So Happy Together......

It was just announced that the Provinces of British Columbia and Alberta have come to an agreement to coordinate their medical supply purchases. Sort of a "Coastal Costco" for the provinces. To work around the provincialization of healthcare in Canada, they created a third-party entity to negotiate volume discounts for the two provinces.

When might the other provinces join in? And why not have the Federal government sponsor such a thing? The clear follow through is lower prices for everyone, but there would be another upside; consistency and continuity of the care experience.

If most supplies and physical resources are the same across the nation, then their management practices would be the same as well. A nurse who moves from Nova Scotia to Ontario would have a much shorter learning curve in getting acclimated a new facility. And a patient really would know what to expect--wherever they are. This would by itself reduce the costs of both "onboarding time" for staff and "patient orientation."

Would this be a good lead to follow for technology? Well, a little over two years ago, the BC Ministry of Health certainly thought so. The Ministry directed the regional health authorities to work together to figure out a unified EMR approach. Coastal (Central Vancouver) and VIHA (Vancouver Island) began working on a joint agreement to use PARIS, a software system already being used at Coastal. As part of this discussion, the issue of "bulk buying" was raised. In early analysis of existing contracts and the license extensions, huge potential savings were identified in the simple elimination of buying and customizing a new software installation. How much could be saved if The Nation were to buy the same software everywhere?

A single system has been done successfully. The United States Department of Defense uses one system, AHLTA for all of the millions of people they serve. Was it easy to do? Not at all (DISCLAIMER: I worked on the AHLTA deployment a number of years ago, when it was still called CHSII). Delays came from the bottleneck created by using a single, new vendor and from doing what had never been done before. The first two deployment efforts were cut short by the refusal of the end-users to implement software that was still, really, only in Beta. Often, new things can only be learned by trying and failing. Once the software was sufficiently developed to work, user adoption was generally successful.

Now, patient records are available wherever the patient goes, not wherever the patient carries them. Prescriptions, drug allergies, provider notes--all are available and accurate. Patient misidentification is fast becoming a bad memory as electronic orders track to accurate patient identification. Are there savings? Certainly of lives, time, and yes, money. (I leave the question of whether healthcare should be about money to Bill Maher's blog.) A full audit of the savings cannot be done yet, but it is looking awfully good.

What is already known is the new mobility of both staff and patients. The orientation period is vastly reduced, and the very necessary and long-overdue ability of staff to "parachute in" to a new facility is greatly increased.

Single-system, bulk buying--call it what you will, but perhaps these examples from both sides of the border might lead CIHI and HITSP to work together towards one cross-border standard. It might enable competition in that larger market, leading to lower prices and ease of use.....one never knows, do one?

"Meaningful Use:" Meaningful to Whom?

In the States, ARRA has authorized funds to assist organizations implementing EHRs. ARRA requires "Meaningful use." The healthcare Information technology Standards Panel (HITSP) has just defined seven core types of data exchange; prescriptions, lab results, clinical data summaries, biosurveillance data, immunization registries, public health and quality measurement. [Full article here] Clearly a committee was involved--certainly prescription data, clinical summaries and labs would enable healthcare while reducing potential misidentification issues.

But what do immunization registries do for patients or providers? public health data? And biosurveillance is about accessing multiple data sources to identify trends or potential outbreaks; so that means making the electronic record readable for "phishing," not improving the care of the patient. Is that wrong?

The American Health Information Management Association (AHIMA) commented to The National Committee on Vital and Health Statistics on this (April 2009, AHIMA), and had some very interesting points. Sandra Fuller delivered a very thorough discussion of both the product and the process to arrive at "meaningful use." AHIMA felt that public funding should be used to drive improved care as well as the public interest.

To improve care, they spoke of prescriptions, labs and results and discharge data. These are all considered core elements of care-information communication and patient transfer (provider to technician, provider to pharmacist, provider to provider) and areas of greatest risk of error.

The report looked beyond the patient--to both public-health policy and to patient-care policy. To serve public health interests (and after all, this is being publicly funded), AHIMA recommends investment in development of improved reporting methods and systems with coordination through the HIEs being developed (and funded) with other ARRA resources. But, at the end, AHIMA circled back to the patient;

Be relevant to consumers: Taxpayers are funding these investments as a prerequisite to effective health reform. More broadly, this is an extraordinary opportunity to be transparent and to increase public recognition of the challenge and opportunity of an interconnected health system and the progress that is being made.

All in all, a very interesting and valuable report--check it out

Well, the committee got to it and politics seems to have moved things to the, if you will, "right." Immunization records should certainly be part of the patient record, but is it really a priority element for standardization? Discharge summaries fell out, but biosurveillance got in. Should readability by outside agencies be a "core element" of meaningful use? If an EHR is about communicating patient data (and it is usually thought of as an active process, not a passive one), then is anxiety overwhelming the mission? Or is this use of "surveillance" simply a way to get Homeland Security behind the drive for a national standards for data formatting and encoding? After all, the multiple-vendor system has led to a wide variety of proprietary methods that inhibit data communication and portability. And are we still in the times of driving by fear? Thoughts?

Some Notes and Then Myth #4, EMRs...

In this slow summer, we are working through the Seven Myths of Healthcare Technology. Myth #2 is "Technology Can Do Healthcare." [check it out below] Here's a comment I found out there--The writer certainly seems to have a reason for his anger. But is he completely correct? What do you think?
Community College - No Way

And is this an attempt at something "Swiftian?"

Responsibility-Based Rationing of Healthcare

"Eat the Elderly" kind of stuff? Or do you think he is serious? With all of the alternate-reality based rhetoric being put out there, I am honestly unsure...

