Is “Meaningful Use” Meaningful?

Now that the “meaningful use” rule has been finalized by the Office of the National Coordinator (ONC), many organizations turn their focus to a rapid deployment of electronic medical record (EMR) systems in an effort to achieve transformation of the United States healthcare system. Unfortunately, EMR adoption is just one tool used to transform health care, and not the single transformative activity so many believe it to be. Transformation of healthcare encompasses enhancing quality of care, improving patient safety, expanding access to care, and reducing the cost of care. EMRs deployed to satisfy the criteria for “meaningful use” can impact these factors, but only within a comprehensive framework that recognizes the role of incentives, clinical decision support, and healthcare information technology (HIT) in facilitating transformation.

Introduction of new technology often distracts us from our primary task. Our fascination with the technology leads us to focus on what the technology can do, rather than what we need the technology to do. This misguided use of technology also occurs when it is used for healthcare delivery. Many EMR implementations focused on the impressive features of the EMR software rather than the workflow requirements of the clinician users.

Healthcare transformation requires a comprehensive vision of care delivery that recognizes the interrelationships of the many stakeholders. Technology by itself only helps improve those interrelationships, while the underlying structure that the interrelationships are built on remains.

Therefore, the “meaningful use” criteria are meaningful in that they help ensure the use of EMRs in ways that can enhance healthcare delivery, they do not transform healthcare. The recently passed Patient Protection and Healthcare Reform Act (2010) does much to move us toward a better healthcare system, but it too does not transform healthcare. Transformation requires many factors working together in an iterative process to deliver the expected results. Some of those factors are outlined below.

Until economic incentives of all the stakeholders align, care delivery will remain inefficient and suboptimal in quality and safety. Providers are incented to provide more care, payors are incented to withhold care, and patients, detached from the direct costs of care, have been molded to always expect care. The culture of healthcare in America is based on the false belief that more care is better care.

Transformation of healthcare requires a complete disruption of our current system of healthcare delivery. Clinical roles require redefining. Workflows will change to meet the needs of these new clinical roles, allowing the HIT tools, such as EMRs, to be leveraged to improve care. “Meaningful use” criteria is a nice first step to help ensure the effective deployment of HIT tools such as EMRs. Nevertheless, it is just a very small step towards truly transforming healthcare.

Excerpts from: – Is “Meaningful Use” Meaningful? July/August, 2010

Photo Courtesy of  Don Guerwitz Photography – First Light. Bhaktapur, Nepal

Regulate HIT Tools as Medical Devices? Yes and No

The Food and Drug Administration recently announced it is reconsidering its previous decision to exclude health information technology (HIT) tools from regulation as medical devices. When last evaluated in the late 1990s, this decision made common sense. At that time HIT consisted of rudimentary clinical documentation systems, electronic reference materials, and administrative applications. As even these tools were not well integrated with each other and into clinical workflow, they represented more of a digitization of paper-based activities rather than something truly transformational.

Today, HIT functionality far outstrips what was even dreamed about 10+ years ago. In addition, applications function in an integrated manner truly providing the clinician with a clinical experience much different than that offered using paper-based clinical documentation or simple clinical decision support tools.

The role of physicians, nurses, and other healthcare professionals is changing. These providers are becoming more dependent upon the clinical content within the HIT tools, often deferring to “decisions” made by these tools. Such examples include differential diagnosis, prescribed diagnostic and therapeutic treatments, choice of drug, and drug dose calculations. Although the previous rationale for not considering such HIT tools medical devices was based upon the intermediation of the provider between the recommended clinical activity and actual actions taken on behalf of the patient, the strong reliance on these very sophisticated HIT tools today puts this premise into question.

The FDA must study in detail the quality and safety issues inherent in integrated HIT applications before rushing to regulate HIT tools as medical devices. An uninformed effort to regulate HIT tools as medical devices may cause more harm than good. Applying the same standards used for medical devices to HIT tools makes little sense as HIT is neither a standalone application nor strictly a medical device. They are integrated applications that can impact quality and safety in ways far dissimilar to standard medical devices.

Regulation of HIT tools as medical devices is currently premature. Although HIT tools do directly impact patient care and therefore surely require some level of regulation, such regulation cannot be done without the requisite understanding of how HIT works within clinical workflow. The regulations must be constructed to advance HIT use while simultaneously protecting patients.

