Brian Ahier sparked a feud with his Google+ post commenting on a recent JAMIA article entitled Shift in the Architecture of the Nationwide Health Information Network. We’re at 60+ comments and going strong. The discussion has also been picked up on in Modern Healthcare.

The JAMIA article was written by Leslie Lenert and colleagues, and Lenert joins in heartily in the Google+ discussion. From the abstract, here are 3 key points they make:

1) …a significant change in the architecture of the NwHIN is taking place. Prior to 2010, the focus of information exchange in the NwHIN was the Regional Health Information Organization (RHIO). Since 2010, the Office of the National Coordinator (ONC) has been sponsoring policies that promote an internetlike architecture that encourages point to-point information exchange and private health information exchange networks.

2) The net effect of these activities is to undercut the limited business model for RHIOs, decreasing the likelihood of their success…

3) These changes may impact the health of patients and communities. Independent, scientifically focused debate is needed on the wisdom of ONC’s proposed changes in its strategy for the NwHIN.

What does the Family Feud survey audience think of these points?

While I’ll acknowledge that one could draw many inferences from the discussion, here’s my interpretation, synthesis and commentary of the main points in the Lenert, et. al. article.

1) A Shift in NwHIN Architecture is Occurring

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The headline in yesterday’s LA Times declares:

‘App Economy’ credited with creating 446,000 jobs.

What’s the App Economy?

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By 2020, the American health insurance industry will be extinct. Insurance companies will be replaced by accountable care organizations — groups of doctors, hospitals and other health care providers who come together to provide the full range of medical care for patients.

Irresponsible

Provoking and demonizing health plans might have had populist appeal and political value in 2009, but in 2012 it’s an unnecessary attack on a constituency that has potential to be one of the administration’s best allies in advancing accountable care.

Prior to ACA reform legislation, health plans had the wrong economic incentives — the rules of the game were not consistent with good public policy:

• Health plans had incentives to AVOID risk, not manage risk. They were economically incentivized to avoid high risk patients (with preexisting conditions) and to get rid of patients that became sick
• Health plans had minimal incentives to CONTROL systemic costs — they could pass them on in the form of premium increases.

ACA changed incentives and disrupted the payer business model:

•  Health plans will longer be allowed to avoid high risk patients; they must accept all comers
•  Health plans must MANAGE, not avoid costs. Health plans are abandoning their old business models.

What are we seeing in the marketplace? Almost all health plans are embracing the vision of accountable care and need to shift the system from Volume to Value. Health plans could be administration’s biggest friend in revamping the health care delivery non-system.

Naive (more…)

Eric Schmidt, Chairman (and former President) of Google, coined the term “Gang of Four” in referring to the similar platform/application technical architecture and business models of these companies. In the case of Apple iOS and Google Android OS, much of the value is created by the 500K+ applications built on these platforms, not just by the platform themselves.

So four of the largest, most successful companies in the world are built on platforms — what does this imply for health care? Are “platforms” in health care a “Nice to Have” or a “Must Have”?

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Please consider attending the inaugural eCollaboration Forum taking place at HIMSS12 on Thursday, February 23, 2012 in Las Vegas at the Venetian Sands Expo Center.

Theme — Collaborative Platforms and Applications in Health Care

This is the Health IT industry’s first-ever event focusing on collaborative health platforms and applications! We take an expansive view of platforms and will be exploring the required technologies, business ecosystems, and clinical care delivery needed to achieve accountable care.

Speakers

Sponsored by HIMSS and Collaborative Health Consortium (formerly the Clinical Groupware Collaborative), the inaugural eCollaboration Forum has scheduled the following speakers [updated as of 2/3/12]:

• Farzad Mostashari, MD, ScM – National Coordinator for Health Information Technology
• Esther Dyson – Principal, EDventure Holdings
• John Mattison, MD – Assistant Medical Director and CMIO of Kaiser Permanente, SCAL
• Jinesh Varia, Technology Evangelist, Amazon Web Services
• Mark Blatt, MD, MBA – Worldwide Medical Director, Intel, “Collaborative Care: An Economic Imperative for Care Delivery Systems”
• David Whitlinger – Executive Director, NY eHealth Collaborative “Supporting New Models of Care Through Collaboration with States & Vendors”
• Steve Adams – President and Chairman, Collaborative Health Consortium; EVP Collaborative Care, Alere
• David Kibbe, MD, MBA – The Kibbe Group and American Academy of Family Physicians “Developing Trust in the Health Internet as a Platform”
• Vince Kuraitis – Principal, Better Health Technologies “The Future of Collaborative Health Platforms”
• Shahid N. Shah – CEO, Netspective and Blogger at HealthcareGuy.com “The Future of Collaborative Health Platforms”
• Brian Ahier – Health IT Evangelist, Mid-Columbia Medical Center
• Joshua Newman, MD, MSHS – Director of Product Management and Health Strategy, Salesforce.com
• West Shell III – Chairman and CEO, Healthline
• Scott Rea – Vice President GOV/EDU Relations and Senior PKI Architect, DigiCert
• Joe Miller – Director of eBusiness, AmeriHealth Mercy
• Richard Migliore, MD, EVP Health Services, United Health Group
• Jordan Shlain, MD – CEO, HealthLoop
• Joseph Miller, Director, eBusiness, AmeriHealth Mercy
• Bettina Experton, MD, MPH, President and CEO, Humetrix
• Josh Mandel, MD, Lead Architect, SMART, Harvard Medical School
• Brian Prestwich, MD, Assistant Professor of Family Medicine, Keck School of Medicine USC
• Rushika Fernandopulle, MD, President, Iora Health
• Jonathan Hare, Chairman, Reslient Networks
• Richard Migliori, MD, Executive Vice President, Business Initiatives & Clinical Affairs, Chief Healthcare Officer, UnitedHealth Group Alliances
• Dave DeBronkart, @ePatientDave
• Robert M. Kolodner, MD, Chief Health Informatics Officer, Open Health Tools
• Scott Barclay, Chief Strategy Officer, SureScripts
• Jinesh Varia, Technology Evangelist, Amazon Web Services

