Telling Grandma "No."

“...creating a national health insurance to cover everyone will probably increase costs, not decrease them, just as feeding the world's hungry three full meals a day would not reduce our grocery bill. Personally, I think instituting universal health care is the humane thing to do, but let's be honest: Somebody will have to pay for it.”
Dr. Tom Shragg, The Sacramento Bee, Sunday, July 5, 2009

Dr. Shragg describes himself as “a specialist in pulmonary and critical-care medicine with 30 years of experience.” In his opinion piece for the Sacramento Bee entitled “The Conversation: Is health care cost debate focused on wrong issues?” Dr. Shragg looks at some of the leading suggestions for healthcare reform in the US--EMRs, shifting of compensation from specialists to primary-care providers and a “single-payer” system---from his own view as an experienced special-care physician in private practice the US. His primary point is these solutions to rising healthcare costs are either inappropriate or plain wrong.
The doctor describes these foci of cost reduction as “the wrong birds.”
Dr. Shragg’s writing is reflective of his practical history. EMRs, he feels, are only a distraction from the healthcare process. Using and EMR, he writes, “slows me down and diverts my attention from the patient to the computer…These computer records may improve accounting, but not health care.” After 30 years in practice, Dr. Shragg (like most physicians) probably does little of his own charting, as nurses, PAs and other staff would be both taking and charting vitals, lab results, etc. He finds increased compensation for primary care over specialized care to be “naïve,” and “somewhat insulting.” As a specialist, he is understandably sensitive to the legitimate need for specialists. But as such, he has limited experience with the current US system’s “only pay for crises” incentive structure (it should be noted that the Doctor’s group practice does accept payment by most major insurance companies). And lastly, national health insurance might be “humane,” but it would not reduce the cost of health insurance (see above). All three are the “wrong birds.”
So, what does Dr. Shragg consider the “right bird?”
Dr. Shragg describes a 92-year old patient suffering a variety of late-stage ailments; renal failure, stroke and mild dementia among others. Her treatment included oxygen, consultation with a nephrology specialist, in-patient intensive care and dialysis. This is Dr. Shragg’s identified “bird.”
“If you wanted to eliminate the costs associated with that patient's treatment, you would have to empower somebody to deny the care she and her family desired. To borrow a popular expression, the elephant in the room that nobody addresses is the ‘R word:’ rationing.”
The US healthcare conversation is still ongoing, and no consensus has been reached, so it cannot be said if Dr. Shragg expresses the mainstream. But the Doctor’s does demonstrate something particular to US healthcare; commodification. Doctor Shragg’s access points to the issue are remuneration and funding--who is getting paid and who is paying them. In this dialectic, healthcare is a consumable--something to be bought and sold.
Every western nation currently has a national approach to healthcare, ranging from the single-payer/single provider (UK) to nationally regulated private-sector insurance with multiple providers (DE).
US focus on healthcare has only recently expanded beyond academia and industry, while many other nations are already at a “Phase 2” stage of revising a chosen healthcare architecture. In none of these nations is finance any longer a barrier to service. Citizens of the UK do not think about “health insurance.” They have “The National Health Service,” and like the Postal Service, it is expected and committed to deliver to everyone.
In none of these other nations is healthcare thought of as a commodity available only to those possessing adequate resources. They have already decided the question “who gets care?” with “Everyone.” Now they are working on the questions of access, of economies of scale and of quality of patient experience.
Canadian healthcare is one of the more mixed-bags of solutions. While healthcare is nationally defined as a basic right of all residents, its management is the responsibility of the Provinces; thus, there is Alberta Health Services, the Ontario Ministry of Health and the Ministry of Health of British Columbia, among others. Each Province has pursued its own solutions to healthcare. In Alberta, there is a single central authority (at present) that directly oversees each discrete facility. Ontario operates with a mix of state and private insurance, with regulated drug prices far below those in the states. The models in Canada, and the changes in these models are many and varied. As Canada successfully delivers on a national commitment to healthcare for all, the ways of managing delivery, access, quality of care, breadth of care and, yes, cost are always evolving.
This example of one nation successfully implementing a variety of solutions could serve as a valuable resource to the US in developing its own solutions. The US has a free-market hodgepodge of healthcare methods; state and local facilities and services; not-for-profit clinics; private practice and public-service doctors, and; insurances of all sorts. The successful mix of many Canadian models could quickly shorten the US learning curve. But to benefit from the Canadian example---or the French or the Swiss or the German--would still require a shift in US thinking. Other nations manage to deliver medicine and care to all of their people because they hold healthcare as a “must,” not a “maybe.”
Dr. Shragg writes of healthcare as something to be bought or “maybe” given as charity. His is not the only voice to lament the cost of late-stage care; but the US is the only nation to consider first and foremost the cost of care. If the US is to make a national effort (and to date the only national efforts have been the regulation of healthcare products--drug and device approval and patents and licensing), a true commitment by the nation must be made---to the nation.

