data from it) and make this a requirement.

Once again Healthstory help satisfy this need allowing for the generation of the fine clinical narrative detail but complementing this with structured tagged data that can be used to process and show the health improvements and facilitate the flow of reimbursement for better results at higher rates.

David Brailer Weighs in on Health Information Technology

David Brailer writes on the Healthaffairs site with guidance to the incoming President on key reforms to our health care systems. The pledge he refers to of $50 Billion does not appear to jive with the released "American Recovery Reinvestment Act of 2009" (pdf file) draft report that features $20 overall for healthcare + $4.1 billion for preventative health care but relative to the previous investments this is a significant program.

He highlights 4 key areas:

The chasm between the have and have not's - not of health care but of EMR's but rightly he says

We should not incent physicians and hospitals simply to purchase electronic records. We get no benefit when a physician or hospital buys an electronic record. What we should do is reward the use of these tools as part of a patient’s care. “Pay for use” can fund the conversion of the health care system to digital records and ensure that we get the life-saving and money saving benefits they promise

I agree - just buying these expensive systems and funding them seems a flawed strategy and we will just end up with a bunch of unused EMR systems.

Second - the need to build a workforce to enable the digitization of health care - 50,000 people by his reckoning, of people who understand both clinical medicine and information technology. Already in short supply and years in the making. This is right on the money (and I say that with a certain sense of pride since I fall very clearly into this category having made this transition long before this was even a career path or specialization). It is bridging this divide with clear understanding of the issue and challenges faced in practicing day to day clinical medicine that will facilitate acceptance and success.

Third - Information sharing, which is a core fundamental but remains a significant challenge by virtue of the proprietary and protectionist nature to the health care vendors to date. This challenge has thawed and there are many initiatives that will move the industry towards real sharing of data. I certainly want to take my complete "Healthstory" with me wherever I go having just completed the valueless paper based forms for the umpteenth time in my daughters physicians office. There are others but Healthstory represents the complete picture with flexibility to allow participation at a wide range of levels and different detail that makes the adoption more likely. Not forcing or mandating specific data or fields may seem like we loose the data but pragmatic approaches that drive adoption quickly will succeed where highly regimented and overly demanding standards tend to fail in complex environments. So here's my pitch to the incoming Obama administration - mandate the Healthstory standard for capture, exchange and sharing of clinical data. The resistance will be minimal and the standard will allow all stake holders to participate quickly and effectively. Granularity of information will increase over time as the value of this increasingly detailed data is demonstrated with real world use cases - market forces at work.

Fourth - freeing up the clinicians to use the technology and to get paid for digital consultation remotely and facilitating telemedicine. While you are at it I suggest resolving the challenges faced over the practice of medicine in different states as detailed here in the sad case of a Colorado Doctor being prosecuted by California.

Health care reform will happen...it has to happen and there is an explosion of suggestions and ideas, but the above four make a great start and I concur with David Brailer on their importance and value in making these reforms a resounding success but lets make sure that the interoperability is a fundamental part of the equation.

Secretary Daschle First Steps

Senator Tom Daschle formally launched into his new role (to be confirmed but seems likely) as the Secretary of Health and Human Services yesterday at the Committee on Health, Education, Labor and Pensions - presided over by Senator Edward Kennedy.

His passion was clear and he was articulate and knowledgeable talking of personal stories of bankruptcy and lack of insurance coverage that he had witnessed. You have to like his agility in dealing with his colleagues from both sides of the floor and certainly his rhetoric resonated with me.

The problems are large and the challenges great but facing up to the issue of uninsured, catastrophic health bankruptcy (covered here in the US vs UK nightmare experience) is a great place to start. He referred back to the health care reform from 1994 which I personally remember well as an observer from the other side of the pond when many thought the two systems from the UK and the US were moving towards each other but unlikely to meet in the middle. The prevailing view then was the US system was moving to a UK style model and the UK was moving towards a pay for service US style..... neither materialized.

On first blush there is much to commend and like about his style, understanding and intent. The system is broken - I think most would agree on that and needs fixing. The process must include all the stake holders involved but requires government involvement with great leadership.

As a note on a colleagues board says - "if you think you are leading and no one is following you then you are just taking a walk".... I'm following for now and watch this with renewed optimism