A Scanner Brightly

$1300 Nose Bleed

noreply@blogger.com (Jaz) — Fri, 02 Oct 2009 14:06:00 +0000

I received the following E-mail this morning on another blog:

"Where is Wyoming on your list. It is a state in the USA. Our local
hospital, Wyoming Medical Center here in Casper Wyoming, is so greedy
about their charges and will not tell you what they charg before
you have your visit. Emergency care for a simple nose bleed wes $1,300.00
Why are they allowed to get away with this.
How do you make the greedy companies tell you what their charges are
BEFORE you agree to have care when it is not a life or death situation. If
I had been informed how much it was going to cost I would have refused the service.
HELP"

The sender did not leave an E-mail address to reply, so I thought I'd reply here.

First things first: $1300 for a "simple nosebleed" is outrageous.

Second things first: going to the emergency room for "a simple nose bleed" is outrageous.

What to do? Call the billing department, make them an offer. But bear in mind you elected to use highly specialised services of a very expensive health care facility.

I had a lot of nose bleeds as a kid. Spontaneous ones, they would just start happening. The remedy cost less than a cent and involved tearing one tissue into two, plugging my nostrils and tilting my head back. Occasionally, I would pinch the bridge of my nose (as instructed) but it didn't really seem to do anything.

When did it become acceptable to go to the ER for a nose bleed? This is half the problem, this is what drives costs up. I don't have nearly enough information to figure out how serious the author thought the situation was, maybe it was the first time it had ever happened and he or she thought their brains were going to fall out, but I'm going to go out on a limb and say no, it was a simple nose bleed.

I feel really bad for the author that they are now stuck with a ridiculous bill. I would absolutely call the hospital and offer them $500 and a payment plan. I agree wholeheartedly that pricing needs to be more upfront. In the absence of hospitals doing this, we're working as hard as we can to publicise as many prices as we can. You can browse pricing at OutOfPocket.com where you'll notice I have a similarly-priced ER visit, for which the insurance paid less than $500.

But I would also counsel that next time you have a nosebleed, ~~tilt your head back~~ lean your head forward (1970s Welsh national health advice aside, apparently the thing to do is lean *forward*, thanks Kenneth!). Visiting the ER for a nosebleed is like going to the car dealer for a flat tire. They'll do pretty much the same thing as the guy on the corner, but charge you ten times as much.

As long as this country refuses to have a public option, you are consuming health care in a free market economy, with all the trappings that come with that. The ER is not your local clinic. But as long as you treat it like one, they will be happy to bill you.

Is it a Bird? A Plane? No, it's Electronic Clinical Data!

noreply@blogger.com (Jaz) — Thu, 24 Sep 2009 16:51:00 +0000

Faster than a speeding bullet, the clinical data portal we launched in June has scored it's first physician! It's pretty exciting to have built it, even more so to actually see a physician using it.

The portal allows a physician - or a group of physicians - to upload clinical data relevant to a given condition, in this case Diabetes. We ask for a set of specific, discrete data, not the entire record, such as blood sugar levels, blood pressure, eye exams and the like, and then using the data from the record we score the physician(s) against an evidence-based measure set that scores the doctor on his or her performance for that condition.

So, in this case, the doctor voluntarily submits to being scored for his performance treating and managing his diabetic patients. Any eligible physician who scores well on the measure will start receiving incentive payments from participating payors and purchasers, as well as be recognised in HealthGrades.com

Pretty cool, huh?

In addition, using the same engine we also scored two batches of physicians who are using the NextGen EHR package, thereby scoring their performance directly from the data.

As EHR adoption in the United States grows I anticipate more and more data being available to more and more performance assessors like ourselves, and I look forward to the next five years. Next step? Live report cards that tell you not how a hospital did last year, but how they did YESTERDAY.

Can't wait.

Netflix Winner Announced

noreply@blogger.com (Jaz) — Tue, 22 Sep 2009 02:19:00 +0000

Health transparency wise we have three great new projects each due to go live in the next 60 days or so, hence the lack of posts, just too much going on. However, I do like to talk about technology that isn't health care-related once in a while. Netflix started an open contest three years ago offering a million dollars to anyone who could improve their movie recommendation engine. The contest is finally over, whittled down from over 50,000 contestants to two teams who came in at the last minute just a few minutes apart. The full story is at Wired, go to http://www.wired.com/epicenter/2009/09/bellkors-pragmatic-chaos-wins-1-million-netflix-prize/ and enjoy the read.

I think it's a great example of both using the collective consciousness and open software principles.

Worldwide Flandemic

noreply@blogger.com (Jaz) — Mon, 06 Jul 2009 19:36:00 +0000

Once in a while, I post a funny. This is one of those times.

For those of you who clicked through, here's a bonus extra.

Physician Performance Assessment

noreply@blogger.com (Jaz) — Wed, 24 Jun 2009 17:57:00 +0000

A bit of a departure from my usual transparency efforts, but this week we launched our Clinical Data Portal, a Web-based portal that allows physicians to upload clinical data directly from the chart or from an electronic medical record software and be assessed instantly on their clinical performance. Physicians who score high enough automatically start receiving bonus checks from the Bridges to Excellence program. Pretty neat stuff.

We have started with Diabetes and Cardiac Care, but we'll be rapidly adding more topics for physicians to measure themselves with. Physicians are free to become recognised for any of the topics, but if they fall under a BTE program area, they are eligible for real reward dollars. Next up we'll be processing batch files of data from EMR vendors. Exciting stuff.

Why I'm Not Camping

noreply@blogger.com (Jaz) — Thu, 11 Jun 2009 21:31:00 +0000

Ahh, my poor blog languishes. As I have nothing interesting to say here's a list of what I'm working on, which may explain why my blog is so sparse these days.