RECs--What, Who and How?

The American Recovery and Reinvestment Act of 2009 (ARRA) has more than just EHR money in it. The act also seeks to encourage the establishment of "regional extension centers" (RECs) to provide support and assistance. Funding is being made available to organizations who meet certain requirements, and this funding is to range from $1-10 Million per year in two-year awards. So far, the government has published some criteria and guidelines for preference. Among other things, they are proposing to give preference to:
• Organizational plans and implementation strategies that include multi-stakeholder collaborations that make use of local resources, such as universities with health-related programs; medical or professional societies; state primary care associations; state or regional hospital organizations; large health centers and networks of rural and/or community health centers; state Area Health Education Centers; HIEs; and government entities such as public health agencies, libraries and information centers with health professional and community outreach programs, and consumer/ patient organizations.
• Applicants identifying viable sources of matching funds, including but not limited to grants from states and not-for-profit foundations, and payment for services from providers.

(as reported by Helen Pfister of Manatt Health Solutions. For her full write up, see ihealthbeat)

Historically, Federal programs have accede to state and local organizations--particularly in matters of geography. And in this instance, as is often seen as sensible, preferred organizations would be those connecting to and working with "local resources, such as universities...and consumer/patient organizations." And while extant organizations may understand their populations, local universities are often restricted in whom they can serve and where they can operate--to the state or locality in question. "State/local organizations" are often funded to serve--and only serve--residents of their state or locality.
In regional community healthcare services, all of this is counterintuitive to success. Providers serving similar populations in similar environmental and economic environments face the same problems and work towards similar solutions. Environments and economies do not stop at the legal boundaries of local or state government. The circumstances and life issues of The Blue Ridge Mountains extend across township, county and even state lines. Providers know this fact that bureaucrats miss. According to a survey of providers and provider organizations released by eHealthinitiative last month (available here), "Nearly half of respondents said that regional extension centers should not be constrained to a specific metropolitan or state boundary." In the eHealth survey, "local government-sponsored entities," are found very poorly suited to manage RECs by 42% of respondents.

The RECs are to provide support, guidance and knowledge-management resources to regional organizations receiving funding. Traditionally, providers have largely depended on publications, conferences and vendors for guidance on industry trends and software support. And vendors certainly meet the
other requirements to;
• Describe proposed levels and approaches of support for providers to be served;
• Address how the applicant would structure its organization and staffing to ensure providers served have ready access to reasonably local health IT "extension agents" and provide training and ongoing support for these critical workers;
• Demonstrate the capacity to facilitate and support cooperation among local providers, health systems, communities and health information exchanges ("HIEs");
• Demonstrate that the applicant is able to meet the needs of providers prioritized for direct assistance; and 
• Propose an efficient and feasible strategy to furnish deep specialized expertise (in such areas as organizational development, legal issues, privacy and security, economic and financing issues, and evaluation) to all providers served, as well as intensive, individualized, "local" presence from an interdisciplinary extension agent to smaller groups of providers assigned to individual agents.

And while vendors are experienced at offering service and support, providers are not that trusting. The absolute last choice by providers and provider groups to manage RECs was vendors--71% of those surveyed find them to be the MOST poorly suited. (Strangely, as to those who DO trust them, only 9% of those surveyed thought they were best suited. Note: Technology vendors made up 11% of the survey).

So who then is to create and manage the RECs?
Associations? HIEs? Not for Profits? Or will new things be formed among vendors, state agencies and inter-jurisdictional NGOs? The comment period for the regulations close at 5pm ET today. It will be interesting to see what people (and vendors, associations and providers) have to day...What do you all think?

The Seven Myths of Healthcare Technology2. Technology Can Do Healthcare

"All involved in the healthcare industry will have to understand the entire healthcare system much more deeply than at present."
Dr. Steven F. Collier, CEO White River Rural Health, Arkansas, US

At the HIMSS GHIT conference this week, Doctor Steven F. Collier presented an overview of his work at White River Rural Health in Arkansas. As CEO, he has overseen the development and implementation of an EMR solution over the past 7 years. With a population spread across 10 counties living in towns (usually) of which the largest is less than 50,000, White River clinics are often the sole providers of healthcare to one of the poorest and most poorly served communities in the US. White River has been lauded as a model of best practices in implementation of EMRs to serve diverse, rural, under-resourced populations. The staff of White River has more than 6 years' experience in driving their technologists to develop and deliver solutions that would serve White River's understanding of their own business; so, when the doctor speaks of "understanding the entire healthcare system," he speaks from great experience and not a little pain.