Excerpts from: – Regulate HIT Tools as Medical Devices? Yes and No. May/June, 2010

Photo Courtesy of  Don Guerwitz Photography – Running the Rapids, Mae Hong Son, Thailand

Keynote Adddress at HIMSS 2010 Annual Conference

(Opening address given at HIMSS 2010 Annual Conference, Georgia World Congress Center, Atlanta, GA, March 1, 2010.)
For PDF of keynote address, click here.

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Our great country is on an unsustainable healthcare cost curve that threatens our ability to bounce back from the severe economic challenges we now face. In addition, healthcare quality and safety, as well as access to care, sit at disappointing levels, especially considering the resources our nation expends on healthcare.

While these healthcare challenges are daunting, I believe the solutions to them must and will come from the professionals sitting in this room and from our colleagues across the country and around the world. Healthcare information technology is the instrument that will transform healthcare and it is we – the informaticists, clinicians, management engineers, senior IT executives, IT specialists and the diverse talents of so many others – who will create the applications, processes and workflows that will improve quality, safety, access and cost-efficiency.

I am confident that we can make this transformation happen because similar revolutions relating to technology and the workplace have happened quite recently. For example, consider the huge changes in how we communicate with each other. Throughout this week, we all will be periodically checking our e-mail inboxes to stay in touch and communicate. According to Merriam-Webster, it was in 1969 that the term “inbox” first entered the American lexicon, to describe a physical tray holding incoming mail and work documents. Over the next 40-plus years, the inbox morphed into an electronic tray where important messages and information are stored. Today, the inbox pervades our working and personal lives, present on our personal computers and mobile smart phones.

The story of the inbox is in many ways the story of the American economy over the past four decades. The inbox tells the story of how a manufacturing-based industrial economy became an information- and knowledge-based service economy driven by data and analytics. The inbox tells the story of how savvy businesses began to share information quickly and inexpensively. These businesses effectively leveraged this information to deliver higher quality products at lower costs. By meeting the needs of their customers, their profits grew while profits of their competitors’ shrank. New ventures sprouted to support these innovators with brand new knowledge-based products. Smart companies thrived in this new data—driven marketplace; others – either unable or unwilling to adapt – could no longer compete.

While most American industries became more efficient and streamlined as a result of these economic realities, healthcare in many ways remained frozen in time. Today, the cost of the American health care system, at 17 percent of GDP, is a millstone around the neck of American businesses, raising the costs of production, stealing wages from the pockets of workers, and restricting the ability of American companies to compete globally. Health care here costs at least 50 percent more than it does in any other industrial country, and according to the World Health Organization, our health care system underperforms in quality, safety, and access to care. In 2006 we ranked 39^th for infant mortality, 43^rd for adult female mortality, 42^nd for adult male mortality, and 36^th for life expectancy. According to a 2008 study reported in the Journal of Health Affairs, the United States trails every single country in the 30-nation Organization for Economic Cooperation and Development in amenable age-standardized death rates, meaning, we are worst at preventing unnecessary death in people under the age of 74. Isn’t the whole point of healthcare delivery to create wellness and prevent unnecessary death? Sadly, we are not doing very well.

In many respects, our health care system still operates like the typical business of 1969 – it is still largely paper-based, it ignores information tools that can facilitate evidence-based best practices, and it functions without analytics to qualify and quantify the care we provide. Medical decisions are made according to implicit criteria – hidden internal knowledge – rather than explicit criteria – external knowledge that can be checked, evaluated, and updated. The Dartmouth Atlas of Health Care provides documented proof of glaring, unacceptable variations in how health care is provided and sheds light on disparities existing across the country. Too many providers are not taking advantage of 21^st-century technologies to access 21^st century information, choosing instead to provide care the same way it was done 40 years ago.

How can we change this? While enacting healthcare reform legislation remains a critical need, any health care bill will primarily impact reimbursement policy, not the transformation of care delivery.  And, because the task of transforming our health care system to meet the challenges of the 21^st century remains to those of us who work in the system, as the HIMSS board chair, I direct these three important messages to your inbox today:

One: HIMSS will play a leading role in the transformation of American health care by effecting positive change in four key areas: quality, safety, access to care and cost.

Two: HIMSS’s purpose – our reason for being – is this health care transformation.

Three: As members of HIMSS, you are the leaders who will create the solutions that will drive this transformation. Through the implementation of compelling healthcare IT solutions, you must transform the way health care is provided in this country. Not the president, not Congress, not clinicians – you. If you don’t do it, it will not happen. You must step forward and you must lead.

