Quiet ORs Better for Patient Safety

This article appears in HealthLeaders Media, May 16, 2013

Music at loud decibels can contribute to miscues among surgeons and nurses in the operating room, raising the risk of medical error, researchers say.

Operating rooms are noisy places. There’s mechanical noise from whirring drills, beeping and humming from vital sign monitors, and whooshing sounds from fans and suction devices. Those sounds are largely unavoidable.

But then there’s human noise, from conversations, doors opening and closing, the clanging of team members handling instruments and equipment, and, of course, the sound of whatever songs the team wants to hear.

Now, a study is suggesting that all that noise could contribute to miscommunication that leads to errors or issues in patient safety, says Matthew Bush, MD, and colleagues from the University of Kentucky, Lexington.

Their project, described in an article this week in the Journal of the American College of Surgeons, exposed 15 volunteering surgeons to varying levels of noise from conversations, machinery and other operating room sounds. They found that the louder the noise, the less the surgeons were able to discern sentences accurately. When the doctors were asked to complete tasks simultaneously, their ability to hear accurately declined even further.

The music—Beatles tunes played at 74.2 decibels—was louder than normal conversational sound of about 60 db. But, Bush says, it was loud enough that “you’d have to raise your voice to be heard over this environment.”

Factor in that auditory ranges for operating room staff may be diminished by age or damage from occupational or environmental exposure, and the risk for miscommunication increases.

In fact, study results show that variances in comprehension levels were statistically significant, and should prompt hospital OR teams to think through their practices.

“We’re not advocating a completely silent operating room that is devoid of music, [or] devoid of social conversations or communication, because these are environments in which people can naturally work well together,” Bush emphasizes. “We certainly don’t want to create a workforce of silent drones.”

“What we do advocate as a result of our study is that each surgical team, and perhaps each institution, consider very carefully what’s being done, and what happens acoustically in their operating room settings.”

If members of the team are having difficulty hearing or communicating, if comments or requests must be repeated, “that all must be weighed by the surgical team, and people should say, ‘You know, I’m having difficulty communicating. Can we address this? Can we turn that monitor down? Could we stop for a minute and make sure we’re not making a mistake?”

In their experiment, which was conducted in an audiology lab not an operating room, surgeons were asked if they understood sentences. Some of the sentences were highly predictable—that is, if someone didn’t hear some of the words he or she could pretty well figure out what they might be from the context.

But other sentences used in the experiment were not highly predictable. When noise levels were high, and when the surgeons were asked to perform tasks in the lab, their ability to figure out the words in the sentence declined.

Bush, an otolaryngologist and audiology researcher, says that in his training experience in medical school, residency, and now in practice, he’s “seen a diverse array of operating room environments, with lots of different music styles and volumes.

“And I know from communicating with my colleagues and the co-authors of this paper that they have been exposed to music or loud conversations and distractions in the background that make it difficult to communicate. Every person who has worked in the operating room can think of times or situations where they weren’t able to communicate as well or hear what is being said because of loud music.”

Bush is quick to acknowledge that his study uses a very small sample, and has major limitations. For example, the surgeons were not tested for their ability to communicate with other members of their surgical team such as nurses or techs. “We need a study with more subjects and which involves more disciplines. But this is a dialogue starter, and that’s what it’s done at our institution.”

At the University of Kentucky’s outpatient surgery center, there’s now a hallway decibel monitor that signals green, yellow and red when noise levels rise.

“We’re trying to raise awareness that the volume of the sound in an environment matters, especially to patients who are scared and nervous as they travel into the operating room, and it’s also important for what happens in the operating room itself.”

Bush says that ongoing research by his team is looking at the impact of noise in the operating room on the ability of hearing-impaired surgeons, nursing and anesthesiology team members to understand what is being said. It may be, he acknowledged, that OR team members’ ability to hear may come under more routine scrutiny as well.

Bush emphasizes that it’s too early to recommend that institutions make policy changes. “There’s no basis to say, ‘No you can’t listen to this or you can’t do this.’ We’re not policy makers; we’re researchers We want to use scientific methods to ask a question and in an unbiased way, answer that question.”

He says, however, that “in medicine, as a culture, we realize that communication among providers is vital, and we’re going to have to look carefully at these factors. There are unavoidable elements, but we may be able to modulate and decrease the volume of some of the things we use in providing care, and minimize other distractions.”

Access to EHR Notes Lauded by Patients, Providers

 

From article in in the May issue of HealthLeaders magazine.

In a pilot, a system which permits patients to view all the notes in their electronic health records was such a hit with hospital patients and physicians that Beth Israel Deaconess Medical Center and Geisinger Health System are dramatically expanding their OpenNotes programs.

Possibly the most famous consumer of electronic health records is Dave deBronkart, better known as e-Patient Dave.

Several years ago, deBronkart participated in a trial of a new program that permitted patients to view all the notes in their EHR.

