Keeping It Clean

By Laurie Gelb, July 7, 2011

Recently I became aware that my husband’s national pharmacy record contains not only his own data, but that of another patient.

The root cause: the other patient, in another state, with a different payor, was never asked to confirm his address when he picked up his meds. He has the same DOB, first and last name as my husband, though their middle initials, and, of course addresses, are different. Naturally, a "boomer" generation yields birth date clusters. Had anyone ever asked him one simple question at each pickup, “What is your address?” and compared it with the primary address on screen, I wouldn't be writing this.

Between the pharmacy that repeatedly pulled up the wrong record, me, the health plan, the Web team and the pharmacy’s HQ, there have been about 20 phone calls + a series of logins to investigate and re-separate the records of these two patients. I have participated in about half of those. I was told that “one other case” has occurred in memory, meaning probably thousands as yet undetected or unresolved.

A month since I first notified the pharmacy of the issue, the incorrect data are still mingled, though not for lack of trying. As a last resort, my husband’s record has been deleted and re-created, so far with two sets of login credentials for the new record, neither of which works.

Now the question for your EHR vendor: what automated internal validity checks are run on the data populating the record associated with a single MR number, other than obvious single-field validations like date formats? We've already seen the error rate in e-Rx. An EHR selling point is medication alerts. We would expect a pharmacy record to do as well, no? However,  for months now, no edits or alerts have popped up, though the combination of my husband and his counterpart results in a patient who has been on two macrolides, a steroid, warfarin, rx NSAID, ED drug, opiate and four antihypertensives, among other things.

So to your knowledge, do clinicians entering EHR data routinely verify anything other than name? Or do they simply presume the applicability of a paper chart that someone else pulled, or the EHR that they just opened? We certainly can’t tell ourselves that they would always spot internal inconsistencies.

No doubt accidental merges have already occurred in EHRs. And clearly the structure underlying most EHRs (if not all) would have a difficult time backing out a large quantity of data and re-associating it with a second identifier, until we really standardize import/export formats. 
And is it the clinician's job to reassign data into the appropriate records?

Certainly there are HIPAA implications as accounting of disclosures becomes more robust. With an increasingly cloud-based environment but no über-record, contradictory information will find its way into multiple databases, with little impetus or procedure for reconciliation.  I don't see the words “cleaning” or “data validation” anywhere in the PCAST HIT report, or in too many near-term HIT agendas. 

My pharmacy woes don't bode well for the far more complex EHR. As it happens, I've seen errors in every personally-verifiable EHR I've ever skimmed, including at sites used as Federal models. And if I weren’t ordering refills via mail order, I would never have seen the merge, with unforeseeable consequences.

For example, my husband wears a MedicAlert bracelet, linked to an accurate drug list. In an ER, which list would a physician believe: the one from a pharmacy, that a fully functional EHR will link in, or the “self-reported” one? But the former would be dangerously misleading, and, in fact, would also call the list of conditions on my husband’s wrist and his PHR into question. Then what?

Probability of 100% human verification in the next decade? Zero, unless you design systems that require it. Of course, there are many solutions for positive ID, from biometrics to unique credentials. All require time and money. Whose?

In the zero payment for errors mindset, as EHRs become the go-to reference, who does the cleanup and how? And why -- what are the incentives for doing so? The answers to these questions may influence your cost trend over the next few years than we yet know.

Gambling on Health Care

by Kim Bellard, November 23, 2010

I heard a speech by Tom Daschle recently, and something he said really struck me: to paraphrase, he pointed out that we can get more performance statistics on virtually every athlete than we can on any physician.  He’s not entirely right, but he’s close enough for this statement to hit home.

My tablemate at the speech suggested to me that fantasy leagues in health care might help solve this problem, which I think is a great idea, but perhaps what we really need to motivate getting more information on health care providers would be to introduce gambling into the health care system.  Oh, wait, cynics might argue that we already have gambling; we call it health insurance, and the bookies are actuaries. 

I’d argue that we have a different and more insidious form of gambling: simply getting care.

The HHS Inspector General recently released a report indicating that 13.5% -- that’s one in seven -- of hospitalized Medicare beneficiaries suffered an adverse event that caused a lasting impact or even death during the month reviewed; some 134,000 patients just in one month.  Worse than that, 15,000 of those patients ended up dying due to their adverse event; just in one month, just for Medicare patients.  An additional 13.5% of the hospitalized beneficiaries suffered events that caused temporary harm.  The researchers determined that 44% of the various events were preventable, and that the adverse events cost Medicare some $4.4 billion annually.  I say again: these deaths, and those costs, are only for Medicare patients. 

Sad to say, but these statistics no longer come as a surprise.  It’s been over ten years since the Institute of Medicine produced their estimates that as many as 98,000 deaths annually are due to medical errors.  The IOM also estimated that medication errors injure 1.5 million people annually.  Various other studies, including Zhan and Miller (2003), come up with similar sorts of numbers for hospital deaths.  I previously blogged about a study reporting on adverse surgical events that should scare anyone facing surgery.  One could conclude that going into a hospital is a crap shoot as to if you’ll be walking out with both legs intact, or walking out at all.

And it’s worse than that.  A study by a study by McGlynn, et. al., indicated it’s also essentially a coin flip as to whether you’ll get the recommended care when going to the doctor’s office.  Similarly, a study by the Urban Institute cautioned that “…patients may be at greater risk of safety problems in the United States than they are elsewhere,” citing issues with surgical and medical errors, issues with safe medication practices, receiving delayed or incorrect test results as examples. 

Given all these problems, one could naively conclude that it is no wonder that medical malpractice costs are high; reimbursing patients harmed by all this problematic care would be expensive.  That would be naïve indeed.  It appears that our malpractice system doesn’t make either patients or health care providers very happy.  Studies suggest that only a very small number of patients suffering actual medical errors even filed claims (see Localio, et. al.), and that as much as 54% of every dollar spent on compensation go to administrative expenses, such as lawyers’ fees and court costs (Studdert, et. al.).  Then there is the shibboleth of defensive medicine, which everyone agrees exists but which is hard to quantify.  Mello, et. al. bravely estimates that defensive medicine accounts for about $46 billion of the estimated $55 billion spent on medical liability, while Jackson Healthcare concluded that the order of magnitude was between $650 billion and $850 billion.  Whatever the number is, we can all agree it is big.  Defensive medicine as a way to reduce malpractice risk is like trying to hit a piñata; not really sure where the target is or what will happen if you do hit it. 

Which leads me back to statistics.  Our current liability system is based on fear and blame.  Documenting and reporting on errors can indeed seem foolhardy in a system that seeks to find deep pockets, not to fix problems or improve care.  It’s no wonder better data doesn’t exist and available data is hard to find.  Reform efforts based around capping liability payments miss the point almost entirely.  We need an entirely different mindset.

We have to start with the data: what happened, what went right, and what went wrong.  We should be looking for patterns, trends, and opportunities – not for culprits. 