As I begin to make the case for why and how healthcare IT will transform health care, I’d like to take us all back to 1981, the year I graduated from medical school. Back then, people spent a good part of each workday managing paper. Upon returning from lunch, a busy executive was handed a pile of pink while you were out messages. She, or more likely he, would find a report draft on top of a bulging inbox. Attached to the report was a brand new, very popular, high-tech item of the day – a post-it note – where the boss scribbled a message to review and advise by writing comments in the margins. On his desk for his signature was a series of letters that his secretary had revised using another technological marvel – white-out. Reminded to call a key contact for advice on an important matter, the executive would quickly thumb through his rolodex to find the telephone number.

During my time as an Epidemic Intelligence Service officer with the Centers for Disease Control back in the 1980s, I do remember working this way. My first outbreak investigation was a foodborne illness on a cruise ship sailing out of Pittsburgh on the Ohio River. When investigating these type of outbreaks, my first task was to construct attack-rate tables that try to statistically identify the food that made people ill. I built these tables by doing all the calculations on a handheld calculator. No PCs were available to me at that time. Needless to say, it took me a few hours to complete the table and identify the cause of the outbreak.

Back then, we were very comfortable going about our business in this fashion and saw no need to change. Still, over the following several years and continuing into the 1990s, the workplace began to change immensely due to personal computers, e-mail and the Internet. Workers did not need to be encouraged to use this technology. They wanted to use it, even demanded to use it, because it made their jobs easier and made them more productive.

Today, in 2010, we must begin to change healthcare in the same fashion – by creating healthcare IT solutions that are so compelling, so irresistible, that people just want to use them. We cannot rely on incentive programs or executive orders.  We must create demand.

We must create electronic systems so appealing that they make physicians want to leave their paper medical records behind. We must create clinical decision support systems that make it routine for physicians to check their internal knowledge with data and evidence. We must offer workflow solutions that improve the efficiency of using health IT. We must make physicians want, yes, demand the enormous power that IT brings to the practice of medicine.

Creating this demand is important because it will improve quality, safety, access to care and cost-efficiency. Simply, we have to change a paper-based system in which most clinical decisions are made primarily by intuitive judgment – based on the ability to recall disparate facts – into an electronic system enabling decisions to be made according to data and evidence.

We must provide clinical decision support tools that reduce the burden of recalling facts and help to assess patients, form diagnoses, and choose therapeutic paths. Healthcare IT opens the door to this higher level of medical practice, one where both physicians and nurses can concentrate on examining, interacting, and motivating patients while technology handles the burdens of collecting, storing and accessing data. The knowledge of best practices and evidence-based care must be delivered to every single clinician at every point of care so that every patient everywhere receives care according this latest knowledge, rather than according to the habits of a clinician disconnected from this knowledge.

American medicine, right now, is relying too heavily on recalling facts. Perhaps the clearest example of this fact is the Pronovost checklist. Each year, about 28,000 Americans die due to I-V line infections. In response, Peter Pronovost, a Johns Hopkins physician, developed a list of five simple steps that intensive-care doctors should take to prevent the introduction of bacteria when inserting an I-V line. Physicians working at 108 hospitals in Michigan adopted the five steps and reduced the infection rate to essentially zero. A paper about their success was published in the New England Journal of Medicine in 2006. But, today, most American intensive-care doctors still don’t use the checklist. They continue to rely on their ability to remember what to do each time they insert an I-V line. Most times, they get it right. The few times they don’t, people die unnecessarily from infections. This is crazy. Every physician I know wants to help patients, not hurt them. Yet, we are hurting them.

It’s up to healthcare IT to make knowledge such as the Pronovost checklist more readily available and its discovery and use more intuitive. This work will require the design of clinical decision-support systems and other tools that merge seamlessly with patient care activities. This work will not just distribute best practices, but embed them into the workflow of medical practice. This work requires a unique multi-disciplinary effort involving not only workflow experts but also virtually any person connected with clinical care.

Bringing this level of sophistication and beyond to American health care will signify true transformation and will require all of the diverse talents represented within HIMSS. No matter who you are, whether you are a senior IT executive, a clinician or an engineer – whether you come from a hospital, a community or public health organization, a clinical practice, a payer or a pharmaceutical company – or whether your primary interest is patient safety, quality, research, privacy, or return on investment – we need you to contribute to the cause of transforming health care through IT.

HIMSS is reaching out to new groups and communities who must engage in the transformation. For example, our Life Sciences Community initiative actively engages pharmaceutical and life science companies, medical researchers, practicing clinicians, the academic community, and device manufacturers. This initiative concentrates on improving the quality, access and usefulness of data through interoperability and interconnectivity – data that can lead to new medical discoveries and treatments. With Board approval, I recently appointed Debra Bremer, Vice President at Pfizer, as an advisor to our Board to offer guidance in these efforts.

