ZachEvans

Believer. Husband. Dad. Coach. Healthcare Thought-Leader. All-Around Good Guy.

Healthcare

Patient-Centered EHRs

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In recent years (especially with the advent of the Patient Protection and Affordable Care Act) and new (actually really old) term came back to the forefront of our healthcare system: Patient-Centered Medical Home.

The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family.

The reason that this is a new idea is that as recently as fifty years ago our healthcare was (primarily) managed by family physicians that knew us personally and took care of most of our needs. (We also paid for most of our care out of pocket, but that’s another post.) With increased specialization and insurance reimbursement, however, our healthcare system fractured in to the model we have today: We typically run to a disconnected specialist first before talking to our primary care physician.

HMOs tried (in vain) to reintroduce this hub-and-spoke model but consumers never got comfortable with the idea that someone in a cubicle hundreds (or thousands) of miles away got to decide if they needed a procedure or not. The patient-centered medical home tries to improve this model by placing a primary care physician at the center of the wheel to work with you on the best course of your care.

Supporting this model (or at least it’s supposed to be supporting the model) is a significant amount of technology that enables coordination of care across access points and stakeholders. The problem with much of this technology (especially EHRs) is that they’re not patient-focused at their cores. Too many EHRs (and the practice management systems that wrap them) are built with the payers and providers at their middle instead of the customers they both serve: Patients.

Usability is terrible. Interoperability is virtually non-existent (although it is getting better as the first HITECH incentive payments have started flowing). Providers are in revolt (see the usability comment above). And the patient is locked out of having visibility in to almost any of it.

I love the idea of the patient-centered medical home. I think it’s where healthcare really needs to go. Unless we put the patient at the middle of all of the enablers of the medical home, however, I do not believe we’ll be able to capture all of the possible benefits.

Life-and-Death Information

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Diligently uncovering information through research is a smart move in my mind. Blindly believing all of the information that your research generates, however, isn’t very wise. Why, you may ask? Not all information is created equally, that’s why. In fact, some information is just that: Created (aka Made Up).

The Internet is a wonderful source of information. Almost anything you want to know is just a Google search away. When it comes to health-and-wellness information, individuals have a myriad of sites to choose from when they’re looking for something. The elephant in the room, however, is that you may not know what information to trust or not. We–as consumers of information–may not have the appropriate context with which to judge the information’s veracity.

That’s why, when I read a summary of a recent survey about how the 89% of the 178 million Americans that go online each month have used the Internet for health research I get a bit nervous.

Other findings of the survey include:

  • The primary reason for going online for health information was to gain general knowledge about a condition (71%), followed by researching symptoms that either the individual or someone else was experiencing (59%);
  • 56% of respondents said a healthcare professional recommendation makes a health website trustworthy, followed by 46% who said the inclusion of academic articles or scientific research does, and 39% who said having information that is easy to understand does;
  • 79% said that they felt the Internet provides a wealth of resources when they are searching for health-and-wellness information, while 74% said they were very cautious about which websites they accessed for health-and-wellness information; and
  • For those recently diagnosed with a condition, 77% said they first turned to online sources for information, second only to 81% who said they turned to a healthcare professional. Nearly 51% relied on magazines, pamphlets or other print publications.

It’s not at all that I’m a Luddite; I have a blog after all. I just want all of us to be careful with what we believe just because it’s online. We need to understand the context of the information. We need to do our research on the research to ensure that it’s accurate and trustworthy. Do your homework. Talk to your primary care physician (which, on average, we don’t do enough). Trust, but verify. You owe it to yourself and your health.

Healthcare Costs Decline?

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How often do you hear about healthcare costs going DOWN? Me neither. That’s why I’m so excited about this post by the CEO of Beth Israel Deconess Medical Center in Boston regarding the first bend in the healthcare cost curve he’s seen on a large scale.

What’s driving this decline? Three important factors:

  1. Better education and communication
  2. Financial incentives from payers
  3. Market forces and lower-cost options

The best part of the shift? All of this is being accomplished without massive government regulation and intervention. Although the article doesn’t mention outcomes, my guess is that they didn’t decline significantly (or at all) or else the hospital CEO would be ranting against the change.

Now, if we can only convince Washington that by letting market forces drive the necessary change–guided by appropriate (and limited) regulation–healthcare costs can be reigned in, we’ll be OK. Don’t you agree?

 

Regional HIEs

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Let me admit something: I’m a nerd. I’m also pretty proud of that fact. In case you haven’t noticed, nerds tend to rule the world and make a lot of money in the process. Sure, Albert Pujols and Peyton Manning make a pretty good living using they physical abilities but they’re also pretty sharp individuals that study hard while working out hard. So, when I view a presentation like the one below and realize that the right people are in the room (and are all pretty nerdy themselves), I simply can’t understand why all of this is so difficult.