We have to recognize that not everything that goes wrong is malpractice.  The notion that we will ever have an error-free health care system is folly, but at least we can get a clearer idea of who is making which errors how often.  Errors need to be tracked, and used to identify processes that can be improved.  Only with that kind of data can true quality improvement efforts happen.

Just as there will always be errors, there will also always be some unexpected medical outcomes.  Those are unfortunate, but they may not be due to any errors and may not be anyone’s fault.  They should be treated and fixed, without recourse to litigation or blame.  However, expecting patients or their insurance to pay for this follow-up care can unduly reward providers in a fee-for-service system, and payment reform should address.

There will still be a small number of situations where a health care provider is practicing in a manner that is not consistent with available medical evidence or best practices, is treating patients while impaired, or otherwise not acting in the patient’s best interests.  These are the situations where liability comes into play, but one would hope in a more transparent environment there would be fewer opportunities for harm to occur.  In theory, the medical profession self-polices itself, disciplining wayward members, but it is hard to imagine how this could ever happen under the current system of haphazard and incomplete reporting. 

Collecting the necessary data, and making it public, should go a long way to ensuring that patients are getting the right kinds of care from the appropriately qualified providers.  If we’re going to gamble with our lives and our well-being, I want to know the odds and I want to make sure I’m getting care from someone who would be on my health care fantasy team.

Kaiser Permanente Goes “Open Source” With Their Internal Medical Terminology

by Clive Riddle, October 1, 2010

In Meaningful Use news, Kaiser Permanente has announced that they are donating their “Convergent Medical Terminology (CMT) to the International Healthcare Terminology Standards Development Organisation (IHTSDO©) for U.S. distribution through the U.S. Department of Health and Human Services (HHS) so that all health care providers—large and small—can benefit from the translation-enabling technology.”

The stated objective is to make KP’s experience and formerly proprietary system available to help U.S. health professionals and hospitals achieve key meaningful use standards set forth by the Office of the National Coordinator of Health IT and the Center for Medicare and Medicaid Services.

HHS Secretary Kathleen Sebelius has commented that “one of the key challenges to achieving a coherent health record for every U.S. consumer is the need for consistent data across all systems and institutions. This donation of the Convergent Medical Terminology from Kaiser Permanente addresses that critical need by making it easier for health professionals and patients to create standardized data in electronic health records."

Jack Cochran, MD, Executive Director of The Permanente Federation added that “utilizing a common terminology that translates complex medical concepts into language that is both clinician- and patient-friendly has helped us coordinate teams, improve the quality of care for our patients and enhance efficiency in our organization. We would like to share the tool we developed with the country."

Kaiser’s system involves “the production of structured health data by creating and linking clinician- and patient-friendly terminology to the health data standards now required for U.S.-wide use. The Convergent Medical Terminology[CMT] has been developed by clinicians and technologists over many years. It is in active use to document thousands of patient encounters every day.”

Kaiser Permanente's CMT donation incorporates the following:

• terminology content KP has already developed
• a set of tools to help create and manage terminology,
• processes to control the quality of terminology that is developed.
• mappings to classifications and standard vocabularies, such as the Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT©) already accepted by U.S. and international health policy makers

Kaiser provided the following additional information about their CMT system:

• CMT is used in the underlying architecture of Kaiser Permanente's HIT systems to support data flow between health care providers. It provides mapping to standardize the use of terminology and ensure systems, some already in use in most U.S. medical offices, can talk to each other effectively. The utilization of CMT will support a common set of medical concept descriptions so that one doctor's diagnosis can be reconciled with another's. CMT includes the key taxonomies required for stage one of the Meaningful Use program such as problem list sets in SNOMED CT. Thus, it can help clinicians map to the standards set forth by the Office of the National Coordinator of Health IT and the Center for Medicare and Medicaid Services.

• CMT is a core component of Kaiser Permanente's comprehensive electronic health record, KP HealthConnect®, helping physicians communicate with their patients more clearly. KP HealthConnect is the world's largest private electronic health record, connecting more than 8.6 million people to their physicians, nurses, and pharmacists, personal information, and the latest medical knowledge.

• CMT is also utilized by Kaiser Permanente's personal health record, My Health Manager, on kp.org so that patients can get a better understanding of their medical care. My Health Manager provides patients with secure, timely access to their lab test results, medication information and refill capabilities, summaries of their health conditions, and other important health information at just the click of a mouse. The technology empowers patients to manage their health by allowing them to access health information and tools and securely e-mail their doctor.

Analytics in the People's Republic of China

By Clive Riddle, September 17, 2010

 This week, the National Predictive Modeling Summit was held in the Washington DC area. During the Thursday afternoon workshop on International Analytics issues, Rong Yi, PhD, Senior Consultant at Milliman, Inc. gave a presentation on Predictive Analytics and the People's Republic of China.

Here’s some of what Rong had to share on health care and analytics in the People's Republic:

• 22% world’s population, 2% world’s health care resources.
• China’s health care spending is 4.7% of GDP.
• 2/3 of the population are in the rural area, supported by only 20% of health care resources.
• Chronic conditions account for 80% of deaths in China
• Hypertension: 18.1% of population (160 mil), increased by 33% in 10 years.
• Diabetes: 9.7% (92 mil) adult diabetes, 15.5% (148 mil) prediabetes.
• Overweight and Obesity: 8.1% children age 7-17, 22.4% adults
• 14 different ministries and commissions are involved in China’s public health and healthcare policymaking
• Rural Coverage: the New Cooperative Medical System started in 2003,  with 100% reach at village level as of 2010
• Urban Coverage: Workers medical insurance started in 1998; Residents medical insurance started in 2007
• Private insurance: Chinese insurers dominant, foreign insurers 5% in market share; Starting in 2011 foreign insurers are allowed to enter the China market for individual and group health insurance
• Reform includes an investment of 2,000 new hospitals in 2009-2012; 3,700 new community health services centers, and 11,000 new community health services stations
• State of Predictive Analytics:  (1) No claim-based predictive modeling at the present time; (2) commercial use of scoring methods and HRA tools include-  HRA research committee under China’s CDC, Proprietary HRA tools developed on China’s data, and specific scoring tools, e.g., ICU scoring systems, disease-specific scoring; (3) Disease risk prediction models based on health screening data on large population in which long term risks are modified using long-term factors such as lifestyle and behavioral factors (smoking, exercise)

Getting One’s Head Around the Physician EHR Marketplace

by Clive Riddle, May 21, 2010

In the midst of health reform and stimulus initiatives to drive EHR adoption, I’ve been trying to get my head around the physician Electronic Health Record marketplace. What is the total size, what is the current level of adoption, who are the major vendors, and what is their market share?