Our Payer Community initiative recognizes the shift from the payer playing the role of a transaction manager to one of a care delivery partner focused on improving chronic care management and overall patient outcomes. With Board approval, I also recently appointed Kevin Hayden, President at WellPoint, as an advisor to our Board to provide guidance in these efforts.

Both Debra and Kevin have been working hard with our staff to engage these two communities as we have engaged other industry specialty areas in our effort to transform healthcare through IT. To further involve and educate professionals we need to achieve our goal, HIMSS also has launched a Diversity Business Roundtable, created and delivered numerous distance learning opportunities, and reached out to several academic institutions.

Transforming healthcare requires the development of imaginative solutions. Cedars-Sinai Medical Center in Los Angeles did just that to improve hand-washing compliance, according to a story in the New York Times. Several research studies have reported that health care providers wash or disinfect their hands in less than half of situations where they should, with physicians being among the worst offenders. In an effort to achieve 90 percent or better hand-washing compliance in advance of a Joint Commission inspection, Cedars-Sinai first tried a campaign of e-mails, faxes and posters, but that didn’t work.  Then, a group of physicians and hospital administrators – who dubbed themselves the Hand Hygiene Safety Posse – started handing out bottles of Purell to physicians rounding on wards or as they stepped out of their cars in the parking lot. Also, the posse awarded a $10 Starbucks card as a reward to any physician “caught” washing his or her hands. This tactic improved compliance from 65 to 80 percent but still fell short of the 90 percent goal.

After delivering these discouraging results to the medical center’s chief of staff advisory group of roughly 20 doctors, the hospital’s epidemiologist handed each doctor a sterile petri dish loaded with a spongy layer of agar. “I would love to culture your hand,” she said.

The resulting cultures were photographed. The images were – in the exact words of the epidemiologist – “disgusting and striking, with gobs of colonies of bacteria.”

But here’s the best part – and where IT comes into play: the hospital harnessed the power of this disgusting image by making it into a screen saver that haunted every computer in Cedars-Sinai. Reluctance to hand washing vanished in the face of this filthy evidence, and compliance shot up to nearly 100 percent, where it remains today. Cedars-Sinai urologist Dr. Leon Bender said in the Times article: “With people who have been in practice 25 or 30 or 40 years, it’s hard to change their behavior. But when you present them with good data, they change their behavior very rapidly.”

Now, Cedars-Sinai obviously did not employ leading-edge IT sophistication to solve its problem.  But I chose to share this story with you because it’s a wonderful example of fast and practical problem solving. It shows how you can solve an important safety problem, relatively quickly, through multidisciplinary teamwork, data gathering and a little bit of IT. Oh, and let’s not forget about some good marketing. I chose to tell this story because I want you to think of what problem of a similar nature you might solve. And how you can work to gather the team and fix it.

This week we will hear about many other examples of problem solving and achievement. This year’s Davies Award winners, for example, have impressively improved access to care, quality performance, cost-efficiency and safety. The 19 hospitals that have achieved the HIMSS Analytics Stage 7 recognition represent the first of the truly paperless hospitals and give all other hospitals something to emulate.

But I have purposely crafted my remarks today to emphasize that it’s no longer about what others have done or what others are doing.  It’s now about what you and your organization are doing to transform American health care. I suspect that some of you may see yourselves clearly within this context while others may not. Let me suggest to you today that no matter who you are and what your role is, you have an important if not critical role to play to achieve transformation. You can fulfill your role by building a multidisciplinary team with the expertise needed to solve a problem. You can fulfill your role by gathering and sharing data and evidence as you go along. And you can fulfill your role by having the courage to stay the course or to change your mind – whatever the situation calls for. Great science comes from flip-flopping – it’s O-K to change your point of view as you gain new knowledge.

The challenge before us now is to help all health care organizations to achieve the standards set by the leaders. Indeed, we are succeeding in changing the culture. We have reached the tipping point. Health IT isn’t just for early adopters anymore; it is expected of all.

I send this urgent message to your inbox today: the transformation of American health care by improving access, quality, safety and cost-efficiency is a cause to which we all must dedicate ourselves. Identify a project, engage experts different from you, embrace diversity, form a team, try something unique, make mistakes, redouble your efforts, celebrate your successes, and then start again with a new idea. It is you who will discover something new. It is you who will develop the needed solutions. It is you who will effectively implement change. It is you who will transform healthcare. It’s your job to act now upon the message in your inbox and to place your contribution to a transformed American health care system in your out-box in due time. Thank you.