“I experienced a direct benefit,” deBronkart recalls. “Weeks after a visit, I thought, ‘Wasn’t I supposed to have something followed up?’ Heaven knows where my printed visit notes were … it was late in the evening, so ordinarily I’d have waited till morning and maybe remembered to call in and have someone look it up—very inefficient and vulnerable to ‘I forgot.’

“Instead, I went online right then and there, just as you might with anything else, from airline reservations to credit card info. There it was: actinic keratosis—a precancerous lesion. I had it removed, quickly, easily, inexpensively.” deBronkart says the diagnosis was “not academic” for him. “Thirty years earlier I had a skin cancer removed from my nose. And about a year later I was found to have a new one on my jaw.

“As a guy who worked in technology all his life,” deBronkart says, “it’s clear to me that what’s happening here is that value in healthcare depends on information plus awareness. In that moment I was aware of the information, which enabled action.”

Now deBronkart’s OpenNotes experience is being deployed at scale, and healthcare will never be the same.

The OpenNotes movement was tested for 12 months at three institutions: Beth Israel Deaconess Medical Center (649 licensed beds), Geisinger Health System (1,363 licensed beds), and the 413-bed Harborview Medical Center, a safety-net hospital that is part of the UW Medicine system in Seattle. Results from the study were published in the October 2012 Annals of Internal Medicine.

At the end of the tests, providers and patients liked OpenNotes so much that for those patients, access to those notes was restored after the trial. This year, Beth Israel and Geisinger are both dramatically expanding their OpenNotes programs.

A total of 105 primary care physicians from the three institutions volunteered to participate in the 2010 trial. About 20,000 patients overall were automatically given access to the clinical notes stored in their electronic medical records, says Jan Walker, RN, MBA, coprincipal investigator with Tom Delbanco, MD, of OpenNotes at BIDMC and Harvard Medical School.

When physicians would compose notes electronically, each institution’s EHRs would automatically trigger an email message to the patient, letting him or her know the note was ready.

“Two weeks before the next visit, we sent them another message saying ‘You have a visit coming up, and we suggest you might want to look at your last note, just to refresh your memory,’ ” Walker says.

Doctors who signed up were initially skeptical about the impact of OpenNotes on their workflow and the effect on their patients. “They were pretty worried that patients reading their notes would trigger an avalanche of questions—emails, telephone calls—that they just didn’t have the time to deal with,” Walker says. “And then they were also worried that patients would be worried or confused or upset by reading their notes.”

After the 12-month experiment, the results were positive: more than 80% of patients who had visited and thus generated a clinical note, had viewed at least one of the notes written during that time. “On the doctor side, they found that those worries about questions and patients being worried basically didn’t materialize,” Walker says. More than 70% of patients reported that they understood their medical conditions better. “They said they took better care of themselves, they better remembered their plan of care, they felt more in control, and about two-thirds of the patients taking medications said they were taking their medications better.”

At all three institutions, researchers asked patients if they wanted to continue to have access to their clinical notes, and 99% in all three places said they did, Walker says. “I’ve never done a survey before where 99% of people said anything.”

In the survey done at the end of the study, 20% of the participating physicians indicated they would not want to continue using the OpenNotes method, but when their commitment ended, not one followed through on those wishes. After reviewing the results of the study, the leadership at BIDMC, including all the clinical chiefs, voted unanimously to expand the OpenNotes program, Walker says. By the end of this summer, it will be rolled out to the 50,000 patients who are registered on BIDMC’s online, she says.

Geisinger’s big OpenNotes expansion, scheduled for April 2013, netted 585 doctors who volunteered to go live, up from the 25 doctors who participated in the trial. “We have some folks who’ve also embraced it very wholeheartedly, including some of our surgeons, which I’m thrilled about,” says Jonathan Darer, MD, chief innovation officer at Geisinger, a system which serves more than 2.6 million residents throughout 44 counties in central and northeastern Pennsylvania.

Leading up to this spring’s expansion, Darer gave 30–40 internal presentations to departments and small groups, listening to concerns. “There are a couple of themes that people express, and I can head those off with a presentation and try to help them understand how we’re going to manage some of the more sticky points,” Darer says. “For example, everybody’s got somebody in their clinic who’s, you know, complicated, emotionally—family issues, whatever it is. I say, ‘Don’t worry. We give the physicians the ability to exclude patients.’ ”

Indeed, Geisinger’s study didn’t find the unanimous good patient vibes found at BIDMC. Two to eight percent of patients “felt some kind of negative impact,” Darer says. “Some felt offended, some felt more worried. Giving the physicians the ability to exclude patients, just like they do with any medication or any medical treatment, based upon their good judgment, is appropriate.”

Nevertheless, at Geisinger, 87% of the patients who participated in the study read every single note generated by caregivers, Darer says. “Eighty-seven percent of patients doing anything is just remarkable, and all we did was send them a little note,” he says. Even more remarkable, 33% of the patients had a high school education or less. “Some of the language or terminology in a physician’s progress note can be pretty challenging for somebody to read, yet there’s incredible engagement with the material, people reading these notes, or at least opening them,” he says. The data also showed patients repeatedly reading their clinical notes, and 20% of them reported sharing their notes with someone else.

