Take Care, Don’t Intervene

Monday, November 26th, 2012

I’ve been reading about P.H.A.S.E.S (Personal Health Assessment and Self-Energizing System) developed by Rebecca McLean and Dr. Roger Jahnke and their Circle of Life Health and Wellness Coaching Process.  McLean and Jahnke are among those who make the distinction between healthcare and medical inventions.  Healthcare should mean caring for one’s health; the common term for programs that do that is “wellness programs.”  The Medical Industrial Complex, the MIC, provides medical interventions.  The MIC is frazzled today because it is a reactive system trying to become a proactive system without much of a paradigm change.  I just toured the new Soin Medical Center in Beavercreek, OH.  It’s a beautiful place, but it is still a separated place of last resort where people go for interventions.

Dr. Synonymous and I set out to define a proactive system when we were conceiving the Human Centered Health Home (HCHH), a humane cocoon of protection for patient teams and provider teams.  We talked about ways to make a health home a destination, like a coffee shop or a juice bar, a place where hanging out could be infused with wellness.  We were pushing toward ways of integrating wellness into daily life, making it sexy as Madison Avenue might say.  We imagined the HCHH in a lively place with dance, food, meditation, exercise, entertainment, and interventions, when required.  We probably should’ve included work in the mix.  I don’t think we’ve pressed the model far enough in that direction yet.

This Thursday, November 29, the Innov8 For Health cycle starts anew with the 2013 Announcement and Ideation Session (1-5 pm at the Health Foundation of Greater Cincinnati).  I would challenge this next group to think beyond apps, and look systematically at how to use technology to insinuate caring for one’s self into our culture.  The industry lacks a platform that takes the burgeoning multitude of discrete wellness apps and devices and builds them into a proactive system that will help the MIC to evolve as it must.  That platform, which will bridge the virtual and actual worlds, will not be a killer app.  It will be a life saver.

More Better

Tuesday, October 30th, 2012

I remember when I was kid hearing one of my friends who was ill asking his mom to help him be “more better.”  As an adult, running around chanting, “More better.  More better,” brings to mind Frankenstein’s monster with Boris Karloff voicing the mantra.  I doubt if the monster was trying to encourage more townspeople to pick up pitchforks and torches to race after him.

However, in healthcare, that seems to be what patients tend to do.  Tara Parker-Pope wrote Overtreatment is Taking a Harmful Toll a few months back.  She leads off “When it comes to medical care, many patients and doctors believe more is better.”  She points out that this is costing the healthcare system at least $210 billion a year and at the same time putting patients at risk.  It seems to me this is because patients, and doctors, are not thinking about whether a test or an image has an impact on their treatment.  Doctors and hospitals, being risk averse, opt for more testing because it protects their, um, backside from litigation.  This practice shifts risks to the patients while the patients are ignorant of the fact.

Back in April, when Larry Ozeran wrote “Ignorance is harmful to your health” he was speaking to the fear people had about the Affordable Care Act, a fear that spills into this election.  The PPACA is a huge document.  I doubt if many of us could claim to know of someone one, let alone know someone, who has read the entire act.  Well, Cathy Paige, healthcare advocate in Yellow Springs, has challenged a group of us to meet regularly — electronically and/or face -to-face — to read through the Act, a small piece at a time, in order to understand what’s in it.  I’m waiting for Cathy to set a kickoff date.

Once we start, I’ll post the section we’re looking at that week, and invite your comments.  It seems like a lot to understand, but I think in this case, more actually is better.

Patient Value and Meaningful Use 2 Measures

Saturday, September 15th, 2012

I’ve been looking over the Stage 2 meaningful use measures.  These are the metrics by which providers will be judged in order for them to receive payments from the government for using electronic health records and electronic medical records.

While looking of the Stage 2 measures, I gave some thought to the measures IFG uses to create value for our customer, the patient.  Here’s the list I came up with.  I’ve labeled them with IFG, so you can differentiate my list from those of the Center for Medicare and Medicare that are provided afterward.