Barry P. Chaiken, MD, FHIMSS
2009-10 Chair HIMSS
CMO, DocsNetwork, Ltd.

Looking Back…and Looking Ahead…on the Progress of EHR Implementation

In the December 2010 issue of the HIMSS Digital Office, leaders in health information technology share their perspective on the progress of EMR adoption in 2009…and their vision for implementation of electronic health records in 2010. Barry P. Chaiken, MD, FHIMSS, HIMSS Chair shares his vision on adotpion below. This is reprinted from that publication.

What do you think is the greatest achievement in health IT in 2009?
Advances in technology just offer new tools, while advances in politics, represented by meaningful funding levels, provide momentum for real change. The billions of dollars provided to the Office of the National Coordinator for Health IT established the ONC as a true driver of advances in health IT use. The appointment of a healthcare policy expert David Blumenthal, MD, rather than an informaticist, signals that the Obama Administration is serious about promoting the use of health IT through policy changes that impact how healthcare is delivered in the United States. In addition, recruiting John Glaser, even on his current temporary basis, partners Dr. Blumenthal with one of the country’s leading health IT experts, Therefore, solidifying the funding of the ONC, and appointing Dr. Blumenthal and Mr. Glaser is 2009’s top health IT achievement that will positively impact the use of health IT to deliver safe, high quality and cost effective healthcare.

What would you like to see happen in 2010 to help move forward the adoption of electronic medical records?
When ATMs first appeared in the 1970s, interconnected financial networks did not exist. Customers of a bank could only use their ATM cards in machines provided by their bank. There was no ATM interoperability. The banks soon realized that providing ATM interoperability was considerably less expensive than installing proprietary ATM machines throughout the country. In addition, interoperability gave all banks a national, rather than regional, presence as customers could withdraw funds from any connected ATM. To advance the adoption of EMRs, information technology vendors must honestly embrace interoperability, building their systems to easily accept and exchange clinical data. True interoperability would provide clinicians with more complete patient records allowing for better quality care. Offering a more complete record that provides more value to the clinician strongly works to advance the adoption of health IT applications.

Photo Courtesy of Don Guerwitz Photography - Rooftop Statues, La Pedrera. Barcelona, Spain.

Hospital Computerization Not a Budget Saver, Concludes Study

By Joshua Feblowitz

The recent survey of over four thousand hospitals found no connection between computerization and reduced costs. In addition, increased computerization led to only small improvements in the quality of care.

Researchers found that more “wired” hospitals had higher total costs and more rapid cost increases. They also examined a list of the “100 Most Wired” hospitals and determined that these institutions had performed no better in terms of administrative expenses or quality of care.

These findings contradict previous anecdotal evidence indicating the benefits of healthcare information technology (IT), a category that includes systems such as electronic medical records and computerized order entry. The study has sparked significant controversy, in part because President Obama and others have widely promoted healthcare IT as a tool for saving money and improving healthcare. The 2009 stimulus bill included over $19 billion to encourage the adoption of healthcare technologies.

Using twenty-four different measures of hospital technology, researchers created a composite “computerization score” and compared this with changes in administrative costs and quality of care during the years 2003 to 2007. The only area in which they found significant improvement was in the quality of care for heart attacks.

“There’s no evidence that what we are doing is actually working,” says lead author Dr. David Himmelstein, a professor at Harvard Medical School, who calls promises of improved quality and reduced costs “propaganda of the healthcare IT industry.”

“It’s easier than saying what needs to be said,” Himmelstein argues. “We need to abolish the private health insurance industry. It’s much easier to say that there’s a silver bullet here, and all we need to do is install these fancy machines.”

However, these results, experts say, are far from definitive. Certain hospital computer systems have proven to yield substantial benefits. Computerized physician order entry, for example, a technology used to enter prescriptions and order tests, has been shown to greatly improve the quality of care. Even things as simple as adding barcodes to medications can dramatically reduce medical errors, says Dr. Barry Chaiken, chair of the Health Information Management Systems Society.

These types of improvements in quality are well documented. A study at Brigham & Women’s Hospital in Boston, Massachusetts, showed that computerized order entry systems could reduce serious errors by up to 55 percent and the overall error rate by over 80 percent.