“Some of the explanation is that folks are used to figuring out how to get information about health, but not from their physician, so if they can’t understand something, instead of asking their doc, they ask their cousin the radiology tech, or their brother-in-law who’s a nurse, or whatever,” Darer says. “People are more savvy than we give them credit for.”

Darer says patients pointed out occasional errors left in the notes by physicians. “Doctors are not perfect,” he says. “We’re human. The patients would sometimes comment, ‘By the way doctor, it wasn’t my left knee, it was my right knee.’ And I never had a single physician feel like that was a bad call. They always felt like it added value. The chart was safer.”

For several kinds of patients, OpenNotes will be slow in coming. Darer describes four categories of exceptions.

“Psychiatry is certainly one of them,” he says. “There are three others that come to mind very quickly. One is there are concerns about child abuse. We’re going live in the pediatric arena, and that’s just very sensitive, and nobody’s comfortable at this point lighting those notes up. The other is the interesting, fascinating area of care of adolescents, where at a certain point, parents are asked to leave the room, because this growing young adult can then ask questions of the physician without having their parent there, and we don’t want the notion that the parent might be able to see the note to inhibit the kid from asking whatever it is they want, so we’re going to exclude patients between the ages of 12 and 17, so that there’s just no question that the parents would be able to see anything at that point.”

Finally, there is a concern about doctors administering therapy for pain. “It’s a less simple relationship with some of their patients due to the issues around potential drug-seeking behavior,” Darer says.

Can OpenNotes make patients healthier?

“That’s the million dollar question, isn’t it?” Walker says. “We didn’t try to do that in this study. And we will probably be looking at that going forward. …. But you know, when people say they understand things better, and they remember what to do, and they’re taking their medications better. I just can’t believe that people aren’t better off with this.”

Harborview Medical Center, the safety-net hospital, faces logistical and budgetary challenges before it can expand its use of OpenNotes, says Joann Elmore, MD, MPH, professor of medicine and adjunct professor of epidemiology at the University of Washington School of Medicine, whose dean and medical staff run Harborview for King County in Washington State.

The medical center’s patient population differs dramatically from the other OpenNotes test sites, and includes substantial numbers of patients who are part of separate groups, including homeless, incarcerated, nonEnglish-speaking, immigrant, and those with psychiatric problems and major trauma, Elmore says. Some had never used a personal computer before. Even if patients don’t own computers or are homeless, they are accessing computers at community libraries and at the hospital in its Patient Education Center.

In addition, since the 2010 trial concluded, Harborview replaced some of its older EHR systems with newer ones, and budget concerns have prevented integrating the OpenNotes tab into those newer records but Harborview is actively working on it, Elmore says. “I should say that Eileen Whalen, our executive director, is so impressed with this, as is the dean, and they want to see us move forward,” she notes.

An End to Medical-Billing Secrecy?

Article By Steven Brill From Time Magazine, May 08, 2013

Our hospital bill is about to get a thorough examination. Acting on the suggestion of her top data crunchers at the department’s Centers for Medicare and Medicaid Services (CMS), Health and Human Services Secretary Kathleen Sebelius released an enormous data file on May 8 that reveals the list—or “chargemaster”—prices of all hospitals across the country for the 100 most common inpatient treatment services in 2011. It then compares those prices with what Medicare actually paid hospitals for the same treatments—which was typically a fraction of the chargemaster prices.

As a result, Americans are a big step closer to being able to compare what hospitals charge them for goods and services with what they actually cost. CMS public-affairs director Brian Cook told me that Sebelius’ action today comes in part as a response to “Bitter Pill,” TIME’s special report on health care pricing practices in the March 4 issue.

There are two reasons Sebelius’ release of this newly crunched, massive data file is a great first step toward a new transparency in health care costs.

First, it reveals the vast disparity between what hospitals charge for pills, procedures and operations and the real cost of those services, as calculated by Medicare.

As I explained in “Bitter Pill,” Medicare uses expense data submitted by all hospitals to determine the actual cost of all treatments—including allocations of overhead such as rent and administrative salaries—and pays accordingly. In other words, Medicare takes seriously—and enforces—the idea that nonprofit hospitals should be nonprofit.

For example, the first line in the more than 163,072 lines of data in the CMS file released May 8 covers the treatment of “extra cranial procedures” (“without complications”) at the Southeast Alabama Medical Center in Dothan, Ala. When Medicare reviewed the list prices on bills it received for 91 patients getting that treatment at the Dothan hospital in 2011, the average chargemaster bill claimed by the hospital was $32,963. Medicare paid only an average of $5,777.

The second reason the compilation and release of this data is a big deal is that it demonstrates the point I tried to make in spotlighting the seven sample medical bills in Time’s “Bitter Pill” report: most hospitals’ chargemaster prices are wildly inconsistent and seem to have no rationale. Thus the release of this fire hose of data—which prints out at 17,511 pages—should become a tip sheet for reporters in every American city and town, who can now ask hospitals to explain their pricing.