So then Chris Thorman of SoftwareAdvise.com surfaces, with his own blog post, EHR Software Market Share Analysis, that takes a pretty good stab at these questions. Here’s  what Chris and Medical Software Advise team determined:

• 65% of all 788,000 U.S. physicians, or 512,000 are outpatient/private practice based and thus in the potential EHR market (U.S. Bureau of Labor and Statistics)

• 44% of these 512,000 physicians, or 225,000 doctors, have adopted either a partial, basic, or fully functional EHR system (CDC)

• The top vendors in this marketplace are:
  • Epic (45,000 ohysicians/ 17% marketshare)
  • Allscripts (40,000 physicians / 15% marketshare)
  • eClinicalWorks (40,000 physicians / 15% amarketshare) 
  • GE Centricity (35,000 physicians / 10% marketshare)
  • NextGen (35,000 / 13% marketshare) 
  • SOAPWare (30,000 physicians / 12% marketshare) 
  • Practice Fusion (18,500 physicians 7% marketshare 
  • Other Vendors (10% marketshare)

There are of course a number of nuances and issues that would benefit from further clarification in their analysis, which Chris details in his post. Chris is also seeking feedback from those with direct knowledge in this area.

Accenture Says Physician Laggards are Poised to Finally Adopt

by Clive Riddle, March 5, 2010

Smaller physician offices, lacking infrastructure and capital and perhaps motivation, have been viewed as the stumbling blocks to widespread physician EMR adoption, And without adequate physician adoption, hospital and health plan adoption won’t likely achieve the level of effectiveness required to justify their investments.

Accenture this week released results from a study conducted by their Innovation Center for Health and Institute for Health & Public Service Value in conjunction with Harris Interactive in which they surveyed 1,000 U.S. physicians from smaller practices (fewer than 10 physicians) regarding EMR use, with 15% of respondents being current EMR users at various levels and 85% non-users.

The good news? The majority of non-users say they now intend to purchase a system, and the percentage goes way up when you ask those who aren’t so close to retirement. The bad news?  (1) The majority if them are looking to hospitals for help and subsidies; (2) saying you intent to purchase a system doesn’t necessarily translate into actually doing so; and (3) there’s still a material number that won’t even go so far as to make that verbal commitment, despite upcoming federal penalties and incentives.

Here’s some of the key findings from Accenture:

• 58% of non-users intend to purchase an EMR system within the next two years;

• About 80% of physicians under age 55 plan to implement an EMR system within the next two years;

• 75% of non-users are potentially interested purchasing an EMR system from a local hospital - if at least subsidized for about half the cost;

• The key driver of EMR adoption is federal legislation - 61% cited federal penalties for non-adoption and 51% cited federal incentives;

• Non-users underestimate the cost and time requirements to implement an EMR system, but also have an exaggerated perception of difficulties in using EMR systems, compared to the actual experiences of EMR users;

• 90% of current EMR users – believe that their system has brought value to their practice- providing an effective overview of patients’ relevant history, records and information; and allowing quick and accurate data entry.

Accenture credits federal legislation for stimulating interest. Dr. Kip Webb, who leads their clinical transformation practice, tells us “our research indicates that, as intended, federal legislation is an important driver of EMR adoption among U.S. physicians. If U.S. health care providers properly implement and use EMRs more broadly, there is no doubt that EMRs can make an important contribution to improving quality of care and controlling costs.”

While a wider number have some level of EMR, Accenture notes that “today, just six percent of U.S. office-based physicians use a fully functioning system.”

Prowling through the Census Bureau 2010 Statistical Abstract

by Clive Riddle, January 15, 2010

Okay, so sifting through The 2010 Statistical Abstract may not rank up there with bungee jumping or running with the bulls (book your trip to the Pamplona Spain San Fermin Festival this July 6^th through the 14^th) on the adrenaline rush meter, and might not be recommended to list as a favorite activity in your Facebook profile, but just the same, there’s some pretty cool, free and easy to access health care data tables available in the Abstract.

I grabbed a few of the excel files from the various categories of health care tables that I found interesting, and compiled summary information from three items I thought would be worth sharing:

From Table 160. Percent Distribution of Number of Visits to Health Care Professionals by Selected Characteristics: I wanted to see how the pie slices up by selected age group for frequency of annual visits to doctors and other health care professionals

Annual Visits by Selected Age Group	Zero	1-3	4-9	10+
Under 18 years	10.3%	57.0%	25.5%	7.2%
45 to 64 years	14.9%	45.3%	23.9%	15.9%
65 to 74 years	8.4%	35.4%	36.0%	20.3%
75 years and over	5.5%	30.6%	36.4%	27.5%

[2007 data from the U.S. National Center for Health Statistics, Health, United States, published 2009.]

From Table 158. Physicians by Sex and Specialty: I wanted to calculate the percentage that were primary care physicians (family practice, internal medicine and pediatrics- I left out Ob-Gyns), and I was surprised to see the percentage has gone up over time

	1980	1990	2000	2007
% Primary Care MDs	28.5%	31.6%	34.3%	34.7%

[Calculated from Source: American Medical Association, Chicago, IL, Physician Characteristics and Distribution in the U.S. annual]

From Table 153. Retail Prescription Drug Sales: I was interested in calculating the percentage mix of prescription sales by type of retail outlet. What you can see is the decline of independent pharmacies and the rise of mail order

Retail Outlet:	1995	2000	2005	2008
Traditional chain	38.5%	40.6%	39.6%	41.0%
Independent	30.4%	23.0%	19.2%	17.3%
Mass merchant	10.7%	9.3%	9.7%	9.8%
Supermarkets	10.2%	12.0%	11.9%	10.2%
Mail order	10.2%	15.2%	19.6%	21.7%

[Calculated from Source: National Association of Chain Drug Stores, Alexandria, VA,NACDS Foundation Chain Pharmacy Industry Profile, 2008]

Survey on Plan, Provider and Vendor ICD10 Transition

By Clive Riddle, December 10, 2009

MCOL this week released results from an exclusive survey of HealthcareWebSummit participants in the ICD-10 web summit and other interested parties. Participants were asked to respond to four items:

1. Please categorize your organization.
2. When do your project your organization will complete transition to ICD-10?
3. How prepared is your organization at this point for transition to ICD-10?
4. Is your organization undertaking other IT or Administrative initiatives to leverage use of the ICD-10 codes?

Here’s what the survey found:

• Overall, only 3.1% of respondents indicated that their organization had completed the transition to ICD-10 while a plurality of respondents, 26.15% projected their organizations would complete the transition in 2013.  A majority (55.3%) of respondents projected their organization to complete transition sometime between 2010 and 2012 (21.5% in 2010; 20.0% in 2011; 13.8% in 2012.)

• A majority (58.7%) of respondents considered their organization to be prepared for transition to ICD-10, with 14.3% indicating being very prepared and 44.4% being somewhat prepared. (17.5% stated unprepared, 14.3% very unprepared and 9.5% were unsure or not applicable.)

• 62.5% respondents indicated that their organization were either undertaking other IT or administrative initiatives to leverage use of the ICD-10 codes (34.4%) or at least considering doing so (28.1%.)

• Responses, in some instances, varied materially by category of respondent.  Those respondents who listed their organization as vendor were not only more prepared for transition than providers or payers, but also projected that they would complete transition sooner and were more likely to be undertaking other IT or administrative initiatives. 

• While payors were more likely than providers to be very prepared for transition, providers were more likely to be some degree of prepared with 55% listing their organization as somewhat prepared.