For the latest up-to-the-minute list of speakers, click here.

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Yet, for my lifetime, I have been incredibly frustrated by medicine’s cultural and practical lack of acknowledgement of this law.

FINALLY, the American College of Physicians (ACP) got it. Kaiser Health News describes the revelation:

The American College of Physicians hit a nerve when it released an updated ethics manual calling for doctors to provide “parsimonious care” – in other words, “to practice effective and efficient health care and to use health care resources responsibly.”

This recommendation, included in the Jan. 3 Annals of Internal Medicine special supplement, drew immediate reaction – and not just because of its use of the infrequently heard “parsimonious.” It’s been viewed as a definitive statement of medical ethics directed at the organization’s 132,000 members – physicians who practice internal medicine and its related specialties, among them cardiology and oncology, that often involve expensive procedures. And, the guidance comes at a time when health care costs are central to the national policy debate.

My personal reactions to this are very mixed. (more…)

Tracey Moorhead, President and CEO of the Care Continuum Alliance, writes today’s inaugural post. She persuasively notes the increasing importance of the full continuum of population health interventions – wellness, prevention and other approaches to improving health, reducing disease risk and raising productivity.

Bob Laszewski’s essay on today’s THCB resonated with me: 2012: A Year of Huge Uncertainty in Health Care Policy. In my 30 years in health care, I have never seen more uncertain and fluid times.

Yet in times of uncertainty and confusion, it’s important to focus on what IS certain and predictable. The need for population health approaches is one of those certainties. While care providers are recognizing the need to develop and invest in strong care management abilities, health plans are redoubling their efforts to develop these capabilities in-house.

Tracey’s first post includes a link to the CCA’s new white paper: Key Issues in Population Health Management: Key Industry Issues for 2012.  Check it out.

What are acceptable bases of competition in health care?

My sense is that the distinctions here are not well understood and often go undiscussed, so I’ll quickly get to the point:

It’s OK for care providers to compete on the bases of quality, price, patient satisfaction, and many other factors

It’s NOT OK for care providers to compete on the basis of controlling or limiting access to patient health information. It’s just not right.

Today’s US healthcare system embraces market competition. For-profit and non-profit health care systems and care providers compete against one another. While we might or might not like this, all I’m asking you to do here is to recognize it.

Hospital based delivery systems work hard to keep patients within their network (walled garden) of providers. That’s understandable. But we need to probe deeper and examine how they are doing this — again, what are the bases of competition.

In many industries we accept the idea of creating proprietary, non-interoperable technology as a means of competitive differentiation. For example, the Apple iTunes system is not interoperable with MP3 players. This is an explicit and intentional part of Apple’s business strategy. I have no problem with this type of competition in digital entertainment.

Health care is different.

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a unicorn — a fantastic creature that is vested with mythical powers. But no one has actually seen one.

a camel — a horse designed by a committee, one that already has its nose in the tent

With this background, you can begin to appreciate the difficulty of conducting an accurate census of ACO animals in the wilderness.  Yet, this is exactly the task undertaken in the excellent Leavitt Partners report measuring ACO activity in the US.

As I will explain, the Leavitt report has the potential both to overestimate and underestimate ACO and accountable care-like activities. In my judgment, however, it’s far more likely to be understating just how much accountable care activity actually is going on.

Findings in the Leavitt Report

The Leavitt researchers “identified ACOs from news releases, media reports, trade groups, collaborations and interviews through the beginning of September 2011. Also included were entities that either self-identified as being an ACOs or specifically adopted the tenets of accountable care.”

The report counts 164 ACOs — 99 that are primarily sponsored by hospital systems, 38 by physician groups, and 27 by insurers.

Here’s how Leavitt summarized their results: (more…)

My mom would not know what I mean by “Standard Health Data Connectivity Specifications,” so I’ll try to write this in plain English.