Helpfully, Sebelius points out in her announcement that “average inpatient charges for services a hospital may provide in connection with a joint replacement range from a low of $5,300 at a hospital in Ada, Oklahoma, to a high of $223,000 at a hospital in Monterey Park, California. Even within the same geographic area,” she notes, “hospital charges for similar services can vary significantly. For example, average inpatient hospital charges for services that may be provided to treat heart failure range from a low of $21,000 to a high of $46,000 in Denver, Colorado, and from a low of $9,000 to a high of $51,000 in Jackson, Mississippi.”

The hospital lobby, led by the American Hospital Association, is going to howl that Sebelius’ publication of these chargemaster prices is unfair. Only a minority of patients are actually asked to pay those amounts, it will argue. Insurance companies, which cover the majority of patients, receive huge discounts off the list prices, though they pay substantially more than Medicare does.

That’s true, but in the through-the-looking-glass world of health care economics, those who are asked to pay chargemaster rates are often under-insured or lack insurance altogether. Moreover, insurers typically negotiate discounts off the grossly inflated chargemaster prices ($77 for a box of gauze pads!), so the chargemaster matters for insured patients too.

So what should Sebelius and her team do next?

The feds need to publish chargemaster and Medicare pricing for the most frequent outpatient procedures and diagnostic tests at clinics—two huge profit venues in the medical world. But an even bigger step toward transparency would be collecting data that Medicare doesn’t have: exactly what insurance companies pay to the various hospitals, testing clinics and other providers for various treatments and services.

After all, as the hospitals themselves concede in downplaying their chargemasters, these insurance prices are the ones that affect most patients.

And that is one price list where there is close to zero transparency.

Under Obamacare program, doctor visits would become data points

Article in Washington Post April 23, 2013

A new nonprofit is putting millions of Obamacare dollars towards an effort to turn routine doctor visits into a treasure trove of data on what medical treatments work best.

The Affordable Care Act created the Patient Centered Research Outcomes Institute (PCORI) to support comparative effectiveness research, studies that identify the most effective treatments when a whole array of options might be available.

PCORI announced Tuesday how it would move forward on that mission: spend $68 million to fund a network of health-care systems that cover as many as 12 million patients. The idea is to use all the doctor visits that already happen — and all the treatments that doctors prescribe — to figure out which ones do best for a certain type of patient.

“There is so much promise in natural experiments that we could run,” PCORI Executive Director Joe Selby says. “Across the country, there is a lot of variation in how diseases get treated. This is a golden opportunity to study which leads to better outcomes.”

Right now, health-care experts say that doesn’t happen: Most doctor visits don’t do much to inform which treatments are most effective.

“Right now, were spending trillions on health care and 99.9999 percent doesn’t contribute anything to medical knowledge,” says Farzad Mostashari, national coordinator for health information technology at Health and Human Services. “That’s the real vision, that we actually take routine care, the heallth care happening in the real world, and have that contribute to knowledge.”

PCORI will spend as much as $68 million to fund “clinical data research networks,” which will each consist of at least two health networks that cover a minimum of 1 million patients. They will each propose three sets of patients to study: one focused on a common disorder, a third focused on a rare medical challenge and the last looking at patients with obesity or diabetes.

“The two networks might have a different formulary which covers different medications,” Selby says, describing one possible experiment that a network could do. “We could look at where each is typically used, and which one leads to a better outcome.”

The nonprofit will also fund another set of “patient-powered research networks,” smaller patient groups, possibly organized by advocacy organizations, that would cover at least 0.5 percent of a given disease’s population — giving researchers a way to study what works best in treating certain conditions.

While patient advocacy groups and industry officials support PCORI’s mission, they do raise concerns over whether the operation will succeed. Many have questioned whether these new networks will be able to easily share data, given that many electronic health records are not interoperable.

“There are significant technical issues that need to be resolved,” says PhRMA President John Castellani, who spoke at a Tuesday panel on the new PCORI initiative. “This is not a short-term product. I’m concerned that if we oversell the short-term potential, the result will be inaccurate analysis based on short-term data.”

Nancy Davenport-Ennis, founder of the National Patient Advocate Foundation, also raised concerns about whether patients would want to participate in these wide-reaching experiments. She recalled attending a recent meeting in Washington, of about 500 people who work in health care, where they were asked how many would be interested in having their data used for research, provided that it was made anonymous.

Only two attendees raised their hands.

“We need to focus on what the patients want and the information they receive,” she says.

Selby does acknowledge that there are challenges in building a research network like this one — but also great potential to better inform the everyday decisions that doctors make.

“This is a chance to actually begin conducting large scale, comparative effectiveness research,” he says. “It’s kind of amazing how long we’ve been willing to wait for answers on these types of questions. Now we’re going to start getting them.”

Cleveland Clinic app helps connect patients, doctors, trials

Posted on MibiHealthNews April 15, 2013
Cleveland Clinic has built an app to help both physicians and patients find cancer clinical trials. The app, available for free from the iOS AppStore and the Google Play store, allows users to search the Cleveland Clinic’s the 130 active clinical trials by disease, phase, hospital location, or doctor. Although the app has been available since the end of January, the Cleveland Clinic has just officially announced it.