• General category of respondents (N = 66):
  • Payor              33.3%
  • Provider          31.8%
  • Vendor/Other   34.9%

Simpson’s Paradox and U.S. Infant Mortality

by Clive Riddle, December 3, 2009

There’s a little tingle you feel when you encounter a term for a phenomenon you’ve previously observed. Maybe not Spiderman’s “spider-sense” tingle, but a tingle none the less. So, a tingling I did detect when reading yesterday’s  Wall Street Journal article, “When Combined Data Reveal the Flaw of Averages.” There I learned about Simpson’s Paradox. Surely I came across it countless times in statistics classes and conferences, but my eyes must have been glazed over.

In non-technical terms, as the WSJ article puts it, “Simpson's Paradox reveals that aggregated data can appear to reverse important trends in the numbers being combined….’It's the magic of weighted averages,"’ says Princeton University economics professor Henry Farber.”

The WSJ article cites Simpson’s Paradox impacting current unemployment figures, baseball comparisons between Derek Jeter and David Justice, UC Berkeley admission rates and a study of Kidney Stone treatments.

For me, it brought déjà vu regarding a report CDC's National Center for Health Statistics released last month: "Behind international rankings of infant mortality: How the United States compares with Europe."

Consistent with numerous studies indicating the U.S. compares unfavorably with Europe regarding various key health outcomes, this report indicates the U.S. infant mortality rate lags behind our European counterparts, and in fact ranks 30^th in the world. As indicated in the table below compiled from the study, the U.S. incurs 6.9 infant deaths per 1,000 live births, worse than all but one country cited below and far off the mark from a rate of 2.4 in Sweden.

So what’s really going on behind the numbers? If one digs one level deeper, one would attribute the higher overall U.S. numbers to a much higher preterm birth rate, given that pre-term births globally experience a higher mortality rate. Stopping there, the conclusion would be to focus solely on reducing the preterm birth rate (an admirable goal.)

Fair enough, the U.S overall infant mortality rate would decline if the preterm birth rate declined. But dig another level deeper, into morality rates by gestation, and one will see that the U.S. mortality rate is highest for full term births, but compares much more favorably with premature births. Thus if the U.S. lowers its preterm birth rate, it won’t improve in overall comparisons, because of unfavorable experience with full term births, which comprise close to 88% of all U.S. births. Thus focus needs to be given on the mortality for our full term cases.

	Infant Mortality Rates (Deaths/1,000 Live Births)
Country	%Preterm	Overall	22 wks+	24-27 wks	28-31 wks	32-36 wks	37 wks+
U.S.	12.4%	6.9	5.8	236.9	45.0	8.6	2.4
Austria	11.4%	4.2	4.1	319.6	43.8	5.8	1.5
Czech Republic	7.0%	3.4	3.7
Denmark	6.9%	4.4	4.4	301.2	42.2	10.3	2.3
England	7.5%	5.0	4.9	298.2	52.2	10.6	1.8
Finland	5.6%	3.0	3.4	315.8	58.5	9.7	1.4
France	6.3%	3.6	3.9
Germany	8.9%	3.9	4.1
Greece	6.0%	3.8	4.0
Hungary	8.6%	6.2	6.6
Ireland	5.5%	4.0	4.6
Italy	6.8%	4.7	4.0
N. Ireland	6.6%	6.3	4.0	268.3	54.5	13.1	1.6
Netherland	7.4%	4.9	4.6
Norway	7.1%	3.1	3.0	220.2	56.4	7.2	1.5
Poland	6.8%	6.4	6.8	530.6	147.7	23.1	2.3
Portugal	6.8%	3.5	3.9
Scotland	7.6%	5.2	4.9	377.0	60.8	8.8	1.7
Slovakia	6.3%	7.2	6.7
Spain	8.0%	4.1	4.0
Sweden	6.3%	2.4	3.0	197.7	41.3	12.8	1.5

Checking out CMS’ Hospital Compare

 By Clive Riddle, July t6, 2009

Last week, CMS issued an announcement touting “important new information was added to the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare Web site that reports how frequently patients return to a hospital after being discharged, a possible indicator of how well the facility did the first time around” They noted around 20% of hospitalized Medicare beneficiaries experience a readmission within 30 days from discharge.

This prompted me to take the opportunity to check out Hospital Compare again, and see what was going on in that cyber neck of the woods. Here’s a few things I learned:

• The tool is being used. Hospital Compare has been on-line since 2005. Last year the site 18 million+ page views, and is receiving around 1 million page views monthly during 2009.
• Here’s how CMS describes the what information Hospital Compare provides: “The Hospital Compare Web site will show a hospital’s mortality or readmissions rate is ‘Better than,’ ‘No different from,’ or ‘Worse than’ the U.S. national rate...Hospital Compare also includes 10 measures that capture patient satisfaction with hospital care, 25 process of care measures, and two children’s asthma care measures. The site also features information about the number of selected elective hospital procedures provided to patients and what Medicare pays for those services.”
• So what are you supposed to do with this information? CMS states that “Public reporting of these and other measures is intended to empower patients and their families with information they need to engage their local hospitals and physicians in active discussions about quality of care..” Charlene Frizzera, CMS Acting Administrator, tells us "Providing readmission rates by hospital will give consumers even better information with which to compare local providers. Readmission rates will help consumers identify those providers in the community who are furnishing high-value healthcare with the best results. CMS believes that all hospitals, regardless of their readmission and mortality rates, should use the data available in these free, detailed reports to find ways to continually improve the care they deliver.”
• Of course, has lawyers on staff, and the hospital web site counsels us that we really shouldn’t “view any one process or outcome measure on Hospital Compare as a tool to ‘shop’ for a hospital” and that “consumers should gather information from multiple sources when choosing a hospital.”
• If you really want to swim around in the hospital compare data, they do provide the option to download the entire database (9MB).
• How old is the data, and how often is it updated? The collection period for the process of care quality measures is generally 12 months. Currently, the Hospital Compare quality measures are refreshed the third month of each quarter. The collection period for the mortality and readmission measures is 36 months. The risk-adjusted 30-day risk-adjusted mortality and readmission measures for heart attack, heart failure and pneumonia are produced from Medicare claims and enrollment data. The mortality and readmission quality measures will be refreshed once annually.
• Downloading and then sifting through the actual database, I came across a table summarizing the national averages (as opposed to the hospital and state specific averages typically displayed in the online reports, or national data just for a specific item. Below are tables with the national HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey data and the national mortality readmission data.