Pay for Performance: Physicians are eligible for many programs that will pay them bonuses for delivering care at defined levels. For example, there are strict measures of evidence-based care that should be delivered to a diabetic patient. Starting this month, physicians will be able to enter data into a new clinical data portal that will instantly or near enough instantly score their performance and - if the physician achieves the correct performance level - be identified to these programs. We'll be kicking off with diabetes and cardiac care. Down the road,we'll also process data directly from EHR systems. Go live mid June, 2009.

Transparency: Illinois has elected to use my team to produce their state's hospital report card, we'll be publishing everything you never wanted to know about Illinois' hospitals. Go live Octoberish, 2009.

Transparency: This year's Regional Health Care Report Card is underway, and will split HMOs from hospitals, making it easier to review one or the other. Additionally, this year's hospital report will be the juiciest report card you've ever seen. Go live end August 2009.

Quality Improvement: Phase two of the WhyNotTheBest.org Web site is coalescing, more data, more benchmarks, more quality improvement resources. User interface is being reworked for a smoother, faster onramp to the content by a very cool team, and we're following behind loading up the new data. Go live November 2009?

Transparency: Pellucid is my new project to collate every ounce of publicly reportable data that exists. As you can imagine, that one's keeping me up nights. Go live of yesterday or never, depending on when you ask me.

All that, plus my youth rugby team made it to the semis in the Annual NYC Mayor's Cup. Busy year...

Uninsured and Charges

noreply@blogger.com (Jaz) — Wed, 03 Jun 2009 17:08:00 +0000

Two items caught my eye today that neatly juxtapose. One is from California, which discusses the publication of hospital charges (retail sticker price) for surgeries, and the hospital's insistence that these prices are meaningless. The other is from a Families USA study counting how many people were without health insurance for some period in 2008.

"That database is meaningless," said Jim Lott of the Hospital Association of Southern California. "There’s no relationship between the price on that list and what your insurance company has negotiated."

OK, fair enough. So how many people *didn't* have insurance, and thereby didn't have the benefit of a negotiated rate?

Turns out in California, during 2007 and 2008, 37.4% of the population under 65 spent some time without health insurance. Of these, 76.9% were without health insurance for six months or more.

80.2% of all people who went without health insurance were members of working families, i.e., someone at the house has a job. i.e., employment does not mean health insurance.

Most interestingly, 26.2% of uninsured people have incomes at or above 200% of the federal poverty level. I would hazard a guess that these folks are not rushing to claim bankruptcy to avoid the bill.

And of course, *all* these people are subject to the meaningless numbers. They all are charged sticker price. Maybe they don't pay them, but someone does, either through direct write-offs which impact us at the local tax level (we pay it for them) or indirectly through these folks becoming indigent.

Sticker prices hurt all of us. They are not meaningless. I myself have been charged them, even with my PPO in place.

I, like many other folk in public reporting, would prefer to report the cost of care - how much it costs a hospital to perform a given procedure - but this data is still hidden from us.

In the meantime, and even if I were to have cost data in hand, I would still publish charges, because charges most certainly do mean something, and they mean something to an ever-growing portion of the population.

National Health Care Reform – and Its Potential Impacts in New York

noreply@blogger.com (Jaz) — Fri, 15 May 2009 12:50:00 +0000

Please join us for a major forum about:

* the urgent problems in health care (escalating costs, increasing numbers of people with no coverage, disparities in access, and unsafe care),
* the increasingly intense debate about options for national health care reform, and
* the potential impacts of national reform in New York

To address these issues, the non-partisan National Coalition on Health Care has invited an extraordinary panel of experts to share their insights about how national reform could affect patients, health care providers, employers, employees, and communities in New York.

Registration: http://www.nchc.org/registrations/?id=12E0D163-D762-488E-B0CD-D47B7599DB41

And we have invited a wide range of leaders and stakeholders – from many organizations and vantage points – to attend and participate.

The future of health care – in the United States and here in New York – could be changed fundamentally by decisions made in the next few months. The stakes – for the health and well-being of all of us, for the growth and competitiveness of our economy, and for our living standards – are enormous.

We hope that you will join us for an important, informative program -- and a vigorous debate of these issues.

Speakers will include (in alphabetical order):

* Ana Abraido-Lanza, Ph.D., Associate Professor of Socio-medical Sciences, Mailman School of Public Health, Columbia University
* David Dobbins, Chief Operating Officer, American Legacy Foundation
* Ben Geyerhahn, New York Project Director, Small Business Majority
* Sherry Glied, Ph.D., Department Chair, Health Policy and Management, and Professor of Health Policy and Management, Mailman School of Public Health, Columbia University
* Mark Goldberg, Executive Vice President, National Coalition on Health Care
* Atul Grover, M.D., Ph.D., Chief Advocacy Officer, Association of American Medical Colleges
* Lori Heim, M.D., President-Elect, American Academy of Family Physicians
* Sue Klug, Assistant in Health Benefits, Program Services, New York State United Teachers
* Joann Lamphere, Dr.P.H., Director, State Government Relations, Health and Long Term Care, AARP
* Susan Lerner, Executive Director, Common Cause/ New York
* Joel E. Miller, Senior Vice President for Operations, National Coalition on Health Care
* Margaret K. Offermann, M.D., Ph.D., Deputy National Vice President for Research, American Cancer Society
* Vivian Riefberg, Principal, McKinsey & Co.
* Anthony Shih, M.D., M.P.H., Chief Quality Officer and Vice President of Strategic Planning, IPRO
* Hugh Waters, Ph.D., Associate Professor, Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University

The National Coalition on Health Care is the nation’s largest and most broadly representative alliance of organizations working for system-wide health care reform. Its 78 member organizations include major businesses and business associations, unions, medical societies, health and pension funds, insurers, faith organizations, patient advocacy and medical research groups, and higher education councils. Its honorary co-chairs are former Presidents George H.W. Bush and Jimmy Carter. Together, the organizations that belong to the Coalition represent – as employees, volunteers, members, and congregants – more than 150 million Americans.