And it looks like telehealth is happening without complex, expensive proprietary software systems...

The doctor is in and logged on

And we continue with…

The Seven Myths of Healthcare Technology; #4 EMRs are for the Doctors

As hospitals and medical facilities move to meet the technological mandates and requirements coming their way (from managers, regulatory agencies and insurance companies), they are confronting the issue of stakeholders--who are they and who is most important. Historically, the final word in healthcare has been that of The Doctor. What the MD says goes. As software is implemented in more and more systems, vendors and internal IT staff are having to customize and personalize software for each facility and clinic.

Healthcare software is not “off the shelf,” as some vendors might present it. It is more “out of the crates, custom-tailored, re-measured and stuck with unusual plug-ins and attachments to serve the vicissitudes of legacy systems.” In the process of making these applications work in the particular digital and business environment, sensitivity to end-user experience is considered essential. And doctors are the obvious end-user stakeholders.

Doctors are characterized as (just a little) demanding. Nurses everywhere tell tales (or at least roll eyes). This is no different, and perhaps worse, with software. Doctors are a technically saavy group and not shy about speaking up. But they are the wrong users on which to model EMR use.

Doctors use EMRs to mostly see data. They look at one or two views of data; to review intake information, view images; check results, or, watch for drug allergy alerts--then they look at the patient. They use systems to place orders or prescriptions--sometimes. Often, these orders are completed by PAs or nurses. Doctors do not move through an EMR very much--they tend not to do patient intake or to record new data very much. They are not the primary users of the digital tools---their skills lie elsewhere. There are certainly providers who are more “hands-on” with electronic systems. These are usually providers in record-intensive practices such as psychiatry or in the unique practice structures of the military.

Clerks, Nurses and PAs are the big users. They are the people using the record systems most--from patient intake through scheduling to checking for labs and rads. Very often it is they who bring up the patient record for a doctor and file orders. And it is the desk staff who are using the EMRs to communicate with insurance companies and other referral facilities. It is their workflow that should be modeled--and theirs are very different workflows.

People will say “Nurses really run the hospital.” I won’t get into that debate, but I will say “If they don’t control the hospital, they certainly control the information in it,” and that is the EMR…..

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.

The Seven Myths of Healthcare Technology 3. Technology Can Do It All

In a letter sent Tuesday to Sens. Edward M. Kennedy (D-Mass.) and Max Baucus (D-Mont.), President Barack Obama reiterated his commitment to promoting the use of information technology as a means of reducing healthcare costs.
healthcareITnews, June 4, 2009
A month later, HealthcareIT news reported
"President Obama called for fixing the broken healthcare system by building upon investments made in electronic medical records in a town hall meeting held Wednesday." [July 1, 2009]

In the US, many of the players--drug makers, provider organizations and insurance companies--have been calling for increased IT investment as the key solution to the problems of healthcare in the US. The advantages of increased IT efficiency are clear. Yet the healthcare business process lags far behind other businesses in the use of electronic automation. Most providers and facilities are just beginning to look at electronic record management, and many are still using only paper records. The most advanced use of IT for healthcare is by the Federal government. The Department of Defense is well along in development of a "lifetime electronic record" and the VA continues to set a high standard for management efficiency. And Medicare/Medicaid manages one of the largest patient bases and payment processes electronically.
But does electronic automation provide ALL the answers?
In Canada, aggressive support of HIT has been a policy of both the Federal and Provincial governments since 2000. A number of hospitals in the greater Toronto area became very active in digitizing patient records and integrating digital patient records into the care process. Record access has been greatly increased. There are years of data recording increased record accuracy and improved efficiency in data entry. Many of the hoped for results have been realized.
Yet, this past year, the Province of Ontario presented a grant pool of millions of dollars to support possible solutions to wait-time reduction. It seems that even after all of the HIT implementations of the last eight years, patients are sometimes experiencing emergency-room waits in excess of five or even 10 hours (these grew even longer in the 2007 flu season). The back-ups waiting for hospital admissions are staggering and seemingly without a solution--even from "fully integrated" HIT systems. According to a 2006 survey by Ipsos Reid, 42% of Canadians surveyed felt that '"a patient wait time guarantee that would reduce wait times for key health services' was the most important to them personally."
So, why has IT not been the solution to the Number One issue for Canadians (lower taxes got only 19%)? Because the solution is not about the technology. According to providers at a number of well-digitized hospitals in Ontario, patient records and patient interaction are great in the ED--patients' records can be created, their histories can be accessed, and intake moves pretty quickly. In-patient care has also been greatly improved; medication conflicts are avoided, patients are correctly identified and prescribed, etc. These providers are quite clear that the breakdown is the connection between in-patient and out.
Because of the differences in workflow and practice, HIT systems are different in the ED than in the rest of a facility. And connecting the data from the one to the information from the other to create usable knowledge that would enable efficiencies is not as easy as just installing a data-mapping agent. It takes people and, more importantly, it takes changes in the ways those people work.
Emergency Department staff do not access bed-management resources. Why would they? Emergency care is just that. And as we have discussed earlier (Myth #1), healthcare providers focus on the immediate task at hand--the here and now. They only look for a clinic/bed assignment when they are done with a patient--and then it can become a rushed, time consuming task for staff both in the ED and on the wards. Perhaps, Upon initial diagnosis of a patient, the search for a clinic/bed assignment were begun (to run in concert with the continued efforts in the ED) in anticipation of an eventual need for admission. Then patients might move more easily and quickly into the inpatient population, and that would reduce the long queues of people waiting in the ED.

A non-technical solution to a problem of technology--Sometimes, Healthcare IT cannot do it all--and should not......