Who Are These Guys? The EHR|HIE Interoperability Workgroup

The workgroup consists of HIEs (Health Information Exchanges) representing seven of the largest states, eight EHR vendors, and three HIE software/services vendors. (more…)

A couple tables in particular caught my attention.

(click on the graphic to view a larger version)

Key findings in this table include:

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by Nate DiNiro

HealthCamp Oregon is organizing 2 events during the 3rd week of October in Portland, Oregon. The events will focus on Healthcare, Health IT, the ePatient & Participatory Medicine movement and all-things Healthcare Transformation!

The first event, a panel that will focus on the impact of social media in healthcare, is scheduled for Thursday 10/20. We’re also helping to promote the annual Kaiser Center for Health Research Saward Lecture, scheduled for Friday 10/21. More information on that event can be found below. The second event we’re planning is a HealthCamp unconference, scheduled on Saturday 10/22 and to be held at the offices of Urban Airship. If you’re unfamiliar with either of the previous terms “HealthCamp” or “unconference”, please read on and we’ll fill you in below.

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Here are six quick first impressions:

1. It’s very creative and innovative. CMS has demonstrated out-of-the-box thinking and leaves a lot of room for applicants to propose their own approaches. Expect to have to read the materials 2-3 times to wrap your thinking around it.

Unlike the Medicare Shared Savings ACO rule, the BPCII is flexible.  Anticipate some innovative and non-traditional proposals from diverse applicants. Unlike the Medicare ACO Shared Savings rule, the BPCII invites flexibility in:

• Definition of care bundles
• Proposal of specific financial terms
• Participation by diverse care providers (see below)
• Risk adjustment of beneficiaries

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by Jaan Sidorov MD, MHSA, FACP and Vince Kuraitis JD, MBA

Physicians face great uncertainty. According to a survey conducted by The Physicians Foundation, the great majority of physicians (89%) believe the traditional model of independent private practice is either “on shaky ground” or “is a dinosaur soon to go extinct.”

In the face of this uncertainty, many physicians are jumping to a conclusion that “I have to sell my practice to the hospital.” In this post of our series on The 100 Year Shift, we will examine physician practice.  We’ll show that the economic and clinical environment  is changing rapidly and that selling to the hospital is one option. However, it is not the only option. (more…)

In our introductory posting of this series, we noted that economic incentives previously aligning doctor-hospital interests were changing. This creates the potential for The 100 Year Shift – physicians awakening to possibilities for stronger partnerships with payers than with hospitals.

In this post, we will zero in on the changing economic position of hospitals and the effect this is having on physician-hospital relationships. We will examine the trend of hospital employment of physicians and point out challenges and tensions for the future. [This is a long post...so now might be the time to refill your coffee cup.] (more…)

IMHO, the recent acquisition by Highmark Blue Cross Blue Shield of West Penn Allegheny Health System (WPAHS) for $475 M is unique to local market conditions. It was done as a last resort and should not be taken as a signal that health plans are starting a hospital buying binge.

Why are hospitals unattractive investments for health plans:

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It’s a different issue whether closed or walled garden HIT is an acceptable means toward that end.

Outside of healthcare, we understand and can accept that businesses used closed, proprietary IT as part of their business model. Apple has designed their iPod with an eye toward incompatibility and high hassle factor in not being plug-and-play with other music players and systems.

IMHO, however, healthcare is different. Keep your proprietary business model away from my body and gimme my damn data.

Google+ v. Facebook on Data Portability

We are witnessing an important dynamic begin to play out between FB and Google+. I note a significant difference in mindset and policies toward data portability. (more…)

by Jaan Sidorov MD, MHSA, FACP and Vince Kuraitis JD, MBA

In our introductory posting, we suggested that a huge shift is underway in the health care industry.  Decades of hospital-physician cooperation are not only eroding, we suggest this trend could accelerate.  Instead of a natural clinical and economic affinity with hospitals, we foresee the potential for physicians forming a new dyad with insurer-buyers.

In this post, we will examine what we and many other commentators view as inevitable: the demise of volume-based payment systems and how the drive for greater value will cause physicians and insurers re-examine their normally antagonistic relationship. (more…)

Gazing at the horizon, we foresee the potential for a tectonic realignment among physicians, hospitals and payers. Here’s a quick visual representation:

This essay is the first of a seven part series. In this first post we will capsulize our vision of this potential 100 Year Shift, answer initial FAQs, and lay out the structure for the rest of the series.

The Lynchpin — Changing Economic Incentives

In the past, physicians and hospitals have benefited from mutually supportive economic interests. (more…)

Readers and commenters (on e-CareManagement and The Health Care Blog) quickly grasped that a social networking platform could play a very useful role in coordinating our health care, yet also agreed with the conclusion that Facebook wasn’t  “it”.

So let’s ask the question again: Could Google+ be your platform for care coordination? This post will

• Describe Google+ and Circles
• Discuss how Google+ gets past some of Facebook’s limitations as a care coordination platform
• Comment on Google+ as a care coordination platform (promising, but too early to tell) (more…)

1) Hospital administrators assume that tighter physician-hospital integration (e.g., through employment of physicians) will result in ”captive referrals” by physicians back to the mother-ship hospital.