The Coalition is grateful to the W.K. Kellogg Foundation for its financial support of this forum.

Registration: http://www.nchc.org/registrations/?id=12E0D163-D762-488E-B0CD-D47B7599DB41

If you have any questions about the forum, contact either Mark Goldberg (goldberg@nchc.org) or Joel Miller (jmiller@nchc.org) at the National Coalition on Health Care. We hope to see you on May 27.

Guest Blog: Collective Clinical Wisdom by Heather Leslie

noreply@blogger.com (Jaz) — Mon, 06 Apr 2009 17:20:00 +0000

I'd like to invite and encourage all clinicians to register for the openEHR Foundation's new Clinical Knowledge Manager (CKM) - found online at www.openehr.org/knowledge.

CKM is an international repository for openEHR archetypes and has two primary purposes - that of archetype publication and archetype governance. It is a real opportunity for clinicians to collaborate and agree on clinical content definitions for publication and use in our electronic health records.

openEHR archetypes are open source, computable specifications that define clinical information about a single and discrete clinical concept. For example there are separate archetypes defining a 'symptom', 'diagnosis', 'blood pressure', 'medication order', and 'risk of disease based on family history'.

As structured and standardised definitions of clinical content, archetypes are increasingly being recognised as fundamental building blocks of electronic health records, especially when integrated with clinical terminologies such as SNOMED CT. If we all start to record information based on the same archetype, then we can meaningfully and unambiguously share health information between systems, and we start to query that information across systems.

A primary goal of CKM is to encourage a broad range of clinician input to make sure that the clinical content in each archetype is correct. Absolutely no openEHR experience is necessary to participate in CKM, although we anticipate you will learn about openEHR as part of the journey. All participation is purely on a volunteer basis, and you can opt out at any point.

Whilst CKM is still in its relatively early days, we are already seeing the benefits that contributions by grassroots clinicians are bringing to the archetypes currently undergoing team review. Technically oriented openEHR experts support the review process to provide guidance on design and implementation issues, so there are no unrealistic expectations of the clinicians. Contributions of clinical and technical nature are equally and gratefully received;-)
By design, each archetype contains all the relevant information about the specific clinical concept - a maximal dataset which can be used in all clinical scenarios. So, for each archetype we are seeking a range of views from a variety of:

- professions - including every type of clinicial expert;
- geographical locations - to make sure we can capture diverse clinical and cultural practice; and
- knowledge domains - from general healthcare to all specialist areas.

Please actively 'adopt' the archetypes that you would like to be involved in. This will ensure that you will be invited to participate in the review of archetypes that are of interest to you. At other times you may also be invited to participate in a review where we consider that your expertise might provide balance out the current team of reviewers.

While we will strive to achieve maximal datasets for each archetype, we are pragmatic and know that we won't get it 100% right - certainly not at first try. However, I suggest that a small group of 3-4 clinicians with complementary skills and appropriate expertise can create and develop a draft archetype to approximately 80-85% complete. Further review within CKM by a team of clinicians from a range of professions, countries, institutions, research, and health domains will contribute and refine the archetype further - maybe this still will only get it to 90% complete; but maybe much more. Our experience to date shows that maximal datasets are much easier to agree on than minimal datasets!!

Over time it will be interesting to see how the models evolve - no doubt a good research topic!

Obtaining agreement on clinical content within archetypes in this manner is a significant achievement, even if in retrospect we find they are not 100% complete at the start. The flow-on benefits that come from sharing a standardised set of clinical specifications for EHRs can potentially transform some eHealth initiatives and is a necessary foundation for the truly sharable electronic health record.

So, all clinicians are welcome to get involved in CKM - we will certainly set you to work very quickly! We expect that by contributing domain expertise and insights, clinicians will also benefit personally by gradually developing openEHR understanding and expertise as part of the experience.

And then of course, there is also the contribution to the good of mankind... ;-)

[Instructions for registering can be found at: www.openehr.org/wiki/display/healthmod/Registration+in+CKM]

Tan While You Work

noreply@blogger.com (Jaz) — Wed, 01 Apr 2009 11:59:00 +0000

It's only vaguely health-related, but I wonder what the evidence says about tanning online? www.computertan.com offers you a five minute free trial and includes a mobile app for your iPhone. I have no idea if this is less or more likely to cause skin damage, but it will help me look good and feel less pasty.

Can't be healthy, can it?

You Gotta Spend Money to Spend Money

noreply@blogger.com (Jaz) — Thu, 19 Mar 2009 15:29:00 +0000

"HHS is establishing a new Office of Recovery Act Coordination within the Office of the Secretary to ensure successful implementation of the American Recovery and Reinvestment Act (ARRA) throughout HHS. This Office will be led by a new Deputy Assistant Secretary for Recovery Act Coordination."

Starting on Tuesday March 3rd, and on each Tuesday thereafter through May 12th, agencies receiving Recovery Act funds will be submitting weekly cumulative reports detailing their latest recovery activities. These reports give regular updates to government officials, Congress, and the public on how much is being spent and on what, and list out the agency's major actions.

Spending data covers appropriations, obligations, and expenditures, by Treasury account, as recorded in the agency's financial system. Using the Treasury account code allows us to track the money by the specific program on which it is spent. For now, only appropriations and obligations are required, and expenditure data reporting is optional. After April 6th, all three types of data will be required.