“When patients come in we’re always seeing if they’re appropriate for our clinical trials,” Dr. Brian Rini, an oncologist at the Cleveland Clinic Taussig Cancer Center and the physician lead on the app, told MobiHealthNews. “The app puts it all into one nice tidy package. It also has general information about clinical trials, consent, process. And it lists all the trials open throughout our system.”

According to the National Cancer Institute, less than 5 percent of adult cancer patients sign up for a clinical trial. And NCI studies have shown most patients don’t know clinical trials are an option for their care. Connecting more patients to trials can help improve patient outcomes and also help to move cancer research forward.

“Anything we can do to get more people is good,” said Rini. “The only way we make research advances is by putting more patients on clinical trials.”

Rini envisions the app as a tool for several different groups. He said that a certain slice of engaged patients are already doing research, searching for clinical trials online and bringing printouts into appointments. Other, older patients might not look at the app themselves, but caregivers or family members might.

“A lot of our patients have daughters, sons, etc. The way they get info is not picking up the phone, it’s looking on the internet or on a smartphone app,” said Rini. “It’s also an easy tool for a referring physician to look at, even if they’re sitting with the patient.”

The app will tell users about the protocols of a trial, what stage it’s in, potential benefits and drawbacks, and basic eligibility criteria. From there, the user can call the Cleveland Clinic’s Cancer Answer Line and possibly schedule a visit to determine final eligibility or get signed up. The app can also help connect patients with patient resources, financial services information, support groups and treatment guides.

Last month Novartis released an app called Clinical Trial Seek, which searches all the clinical trials in the government’s ClinicalTrials.gov database. The Orlando Business Journal reported yesterday that Florida Hospital just launched its own clinical trial app, called MD Trial, although that app appears to have been in the AppStore since December. Florida Hospital’s app searches ClinicalTrials.gov as well, but users can limit their search to Florida Hospital trials. Rini said he expects most major cancer centers will have an app like this soon if they don’t already.

“It sort of seems obvious,” he said. “We probably should have done it years ago.”

Father says HIPAA law may have contributed to son’s death

By Ali Gorman, R.N. for Action News 6, Philadelphia, PA

PHILADELPHIA – April 2, 2013 (WPVI) — If you have visited any medical center in the past 15 years, you have probably heard of the HIPAA privacy law. One local father is now urging lawmakers to change it. He says it is too strict in some cases and may have contributed to his son’s death.

In a tribute posted on YouTube, Justin Wolfe’s fraternity brothers at Temple University say he was genuine, fun-loving and caring. “Always having our backs. That is something I always appreciated and admired about him,” Ross Goodman said in the video. His father also says he was the light of his life from the very beginning. But tragically that light went dark last December.

Justin died of an accidental heroin overdose. He was 21.

His parents knew he was addicted to painkillers. He was on their insurance and so they got help for him from doctors. Wolfe says those doctors also knew Justin was snorting heroin. But due to the HIPAA privacy rule, that was kept confidential. “Myself or his mother as the caretaker for him should have been made aware of his heroin addiction and that it escalated because now it is a life-threatening situation,” Justin’s father Gregg Wolfe said. He says had he known the severity of his son’s problem, he would have made him go to an in-patient rehab center. “Every day of my life I suffer knowing there would have been or could have been something I could have done to save his life,” Wolfe said.

So now he is writing to lawmakers including President Obama. He wants an exception to the HIPAA law stating parents can have access to vital information regarding their children if they are under the age of 26 and not mentally stable or addicted to drugs.

We spoke to Robert Field, a health policy expert at Drexel’s Earle Mack School of Law. He says HIPAA can be a tough balancing act. “On the one hand we want people to feel comfortable releasing private information to their provider because otherwise the provider can’t decide on appropriate treatment,” Field said. And without that trust, a patient may not seek treatment at all. But on the other hand, he says you have cases like this where sharing information could have been helpful. Still, he says, the law must be one size fits all.

Justin’s father says he will continue the fight as he continues to mourn the loss of his firstborn son. “I miss his love. I miss his smile, his caring, his compassion, his friendship,” Wolfe said.

Administration pushes toward electronic medical records

Article first posted on TheHill.com – April 8, 2013

The Obama administration is moving to ease the national transition from paper to electronic health records through a pair of proposed rules to be published this week.

The rules, to hit Tuesday’s Federal Register, would update and extend existing regulations surrounding the sharing of patient electronic records.

Federal law generally prohibits hospitals from giving medical record software to doctors who would then use it to refer patients back to the facility for treatment. Violations can be charged as felonies and are punishable by prison time and fined up to $25,000.

This “anti-kickback“ provision, along with similar measures designed to keep doctors from referring patients to hospitals in which they have a financial stake, are seen by some as counterproductive in the push toward expensive electronic systems. In response, the federal government has repeatedly implemented safe harbor rules, allowing for certain arrangements that “do not pose a risk of program or patient abuse,” according to a notice describing one of the new proposals.