2) Medicare administrators are assuming that Medicare Shared Savings ACOs will be able to coordinate patient care even without limitations on patients’ choice to go to providers outside of the ACO provider network.

Here’s the data that challenges the validity of BOTH of these assumptions:

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Ironically — at the same time — commercial payers are awakening to ACO opportunities.

Please read further.

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Major U.S. health insurers, including Aetna Inc., Humana Inc. and WellPoint Inc., are retooling to become more than just health plans, in the wake of the federal health-care overhaul that is changing the rules for the industry’s core business.

Diversification plans, touted in meetings with investors this year, include stepped up acquisitions and partnerships that will allow the companies to employ doctors directly, deliver health-information technologies, and participate in new hospital-doctor groups known as accountable-care organizations.

Wall Street Journal; May 12, 2011

Does this make sense? Absolutely!

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Why have hospitals increasingly been buying physician practices?  Are these marriages based on true love or convenience? Will these marriages survive?

To address these questions, let’s take the long view (50–100 years) and revisit 7 assumptions that have driven us to today’s healthcare non-system:

1. Healthcare payment systems have rewarded piecemeal work.
2. Despite uneasiness, hospital-physician relationships have been cooperative.
3. Physicians can function effectively in small/medium size practices.
4. The healthcare mindset: built on control, not collaboration.
5. Barriers to sharing patient info and coordinating care are high.
6. The hospital has been the economic bedrock of the community.
7. Health plans are the bad guys.

For more details and discussion, tune in to tomorrow to BlogTalk Radio. Host and ACO guru Gregg Masters will be interviewing me and we’ll discuss the topic of “Is Hospital-Physician Integration Sustainable?”

The details:

Wednesday May 11th 2011 broadcast, at 11AM Pacific/2PM Eastern

Click here to add a reminder to your calendar or to read more information about our session.

UPDATE: May 11, 2011. A replay or download of the interview is now available by clicking here.

According to the Pew Internet and American Life Project, 88% of American adults with Internet access research health information online and 60% say Internet info influenced a decision about how to manage a health condition. Further, going online no longer is a one-way stream of information from computer to patient, but has launched into the web 2.0 reality of social networking. Patients go online to find meaningful engagements with other patients and now – not so uncommonly – with their providers. Such a trend provides opportunity for providers to distinguish themselves competitively, and more importantly, to improve the patient experience and quite pos­sibly their health outcomes.

The report is a compilation of what key health IT experts from across the United States think are the most important things you need to know about engaging patients in the digital age. There are also four key recommendations for practical action. It discusses how healthcare organizations that provide high quality outcomes for patients will be the ones who prosper under new health reform models, such as Accountable Care Organizations (ACOs) and the Patient-Centered Medical Home (PCMH). This report also explores the concerns that come with patient engagement and the advantages and strategies that should be explored. (more…)

Reprinted courtesy of MCOL.

Perspectives on a Selected Key Topic |     April 2011/May 2011     |   Volume Three Issue Two

Will a material number of hospitals and their core medical staffs, that are relatively independent, evolve into highly integrated delivery systems during this decade, and why?

William J DeMarco MA, CMC

President and CEO, Pendulum HealthCare Development Corporation

The great momentum brought about by government and private payers demand for more accountability is unstoppable. Rapid consolidation of hospitals and consolidation of physicians by physician groups, hospitals and now insurers will shift referral patterns and consumer preference. 1 out of 4 hospitals will fall short of providing value and close or be absorbed within 10 years.

Physicians will be offered higher prices to sell out to insurers and investors who value the short supply of PCPs and will try to control care demand by retooling the care system building ASC and small scale short stay hospital.

True clinical integration will follow for the survivors. The ability to prospectively develop clinical budgets and bundles of services will connect regional tertiary and quaternary care facilities to local hospitals so integration can be regionalized across larger populations and payer segments.

Once these delivery systems realize they need a product recognizable to individual consumers they will seek alliance with select insurers or create their own insurance company thereby achieving the true definition of integration which is to integrate financing and delivery of care.

This offers the shared savings with themselves and stabilizes patient flow and overhead to achieve value to purchasers and users of care.

We think these opportunities will be at a tipping point on a market by market basis over the next 5 years and will be a national definition of success within 8 years. We believe this will happen because already the bond rating companies are looking at physician alignment and payer alignment as factors in establishing credit worthiness of hospitals for expansion and mergers.

Benjamin Isgur

Director, PricewaterhouseCoopers LLP’s Health Research Institute

Integration is certainly on the rise. The notion of independent physicians may be a myth because so-called independent physicians are becoming increasingly financially tethered to hospitals. In fact fifty-six percent of physicians PwC surveyed want to more closely align with a hospital in order to increase their income. The new health reform law focuses on population health and adopts a Medicare compensation model that penalizes poor quality and rewards cost savings and electronic information sharing. Some commercial payers are also pushing this business model. (more…)

Healthcare needs positive role models for innovation…and we have a real-time mentor in Netflix.