All Quiet on the Western Front?

noreply@blogger.com (Jaz) — Thu, 19 Mar 2009 13:04:00 +0000

You'd think with all the hubbub around transparency and EMRs that I'd be writing like a man possessed these days. While it's true that I've rarely been busier, I'm mostly sitting, watching, waiting. Something big is about to happen, that's for sure.

Stimulus money is already being spent, agencies are fervently plannign on where best to put the money once it starts flowing. I've been part of some very interesting discussions, and I've gotten to hear about som every interesting plans. I've also been part of some very odd discussions, with the requisite odder plans.

Myself, I'm working on several health care transparency projects right now, plus a P4P project which is extremely interesting, so I'm keeping busy for sure, but I am on tenterhooks, drooling with the thought of all the data that might start becoming available if any of this health reform movement actually gets it's steam up.

The problem is, you can't really mix health reform, which by definition means trying to attain lower costs, with stimulus spending, which by definition means spending like there's no tomorrow.

With the proposition that moeny will fall from the sky for physicians to buy EMR software, lots of companies are gearing up to offer their product to a much wider market. SoftwareAdvice.com has updated it's advice on EMR selection with a timely article update on "Should CCHIT Influence Your EHR Selection?"

Anyone thinking about buying an EMR package should read this. It succinctly explains what CCHIT is, and why you need to care what it is. For the uninitiated, CCHIT is the Certification Commission for Healthcare Information Technology, which simply means they say what an EMR has to do to pass muster.

If only it were that simple...

However, if you go on to read the related article on stimulus monies being used to reward adoption of EMR software, the larger picture starts coming in to focus. Roughly twenty billion dollars is sitting in a pot waiting to be given to physicians who become "meaningful users" of "qualified EHR" software.

"Meaningful" and "qualified" are where the rubber hits the road, and these two articles will help you sort through the NewSpeak.

--

On a related note, I was forwarded this WP piece this morning: Bad Bet on Medical Records. Long story short, health care professionals (Stephen B. Soumerai and Sumit R. Majumdar) posit there's no clinical evidence that electronicization is a good thing.

"there is little evidence that currently available computerized systems will improve care."

Those of us in the common sense portion of the universe may want to point out that very, very few physicians use EMR, therefore there is, by definition, very little evidence.

Oh, wait.

"The latest national survey, published in the New England Journal of Medicine, shows that only 4 percent of doctors have fully functional electronic records that can provide any kind of clinical recommendations."

They did it for me.

How is this not the bleeding obvious? More worryingly, how is dragging the only industry on the planet currently NOT participating in the Information Age not a bleedingly obvious good thing to do?

Do we *really* need clinical evidence to prove that these new-fangled com-poo-ters are good tools?

As the authors suggest:

"Before moving ahead, the administration should first consider conducting well-controlled research on the cost-effectiveness of health IT in office practices, which are the bulk of the U.S. medical system."

I agree totally.

Lets start by PUTTING SOME SOFTWARE IN THE OFFICE PRACTICES.

I wonder how people so bent on evidence-based judgment for everything park their cars in the morning. I see no clinical evidence on the efficacy of E-mail. In fact, I see plenty of anecdotal and research-based evidence that E-mail can be harmful to efficient work processes. I hope the authors took that into account before sending in their article.

What else? Oh yeh, the system is corrupt.

"Moreover, personal financial ties have been found between some researchers and the companies that produce these systems, and as far back as 2005 studies have shown that health IT developers are about three times more likely to report "success" than evaluators who had no part in system development."

However, physicians who don't use said software and have their Medicare payments reduced but rail against the use of such software, that's not self-serving at all? Getting rid of these requirements directly impacts every physicians income.

And if you look to your IT developer for success stories, you probably believe everything your car dealer tells you, and I have a bridge I'd like to sell you.

To rephrase the above sentence, we could say that "studies have shown that people who make stuff are three times more likely to say the stuff they make is awesome."

Well, duh.

Let's take a closer look at self-serving protectionism. The authors clearly state that one way they can affirm a positive impact is in single payer systems. This article tells me that for true improvement, we need not only EMR but less players in the market. Do the authors examine the feasibility of a single payer in the US? Of course not, it's business as usual. We have too many players and payers, EMR will never work.

Bah.

But of course, you can't just stand up and complain, you have to think of the children.

"For many chronically ill and vulnerable patients, it does not matter much whether their health records are digital or their prescriptions typed. Without patient access to clinicians and adequate health insurance that includes affordable drug coverage, a $50 billion investment in health information technology won't do much for many Americans. These funds are needed elsewhere."

That old whine. Money is needed elsewhere, so it instantly becomes an either/or argument. This is a logical fallacy at best. Money is needed in LOTS of places. HIT is one of them.

NO-one who wants to spend money on HIT thinks it's the only problem.

It is 2009. We use computers now. We have begged the industry to figure it out, but they can't or won't.

Need clinical evidence that computers are a good thing?

Hmm...

I propose that the physician population start submitting hand-written bills to the insurance companies they work with. And insurance companies should start hand-writing checks to doctors. It'll slow things down a bit, but at least we'll be able to gauge the average physician's love or lack thereof of interconnected data systems.

YES to computerized billing systems so I get paid faster!

NO to electronically storing my patient's data!

Seriously?

Medical Data Privacy: Consumers v Hackers

noreply@blogger.com (Jaz) — Tue, 03 Mar 2009 16:54:00 +0000

I just left the following as a comment over at THCB, but after I got done ranting it seemed like a mouthful so I'm reposting it here.

I enjoy the position of being involved in HIT, clinical and claims data, *and* being one of the afore-mentioned hackers. Please distinguish hacker from malicious hacker or "cracker". The term "hacker" has no negative connotation in the community.