Regional Health Information Exchanges (HIEs–also known as Regional Health Information Organizations) are attempting to start-up all around the country and they certainly need to. Well-functioning  HIEs are a vital part of sharing our healthcare information between parties that need rapid access to it to drive down costs in a meaningful way. Too many organizations, however, are simply dragging their heels when it comes to letting their data (shouldn’t they really should view it as YOUR data?) outside of their own four walls–and this is a shame.

I would love to say that there is an answer to this question that doesn’t involve some form of government regulation/incentive/strong-arming, but I’m not sure if there is. The complaints about missing standards can be overcome and the free market should be able to derive enough value from the HIE to justify private funding, so why is this so hard? Maybe getting the right nerds in the room isn’t enough, but it really should be.

UPDATE: This is a very timely and interesting article on letting the data flow.

UPDATE 2: If you’re looking for some basic information, here is a great HIE guide.

UPDATE 3: This is a great article on SureScripts as a defacto NHIN.

UPDATE 4: Health Information Exchange Sustainability.

Destination Nashville

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I’ve grown to love Nashville more each year since I moved here in the mid-90s. It’s a great place to raise a family, has a wonderful community of faith, and offers both the trappings of the big city and wide open spaces (for example, I live in Franklin, which is close enough to downtown to be there in about 20 minutes but is surrounded by farms). My love affair with the city received a huge boast in early May when the city responded to massive flooding not by complaining and waiting for a handout, but by rallying around those that needed help and doing something about the devastation.

Nashville and its surrounding counties have also been on a role in recent years landing several big-name corporate headquarter relocations (LP, Caremark, and Nissan are just three examples). Furthermore, Nashville is known (although, perhaps, not best-known for) as a healthcare mecca, as pointed out in a recent article by MarketWatch. Granted, Tennessee as a state has a long way to go when it comes to the health of our population (and so does much of the deep south), but I’m thrilled to live in a area doing things that positively affect so much of our national economy. I’m also proud to be working for one of the 550-plus healthcare companies–CareHere–that calls the Nashville-area home.

So, hats off to you, Nashville. I’m honored to call you home and am looking forward to many more years of growth, success, and fun.

Why Sharing Our Data Is Difficult

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Unless you’ve been living under a rock (or simply don’t care about the topic–which is much more likely), you’ve heard a lot about electronic health/medical records, sharing of healthcare information, and how this panacea will dramatically increase the quality, and decrease the cost, of healthcare. There’s a big problem, however. Hardly anyone is doing it (yet), which begs the question: Why is this so hard?

We could go down the route of talking about the lack of inter-connected RHIOs, HIEs, and other IT-related alphabet-soup short-hand names but I think there’s a deeper problem that’s keeping the public at large from demanding such sweeping changes (and funding them). One word: Privacy.

We want our cardiologist to be able to get our electronic health record directly from our primary care physician but we’re simply not comfortable with a few, or perhaps just one, entity housing all of our healthcare data (or at least facilitating the dissemination of that data). We’re afraid that Big Brother is watching and will do evil things with our data (without our knowledge, of course) if we don’t control it.

Tim O’Reilly makes what I think is one of the best points about what we’re actually afraid of when it comes to our healthcare data:

Technology is taking us a direction where more and more is known about us…It’s hard to be completely anonymized. I think we need a complete fresh look at what tradeoffs we’re making and why. A good example is health care privacy. It’s true that there are some diseases that still have stigmas around them, but our need for privacy is mostly about adverse selection from insurance companies. The problem we need to solve is adverse selection due to pre-existing conditions, not to treat the info like it’s toxic waste. If we look at the benefits of using the information – they are incredible.

Is it possible that we’ve been asking the wrong question when it comes to privacy? I think so, perhaps. The root problem is what people may do with the data, not the fact that they have access to the data in the first place. While I’m not a big fan of governmental regulation, this is something that can be controlled by regulation and could help spur along additional data-sharing advancements.

So, if we could solve problems such as adverse selection (and a host of others), would you be more willing to have your healthcare data readily available to those that need it in order to provide you with better quality and lower cost care?

(PS: For those of you still concerned with the technical interoperability issues, one needs only look at the financial services industry to see that this problem can be overcome. Need an example? Go to the ATM of a bank where you don’t have an account and withdraw some money.)

(PPS: If you’d like some more information about privacy–especially online privacy–you can check out a research paper I wrote in graduate school entitled Online Privacy: A Global Perspective.)

UPDATE: Seth Godin makes a good point that privacy isn’t the real problem. Rather, being surprised by what is done with our data is.

You Don’t Always Get What You Pay For

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According to a story recently reported by NPR, the U.S. spends the most on health care, but gets the least bang for its buck. The story is based on a survey released by The Commonwealth Fund and paints a pretty bleak picture of the current state of our healthcare system.

In its ranking, the US fell dead last after Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom. Criteria evaluated included quality, access, efficiency, equity, whether people in each country lived long and productive lives, and how much each country spent per person on care.