If you have a Netflix subscription, you probably identify with the company as providing a convenient DVD rental service — order on the web, the DVD arrives by mail, send it back in the handy pre-paid envelope when you’re done.

Today’s ReadWriteWeb describes Netflix’ latest letter to shareholders and explains how the company is preparing for the demise of DVDs:

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Let’s take a minute to consider the mechanics of how this will occur. You’ve received a prescription, and it directs the pharmacist to tailor the medicine to YOUR genetic profile.

Consider two possible scenarios of how this transaction might happen. You’re on the phone with your pharmacist:

1) “OK, you need my DNA sequence. I keep my genetic profile in my mattress…let me get it and I’ll read it out loud to you.  C, A, T, G, G, A, T… no,  that was actually a G…let me start over.  C, A, T, G, G, A, T… (19 hours later) … T, and G. Can you read that back to me to make sure you got it right?”

2) “You have permission to access my DNA sequence at my health URL (or maybe a health record bank, or perhaps hand her a flash drive, or ??).

Still think you’ll never use a PHR?

In my mind, the issue isn’t WHETHER, but WHEN.

Yes, I know that adoption has lagged and that surveys suggest 7% or less of the U.S. population has used a PHR.

Stay with me on this one for a minute. You’d have to have two underlying beliefs to conclude that PHR systems won’t eventually emerge:

• That health record data will persist in non-electronic formats, i.e., paper
• That people won’t have interest in accessing or using their health record data (more…)

(click on the graphics to link to original sources)

Regular readers know that I find Professor Clay Christensen’s theory of disruptive innovation to be a useful lens to explain industry evolution. Let’s look at two recent health IT initiatives and see why one is working and the other is stalled.

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1. Technical barriers aren’t the limiting factors to Facebook becoming a care coordination platform.
2. Facebook’s company DNA won’t play well in health care.
3. Could Facebook become the care coordination platform of the future? If not Facebook, then what?

1) Technical barriers aren’t the limiting factors to Facebook as a care coordination platform.

Can you imagine Facebook as a care coordination platform? I don’t think it’s much of a stretch. Facebook already has 650 million people on its network with a myriad of tools that allow for one-to-one or group interactions.

What would it take to make Facebook a viable care coordination platform?

• More servers to handle the volume — not a problem
• Specialized applications suited for health care conditions — not a problem
• Privacy settings that made people comfortable — more on this later
• A mechanism to identify and connect the members of YOUR care team — really tough, BUT this is NOT a technological problem, but a health system one

Suppose you are a 55–year-old woman who is a brittle diabetic. Your care team might include a family physician, an endocrinologist, a registered dietitian, a diabetic nurse, a ophthalmologist, a podiatrist, a psychologist, and others. Ideally you’d have one care plan that coordinates the care among members of the team, including you.

What’s the reality of today’s health care non-system?

• There is no formal designation of “your team.”
• There is no mechanism to designate one “plan” that coordinates the plays among your team members.
• It’s possible that multiple quarterbacks are calling the plays for your care.
• It’s possible that members of your team have no knowledge THAT you are being treated by others and HOW you are being treated by others.

Care coordination today is in the stone ages — there is no system for care coordination.

Supplying a modern Facebook-type technology platform doesn’t change this. The major limiting factors in Facebook’s becoming a care coordination platform aren’t technological.

Let’s look a bit deeper.

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1. Administrative Mandates (Compliance HIPAA 5010, ICD-10, etc.).
2. Care Management, Data Analytics, and Informatics.
3. Health Insurance Exchanges and Individual Markets.
4. New Provider Payment & Delivery Systems (ACOs, PCMHs, etc.).
5. Bend the Cost Trend.
6. Medicare and Medicaid.
7. Health Information Exchanges and EMRs.
8. Consumer’s Role in the Modernization of Healthcare.
9. Reform Uncertainties.
10. Payer/Provider Interoperability.

Dear health plan colleagues,

Wake up! The order of this list is totally out of whack.

#2: Care Management, Data Analytics, Informatics. Good…sounds about right.

However,

#2 can’t happen before you address:

#7: HIEs and EMRs

#10: Payer/Provider Interoperability

Health plans can’t analyze the data and assist in care management unless they first have access to it. Payers need access to clinical data, and they are at risk of being cut out of the loop.

P.S.

Please also take a look at priority #1: Administrative Mandates (Compliance HIPAA 5010, ICD-10, etc.). This is completely reactive!

In these times of great change, is this how health plans want to posture themselves in the community?

On March 31, CMS released the long-awaited “Medicare Shared Savings Program: Accountable Care Organizations” document (ACO Rule). Read the details here (strong suggestion: unless you’re working on your PhD in ACOs, start with the fact sheets).