HCAHPS Measures	HCAHPS Response Categories	Overall Survey %Response Rate
How often were the patients rooms and bathrooms kept clean?	Room was always clean	69%
How often were the patients rooms and bathrooms kept clean?	Room was sometimes or never clean	10%
How often were the patients rooms and bathrooms kept clean?	Room was usually clean	21%
How often did nurses communicate well with patients?	Nurses always communicated well	74%
How often did nurses communicate well with patients?	Nurses sometimes or never communicated well	6%
How often did nurses communicate well with patients?	Nurses usually communicated well	20%
How often did doctors communicate well with patients?	Doctors always communicated well	80%
How often did doctors communicate well with patients?	Doctors sometimes or never communicated well	5%
How often did doctors communicate well with patients?	Doctors usually communicated well	15%
How often did patients receive help quickly from hospital staff?	Patients always received help as soon as they wanted	62%
How often did patients receive help quickly from hospital staff?	Patients sometimes or never received help as soon as they wanted	12%
How often did patients receive help quickly from hospital staff?	Patients usually received help as soon as they wanted	26%
How often was patients pain well controlled?	Pain was always well controlled	68%
How often was patients pain well controlled?	Pain was sometimes or never well controlled	8%
How often was patients pain well controlled?	Pain was usually well controlled	24%
How often did staff explain about medicines before giving them to patients?	Staff always explained	59%
How often did staff explain about medicines before giving them to patients?	Staff sometimes or never explained	23%
How often did staff explain about medicines before giving them to patients?	Staff usually explained	18%
Were patients given information about what to do during their recovery at home?	No, staff did not give patients this information	20%
Were patients given information about what to do during their recovery at home?	Yes, staff did give patients this information	80%
How do patients rate the hospital overall?	Patients who gave a rating of 6 or lower (low)	10%
How do patients rate the hospital overall?	Patients who gave a rating of 7 or 8 (medium)	26%
How do patients rate the hospital overall?	Patients who gave a rating of 9 or 10 (high)	64%
How often was the area around patients rooms kept quiet at night?	Always quiet at night	56%
How often was the area around patients rooms kept quiet at night?	Sometimes or never quiet at night	13%
How often was the area around patients rooms kept quiet at night?	Usually quiet at night	31%
Would patients recommend the hospital to friends and family?	NO, patients would not recommend the hospital (they probably would not or definitely would not recommend it)	6%
Would patients recommend the hospital to friends and family?	YES, patients would definitely recommend the hospital	68%
Would patients recommend the hospital to friends and family?	YES, patients would probably recommend the hospital	26%

Condition	Measure Name	National Mortality_Readm Rate
Heart Attack	Hospital 30-Day Death (Mortality) Rates for Heart Attack	16.6
Heart Attack	Hospital 30-Day Readmission Rates for Heart Attack	19.9
Heart Failure	Hospital 30-Day Death (Mortality) Rates for Heart Failure	11.1
Heart Failure	Hospital 30-Day Readmission Rates for Heart Failure	24.5
Pneumonia	Hospital 30-Day Death (Mortality) Rates for Pneumonia	11.5
Pneumonia	Hospital 30-Day Readmission Rates for Pneumonia	18.2

Serious Games: Health Plans and Health Games

By Clive Riddle, March 25, 2009

Should you be playing games with your health? (Alright, maybe the correct word is “for” and not “with”, but I wanted your attention.) Nevertheless, a growing body of policy, research, health care, and health insurance organizations think you should.

The Serious Games Initiative founded at the Washington DC based Woodrow Wilson Center for International Scholars, “applies cutting edge games and game technologies to a range of public and private policy, leadership, and management issues.” The Initiative earlier this decade launched Games for Health to coalesce a community of researchers, health care professionals and game developers involved with games designed for health care applications. The organization’s Games for Health Fifth Annual Conference will be held June 11-12, 2009 in Boston.

Humana became a believer in the movement. In September 2007 , Grant Harrison, vice-president of Humana’s Integrated Consumer Experience said “giving healthcare consumers the ability to become more closely connected with the management of their health through video games is a unique way in which to accomplish Humana’s goal of helping members become both mentally and physically health.” The company stated that Humana’s Innovation Center would research and develop “the best ways to connect with consumers using game technology. In collaboration with Serious Games pioneer Digitalmill Inc., Humana is evaluating all aspects of the games for health space.”

In May 2008 they launched HG4H: Humana Games for Health, a web site for their initiative, and began forging partnerships with schools and other organizations to offer various exercise and games for health programs. HG4H has since partnered with various game developers to offer “interactive video games that provide fun physical and mental workouts and motivate healthy lifestyle choices.” HG4H has categorized their offerings into six categories: exergames, persuasive games, casual games, educational games, virtual world games and pervasive games.

Just last month, when announcing new online games added to the HG4H program, Paul Puopolo, Humana’s director of consumer innovation stated “we know that a healthier lifestyle doesn’t have to be boring and these games are a perfect way for consumers to connect health with a technology they already enjoy. With childhood obesity on the rise, games like Lunch Crunch and Bubble Trouble give kids the lessons in health they need but present the message in an entertaining way – through a little friendly competition online. We also know that baby boomers are looking for ways to keep their minds young, so games like Split Words and Entangled Objects help with cognitive functions and attention skills – exercises that so many adults need.”

Lunch Crunch? Bubble Trouble? Split Words? Entangled Objects? These don’t sound like the offerings typically announced in press releases by health plan. Trying to get to the bottom of just what’s going on here, I spoke to Laura Fay, CEO of HAPPYneuron, Inc., a developer partner with Humana. HAPPYneuron is a majority owned subsidiary of Scientific Brain Training (NYSE Euronext: MLSBT) and offers a broad range of personalized brain training workouts in multi-media formats. Scientific Brain Training was founded in 2000, and the company has had a North American presence since 2006.

For Humana, the HAPPYneuron games offered online were “designed to stimulate your attention, language, memory, planning and abstract-thinking skills” with the core targeted audience including seniors for the purpose of deferring the onset of age related brain decline. Laura told me that their Humana applications have now been up two months with public access at www.humanagames.com with five HAPPYneuron click and play games offered.

Laura shared that HAPPYneuron offers direct to consumer individual products from their web site, in addition to partnerships with organizations such as Humana. Their current and prospective partners include health plans, publications, employers, pharmaceutical companies, research organizations, educational institutions, and senior centers.

HAPPYneuron product offering include individual online memberships with “access to more than 3,000 hours of unique game play with its 34 innovative online games... designed and developed by a team of neurologists and cognitive psychologists to work the brain’s five major cognitive functions: memory, attention, language, visual/spatial and executive” and “HAPPYneuron Junior, a series of 24 online games has been developed by a group of neurologists and specifically designed for children 8 through 12 years old.” The company also offers CD/DVDs and books.

Their core offerings involve memory games providing “cognitive training fun with very diverse exercises, each one with numerous options, difficulty levels and data sets.” Laura stated an end result is to deliver a level of peer comparison, with exercise data results that provide feedback on a given exercise compared to the applicable peer group

I asked Laura what ROI can their cognitive training games offer Humana or other health care partners? She answered that “a one-point increase in cognitive activity corresponded with a 33% reduction in the risk of Alzheimer’s” and share the following cost implications (citing the Alzheimer’s Association as her source):

• 10 million Boomers will get Alzheimer’s Disease
• The average lifetime cost of care for someone with Alzheimer’s disease is $174,000
• The annual of caring for someone with Alzheimer's is $18,400 for someone with mild symptoms, $30,100 for moderate symptoms and $36,132 for severe symptoms.
• Medicare costs for beneficiaries with Alzheimer’s disease were $91 billion in 2005. Medicare costs are expected to increase by 75% to $160 billion in 2010 and to $180B by 2015

For developers such as HAPPYneuron, there’s more than fun and games at stake here in the emerging games for health sector. According to the Health eGames Market Report 2008 “iConecto estimates the Health eGaming market at approximately $7 billion during the next 12 months including the markets for brain fitness ($267M), exergaming ($6.4B+) and other Health eGames on the consumer and professional side ($250M+).”