That said, I'd like to promise you all this:

When we're done, your health information will be as private and secure as your credit card information.

It will flow across secured networks using portions of the public Internet. It will be covered by copious security policies, all well-intentioned, and few implemented fully.

It will be accessible to you, the patient, electronically. A vague audit trail will also be available.

People who have access to this data - doctors, nurses, covered entities, HMOs, government workers, will store it on their laptops. Their thumb drives. Some will have identifiable data. Some will have deidentified. Some will have patient-level data, some will have aggregated.

Some of them will have their laptop stolen, forget it at the airport, lose their thumb drive. Some will just take it because they can sell it to some guy in Romania.

Third parties will make decisions about you based on your unique profile. Some of these decision will help you, such as reminding you to go get that mammogram. Some will hurt you, because you, like me, have not yet fully quit smoking.

All the above is going to happen. You have no say in it. It's begun, it's overdue, and it will be as imperfect a system as the current one, but with more detailed history of its imperfections.

It will surface new ways to practice medicine, and many of them will be for the collective good. It will surface new ways to lower cost, and many of them will be for the collective good.

You will be as secure in the safety of your medical data as you currently are with your credit data. You all punch your PIN in to the supermarket checkout machine while 15 people watch you. Right?

The government does not have your credit history any more than I have your credit history. The government may have your health score, the same way it can access your credit score. Or your landlord, or your employer, or your private detective.

You will have no more and no less security than with any other confidential information you currently manage, such as your Web site password for your online broker or your online checking account, the credit card bill you throw away unshredded, your mother's maiden name.

I don't hear any of you cutting up your credit cards.

I am not a doctor, a health provider, nor a policy maker. I am merely a tech-savvy consumer who happens to build health report cards using what little data is available to me. If nothing else, I look forward to the day I can actively score the use of evidence based medicine using clinical data delivered deidentified. That and I'd like to know what my last test result were, even if they were a couple years ago.

This is a non-conversation, and allowing the world and their mother to have a say in the indisputably inevitable is merely costing more money and wasting more time. HIPAA already covers who can see what when; properly implemented using standards-based EHR software is already happening, and will continue to happen.

The sooner we build it, the sooner we can start making it better day by day.

Wow. Seriously Interesting.

noreply@blogger.com (Jaz) — Thu, 29 Jan 2009 17:39:00 +0000

http://recovery.gov/

That is all.

Open Source Government Predictions

noreply@blogger.com (Jaz) — Tue, 20 Jan 2009 15:25:00 +0000

Open source software, for those of you who don't know, is software developed by the people, for the people. It is sometimes, if not almost always, free of cost. But more importantly, it is software that is easily inspected, changed and repurposed. The "free" we care most about is freedom; freedom to edit, freedom to review, freedom to share.

Some examples of open source software that you rely on everyday include the Apache Web server software, which runs most of the world's Web sites. The Firefox Web browser is open source. Linux is a famous example of an entire computer operating system that is free of cost and developed by volunteers yet seriously threatens the Microsoft Windows platform.

Government, in the USA anyway, has had trouble adopting or implementing open source software. I think this about to change in a huge way.

Many nations around the world have adopted open source software for a number of reasons, the two main ones being freedom from vendor lock-in and lower cost of ownership.

Many governments prefer open source file formats, as they do not restrict access to documents in the public domain. Another concern is security; software that cannot be inspected or peer reviewed cannot truly be deemed secure. And of course, there are usually much lower up front costs associated with open source software.

Barack Obama's campaign for president has been fueled by an army of Web volunteers, relying on open source Web technologies to dominate the space. The Obama team is quite obviously staffed with open source users and proponents, which leads me to ponder a few things.

Obama promises transparency, and open source delivers. No software is as transparent as open source. All code is open to review and change. All edits are documented and owned. Obama promises accountability. Open source promotes accountability, everyone knows who did what where and when. Everyone is able to ask questions, suggest changes, describe errors. Obama promotes accessibility. Open source software leads the way in designing accessible software not only for disabled users but abled users also.

Obama's Web team have signaled their intent at www.change.gov. Liberal use of copyleft statements, free-flowing communication, use of video and audio, blogs, you name it.

What makes this interesting, is that these folk will soon take over www.whitehouse.gov. I even got an invite this morning to join the new WhiteHouse.gov community.

Hence, I make the following predictions:

1. There will be an early and short lived battle between Obama Web and Gov Web. Gov will throw reams of documents, rules, specs and protocols at Obama Web and tell them to use approved software only. Obama Web will simply do what they want, with the explicit backing of Obama. This will be fun to watch.

2. There will be a slow but steady increase in the number of companies, state governments, and finally end users who use open source multimedia formats and officing software, due to the new WhiteHouse.gov publishing documents in open source formats only. This will be transformative.

3. WhiteHouse.gov will stop using Windows Media and move to Ogg or similar. iTunes will be involved somehow. This will be less cool than it sounds.

4. WhiteHouse.gov will have a discussion forum. This forum will be next to useless.

5. Senior cabinet members will have blogs. These will be fun at first, but will soon become next to useless.

6. Bills will be written using versioning software. OK, this one's a joke, but seriously, it could be a fun idea.

Overall, I think the new administration's Web team will have a subtle, but quietly forceful impact on the everyday lives of Americans as they will slowly but surely be introduced to open source philosophy and implementation. By the end of the Obama administration, I feel confident Microsoft Office will be next to dead or have moved to documented specs and standards and will be mostly free, if not entirely Web-based.

Expect to see a slew of documentation being posted to the White House Web site, with excellent search tools.

And most of all, expect to see the most partisan conversation you've ever witnessed at the soon-to-be-released White House Online Community. Apple fanboys have nothing on Obamaniacs. Legitimizing their tirades via a government-hosted community discussion site will be one of the more humourous things you've seen in a long while.