There are many surprises. Here are eight first impressions on this 429 page tome:

1. The bar has been set high…very high.  Tire kickers need not apply.
2. Don’t expect to see many or any small ACOs.
3. Patients will be confused by ACOs.
4. Concerns over maintaining competition and avoiding antitrust are being taken seriously.
5. CMS scores points for coordinating the ACO Rule across Federal agencies.
6. CMS loses points for micromanagement and a controlling mindset.
7. Possible losers — hospitals, ACO vendors.
8. Possible winners — physicians, health plans.

The details follow.

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On Friday April 1st, 2011 (yes, ‘April Fools day’) at 4 PM Eastern and 1 PM Pacific

ACO Watch: A Mid Week Review will host a special roundtable series on the ‘hot of the press’ Notice of Proposed Rules’ pertaining to the implementation of Accountable Care Organizations. For the published rule, click here.

The roundtable team will consist of Mark Browne, MD, PYA, aka @consultdoc, Vince Kuraitis, e-Care Management blog, aka @VinceKuraitis, and David Harlow, the Harlow Group, LLC,  aka @healthblawg, with Gregg Masters, aka @2healthguru, as moderator and host.

To listen live, or via archived replay, click here. During the broadcast you may also listen in via (619) 393-2836, and even participate in the chatroom.

ACO Fact sheet from HHS

Medicare Fact Sheet: What Providers Need to Know

HHS press release

Don Berwick’s article on ACOs in the NEJM

ACO Quality Performance Standards Summary

FTC/DOJ Joint Antitrust Statement on ACOs

TheHill article “Leaked memo reveals Dem strategy for defending healthcare reg”

The leaked memo

Having been a debater in high school and then trained as a lawyer, my default mode of thinking is to be critical:

“Hey, Vince, how ya doin’? Great day isn’t it?”

“Well, …err…maybe, maybe not…actually, here’s 14 reasons why not.”

My wife and friends kindly tell me that this personal quality can be insufferable, and if you’ve ever met a lawyer you know what I’m talking about. My internal defense mechanism against my inner-critical brain is simply to turn it off — just go along for the ride and live in the moment.

To the extent that you can connect with what I’m saying, I suggest that before reading this report that you turn off the critical part of your brain.

If you’re a regular reader, chances are you’ve read individual white papers on these topics:

• PCMH — the Patient Centered Medical Home
• Care Coordination
• Access to care for the un and underinsured
• HIT — health information technology and the HITECH Act
• Payment reform, especially as it’s been discussed around ACOs (accountable care organizations).

“Better to Best” transcends all these topics — it weaves them together, displays the interrelationships, and describes specific components of what a truly integrated health system could look like. (more…)

Health care lobbyists and advocates are bracing for six pages of the health care reform law to explode into more than 1,000 pages of federal regulations when the Department of Health and Human Services releases its long-delayed accountable care organization rules this week. Politico

What should you be looking for as you snuggle by the fireplace this weekend reading the draft ACO regs?

Rob Lazerow writes a helpful article listing 5 Things to Watch in the Medicare Shared Savings Program Proposed Rule. His list of five key design issues includes:

1. How will patients be assigned to ACOs?
2. To what cost benchmark will ACOs be compared?
3. How will bonuses be calculated and paid?
4. For which quality metrics will ACOs be responsible?
5. What is the application process?

I’d like to add a sixth  item — which actually would be #1 on my list.

As I’ve previously written, IMHO the central issue around ACOs is:

Are (hospitals and doctors) viewing ACOs as a way to truly develop patient centric, collaborative care or as a means toward consolidating market power against payers? We really don’t know.

So here’s item #6:

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Click here.

The whitepaper is a great overview of accountable care and ACOs (Accountable Care Organizations). It’s a quick and easily digestible read.

However, there is one key point articulated in the paper that I’d like to emphasize here:

accountable care is not synonymous with ACOs.

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“If banks can exchange funds electronically through the ATM system, why can’t my doctor and hospital exchange information electronically?”

Keith Boone’s concise article “A Doctor is Not a Bank” explains why this conclusion about healthcare interoperability is overly-simplistic.

…and Keith’s article reminded me of an even deeper explanation presented in the National Academies’ Frontiers of Engineering series — Why Health Information Technology Doesn’t Work, by Elmer Bernstam and Todd Johnson. The table below summarizes the differences between health data and banking data.

  (more…)

What struck me about the list is that the state-of-the-art is stand alone applications — I didn’t see any that had any connection to an EHR (electronic health record).  Here’s the top 5 to give you a flavor of what’s on the list:

1. Medscape
2. Micromedex
3. New England Journal of Medicine
4. Epocrates
5. Free Medical Calculators

I expect that this list will begin to look very different in coming years as EHRs continue to open their platforms to outside developers…and applications will increasingly be integrated into direct patient care.

Doctors love iPads…not surprising? But, how might you explain this?

There are at least two different possibilities:

• Coincidence Theory
• Conspiracy Theory

The Coincidence Theory

So doctors want to access EHR software through the iPad…what’s the big deal?

Apple has built a great new hardware platform with the iPad. There’s nothing else like it in the marketplace.  While other companies are building competing tablets, Apple’s has been the only viable option in the market for over a year.