Personal Health Records: The Hot Consumerism Tool

By Lindsay Resnick

Consumer Directed Healthcare (CDH) is past the tipping point. Employers, employees, payers and providers have embraced these free market style health benefit plans that put consumers in the center of deciding where, when, and from whom they receive care---the customer now has more skin in the game. CDH success means changing the way people think about and deal with their healthcare choices. It takes practical decision support tools, credible information and increased connectivity throughout the healthcare system. Now, the newest consumer trend is allowing individuals and families to maintain their own online health records.
Personal Health Records (PHRs) enable consumers to have easy access to their health history and clinical make-up in order to manage benefit and medical decisions. It gives consumers more knowledge and control over their health information. In essence, it creates a smarter, better informed healthcare customer. PHRs allow an individual to enter and record personal medical information such as medical history, prescriptions, examination results, office visit tracking and, lab and diagnostic test results. Based on PHR functionality, consumers can input or scan images, charts, graphs, and print reports.
The result is a PHR that provides an accurate, up-to-date summary of a person’s health status and medical history. The information is secured online and only accessible by the individual or, medical professionals with approved authorization, at the PHR owner’s discretion. In addition to a standalone, consumer-driven PHR, other models are emerging that take a more integrated approach allowing information to be input through other, secure sources such as physicians, pharmacists, home care and even linked-in claims data.
In a predominately paper-driven medical record world, online PHRs bring the portability and connectivity that make reliable information available, quickly. The result can be lifesaving in emergency situations, help avoid harmful medication interactions, reduce unnecessary tests and properly prepare consumers with the context to ask the “right” questions. Most importantly, PHRs give consumers the control they need to make informed, confident decisions.
Internet-based Personal Health Records are rapidly emerging. In a State of the Union address, the President called for every American to have one in ten years. This year, Microsoft launched HealthVault and, Google Health is testing its own PHR. It is estimated that there are more than 200 PHR products available in the market with a wide range of functionality, level of integration and “cool” features.
With consumers well on the way to being the centerpiece in the future of healthcare benefit and medical decision-making, PHRs will continue to grow in popularity and acceptance. A recent Markle Foundation survey shows that almost 80% of the public believes PHRs would provide significant benefits to individuals in managing their health, although many (57%) express concern over privacy and security of their information. PHRs are here to stay. They represent another step in healthcare’s technological movement built around content, community, commerce and connectivity.

Data from the Consumer Driven Healthcare Summit

By Clive Riddle

The Third National Consumer Driven Healthcare Summit was held earlier this week in Washington DC, addressing a wide range of current key health care consumerism issues, with leading thought leaders and industry experts from around the country. Here's some interesting data shared by speakers from four selected Track Sessions during the conference:

Individual Health Insurance

Samuel Gibbs, Senior Vice President of Sales of eHealth, Inc.(parent of eHealthInsurance) gave a presentation on "The Online Individual Insurance Market - Perspectives, Experiences and Trends." EHealth represents over 180 health insurance carriers nationwide, which are available directly to consumer via their eHealthInsurance web site. Sam shared that eHealth's individual plan profile for 2007 was as follows:

* Average Age: 36
* Percent Male: 54%
* Percent Single: 61%
* Average Annual Premium: $1,896
* Range of Average Monthly Premiums: $83 to $388
* Average Annual Deductible: $1,971

Ann Ritter from the Convenient Care Association participated in a session on "The State of Convenient Care for 2009" and shared just released RAND convenient care data including:

* Patients by age breakdown as follows: under age 2 - 0.2%; age 2-5 - 6.3%; age 6-17 - 20.3%; age 18-44 - 43.0%; age 45-64 - 22.6%; age 65+ 7.5%
* 2.3% of patients were triaged to an emergency department or physician's office
* Among patients age 65+, 73.65% of visits were for immunizations
* Ten basic treatments and services accounted for more than 90% of visits

Paul H. Rubin, PhD, Samuel Candler Dobbs Professor of Economics and Law, Department of Economics, Emory University, in a presentation on "The Cost Effectiveness of Direct to Consumer Advertising for Prescription Drugs" discussed findings from a study and paper he co-wrote with Adam Atherly of Emory University, in which they found during patient visits to their physician:

* 4% of patients schedule physician visits to ask about a drug
* 14% of patients discussed a concern because of DTC advertising
* If patients ask for a drug, 39% receive that prescription, 22% are prescribed a different drug, and 18% receive no drug
* 5.5% of physicians prescribed a requested DTC drug, but thought a different drug was better
* 88% of patients requesting a DTC drug had a relevant condition
* 75% who received the requested drug reported subsequently feeling better

Michael Vittoria, Vice President, Human Resources, Sperian Protection, in his presentation on "Integrating Wellness & Preventative Care into a CDHP" told us that Sperian, with 1,300 U.S. employees, adopted a self funded HRA in 2004, introduced HSAs in 2007 and introduced Wellness Incentives in 2008. Sperian currently has 56% of employees enrolled in PPOs, 14% in HMOs and 30% in the self funded HSA options. 34% of their 2008 HSA participants earn < $30k, 21% earn between $30k to $50k, 17% earn between $50k to $75k, 16% earn between $75k and $100k, and 12% earn more than $100k. Sperian conducted various wellness incentive programs during 2008, with their weight loss program yielding a BMI reduction in participating employees from 30.7 to 29.4. Sperian's overall medical cost trend from each previous year has been:

* 2004 - 11.7% increase
* 2005 - 4.5% increase
* 2006 - 3.6% increase
* 2007 - 2.6% increase
* 2008 - 1.8% increase

Can decision support consist of more than threats, promises and stiff upper lips?

By Laurie Gelb

Can decision support consist of more than threats, promises and stiff upper
lips?

Here's where domains, measures and thresholds come in.

Here's where the rubber hits the road.

In one study, sufferers, clinicians and payors were asked how they would
measure the value of a drug for a condition for which disease- modifying
therapy did not yet exist. The same methodology works whether options are
plentiful, mediocre, whatever.  But in this case--

Physicians highlighted clinical results in one or more domains, all of which
have a demonstrable impact on quality of life.
Patients focused on being able to experience things they have not been able
to experience recently.
Payors wanted to see statistically significant differences from placebo on
some objective measures, not really caring which -- the FDA's job.

Every stakeholder was able to specify domains (pain being one, just so we're
clear on what a domain is) that were relevant to him, and whether or not an
improvement in that particular domain would in itself justify
prescribing/taking/reimbursing therapy. Obviously, not all domains were
salient to every stakeholder.