As discussed in "Myth #1: Healthcare Does Technology," the very dialectics of healthcare are the opposite of those of technology. Healthcare is urgent, responsive and independent where technology development is planned, scalar, and collegial. Healthcare personnel neither understand nor welcome technologists in their environments--and the requirements of technologists do not track to the common expectations of healthcare organizations. Doctor Collier made clear that he is a healthcare provider. He spoke of results in clinical terms, of motivating problems as patient needs, and of success metrics in terms of patient wellness.

Technologists do not share this worldview. They speak of results in processing terms (operations/sec), of motivating problems as "needs for new calculus," and of success metrics in terms of technical performance. And while internal IT personnel may want to deliver solutions that serve the organizations' needs and timelines, external technologists are even less likely to succeed at healthcare. In addition to the cultural gap between technology and healthcare, they have the additional gap of being outsiders to the organization. And they are not just technologists--they are vendors.

Vendors have their own priorities, many of which are counter to both the organizational and the cultural interests of their healthcare clients. "Close-out" delivery of a completed solution is a goal of healthcare. Vendors in HIT have a number of self-serving goals that require more time and less closure. Often, technology solutions involve hastily or imperfectly written pieces of software which require more customization or "shake-down" time than a vendor might care to admit. As the HIT industry is growing so rapidly and as many of the vendor companies are so new, solutions are sold before they are fully developed. This leads vendors to use clients as "beta sites" to extend their development time while garnering revenue. Healthcare organizations are so eager for solutions and are often so averse to technology that they will buy "total solutions" with "full support and maintenance." This puts the IT infrastructure of an organization in the control of the vendor being paid to deliver it--where is the motivation for close-out in that? And vendors are businesses. They sell things; software, services, support, training. While interfacing with clients to deliver one product, they are motivated, even driven to upsell more products. which just pushes out the horizon to "solving the problem," when all healthcare wants is to solve the problem.

In a recent KLAS survey, of all organizations who reported a vendor promising tremendous ROI on an investment, not one was able to report actually realizing it within the original purchase. Not one.

So, if technologist can't do healthcare and if healthcare organizations can't do technology for themselves, what is the solution? Is there a third option?

Myths Will Wait--What's a PHR?

Today's column was supposed to be "The Seven Myths of Healthcare Technology; 2. Technology Can Do Healthcare." However, this evening was the opening reception for the Government Health Information Technology (GHIT) Conference in Washington, DC (June 4, 5 at the Ronald Reagan Center). It was hosted at the Canadian Embassy and there were senior representatives of some of the leading organizations in GHIT. It was a good time; There was talk--and rumour. And news.
The word was that there is an urgent push on the Hill to modify the HIT legislation to include Personal Health Record (PHR) with the Electronic Health Record. This led to an impromptu roundtable of core people from HIMSS and the GHIT conference to consider the question;

"Why a PHR? What Would It Be? How Would It Work?

There were different ideas of "Why." A regulatory thinker felt a PHR to be nothing more than a comfort to paranoid citizens who want to "control" their personal information, but that it could never be used as a trustworthy resource by a provider. A sociological view saw the PHR as an opportunity to gather massive amounts of statistical data to drive cultural, epidemiological and other study data--all identity-scrubbed, of course. Others saw it as a traveler's safety, providing accurate information for use in a critical-care situation.
The group came to see it as having value in each of these ways, but requiring two types of data; Mandatory information written and managed by authorized providers (drug interaction/allergies, for example) and optional data which the patient could modify or erase as they wish (treatment for a wart).
This dichotomy would have specific requirements. Among the many discussed, were;
Data requirements to qualify as a PHA (what information MUST be in the record to qualify as a PHA)
Standards of encoding
Clearly defined, documented and controlled workflows for access, addition, modification and deletion of data.
Security and privacy considerations
Most importantly, a standard storage, transportation and access method
This storage method must have access control; For instance, a method to "sign" for "consent to view" by the patient.
A physically secure method to "sign" for "access to write" by providers.

One method posited for serving these requirements was a smartcard. Specifically, a smart-Social Security-card. As a number is issued at birth (or immigration), data collection can begin shorty after the card is issued, ensuring that even children have a PHA to carry into adulthood.This would, however, have to be a very smart card. It would require two physical sections; one secured against patient access and the other enabled for patient access. These securities would have to be "countersigned" biometrically, perhaps in combination with passcode. There were some high-level workflows discussed as well.
A patient enters a new facility and meets a new provider. They present their smartSScard and swipe a fingerprint reader to authorize read-only access to their data.
Following on treatment, the provider wants to add data to the record. Some may be defined as "mandatory." For example, a new drug allergy is discovered. The provider must also identify biometrically, with crosscheck at a centralized, government record. This data would then be written to the "secured" side of the smartchip.
Some of the data may not be mandatory; Perhaps, notes of elective plastic surgery. These would be written to the "optional" side of the smartchip. All of the data would still be entered into and maintained in the regular medical record.
This is only one workflow. There are still questions; How would a PHR be used when traveling? Would an international standard be developed? How could providers from outside the system add data? If the data is pertinent to critical care, how to access the data when the patient is unresponsive? How could data be added without the specialized equipment needed to access the card, contact external databases and read biometric data? What, if any liabilities could arise from use of PHR data? How would PHR data be validated with the EHR?