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At that time, the Direct Project was still being incubated and was not widely known or understood. Since then, it’s gone from being an idea to a project in full-speed implementation.

The simplest conceptualization of the Direct Project has been as a secure email alternative to medically-related transactions that today typically occur by fax, e.g., Dr. A faxes a medical record to Dr. B.

The functionality of the Direct Project has been described as “push-only”. Fred notes that

Push-only means that A can send messages to B, but B cannot automatically get data  from A (that would be pulling). Email and Faxes are push models. Web pages are pull models (i.e. sent to you when your browser asks for them).

“Push-only” misses the innovative potential of how the Direct-Project could be used. Let me try to make a simple conceptual leap that hopefully will open your eyes to The Power of Push.

With a little creativity and jury rigging, push transactions can easily become pull transactions.  For example, what if I were to call you on the phone (or send you an email, a fax, a carrier pigeon, a smoke signal) simply asking you to send (push) me some information.

Voila. Push is turned into push and pull.

Fred describes examples of  higher level functionality enabled when you get creative with push:

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Keith Wright and Gregory Drutchas’ incisive article Economic Credentialing: A Prescription To Secure Shared Savings Under Accountable Care provides useful history and context about economic credentialing:

For many years, the use of economic factors by hospitals in making medical staff credentialing decisions has been the subject of much discussion and debate among physicians, groups such as the American Medical Association (AMA), healthcare providers, payors, and attorneys….the implementation of healthcare reform is likely to bring the debate over economic credentialing to the forefront once again.

While economic credentialing has been talked about a lot, it’s rarely been used.

The controversy over economic credentialing arises again with ACO’s…and this time the answer might be different — and opportunistic for primary care.

Economic Credentialing from the Hospital POV— The Big Red Button

From my personal experiences, the threat of a hospital imposing any type of economic credentialing on their medical staff has been a big red button  issue — akin to a hospital declaring war on some physicians, with the risk of alienating nearly all physicians.

Management guru Peter Drucker wrote that the two most difficult organizations to “manage” were hospitals and the military. Most hospitals work hard to integrate physicians in decision making and they share a great deal of information about clinical and business issues. (more…)

A patient’s health records are no longer confined to a doctor’s office, shelved inside a dusty file cabinet. With the advent of the Nationwide Health Information Network, a framework of standards, services and policies that allow health practitioners to securely exchange health data, medical records digitized to be easily shared between doctor’s offices, hospitals, benefit providers, government agencies and other health organizations, all across America.

This health information exchange is dramatically enhanced by the Direct Project. Launched in March 2010, the Direct Project was created to enable a simple, direct, secure and scalable way for participants to send authenticated, encrypted health information to known, trusted recipients over the Internet in support of Stage 1 Meaningful Use requirements. The Direct Project has more than 200 participants from over 60 different organizations. These participants include EHR and PHR vendors, medical organizations, systems integrators, integrated delivery networks, federal organizations, state and regional health information organizations, organizations that provide health information exchange capabilities, and health information technology vendors. (more…)

Access to the full online article is currently available for free on the Center for Studying Health System Change website.

Key excerpts:

Conclusions. Health reform policies currently envisioned to improve care and lower costs may have small effects on high-cost patients who consume most resources. Instead, developing interventions tailored to improve care and lowering cost for specific types of complex and costly patients may hold greater potential for ‘‘bending the cost curve.’’

This research uses patient-level data and a much richer set of explanatory factors than previous studies to examine key patient, physician, practice, and market characteristics associated with costs of high-cost Medicare beneficiaries, defined as the top 25 percent of beneficiaries arrayed by expected Medicare costs… we estimate determinants of Medicare expenditures (costs) at the beneficiary level….After exclusions, the analysis sample comprised approximately 1.6 million beneficiaries. (more…)

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Webinar Title: An Impending Marriage: Electronic Health Records (EHRs) and Care Management Software

The presentation will be geared at practicing clinical case managers in health plans, hospitals, disease management companies, and similar organizations:

• Describe market forces driving integration of EHRs and care management software. 
• Review care management software survey data and stimulus funding for EHR adoption. 
• Describe a 3 stage framework for the evolution of EHRs and care management software. 
• Characterize benefits to patients and impacts on care manager responsibilities.

The event is sponsored by HealthSciences Institute and the PartnersinImprovement Alliance.

When:

Friday, February 4, 2011
11:30 am Eastern Time
10:30 am Central Time
9:30 am Mountain Time
8:30 am Pacific Time

Your Presenters:

Vince Kuraitis JD, MBA
Better Health Technologies, LLC

Garry Carneal, JD, MA
Schooner Healthcare Services

More Information and Registration:  Click here.

The Health 2.0 movement has seen incredible growth recently, with new tools and services continuously being released. Of course, Health 2.0 developers face a number of challenges when it comes to getting providers and patients to adopt new tools, including integrating into a health system that is still mostly paper-based. Another serious obstacle facing developers is how to interpret and, where appropriate, comply with the HIPAA privacy and security regulations. 