The two rules – one put forth by the Department of Heath and Human Services’ inspector general and the other crafted by the Centers for Medicare & Medicaid Services – seek to expand the safe harbor exceptions, and extend their sunset dates.

“We expect these proposed changes to continue to facilitate the adoption of electronic health records technology,” the HHS Inspector General’s proposal says. 


Beginning Tuesday, interested parties and members of the public will have 60 days to comment on the proposed rules.

HIMSS: Should Healthcare Be More Like Airline Industry?

From March 5, 2013 article on InformationWeek Healthcare

Such a comparison says not only that the healthcare industry must change, but also that those changes will be dramatic and gut wrenching.

The boldest thing I heard at my first day at HIMSS 13, the big healthcare IT event this week in New Orleans, was that the healthcare industry needs to be more like the airline industry. What could healthcare learn from a financially strapped industry that people love to hate?

It’s the fact that U.S. commercial airlines carried 52% more people in 2010 than they did in 1995, and yet they employed 2% fewer people. It’s that airlines did away with unprofitable luxuries such as meals in coach and filled excess flight capacity. It’s that airlines shed lots of jobs at front counters and reservation call centers and replaced them with kiosks and online bookings.

“We do a bunch of their work for them — and we like it,” said Warner Thomas, CEO of Louisiana’s big Ochsner Health System, during his HIMSS opening keynote. People today would howl in protest if they lost the ability to look online for their own flights and could do it only by phone, Thomas said. “How do we get people to make more of their own appointments for us, to check their own results?” he said.

Comparing the airline industry to the healthcare industry was an inspired choice by Thomas. It says not only that the healthcare industry must change, but also that those changes will be dramatic and gut wrenching. Thomas also pointed to banks’ use of ATMs to let customers do self service, and to retailers such as Amazon.com and Wal-Mart using analytics to acquire a better understanding of their customers and their own operations.

Thomas laid out the big number: Healthcare must be 15% to 20% cheaper. That’s not going to happen without pain and radical change. “It’s going to take changes in how we do business,” he said.

One example of this radical change I saw on the HIMSS show floor was the startup HealthSpot. It offers a telemedicine kiosk for remote patient-doctor interaction that includes not only video, but also a blood pressure cuff, thermometer, stethoscope and other tools a patient could use on himself with the supervision of a remote clinician. As I walked the HIMSS floor, though, I was struck by how few ideas like HealthSpot I saw that involved really radical changes to the way customers interact with their healthcare providers.

In his keynote Thomas laid out three results he expects healthcare IT to deliver: safer, higher-quality care; lower costs; and happier, more productive physicians and other caregivers.

I doubt that last one will always be possible. Getting to that future state of healthcare, one that costs as much as one-fifth less, won’t always make people working in the industry — or getting service from the industry — happy. The airline industry has had to make some very hard choices about what services it can and can’t provide. Healthcare has many more of those sometimes unpopular decisions ahead of it.

The Face of Future Health Care

From New York Times Article – March 20, 2013

OAKLAND, Calif. — When people talk about the future of health care, Kaiser Permanente is often the model they have in mind.

The organization, which combines a nonprofit insurance plan with its own hospitals and clinics, is the kind of holistic health system that President Obama’s health care law encourages.

Kaiser has sophisticated electronic records and computer systems that — after 10 years and $30 billion in technology spending — have led to better-coordinated patient care, another goal of the president. And because the plan is paid a fixed amount for medical care per member, there is a strong financial incentive to keep people healthy and out of the hospital, the same goal of the hundreds of accountable care organizations now being created.

“Over the course of the last 15 years, they’ve been just going into high gear and doing everything right,” said Dr. Thomas S. Bodenheimer, a health policy expert at the University of California, San Francisco who recently chose Kaiser as his own health plan.

Yet even with all of its effort, its chairman and chief executive, George C. Halvorson, acknowledges Kaiser has yet to achieve the holy grail of delivering that care at a low enough cost. He says he and other health systems must fundamentally rethink what they do or risk having cost controls imposed on them either by the government or by employers, who are absorbing the bulk of health insurance costs. “We think the future of health care is going to be rationing or re-engineering,” he said.

Mr. Halvorson is convinced that Kaiser’s improvements in the quality of care save money. But he also says that the way to get costs lower is to move care farther and farther from the hospital setting — and even out of doctors’ offices. Kaiser is experimenting with ways to provide care at home or over the Internet, without the need for a physical office visit at all. He also argues that lower costs are going to be about finding ways to get people to take more responsibility for their health — for losing weight, for example, or bringing their blood pressure down.

“The work is incredibly difficult,” he said. “It’s very, very hard to move the marker.”

Other health care experts say that while Kaiser has a place in the future, whether it is the best model for the country’s health care remains unclear. “They have not translated some of their strengths into better prices,” said David Lansky, the president and chief executive of the Pacific Business Group on Health, which represents employers on the West Coast, many of whom purchase coverage from Kaiser for their workers.