This study is especially relevant in light of the recent debate (and passage) of the healthcare reform law. While I may disagree with many of the provisions in the law, I do agree that something needed to be done. Insurance mandates? I’m on board but believe that they need to be paid for in a different manner.

(Interestingly, as the article points out, the Netherlands came in first in the survey and doesn’t have a government-run system. Rather, they have insurance mandates like those referenced above).

So what type of changes do I think need to be made? I’ve compiled a list below of my top six, in no particular order, but I have purposefully left off the exact manner in which I think they need to be implemented. Those debates need to be held in an open forum with everyone getting a chance to voice their opinions before decisions are made.

  1. We need to take more personal accountability for our choices. A study by PriceWaterhouseCoopers found that 25 percent of insurance premium cost increases are a result of increased utilization. A large portion of this increase in utilization can be attributed to one thing: Poor personal choices. Many cases of high cholesterol, diabetes, heart disease, and obesity–just to name a few–could be prevented if we make healthier decisions. Many people,  however, don’t want to take responsibility for these poor choices. Instead, they want the healthcare they need without having to pay for it. Dealing with a systemic problem such as this without making changes to this fact simply isn’t sustainable. One way for us to make better choices is to have better information on things like costs and, fortunately, tools from companies such as change:healthcare are coming to market to help us with this. (Disclaimer: The PWC study was commissioned and paid for by America’s Health Insurance Plans, which is the lobbying arm of the health insurance industry).
  2. We need to increase the use (and compensation) of primary care doctors. Study after study points to the fact that our healthcare system fails to recognize the long-term effects of primary care and that we don’t compensate enough for the care that is delivered. Most other industrialized countries are the inverse of our current system where we tend to rely on specialists and relegate primary care doctors to the back burner. Those same countries are getting better outcomes for their dollars spent. My current company, CareHere, is focused on breaking down barriers to primary care with on-site medical clinics and is delivering some pretty incredible results for our clients.
  3. We need to find a way to end defensive medicine. Have you ever felt that your doctor ordered tests that may not have been needed? I certainly have. Sometimes the extra tests are needed to rule-out something that the doctor is unsure of (and that you’re unaware of) but often they’re ordered because you doctor is afraid that they may miss something that’s a one-in-a-million chance and they don’t want to be sued. This fear leads to the practice of defensive medicine. It also leads to higher healthcare costs without a corresponding improvement in outcomes. How do we accomplish this? By enacting comprehensive and sensible tort reform.
  4. We need to find a way to get new medical technology and treatments to scale faster. Andy Kessler wrote a book entitled “The End of Medicine“ that really brought this concept into focus for me. Drug companies routinely spend hundreds of millions of dollars doing drug research without a guarantee of a return. Medical technology companies bring new treatments to market but they’re so expensive that they’re relegated to ‘experimental’ status because they simply cost too much. Scale can be achieved in our current healthcare system but it simply takes too long. Somehow we’ve got to find a way to get medicine to scale faster, which will extend life-saving treatments to the masses at an ever-lower cost.
  5. We need to understand that we can have two out of three (but not all three): Medical treatments that are quick, cheap, or of high quality. In a perfect world everyone would have access to the highest quality care when ever and where ever they needed (or wanted) it at little-or-no cost to themselves. This, unfortunately, simply isn’t reality and will most-likely never be achievable. When it comes to project management an old saying goes something like this: “You can have it (your project) cheap, fast, or good but not all three”. People (or politicians) that want immediate access to high quality care without paying for it are delusional. This position simply isn’t debatable even if how you pay for it is.
  6. We need to have open, honest discussions about end-of-life care. Fortunately, I have not had to make end-of-life care decisions for anyone close to me. I will most likely, however, face these decisions at some point in my life. Several years ago I signed documents giving me power of attorney over the healthcare decisions that relate to my parents if they are unable to make decisions for themselves. The Dartmouth Atlas of Health Care finds that 32 percent of total Medicare spending for patients with chronic illnesses occurs in the last two years of their lives. Furthermore, a majority of people that indicate that they’d prefer to die at home end up dying in the hospital. What should we do about this? I’m not advocating ‘death panels’ but we should all have honest discussions with our loved ones so that we clearly understand their wishes. For most, it will be about quality and not quantity and the end of our lives. (UPDATE: For a heart-wrenching account of how end-of-life discussions take place–or don’t take place–take a look at this article from The New Yorker.)

UPDATE 2: I recently came across an article by the Council on Foreign Relations that further makes another very important point about how healthcare costs are hurting the competitiveness of US companies and our overall economy.

Do you think that I’ve left out something big? Do you completely agree or disagree with my priorities? Let me know. Debate without consequence is one of the many things that make America great.

UPDATE 3: Read about demand-side issues with healthcare costs.

UPDATE 4: Read about how healthcare costs have more than doubled in the past decade.