I'd Blog Something Interesting...

noreply@blogger.com (Jaz) — Tue, 06 Jan 2009 17:52:00 +0000

But I'm too busy trying not to smoke.

I've been a two pack a day guy for many years. I had a total of three cigs yesterday. This might be the year!

Why Not The Best? A New Web Site for Quality Improvement Professionals

noreply@blogger.com (Jaz) — Wed, 10 Dec 2008 14:09:00 +0000

Over the past six years I've been building consumer-oriented report health care cards pretty much non-stop. The field is young and short on evidence, but it's interesting work with noticeable impact. However, the truth is that the largest portion of readers of these report cards are not consumers, but providers.

To that end, I have long been wanting to build a report card for providers, not only to report their data but also to link directly to freely available improvement tools and knowledge directly from the report. My goal being, not only identify poor performance but right there, in the data, link to relevant interventions to impact that data in a positive way.

Well, it's done.

I met with the Commonwealth Fund earlier this year and they were looking to build something around their Why Not The Best? National Scorecard on U.S. Health System Performance. The Fund was looking for a vehicle to deliver their high performer cases studies, wherein hospitals identified as being high performers in a given set of measures were interviewed and the resultant wisdom distilled into case studies for other hospitals to learn from.

After many, many sleepless nights, I'm hugely proud to announce the launch of www.WhyNotTheBest.org - a quality improvement resource for providers from the Commonwealth Fund. A ton of very talented people have been working on this and we are all very, very excited to see how the site is received.

The site includes all clinical quality and patient satisfaction data ever released on CMS' Hospital Compare. This means 24 clinical measures and 10 satisfaction measures. In addition, we created 5 summary scores, 4 being topical and one overall composite quality measure.

Users can register for a profile that will remember all their choices for the next visit. This is important as there are many ways to personalise this site.

Profiles are a basic three step process, you choose hospitals that you wish to compare yourself to, then choose measures you wish to track, then choose benchmarks of care you wish to compare against.

We have every hospital in the US that bills Medicare. This is about 4500 hospitals. We have collected the quality and satisfaction data since the launch of the public dataset.

Using this data, we can calculate state and national averages, as well as top percentiles. Commonwealth then asked us to identify just those hospitals that reported all measures and had at least 30 patients in each of four topics, and using that subset we further stratified the population to ascertain the high performing hospitals.

This means that for any measure, you can load the current top 1% of hospitals for each measure.

Choosing A Hospital

You can choose a hospital to add to your profile in three ways. First, you can simply start typing a name and the database will let you know if we have a match.

Another interesting way to build a group of hospitals would be to find facilities that are like your own. Users can choose from a variety of characteristics to whittle down the list to a useful set of comparator hospitals. In the example below I've asked for all teaching hospitals in New York with 400 or more beds.

Finally, users can simply browse a map and grab hospitals of interest.

We don't limit the number of hospitals you can save to your profile, but if you add more than 50 the site will start to look a bit busy. Theoretically, you could store all hospitals in the country, but don't call me when it takes half an hour to load.

You can then choose any or all of the measures and benchmarks, these will then be available to you in any charts you choose to generate, and this is where things get interesting.

User-Generated Charts

We have implemented a dynamic charting application that will build charts on the fly based on your choices and your profile.

This means that for any chart you choose to load, it will populate dynamically based on the hospitals, measures and benchmarks you selected.

Here are a few examples:

Pretty nifty huh?

You can see in the example that we even calculated each hospital's rank in the nation for a given measure.

Each chart is followed by an array of options:

Among other things, you can download a comma separated file of the data used to create the chart, save the chart as an image to use in Powerpoint or similar, and click through to browse related case studies and intervention tools.

There are a wealth of additional features, please stop by and kick the tires! The site is www.WhyNotTheBest.org - enjoy! And please feel free to leave me your comments.

Change Dot Gov - Copyright 2008

noreply@blogger.com (Jaz) — Mon, 01 Dec 2008 16:57:00 +0000

Although most of my posts on this blog are health care-oriented, it also covers Internet technology, freedom of information and related matters from time to time. Today is one of those days.

I was surprised to see Senator Obama standing behind a podium adorned with the Great Seal of the United States of America this morning, and further surprised to learn of the apparent existence of the Office of the President Elect. For one thing, he's not the President Elect. Yet.

You Did Not Vote For President

The Electoral College, which lives at archives.gov (National Archives), meets on the first Monday after the second Wednesday in December. This year that will be December 15th. On that day, the electors (most of whom were elected on November 4th in a political party election process that most people think is a presidential vote) - on that day, December 15th, the electors will elect the President.

This is basic US Constitutional stuff. The country votes for electors, electors meet a month later and vote for President. These electors are not legally bound to follow the popular vote. In the USA, the People popularly elect members of Congress, the Executive are elected through indirect election.

One more time, to be clear:

On November 4th, the US people elected a slate of electors.

On December 15th, these electors will meet and vote for President and Vice President. After this vote, one can say that there is a President elect.

On January 6th, Congress assembles and counts those votes in the House of Representatives. If a majority winner (270 of the 538 votes) is found the President and Vice President are declared and the Senators leave the House Chamber. If there is no majority winner the House votes for President and the Senate votes for VP.

But, I digress.

When is .gov not .gov?

Change.gov is a Web site that appears to represent an official government entity. Dot gov addresses are hard to come by, and are strictly regulated. It is with concern and curiosity then that I see change.gov to proclaim itself to be the Web site of the official-sounding Office of the President Elect.