Computerization accomplishes these improvements, experts argue, by giving hospitals the ability to manage information more efficiently. “When a facility installs software, they are looking for something that gives them better control over the chaos in their department,” says Keith Herron, representative for Patient Care Technology Systems, a healthcare IT company. “They also want to be able to document the patient encounter and document more fully.”

“If your physician has more information about your health, they are likely to make better decisions,” says Dr. Ashish Jha, professor at Harvard Medical School. “In a paper-based world, important pieces of information are often missing. Mistakes aren’t caught as easily. There are many ways in which technology if designed and implemented effectively can improve quality.”

Experts also criticize the study’s methods of examining hospital computerization. “This study is very problematic because both their measures of cost and their measures of technology have serious limitations,” says Jha.

“If you look at something and don’t find it, it could be that there’s no effect,” Jha continues, “Or, it could be that the way you looked at it didn’t make sense.” Specifically, Jha notes that the study’s “computerization score” included factors unrelated to patient care, such as accounting and staff scheduling.

Jha also says that the study’s measures of costs and quality are very broad and may not accurately reflect the benefits of healthcare information technology. Data on computerization was reported by hospitals and collected by the Health Information Management Systems Society. Researchers compiled this data into their own composite scores of quality, costs and computerization before performing statistical analysis.

Others suggest the reason for these findings is that current hospital systems simply aren’t very advanced. Although many hospitals spend a great deal on information technology, says Dr. Robert Kolodner, former National Coordinator for Healthcare IT, the number of hospitals with sophisticated electronic health records is “vanishingly small,” less than two percent.

“They are using the best data they have,” agrees Chaiken. “But I don’t think we’ve reached a tipping point as to what healthcare IT can do.”

In addition, experts say, healthcare IT is only beneficial if applied in the correct way. “It all comes down to how you implement these systems,” says Dr. Adam Wright, co-author of the study, “It’s not the technical quality of the system that you purchase but the way you use it.”

In order to benefit from these technologies, says Dr. Michael Siegel, head of the Digital Health group at MIT, we must accept new approaches to healthcare. “We’re managing the process, moving at incredible speeds, as if things were still the same. There has been lots research done that when you introduce IT and don’t change what you’re doing, it doesn’t help.”

“I would call for some patience,” says Wright, who likens the process of development to the construction of the Transcontinental Railroad. “Imagine you’re building a railroad. Laying tracks across the country. It’s very boring and very expensive. And until you hammer in the Golden Spike, you can’t actually drive a train across the country.”

Reprinted from Scope, December, 2009.

Photo Courtesy of Don Guerwitz Photography - La Pedrera. Barcelona, Spain.

Making Meaningful Use Meaningful

A short three years ago, the Office of the National Coordinator for Health Information Technology (ONC) was funded at a level of less than $150 million. Today, thanks to the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH)—part of the American Recovery and Reinvestment Act (ARRA)—the ONC received a budget of over $2 billion. In addition, no less than an additional $19 billion is set aside to facilitate the adoption of electronic medical records over the next decade.

For both industry and government, budgets provide a more reliable picture of strategy than do policy statements. Therefore, there is little doubt that the current administration expects health information technology to play an important role in reducing healthcare costs while improving quality, safety, and access, a high priority of the president.

To accomplish this goal, adoption of technology is not enough. These new tools must be utilized effectively to achieve desirable and measureable results. Therefore, almost all of the incentive funding available to providers for the adoption of health information technology is tied to the “meaningful use” of that technology.

So what is “meaningful use?” Perhaps former Supreme Court Justice Potter Stewart provides some guidance. In a 1964 opinion on an obscenity case (Jacobellis v. Ohio) the late Justice Stewart described hard-core pornography as follows:

“It is hard to define, but I know it when I see it”

In spite of the work performed by many ONC committees to date, many working in healthcare believe the ONC is taking the same approach to defining “meaningful use.”

To its credit, the ONC is working to offer providers a hard and fast definition of meaningful use backed up by exactly defined, collectable measures. By statute, the secretary of health and human services has until December 31, 2009, to issue an interim rule on meaningful use. As the rule must go out for comment for a minimum period of time, a final rule is not expected until late Q1, 2010.

Source: Making Meaningful Use “Meaningful” – PSQH, November/December, 2009

Photo Courtesy of Don Guerwitz Photography – Young Pioneers, Havana, Cuba.

Is There Any Doubt It’s Broken?

What have we learned from the Massachusetts healthcare reform effort? Although costs to the state are running higher than anticipated - a problem in a recession – about 97% of MA residents enjoy some type of healthcare insurance. Considering the national rate is about 81%, this is a monumental achievement.