IFG Healthcare IT Meaningful Use Criteria

IFG a) Patients shall have immediate and continuous access to their health and wellness records and information.

IFG b) Health and wellness information shall be recorded in terms patients and their families can understand.

IFG c) Patients’ records shall be used as a quality check on provider records.

IFG d) Personalized results of care plan and discharge instructions shall be included in patient health and wellness records.

IFG e) Cost, time, and risk impacts shall be associated with health and wellness choices.

IFG f) Patient health and wellness records shall be safe and secure.

IFG g) Patient health and wellness information shall be shared only with the patient’s explicit permission.

IFG h) Patient health and wellness information shall be storable and retrievable in structured and unstructured formats.

IFG i) Patient health wellness information shall support shared control of interactions with the healthcare system workflows.  Shared control means decisions are made jointly by providers and patients.

Contrast my list with the the Center for Medicare and Medicaid satisfaction criteria (below) for the Stage 2 meaningful use criteria that eligible professionals, eligible hospitals, and critical access hospitals must meet in order to continue to participate in the Medicare and Medicaid Electronic Health Record Incentive Programs.

Center for Medicare and Medicaid Healthcare IT Meaningful Use Criteria (Stage 2)

1) Computerized order entry for medication (more than 60% of all orders), laboratory ( more than 30% of all orders) and radiology orders (more than 30% of all orders).

2) ePrescriptions – generate and transmit permissible prescriptions electronically and compare to at least one drug formulary (more than 50% of all prescriptions).

3) Record patient demographics  including preferred language, gender, race, ethnicity, and date of birth as structured data (for more than 80% of all unique patients).

4) Record and chart changes in vital signs including height, weight, blood pressure, body mass index, growth charts for children (for more than 80% of all unique patients).

5) Record patient’s smoking status for people 13 years and older (for more than 80% of all unique patients).

6) Use clinical decision support to  improve performance on high-priority health conditions.  Record 5 clinical support interventions related to 4 or more clinical quality measures  (click here to download quality measures).  Enable drug-drug, drug-allergy interaction checks.

7) Provide patients the ability to view online, download and transmit their health information within four business days of the information being available to the eligible provider (for more than 50% of all unique patients).  More than 5% of all unique patients view, download, or transmit to a third party their health information.

8) Provide clinical summaries for patients for each office visit within one business day ( for more than 50% of office visits).

9) Provide electronic health information created or maintained by the certified electronic health record technology through the implementation of appropriate technical capabilities.  Conduct or review a security risk analysis and implement security updates and correct identified security deficiencies as part of its risk management process.

10) Incorporate clinical lab-test results into certified electronic health record technology as structured data ( more than 55% of all clinical lab tests).

11) Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach ( at least 1 report).

12) Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care ( for more than 10% for patients with 2 or more office visits in last 2 years).

13)  Use certified electronic health record technology to identify patient-specific education resources and provide those resources to the patient if appropriate (for more than 10% of all unique patients).

14)  The eligible provider who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform a medication reconciliation. (for more than 50% of all transitions).

15) The eligible provider who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care should provide summary of care record for each transition of care or referral (more than 50% by hardcopy or electronically; 10% electronically).

16) Capability to submit electronic data to immunization registries or immunization information systems and actual submission except where prohibited and in accordance with applicable law and practice (ongoing successful submission).

17) Use electronic messages to communicate with patients on relevant health information ( for more than 5% of unique patients).

Menu of objectives (eligible providers get to pick 3 of the 6)

1) Capability to submit electronic syndromic surveillance data to public health agencies and actual submission except where prohibited and in accordance with applicable law and practice (ongoing successful submission).

2) Record electronic notes in patient records (at least one note for more than 30% of unique patients).

3) Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through certified electronic health record technology (>10% of all scans).

4) Record patient family health history as structured data (for >20% of all unique patients).