However, this entity is in fact a private 501c(4) organisation, not a government office. I heartily salute Senator Obama's evident direction to bring greater transparency to the government through the use of Internet technologies, and I also look forward to the inclusivity promised through the use of blogs and similar modern concepts. However, what I do not ever want to see is a copyright notice on a dot gov Web site.

The Obama campaign's attempt to communicate it's freedom-loving principles are exhibited through the use of a Copyleft statement, the copyright notice on this Web site references a Creative Commons license.

I use the Creative Commons license myself wherever and whenever I can, it freely allows people to use and copy certain content with limited restrictions. It's a great tool.

But not for government. See, the government can't copyright anything. Ever.

The government is us. Well, technically not me as I'm not a citizen, but it is composed entirely of US citizens, for US citizens. Everything the government produces that is not secret is in the public domain. Because it *is* the public domain.

A dot gov Web site with a copyright notice is bad bad bad, unless that copyright notice says something to the effect of "there is no copyright". The government cannot put documents in the public domain via a Creative Commons license.

Here's an example of what a dot gov copyright should say, this one coming from the US Department of State:

"Links to State Department sites are welcomed. Unless a copyright is indicated, information on the State Department’s main website is in the public domain and may be copied and distributed without permission. Citation of the U.S. State Department as source of the information is appreciated.

If a copyright is indicated on a photo, graphic, or other material, permission to copy these materials must be obtained from the original source. For photos without captions or with only partial captions, hold your cursor over the photo to view the "alt tag" for any copyright information. Please note that many photos used on this website are copyrighted."

According to 17 USC § 105, copyright protection

"is not available for any work of the United States Government, but the United States is not precluded from receiving and holding copyrights transferred to it by assignment, bequest, or otherwise".

Further, we've witnessed the dilution of Web domains such as the dot org and the dot net, whose meaning's have now become shrouded in pre-2000 history. But dot gov is supposed to be sacred. I work and have worked on federal and state gov Web sites, the rules are long, complicated and necessary.

They ensure that when you visit a dot gov address, you can trust it. It represents government. It is the word of government. It is accessible, publicly-funded and accountable to the people.

Not a private lobby group.

In fact, the GSA, which administers the .gov domain, explicitly states:

"No Political or Campaign Information: The Gov domain is for the operation of government, not the political, political party, or campaign environment. No campaigning can be done using Gov Internet domains. The Gov Internet domain websites may not be directly linked to or refer to websites created or operated by a campaign or any campaign entity or committee. No political sites or party names or acronyms can be used. Separate webites and e-mail on other top-level domains (TLDs), such as .org, will have to be used for political activity."

(See Dot Gov Eligibility)

Obama's transition team is funded by appropriations from government, true. But it is also funded by donors. Private donors. This is not a government entity. The one link on this Web site that leads to a truly governmental source is the link below the copyright to the GSA, you'll notice a "leaving the Web site" notice as well as no copyright notice on the actual government Web site you end up at.

The Obama transition team is budgeted at 12 million dollars, 5.2 million of which comes from public coffers. The rest is private donations (under $5,000 each).

Presidential Transition services are an accepted part of the General Services Administration function. That's why the GSA has a transition Web site.

Regarding the use of the Great Seal (which of course is not the same as the Presidential Seal he will get to use soon...)

Use of U.S. State Department Seal (the U.S. Great Seal) and Other Official Insignia
U.S. State Department seals (the U.S. Great Seal), logos and other official insignia may not be used or reproduced without written permission. Use of the Great Seal of the United States is governed by Public Law 91-651, Title 18 of the United States Code. This is a criminal statute with penal provisions, prohibiting certain uses of the Great Seal that would convey or reasonably be calculated to convey a false impression of sponsorship or approval by the Government of the United States or any department, agency, or instrumentality thereof."

Senator Obama is doing himself, and the Web, a disservice by misappropriating the dot gov domain and the Great Seal while he awaits his turn in office. He holds no federal power, he represents no executive office, and he should wait his turn.

Addendum:

Having looked at the privacy policy, I'm now even more curious. If this is a dot gov site, why is there a COPPA notice? Further, this site actively solicits contributed content from readers via "Your Story" and other similar links, are these readers sending information to the government or to a private organisation? If the former, there a re serious privacy issues to be considered. If the latter, I think it is vital and fair for these individuals to fully understand they are dealing with a private, non-governmental Web site.

Free Guide to Health Pricing

noreply@blogger.com (Jaz) — Tue, 25 Nov 2008 17:02:00 +0000

I'm working very long hours right now, but I want to take a minute to point out a new site I was asked to look at. It's an expansive price guide to fair and reasonable prices for hospital visits, physician visits, dental, cosmetic surgery and more.

http://healthcarebluebook.com allows you to tap in your ZIP code and browse based on regional pricing. It's not evident, you'll need to put your ZIP code in *after* you start browsing, but once it's in it's remembered for each category.

The site nicely separates out procedures from hospital charges, so for example if you review Carpal Tunnel, you'll see the surgeon's price, the anesthetist's price, and the hospital bill. These rates are intended to reflect the amount a decent health insurer would pay, or more precisely, the amount these individuals will happily accept from an insurer.

As I've railed about before, if you have high deductibles or are self pay, you will be billed at a nonsensical sticker price that has no business or financial reason for existing outside of having a random number that once, many years ago, meant to reflect the full cost of something, but over the years has simply grown by 4% a year regardless of actual cost.

So, while the sticker price for carpal tunnel release may be $12,000 or so, Healthcare Blue Book lets me know that on average, people are getting paid about $5500 in my ZIP code.

I can then use that to negotiate with my provider.

Navigation is pretty intuitive, you can browse by condition or procedure for example, and a free form search allows you to search for words like "appendix" and get the appendectomy prices on the site.