And there are other concerns, such as whether an all-encompassing system like Kaiser’s can really be replicated and whether the limits it places on where patients can seek care will be accepted by enough people to make a difference. Or whether, as the nation’s flirtation with health maintenance organizations, or H.M.O.’s, in the 1990s showed — people will balk at the concept of not being able to go to any doctor or hospital of their choice.

“The more you restrict the patient’s ability to do what they want, you risk reigniting the backlash we had in the past,” Mr. Lansky said.

In many ways, Kaiser has been ahead of the curve on health care for decades. Started by a surgeon running a tiny hospital near Desert Center, Calif., to serve construction workers, Kaiser became an H.M.O. with its own doctors and hospital in the mid-1940s and expanded beyond California over the next 50 years. But, as H.M.O.’s fell out of favor, it was forced to leave states like New York, Connecticut and Texas.

But Kaiser persevered, and its membership, which peaked in 1998, is now about the same as its previous high of 9.1 million, about three-quarters of whom are in California. It still operates in a half-dozen states from Maryland to Hawaii and is looking to expand in the Mid-Atlantic region, where membership had been dropping.

The organization, with some $50 billion in annual revenue, owns 37 hospitals and employs 17,000 doctors, all on salary. And its integrated model is in favor again. Hospitals across the country are buying physician practices or partnering with doctors and health insurers to form accountable care organizations, or A. C.O.’s, as a way of controlling more aspects of patient care. Doctors are also creating so-called medical homes, where patient care is better coordinated.

The days when doctors, hospitals and other providers are paid separately for each procedure will disappear eventually, health experts say. Instead, providers will have financial incentives to encourage them to keep people healthy, including lump sums to care for patients or provide comprehensive care for a specific condition. “All of care is going to move down this path, and it has to,” Mr. Halvorson said. “Medical homes are doing it; the very best A. C.O’s are going to figure out how to do it.”

The move by hospitals to buy physician practices is being viewed cautiously by health experts, who say there are downsides to the creation of large health care systems that may be motivated by the desire to increase their clout in the market, making it easier to fill beds and charge the insurers more for care. “They become these huge local monopolies,” said Dr. Robert Berenson, a health policy expert at the Urban Institute.

<p”>But having an integrated system seems essential to the success of Kaiser and a handful of similar, if smaller, organizations, like Intermountain Healthcare in Utah and Geisinger Health System in Pennsylvania, although some work with doctors whom they do not employ. In California, Kaiser controls nearly every aspect of a patient’s care, from providing the M.R.I. for a diagnosis to filling a prescription at one of its pharmacies to running a hospital where the patient undergoes surgery.

“We have all the pieces,” said Philip Fasano, Kaiser’s chief information officer. “Anything a patient needs you get in the four walls of our offices,” he said. As a result, while Kaiser can point to an analysis done by Aon Hewitt, a benefits consultant, showing that its plans are typically at least 10 percent less expensive than others, especially where they control all the providers, its costs are more like the average in places in Ohio, where it does not have its own hospitals and offer as broad a range of services.

And some patients outside of California, where Kaiser operations are less concentrated, complain about being forced to travel for treatment by Kaiser providers. Arva Priola, a 62-year-old Kaiser patient in Fredericksburg, Va., said her Kaiser doctors “are wonderful,” but that the plan recently started requiring her to get some treatments where they had physical facilities.

To get IV antibiotics after surgery, for example, she recently had to drive an hour and a half to a Kaiser office in Tysons Corner, Va. “Who wants to drive when you’re sick?” she asked. Kaiser says it is adding more services closer to Fredericksburg.

A California state agency recently criticized Kaiser for the long wait times its members had for mental health services and for providing inaccurate information about what services it provides. Kaiser says it has corrected the misinformation and is working to reduce and better track member wait times.

Where Kaiser has a head start that others may have difficulty catching up to is its use of electronic records and technology systems for tracking patient care.

When Dr. Jennifer Slovis, a Kaiser internist in Oakland, recently saw a patient, she was able to spot that the patient had an abnormal blood test several years ago. By reading through the patient’s medical history, she determined he was now overdue for an M.R.I. to check the status of a growth in his brain. She was able to e-mail his endocrinologist and schedule the necessary tests without the patient having to make an appointment with the specialist or her having to make her own diagnosis. “It saved a lot of starting over,” she said.

In the last five or so years, Kaiser has also been using the information to identify those doctors or clinics that excel in certain areas, as well as those in need of improvement. The organization has also used the records to change how it delivers care, identifying patients at risk for developing bed sores in the hospital and then sending electronic alerts every two hours to remind the nurses to turn the patients. The percentage of patients with serious pressure ulcers, or bed sores, dropped to well under 1 percent from 3.5 percent.

“The tool is an enabler to give information to people who give a damn,” said Dr. Jack Cochran, the executive who represents Kaiser’s physicians through the Permanente Federation.

Mr. Halvorson, the Kaiser chief, who plans to retire at the end of this year, says the organization is providing evidence to other health systems that re-engineering works. “All of that adds up to better care and cheaper care,” he said.