5) Capability to identify and report cancer cases to a State cancer registry, except where prohibited, and in accordance with applicable law and practice (ongoing successful submission).

6) Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice (ongoing successful submission).

Comparison between IFG measures and Center for Medicare and Medicare Services Stage 2 Measures

While it can be argued that each of the Stage 2 measures directly or indirectly impact patients, most of them represent the requirements of stakeholders that are not patients or providers, the payers.  Few give patients the ability to effectively manage their healthcare experiences which the Institute of Medicine states is essential for cost and safety control.

For example, delay in receiving copies of electronic records can range from one day for clinical results to four days for their records!  For a family in the middle of a healthcare crisis that can be a long time, particularly when one thinks of electronic measures moving at the speed of light.  And only a single measure provides an action point for patients.  The rest describe things that are done to the patient and the patient’s data, or duties that are imposed on the healthcare provider.  The imposition, to me, is evident from the percentages placed on compliance.  They tell me, “It’s no big deal.  You only have to do this much to pass.”  They don’t say, “Hey, this is great!  You’re all going to want to do this stuff.  You’ll see how cool it is!”

Measures intended to modify provider behavior come with a long-process control and audit tail that will add overhead costs to the healthcare system.  The Center for Medicare and Medicaid Services will need to check compliance.  Providers will need to spend time and money assessing their own compliance.  Many primary care providers will leave the business, because they can’t afford the additional overhead.  Will the total costs of control overwhelm the desired benefit?  I wonder if anyone has thought to check.

IFG Health’s meaningful use measures don’t have that overhead.  Eligible providers want to stay in business and do their jobs well.  Patients and their families want to be healthy and safe; they don’t want to be bankrupted by healthcare costs.  Providers and patients want tools that help them to make good decisions together.

Valuable healthcare IT products will reflect these desires in product requirements.  If  IT product functionality satisfies patient and provider requirements,  healthcare IT companies will measure meaningful use by counting their customers.  Patients and providers will measure meaningful use each time they use the product.  What strikes me most about Meaningful Use Stage 2 measures is the disturbing lack of quality assessments like understandability, usability and usefulness.

The IFG Health meaningful use measures provide immediacy, chain of data custody, availability, security, and understandability to patients.   These are quality measures that we believe reflect immediately perceivable value and true, meaningful use.

Why Not?

Friday, August 24th, 2012

There are those who look at things the way they are, and ask why… I dream of things that never were, and ask why not? Robert Kennedy

Through the Innov8 for Health experience, it has been difficult to communicate to people the power of healthcare decision aids for patients. This past week I made the email acquaintance of Palo Alto Medical Foundation researcher Dominick Frosch, PhD.

Dr. Frosch’s research area is Shared Decision Making. Shared Decision Making between clinicians and patients spreads places patient needs and preferences into the mix when a medical decision is made. Frosch introduced me to a paper by Barry et al in which a shared decision invention, in this case a video, was used to determine if such use would reduce physician malpractice risk. The results of the small study seemed to indicate the Shared Decision Making intervention, in this instance, provided a high “degree of medical legal protection.”

We at IFG Health anticipate that putting patient data in patients’ hands and using their information and preferences in diagnoses and care planning will create an atmosphere of shared responsibility and shared risk that will alleviate a lot of systemic complaints. Learning will need to take place on the clinical and on the patient side in order for this to occur.  However, the vision of a system in which healthcare is a joint activity is one of a hopeful future.  Why not!

Take Control

Wednesday, August 15th, 2012

The Institute of Medicine asserts patients need to be in control of their healthcare experience.  While this sounds attractive and empowering, most of us have little insight into the inner workings of the Medical Industrial Complex (MIC).

The MIC has the power of information technology that presents the impression that it knows all and sees all.  “Pay no attention to the man behind the curtain!”

IFG Health aims to level the playing field.  We provide insights into MIC operations, and tips on navigating the system.  Our products are powerful management tools that humanize and organize the healthcare experience.