In addition, there is a very informative "How to negotiate prices with doctors and hospitals" page, well worth the visit. All that's really missing is an "understanding your bill" page, because that's when the price issue usually hits home, when you get an unreadable bill covered in codes and numbers that are completely indecipherable.

Overall the site is extremely easy to use, is light on methodology, I'm not entirely sure where these prices are coming from, but it's clean and easy to use, so go check it out.

History of Health Care

noreply@blogger.com (Jaz) — Fri, 31 Oct 2008 20:47:00 +0000

Saw this on the ye olde interwebs today

2000 BC : "Eat this root"
1000 AD : "That root is heathen, say this prayer."
1500 AD : "That prayer is superstition, drink this elixir."
1800 AD : "That elixir is snake oil, take this pill."
1900 AD : "That pill is ineffective, take this antibiotic."
2000 AD : "That antibiotic is artificial, eat this root."
:)

2008 Health Accountability Health Care Report

noreply@blogger.com (Jaz) — Wed, 29 Oct 2008 03:12:00 +0000

So here's why I haven't been posting too much lately...

I've been working on two major projects and this is one of them. I finally got the Health Accountability Report Card out today, it covers all hospitals and HMOs in NY, NJ, CT, VT and RI.

It's huge, but my other project - due in December - is even more exciting, stay tuned.

The report card started off as a printed HMO report in 1999, I first put it online in 2002 I think.

I've been slowly adding more and more to it, three years ago I added hospitals and last year I included NJ. Here's a brief, OK, not brief summary of what's in it.

The team that puts this together is large, all in all about 25 people contributed their expertise to the report. The short story is that it's a public data gumbo, it collects up about 20 data sources from which we extract roughly 250 measures. For each measure, if we can find a standard comparator we run a variance analysis to find out if the HMO or hospital deviates significantly from the state average. We then simply paste a red, yellow or green circle onto the data to give you a really quick idea of just how well the HMO or hospital you're looking at is doing.

On the HMO side you can review quality of care data from NCQA HEDIS scores. This covers stuff like getting the correct medicines, asthma and diabetes care, vaccinations and that sort of thing. Also for HMOs we have a customer satisfaction survey results from CAHPS surveys. We then scoop up retail premium rates for standardised plans.

Unfortunately states differ slightly in how they measure HMOs, so we can't make a national comparison across the board, so in this report you're seeing either a comparison to a state average or a regional average.

On the hospital side it gets way more complicated. HHS puts out the Hospital Compare data for download, so we grab that and crunch some additional measures to derive composite topical scores from the appropriateness of care measures. This year we also got to add patient satisfaction score and Medicare reimbursement rates.

The real fun part was requesting discharge data from five states. I actually requested data from every state that borders New York, plus Canada, and I went with the four I got back. That data is a full set of every single hospital discharge in each state, deidentified. In it you can see primary diagnoses, age, gender, enough to make some serious measurements. So, we have the AHRQ Inpatient Quality Indicators as well as new this year some Patient Safety Indicators, recently endorsed by the National Quality Forum. These include mortality rates and adverse events.

I did have to lose Caesarean section rates, but I'll keep hunting for an NQF endorsed measure for this.

In addition, we calculate number of cases, average length of stay and average hospital charges. Besides that there's the now-recurring Leapfrog patient safety measures. Cardiac surgery mortality came out this year for the most part, but it'll be back next year.

Here's a full list of all the measures.

Go check out the report and please, please, please send me your feedback.

Now I'm going to sleep.

USA Hospital Patient Satisfaction Report

noreply@blogger.com (Jaz) — Wed, 22 Oct 2008 15:26:00 +0000

It's not widely known, but Medicare began collecting survey responses recently that asked patients a number of questions about their recent hospital stay. CMS has not restricted this to Medicare patients only, they call anyone who is eligible, regardless of payer. My boss was kind enough to give me the opportunity to take the data from Medicare and make a consumer-oriented report card that is easy and quick to use.

The site is AboutHealthSatisfaction.org and is completely free to use, no registration required, and does not contain ads. The source data is available on the Hospital Compare Web site put out by CMS, but it's hard to get to, hard to read, and restricts you to only a handful of hospitals to compare at a time. However, CMS makes the data freely available for download, so this is what I came up with.

Please go check it out, and let me know your thoughts and feedback here. I plan on updating the site every three months when the fresh data comes out. Right now I have three editions of the data, so you can even track numbers from quarter to quarter. Go have a look, and check back here to let me know what you think.

Yowser

noreply@blogger.com (Jaz) — Thu, 16 Oct 2008 15:33:00 +0000

Herald Sun reports: A gynaecologist and two trainee doctors in northern Greece have been handed suspended prison sentences after forgetting a 22-centimetre medical spatula in a patient's abdomen.

The three accused and a scrub nurse today received suspended prison sentences of between 10 months and a year.

The oversight took place during minor surgery on a 45-year-old woman at a hospital in the northern city of Serres in January 2005.

The patient soon developed breathing problems, a skin rash, fever and a gathering of fluid in her abdomen.

Her doctors initially attributed the problems to an allergic reaction and gave her medication but a CAT scan subsequently found the missing surgical instrument.

The patient had been awarded €50,000 ($98,000) in damages in a prior civil trial.

Interoperability, EU Style

noreply@blogger.com (Jaz) — Mon, 06 Oct 2008 18:22:00 +0000

Seriously, is anyone in the US paying attention?

Twelve countries. Three years. Internationally-accessible personal health records. Wow.

Medicare Payment Changes

noreply@blogger.com (Jaz) — Mon, 06 Oct 2008 14:29:00 +0000

The Miami Herald has a very readable piece on exactly how the new Medicare policy on certain services that will no longer be paid for will work out.

Makes a very clear argument for and against some of the conditions that are now deemed "preventable".