The Doctor Is In (Well, Logged In)

From March 19, 2013 Article in the New York Times

Surfing the Web in his all-white Dumbo loft, Dr. Jay Parkinson, 37, looks like any other young tech visionary. He has a trim beard and thick-framed glasses. He wears slim-fitting black outfits and jaunty scarves. He speaks with a measured, “This American Life”-like cadence. And he’s a firm believer in the utopian promise of the Internet.

But Dr. Parkinson’s start-up isn’t a new app or social network. He is a founder of Sherpaa, a Web site that operates like a virtual doctor’s office, examining patients by e-mail and text message.

“We’re using the Internet to reinvent health care,” Dr. Parkinson said proudly, seated next to a Ping-Pong table and a shaggy goldendoodle.

Have a mysterious rash? Send a photo of it to Sherpaa, reply to a few e-mails (Are you sure it’s not a bruise? Do you have bed bugs?), and proceed to the nearest Duane Reade to pick up your prescription.

This may seem like health care for the “OMG, I’m sick” generation, but clients include high-tech players in New York like Tumblr, Skillshare, General Assembly and Hard Candy Shell. “We’re tech-savvy doctors,” he said, “for tech-savvy patients.”

In fact, Dr. Parkinson is perhaps the most prominent of the city’s 2.0 doctors, who are rethinking the health care model along 21st-century lines.

In 2007, after graduating from Penn State College of Medicine, and completing a residency in pediatrics at St. Vincent’s Manhattan Hospital in Greenwich Village, and another in preventive medicine at Johns Hopkins in Baltimore, he did what every young roustabout did at the time: he moved to Williamsburg, Brooklyn.

Dr. Parkinson rented a ground-floor apartment on North Ninth Street, and spent his nights at Hotel Delmano and the Brooklyn Ale House and his days caffeinating at Atlas Cafe. He was adrift.

“I knew I didn’t want to join a private practice,” he said. “I’d be the low man on the totem poll, get paid poorly and not be in control of my hours.”

Instead, he started a self-titled blog on which he wrote about health issues relevant to the L train crowd, like the dangers of cocaine and the wonder of Thom Yorke’s left eye ptosis. He also started a Tumblr page, which included a flattering photo of himself standing underneath the Williamsburg Bridge with a stethoscope.

Rather than set up a standard practice — an office with, say, back issues of Vice magazine and a surly tattooed receptionist to schedule appointments — he invited patients to contact him directly through instant message and e-mail. “We can figure out if I need to come to your work, your home or meet somewhere else in the city,” he wrote on the site. “We can even meet in the park or a coffee shop.”

The concept seemed so trendy that Gawker mocked Dr. Parkinson in a post entitled, “Williamsburg’s Hipster Doctor Will Diagnose You Via IM.” The article went viral. “When I read that,” he recalled, “I thought my career was over. But after it came out, I had seven million visitors on my site that month. I was offered both a book deal and a movie deal. ‘The Tyra Banks Show’ called. They wanted me as their Dr. Oz.”

(Full disclosure: I was an editor at Gawker at the time but did not write the post in question.)

Dr. Parkinson turned down the various offers, but he rode the wave of popularity. He started a design consultancy called the Future Well. He also stopped seeing patients and let his license to practice medicine lapse. “Seeing patients is stressful for me,” Dr. Parkinson said. Instead, he networked.

He held parties, cocktail mixers and backyard barbecues that attracted Web luminaries like David Karp, founder of Tumblr; Chris Hughes, a founder of Facebook and current publisher of The New Republic; and Jakob Lodwick, a founder of Vimeo. “The Internet crowd really latched on to my practice,” Dr. Parkinson said.

Instead of making house calls to ailing freelancers, Dr. Parkinson was now hobnobbing with their bosses. His new start-up, he decided, would work exclusively with companies.

Started in 2012, Sherpaa now has eight employees, including two primary-care physicians, and counts 500 customers from 30 companies. Sherpaa’s network includes 100 specialists to whom it refers clients.

More than offering 24/7 service, Sherpaa’s main selling point to employers is cost. By moving away from a reliance on traditional primary-care physicians and emergency room visits, Sherpaa claims that it can save companies up to $4,000 a year for each employee. (It charges $50 a month for each employee.)

Dr. Parkinson still holds mixers for hepcat medical professionals. At a recent barbecue, he served sausages from the Meat Hook and whisky cheese from the Bedford Cheese Shop at the apartment he now shares with his girlfriend, Paige Ferrari, 30, a producer for “Doomsday Preppers.” The décor is classic Bedford Avenue contemporary: a pair of suspenders hang from a lamp; a stuffed javelina is mounted above the bed.

Sitting under a vintage World War II Red Cross flag, guests discussed the health issues of the day like the “quarter-life crisis” among 20-somethings and “hipster belly,” a result of too much pulled pork and too few pull-ups.

“Part of being a 20-year-old is doing stupid things,” said Dr. Parkinson, spearing a bratwurst. “And part of being a 30-year-old is realizing you can’t have this sexy body doing the same thing forever.”