Lots of questions. Lots of ideas. The PHR/EHR discussions are picking up, and at GHIT there should be quite a few as they come into play with the panel discussion of remote and rural communities......

Let us know what you think....

The Seven Myths of Healthcare Technology: 1. Healthcare Can Do Technology

80% of healthcare organizations want vendor-neutral advice on technology purchasing decisions, according to the newest survey by the eHealth Initiative www.ehealthinitiative.org, and 92% want guidance for workflow modification related to technology implementation. More than 320 organizations of the 425 surveyed say that they cannot do it for themselves and overwhelmingly want funds from the health IT provisions of the American Recovery and Reinvestment Act directed to these issues. (the entire survey is available from their website hereHow is this? Hospitals and healthcare organizations are big, complicated systems managing services as varied as nutrition and transportation. At first glance, it would seem logical that information technology would be just one more service area in the portfolio. But then, healthcare teaches us that first glances are usually wrong.

Healthcare is urgent. It is about reacting to a problem and driving as quickly as possible to the diagnosis. Escalation is to specialists of ever-more granular views. Healthcare priorities are patient care, diagnosis and treatment--speed in all things.

Technology development and implementation is none of these things. IT requires long-term, broad-vision strategy and planning. To be successful, it must be both proactive and patient--and while technologists are known to carry every detail in their heads, specialization is antithetical to valuable solutions. Where healthcare providers are trained to "make the call," technologists are collegial. Technologists seek the input of others and work in "teams."

Healthcare organizations are driven to seek technology solutions. The needs to reduce costs, to improve patient safety and to increase patient service rates have been joined by Federal mandates in both the US and Canada. Two approaches have been used to get manage technology in healthcare environments. Neither of these is truly successful, as both are bound for failure from the start.

Many organizations try integration of a technology group. This is never easy and rarely a complete success--by any metric. In the revenue-centric organizations of the US, internal IT resources are viewed as cost centers without billable services and ever-expanding maintenance expenses. Technical personnel are only welcome on the floor if they are there for an immediate problem--to fix or replace something. Even in the non-revenue driven facilities (in Canada, for example), the balance of investment is tilts in favor of direct patient-care costs over long-term technology investment. In all organizations, the longer, planned cycles of research and development are not seen as contributing to patient care, and the time required for interaction with providers is largely seen as a distraction from patient care. The cultural difference between providers--reactive and urgent--and technologists--proactive and considered--is a source of conflict and an extra impediment to successful development and deployment of new technologies.

Other organizations trust management of new technology endeavors to the outside vendors from whom they purchase their technology. However, this approach almost invariably costs a great deal more than expected and there is little control of ongoing maintenance costs. As documented in today's KLAS study,

Building the case for and helping a client achieve an ROI is something that every vendor reports they do well, yet not a single provider said that their vendor had truly met their expectations. Providers continually expressed their willingness to have a vendor come in and optimize their systems and processes to help get more out of their investment, but few vendors are willing to deliver on that invitation without significant cash from the provider...No major IT vendor in healthcare is leading out with creative, helpful solutions to reduce ongoing financial concerns. Chief among these concerns are the routine maintenance fees inherent to major IT service contracts.

Executive Reaction to the Stimulus Package, May 2009
KLAS Confidential Information.
© 2009 KLAS Enterprises, LLC. All rights reserved.

Most hospitals try to use some combination of these two approaches. This results in multiple layers of management; internal vendor managing IT staff, internal support management, external vendor management, external client-relations management and clinical management. And this model doesn't serve the priorities of the facility successfully.

So, how to succeed? How to develop valuable technology solutions that a healthcare organization can use, manage, maintain and integrate into the healthcare culture? Perhaps the more than 300 organizations that responded to the eHealth Initiative survey have it right and do not even realize it--an external resource to support dissemination of best practices, to provide technical assistance, to aid with workflow modification and most importantly, vendor-neutral advice.

For more on this, see tomorrow's The Seven Myths of Healthcare Technology: 2. Technology Can Do Healthcare

As always, let us know your thoughts and experiences. We will bring them into the discussion.