Every stakeholder was able to specify how improvements in salient domains
would be measured (numerically and/or categorically) as well as her
threshold for that improvement -- what number or value or outcome would
constitute sufficient reason to act.

But the answers were different for everyone.  (So were the questions, of
course -- computer-assisted interviewing uses previous answers to frame
relevant questions).

So, when you're doing stakeholder research, instead of dragging out a stack
(real or virtual) of static scenario cards for tradeoff analysis and
sorting, instead of asking about abstractions like preference and
satisfaction that aren't used in real life, what if you asked about:

Domains that are salient
Measures that are used to measure change or value in those domains
Thresholds applied to those measures to justify action

Bear in mind, these are studies that run (very) low five figures and a few
weeks, all told -- this is a framework for frequent studies, not once a
decade. So you can track how the findings change as the environment does.

What next? You might design decision support that makes very clear...

What domain(s) are affected by the intervention you recommend or wish
considered What measures show change when the intervention is used, in whom,
and how frequently. how predictably To what extent any particular threshold
of change can be predicted, guaranteed or even hoped for

Of course, you update this as the data come in and time goes on.

Presto! User-centric decision support can be yours.
And it can be theirs.
If you do all this on the Web, kiosk or CD-ROM, you can develop a "wizard"
that enables the user to "buy in" to their choice using their own criteria.

The decision that's owned is the result that's achieved.

We're not just talking about justifying or avoiding therapy -- this is about
staff/physician recruitment/retention, open enrollment and a thousand other
choices.

Effective decision support reduces and supports the burden of choice.
How is yours doing?
Any stories to share?

e-Visit Data

By Clive Riddle

Patient online e-visits, introduced at the start of this decade, continue to gain momentum as technologies improve, consumer demand increases, experience from prior pilot studies becomes more widespread and major health plans advance and adopt e-visit initiatives. Here's a collection of some recent data on e-visits, compiled in MCOL's March @How-TO newsletter:

• Trinity Clinic in Whitehouse, Texas, reports e-visits average five minutes, compared with 15 to 20 minutes for comparable office encounters, and averages one to two billable e-visits per month per doctor (1)
• Medfusion, an e-visit vendor, has process half a million e-visits for about 2,500 physicians during the last three years (1)
• McKesson's Relay Health, an e-visit vendor, charges physicians $25 per month per doctor for use of the web visit tools (2). RelayHealth, has 15,000 subscribing physicians (3)
• Manhattan Research survey results found 31% of physicians reported using some type of online communication with their patients in the first quarter of 2007, up from 24% in 2005, and 19% in 2003 (3)
• "National surveys suggest that the majority of online consumers now desire e-mail access to their physician and are willing to pay about $25 for an online consultation. A recent Wall Street Journal Online/Harris Interactive Poll found that 62 percent of patients said the ability to talk to a physician electronically would affect their choice of doctors and a Harris Interactive poll conducted in 2006 found that 74 percent of patients would like to use e-mail to communicate directly with their physicians." (3)
• "A recent Kaiser Permanente study of patients who used the medical group’s secure e-mail system between 2002 and 2005 to access their physicians found that they phoned their physicians nearly 14 percent less than did patients not using the system, while each doctor averaged about two e-mail messages per day." (3)
• "A two-year study of a pediatric rheumatologist’s e-mail and telephone interactions with 121 patient families, published in last October’s Pediatrics, found that the physician received an average of 1.2 e-mails per day, while answering patient questions by e-mail was 57 percent faster than using the telephone." (3)
• "75% of patients polled in the 2007 WSJ/Harris poll reported that their doctor does not currently offer e-Visits or other e-services" (4)
• "Blue Shield of California has estimated that the use of online patient-provider communications tools by its members will save the organization $4 million a year in office visit claims." (4) 

(1) Demand for e-visits grows but uptake still sluggish
Managed Healthcare Executive, November 1, 2007
http://managedhealthcareexecutive.modernmedicine.com/

(2) Physicians diagnose their patients via mouse calls
Akron Beacon Journal, March 10, 2008
http://www.statesman.com/life/content/life/stories/health/03/10/0310housecalls.html

(3) Online physician communication 
Physicians News Digest, March 2008
http://www.physiciansnews.com/cover/308.html 

(4) e-Visits:The Tipping Point - Are We There Yet?
Rhondda Francis, TransforMed, 2008
http://www.transformed.com/e-Visits/e-Visits_Are_We_There_Yet.cfm 

Online Consumer PHRs in MicrosoftLand and GoogleLand: Winning Hearts and Minds

By Clive Riddle

Quest Diagnostics Inc. and Health Grades Inc. announced this week that they will partner with Google to provide patients online access to their diagnostic laboratory records and rating information regarding hospitals and physicians. Google also provided further information this week on its Google Health PHR initiative.

There has been much attention given to Google's announcement last week regarding their PHR  pilot initiative with the Cleveland Clinic. Google Health is being designed to "assist providers to create a new kind of healthcare experience that puts patients in charge of their own health information." The Clevland Clinic pilot involves an invitation-only opportunity for a targeted patient group of between 1,500 and 10,000 that are among Cleveland Clinic's more than 100,000 patients currently using their PHR system called eCleveland Clinic MyChart. The pilot "will test secure exchange of patient medical record data such as prescriptions, conditions and allergies between their Cleveland Clinic PHR to a secure Google profile in a live clinical delivery setting. The ultimate goal of this patient-centered and controlled model is to give patients the ability to interact with multiple physicians, healthcare service providers and pharmacies. The pilot will eventually extend Cleveland Clinic’s online patient services to a broader audience while enabling the portability of patient data so patients can take their data with them wherever they go — even outside the Cleveland Clinic Health System."

The Associated Press reports that the profiles will be protected by the same password required to use other Google services such as email. The previously available beta Google Health login screen stated: "With Google Health, you can: * Build online health profiles that belong to you; * Download medical records from doctors and pharmacies; * Get personalized health guidance and relevant news; * Find qualified doctors and connect to time-saving services; * Share selected information with family or caregivers"

Meanwhile, what' s going on with Microsoft's HealthVault initiative? Sean Nolan, the Chief Architect for HealthVault, opened a blog on that topic last month: http://www.familyhealthguy.com . He uses an interesting term: "we spend a bunch of time thinking about how to increase what we call "data liquidity" (a term only an engineer could love) -- how do we create pipes that let people easily and securely move data back and forth between their Vault and primary care doctors, specialists, hospitals, pharmacies, and so on, all under their consent and control." Sean states that "Microsoft will make the complete HealthVault XML interface protocol specification public. With this information, developers will be able to reimplement the HealthVault service and run their own versions of the system." Microsoft also just received publicity for its announcement to fund $3 million to outside parties to research and develop online tools to improve health. There has also been considerable discussion, in the wake of these announcements, regarding privacy concerns as consumer use these tools.