As for our lessons learned, the individual mandate is necessary to achieve universal coverage and the employer mandate helps get you there.

Additionally, a competitor to the insurers must be established, whether a public option or a non-profit regional option, to incent the insurers to better manage costs.  Currently, these options do not exist in Massachusetts. The state now subsidizes healthcare insurance for those who cannot afford it by paying private insurers to cover these individuals.

Realistically, the Massachusetts reform plan is just a partial framework for what is needed nationally, not the entire plan. Any federal effort must be more broadly based and far reaching, something states, due to existing rules on trade, Medicare, and Medicaid, cannot achieve on their own.

Success requires all stakeholders to sacrifice a bit of their pie or fiefdom. Right now that is not happening fast enough or in significant areas to deliver meaningful reform. For example, there is a good argument presented by physicians for tort reform, but there is little talk about linked changes in licensing that can help identify and retrain poor physicians.

The goal needs to be universal coverage. Actually, we have that already. Unfortunately, it is very inefficient and possibly the dumbest deployment of universal coverage possible. (See – Marking 33 Years of Universal Health Coverage) Although the uninsured eventually get care now, it is the rest of us through our insurance and taxes who pay for it indirectly. And for those unfortunate enough to get seriously ill, they often lose their homes and life savings. About 50% of all bankruptcies in the U.S. are related to medical bills.

How we get to universal coverage is through a holistic approach that addresses access, quality, and cost. Considering the number of powerful stakeholders – physicians, insurance companies, pharmaceutical companies, hospitals, and consumer groups - passing any meaningful legislation would be an amazing accomplishment.

Paying $7,300 per capita per year for healthcare is way too much considering the poor outcomes we get from spending all that money. Other countries pay less and receive more value. And if you want to make the argument that the U.S. healthcare system is better at this procedure or that treatment, considering we are spending at least 40% more than the other countries, we should be trouncing those other countries on all measures of quality, safety, and clinical outcomes. Sadly, we are not.

If George Steinbrenner expects the Yankees to win the World Series every year considering he spends 40% more than any other team on payroll, is it wrong for us to expect the same from our spending on healthcare? Should we not receive the best care in the world?

Anyone who thinks healthcare is not broken is not paying attention to the facts. How it gets fixed, is debatable. Whether it is broken, is not.

Photo Courtesy of Don Guerwitz Photography – Daycare Center, Havana, Cuba.

We Need Privacy Now

Does the Fourth Amendment apply to our medical data?

The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no warrants shall issue, but upon probable cause, supported by oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized.

According to a report by Milt Freudenheim in the New York Times (And you thought a Prescription Was Private, August 9, 2009), it sure doesn’t look like it.

More than two years ago (Patient Information: Who’s Your Daddy) I warned that for-profit entities might use private patient data to market products to consumers.

Patient data may be used to target relevant product ads to individuals based upon the data contained in the medical record.

Today, patient information is actively being used to target market products and services to patients. Large pharmacy chains such as CVS Caremark and Walgreens regularly utilize pharmacy information to identify patients to whom they send out email messages, coupons, and flyers. Although the data they utilize is de-identified, they employ reverse lookup utilities to reconstruct the information with patient identifiers.

At a meeting with several health information technology leaders at the HIMSS 2008 Annual Conference, Google’s CEO, Eric Schmidt, was cautioned about the use of patient data contained within Google Health. Although WebMD and Microsoft currently acknowledge the privacy rules outlined in ARRA apply to them, Google disagrees. Freudenheim quoted in his article a representative of Google who said:

Google is bound by the privacy policy that people agree to when they sign up.

WOW. To this day I still have not met anyone who reads those legal notices we all are asked to accept before using software or accessing certain websites. To rely on the acceptance of the privacy policy upon sign up as a defense for using patient information in any commercial way deemed appropriate seems weak and suggests exploitation.

Excerpts from: – We Need Privacy Now – PSQH, September/Ocotober, 2009

Photo Courtesy of  Don Guerwitz Photography – Surprised! Stonetown, Zanzibar, Tanzania.

HIT Alone Not the Solution

In 1980 a Stanford University School of Business professor Alain Enthoven authored a book titled Health Plan: The Only Practical Solution to the Soaring Cost of Medical Care. Dr. Enthoven provided the theoretical underpinnings of managed competition, an approach to reducing healthcare costs embraced by the Clinton administration’s Task Force on National Health Care Reform. Chaired by the then first lady Hillary Rodham Clinton, the task force failed to convince Congress to pass comprehensive healthcare reform legislation. This unsuccessful “breakthrough solution” was just one of many proposed over the last 30 years to save our healthcare system from collapse.

On the first page of Enthoven’s book he wrote about the strain healthcare costs were putting on federal, state and local governments. He then addressed the private sector, particularly the automobile industry, where soaring health insurance costs were a difficult burden on employers. According to Enthoven, healthcare costs made up 6.2% of GDP in 1965 and ballooned to 9.1% in 1978. (1) Today, healthcare costs eat up over 16% of GDP. In the 27 years since Enthoven published his book the United States has seen little progress in controlling healthcare expenditures.

Although our healthcare system struggles with access, covering the uninsured, and medical errors, generally Americans receive pretty good healthcare, especially when their illness is not routine. Unfortunately, the resources currently required to provide that level of care are beginning to impact our standard of living and competitiveness in the world.

Unequivocally, healthcare information technology alone cannot solve the problems our nation faces in delivering high quality, affordable healthcare to all Americans.

A comprehensive approach to healthcare reform is necessary. Everyone, including physicians, nurses, patients, administrators, and insurers must work together to form the solution. Continuing to approach illness and deliver care the same way we have been doing for decades is sure folly.

Physicians and nurses must begin to see their responsibilities in a different light and begin to do their tasks differently. Administrators and insurers must assist and incent them. Patients must take responsibility for their care and work to prevent illness rather than wait passively for resource intense medical miracles to fix them.

Therapies need to be driven by science and rational thinking rather than habit and personal preference.

Healthcare information technology can provide some critical tools to achieve this necessary change, but those working within the healthcare system must employ these tools in different workflows and processes. Utilizing the tools to “automate” existing processes only works to continue delivering unacceptable outcomes.

If we want to truly address our problem of spiraling healthcare costs, it is time to get to work fostering the change management necessary to reform our healthcare system for the better. Otherwise, we will read Enthoven’s book a decade hence and realize nothing has changed except for the slogan.

Source: Healthcare IT: Slogan or Solution? – PSQH, January/February, 2008

Savings from Effectiveness Research Can Fund Reform

The American Reinvestment and Recovery Act 2009 (ARRA) earmarks more than $800 million toward research on comparative effectiveness of medical treatments. In addition, more than $700 million is directed to the Agency for Healthcare Research and Quality, a research institution with a long history of evaluating effectiveness of treatments. With healthcare reform at the top of the agenda for the 111^th Congress and the Obama administration, will a NICE-like entity be part of the reform package?

NICE, the National Institute for Health and Clinical Excellence, makes recommendations on how care, treatments, and medications are distributed through the United Kingdom’s National Health Service (NHS). More than 95% of the healthcare provided in Britain is through the NHS. Prior to NICE, hospitals made decisions about care based upon financial constraints which led to great disparities in care. NICE’s prior approval of drugs and treatments guarantees that all institutions offer the same care options.

Although the use of cost-benefit analysis to evaluate the appropriateness of medical treatments n the United States may seem unique, the state of Oregon first used such an approach more than 15 years ago. The plan’s administrators assembled research panels that reviewed hundreds of treatments, ranked them by benefit and cost, and produced an overall ranking of the treatments for which Medicaid should pay. Estimating the expected demand for each treatment, the administrators then applied the Medicaid budget to the costs of the treatments as ranked, thereby producing a list of approved treatments:

[Budget – (Treatment 1 Cost * Estimated Frequency) – (Treatment 2 Cost * Estimated Frequency) – etc.]

The rejected treatments were those ranked where the budgeted Medicaid funds ran out. Since the list was developed from both cost-benefit analysis and budgeted amounts, many critics of the plan claimed it to be care rationing. Similar cries of foul currently exist in Britain.

Much of the resistance to healthcare reform in Congress and beyond is based on cost concerns. Even though the United States spends more than 30% more per capita on healthcare than any other country, healthcare policymakers struggle to find the sources of revenue to enact reform. The ARRA offers a large sum of money to research the same issues currently investigated by NICE. Perhaps the success of healthcare reform is dependent upon the ability of comparative effectiveness research to show the way to cost savings that can fund the reform.

How the Obama administration intends to apply comparative effectiveness research in future forms of healthcare delivery is unknown. Nevertheless, considering the large investment in this area, it makes sense that at some point it will be offered up as a source of revenue to pay for healthcare reform. This is the only way we can expand access and improve quality without bankrupting our economy and destroying American businesses.

Source: Is It Time to Play NICE? – PSQH, May/June, 2009