Microsoft, received less publicity, but may be making more of an impact, for its just announced accelerated push towards interoperability with its HealthVault PHR platform. Further down the page in Microsoft’s just issued press release, they stated that “the company will release HealthVault XML interfaces under the Microsoft Open Specification Promise (OSP). The OSP is a simple and clear way to help developers and solution providers working with commercial or open source software to implement specifications through a simplified method of sharing of technical assets, while also recognizing the legitimacy of intellectual property. Further reinforcing the company’s commitment to open interoperability, Microsoft is hosting a HealthVault community open source project — an implementation of the HealthVault API wrapper for the Java development environment — on Microsoft CodePlex, Microsoft’s open source project hosting Web site. This will be the first of many projects designed to make it easier for developers and solution providers to use the language and framework of their choice to deliver HealthVault-compatible applications.” What does all that technical jargon mean? That Microsoft has shifted, at least somewhat, from its historic total proprietary system stance, to a more open system that encourages interoperability. This should bode well for HealthVault, and PHRs in general.

Of course that PHR stakes are most definitely limited to Google and Microsoft. Steve Case's Revolution Health Group, Aetna, WellPoint and almost 200 other vendors are involved in this space. But, the Microsoft, Google's and other large vendor announcements have been greeted by privacy concerns in some corners. Gannett cites "Greg Sterling, an analyst at Sterling Market Intelligence in San Francisco, calls Google's initiative a 'good idea.' But, he adds, 'The problem and the challenge arise in the context of consumer privacy and data security.' " Also this week, the World Privacy Forum issued a report "Personal Health Records: Why Many PHRs Threaten Privacy". The report concludes that a number of PHR vendors, are not truly "covered by HIPAA", but rather tout that they are "compliant with HIPAA", which the report notes, could be subject to change. The report notes concerns that PHRs not covered by HIPAA include: Health records could lose their privileged status; records could more easily subpoenaed by a third party; and Information in some cases may be sold, rented, or otherwise shared.

What may be more significant in the long run, is the ultimate interoperability of these initiatives. If we want to simplify health care, technology must be a partner. But technology can become an obstacle if it consists of endless disparate tools and proprietary systems that can’t relate with other. Unfortunately, the latest survey and report on this topic indicates we're no where near close where we need to be. The California Health Care Foundation (CHCF) recently released three reports on Health Information Technology (HIT) adoption, regarding: HIT adoption and use in California; national HIT perspectives; and open source systems. Detailed information and downloads are available at http://www.chcf.org/press/view.cfm?itemID=133554

Jonah Frohlich, CHCF senior program officer, tells us "HIT can play a significant role in preventing medical errors, giving patients the appropriate level of care, and making health care more efficient. HIT is not a cure-all for what ails our health care system, but where it is used, it has helped support better care." CHCF points out that California has the highest rate in the nation for MD use of electronic health records (EHRs): 37% compared to 28% nationally. Still, that means the leading state, the home of Silicon Valley, barely has one in three doctors properly wired. According to their study, 'The State of Health Information Technology in California', "the larger the medical practice, the more likely it uses EHRs. Some 79% of Kaiser Permanente physicians reported using EHRs, followed by 57% of patients in large practices of ten or more physicians. But EHR usage dropped considerably among small/medium practices (25%) and solo practitioners (13%)."

In another CHCF report, 'Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field' author Bruce Merlin Fried states "despite President Bush's 2004 plan to ensure that most Americans have interoperable electronic health records by 2014, the vast majority of practicing physicians, those who practice alone or in small groups, are no closer to using HIT now than they were three years ago."

Blogger Dana Blankenhorn gets it right in the ZDNet Healthcare blog: “In the context of the medical market, however, Microsoft’s process seems more reasonable. This is less about gaining the trust of consumers than it is about winning over doctors, hospitals, and payment processors.” In other words, this is about winning the hearts and minds of doctors, hospitals and payment processors, which requires interoperability.

Health Literacy and the Misplaced Mantra, part 2 of 2

Health Literacy and the Misplaced Mantra, part 2 of 2

The Dilemma

Web-based decision support and concierge health services are on the rise, yet most people still believe (with considerable justification) that the most complete and objective advice remains reserved for the rich or well-connected. Meanwhile, system integrators believe that the best consumer is informed and would rather, for example, link her BMI to cash than evaluate plan designs. So, while incentives to “do the right thing” are coming into play, when/how to do it is still a very real issue for the consumer receiving constant, often contradictory, stimuli.

At the point of care, the patient, who still lacks access to much of her medical record, is told at one visit, "I can't decide for you," and acted for paternalistically the next, in both cases with the best of intentions, under a system that rewards speed, test orders and upcoding more than outcomes.

The Reality

The ability to limit health information stimuli to self-initiated searches no longer exists. What if you were as besieged with information about lawn mowers (which you may not even need) as you are with health information? How soon would you turn off and drop out? Now, what makes health information so compelling? At its root, it’s a catalog of ways to die. There are ways to dress it up, but charging ahead under the assumption that living’s easy is not the way. High utilizers are often the most likely to have at least one uncontrollable risk factor. How well are you illuminating what’s controllable and what’s not? And when you put together your health/disease education modules, shouldn’t you overlay all the content with incentive to actually use it?

We need to address the barriers to optimal decision-making head-on, rational or not. These include lack of self-efficacy, emotion/information overload and a perception that inputs relate poorly to outputs (everyone hears about the runner who dies of an early MI). P4P and CDHC designs in and of themselves cannot drive outcomes and may even make things worse. So we need to address the most pressing patient questions head-on:

• How important is making this decision? What are the risks and benefits of doing nothing vs. acting?
• How controllable is the risk of acting? Can the risks be spread out by making a series of decisions over time?
• What are the best and worst cases?
• How achievable is a positive outcome?
• How predictable are the positive and negative consequences?

In short, we can help deciders prioritize their decisions to optimize the achievable delta. Rather than agonize over which multivitamin to buy this month, what if I can spend that energy on overcoming my addiction to sweetened fruit drinks? The reason that so many people read Prevention, a monthly digest of often contradictory information, is that when its authors make a declarative statement, they are usually fairly good about telling readers how to implement it in their own lives. How well do your Web site, direct mail, brochures and e-mails do that? And no, “it’s easy to eat 5-7 vegetable servings per day” doesn’t count, because it’s not easy!

Imagine…

Today, tests for the extent of health literacy (e.g. the ability to read a product label) don’t measure the propensity to follow the label’s instructions, take it seriously, extrapolate it to other health decisions, etc. These are where motivation to spend time on the key decisions and wade through all the extraneous and repetitive information comes in.

Now imagine it’s 2017, and there are robust question batteries that reliably predict the capacity for and propensity to use health literacy. When rating or treating a group or individual, wouldn’t you want to combine this assay with medical underwriting and the patient’s past ratio of achieved to achievable health improvement, since the three together have a more direct effect on costs and outcomes?

So what is your organization putting into place today, to prepare you to develop, implement and/or integrate this algorithm in 2017? And underlying this entire fantasy has to be real-time access to claims and/or chart data, with the clinical and communication savvy to use these data intelligently. How close are you there?

Next…what self-administered risk assessments do and don’t do…and what might work better.