Questions abound when it comes to Health 2.0 and HIPAA, and it’s vital we get them answered, both for the sake of protecting users’ privacy and to ensure people are able to experience the full benefits of innovative Health 2.0 tools. We can’t afford to see the public’s trust in new health information technology put at risk, nor can we afford to have innovation stifled.

To help solve this problem, the Center for Democracy & Technology (CDT) has launched a crowdsourcing project to determine the most vexing Health 2.0/HIPAA questions.

This is where you come in: (more…)

Early Feedback on PCAST 

• Limited. The first commentaries were primarily by technical and/or clinical bloggers. The mainstream HIT world had remarkably little initial reaction to the Report. 
• Respectful of the imprimatur of “The President’s” Report and noting some of the big names associated with the report (e.g., Google’s Eric Schmidt and Microsoft’s Craig Mundie.)
• Focused on technical and/or clinical perspectives around two broad themes.
  • The vision is on target:  “extraordinary”, “breathtakingly innovative”.
  • These guys didn’t do all their technical homework. The range varies, but the message is consistent. 

Today’s POV on PCAST 

What  a difference a six weeks makes.  (more…)

I’ll share a couple of particularly useful and well written analyses and commentaries by colleagues.

Health IT guru and thought leader Dr. John Halamka writes about The Proposed Stage 2 and 3 Meaningful Use Recommendations in his blog.

This is a great article to get a thumbnail overview of all the proposed recommendations. John lists 38 criteria and provides a quick commentary on how challenging he sees each of them. (Keep in mind that he’s CIO at one of the most HIT-advanced health systems in the country — your definition of “easy” and his might not be alike.)

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A full list of objectives for Stages 1, 2 & 3 is available in the PowerPoint presented to HITPC.

The proposed objectives contain a mix of items that are:

• Unchanged from Stage 1
• Similar MU criteria with higher implementation goals, e.g.,
  • Stage 1: CPOE for Rx orders 30%
  • Stage 2: CPOE for 60% of Rx, lab and radiology orders entered by licensed professionals
• Clarifications or more detailed specifications
• Discretionary objectives moved to core set
• New items

Here’s a list of proposed new objectives for Stage 2 MU: (more…)

The reviews are filtering in and I’m seeing two major themes: 

1. The vision is on target:  “extraordinary”, “breathtakingly innovative”.
2. These guys didn’t do all their technical homework. The range varies, but the message is consistent. 

Here are some early critiques of the PCAST report. Let the debate continue! (more…)

Evaluation of Medicare Care Management for High Cost Beneficiaries (CMHCB) Demonstration: Massachusetts General Hospital and Massachusetts General Physicians Organization (MGH)

Remind Me Again About the CMHCB Medicare Demo…

The CMHCB started in 2005. My recollection is that the demo requirements were extremely similar to the Medicare Health Support (MHS) project, with a few exceptions: 1) Applicants had to include direct care providers (delivery systems, physicians) in their program design, 2) patient populations were significantly smaller than MHS.  Please comment on anything I’m missing.

I’ve included an addendum at the bottom providing more info about this little known and not widely discussed Medicare demo.

…and what was the MGH CMP project for the CMHCB?

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For three years running now, many of us bloggers have participated in what we’ve called a “blog rally” to promote Engage With Grace – a movement aimed at making sure all of us understand, communicate, and have honored our end-of-life wishes.

The rally is timed to coincide with a weekend when most of us are with the very people with whom we should be having these unbelievably important conversations – our closest friends and family.

At the heart of Engage With Grace are five questions designed to get the conversation about end-of-life started. We’ve included them at the end of this post. They’re not easy questions, but they are important — and believe it or not, most people find they actually enjoy discussing their answers with loved ones. The key is having the conversation before it’s too late.

This past year has done so much to support our mission to get more and more people talking about their end-of-life wishes. We’ve heard stories with happy endings … and stories with endings that could’ve (and should’ve) been better. We’ve stared down political opposition. We’ve supported each other’s efforts. And we’ve helped make this a topic of national importance.

So in the spirit of the upcoming Thanksgiving weekend, we’d like to highlight some things for which we’re grateful.

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Remember the penguin problem described by economists?

No one moves unless everyone moves, so no one moves. 

Overcoming the penguin problem has a lot to do with creating expectations. A recent writing by Dr. James O’Connor in Physician Practice expresses a voice from the physician community that I’ve never heard before.  His essay is entitled “Meaningful Use — Doctors Have No Choice”.

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If you went to their Twitter feed today, here’s what you’d see:

This struck me as a great pictorial representation of the broader challenges the CMS Innovation Center faces:

• They’ve kinda sorta figured out there’s a conversation going on out there — they’ve joined Twitter
• They haven’t figured out that they need to listen:  Following = 0
• They haven’t figured out they they need to talk:  Tweets = 0

I remain hopeful, but the CMS Innovation Center has a long way to go.  Dr. Berwick, opening up this closed organization is going to be the challenge of your lifetime.

The results from the National Institutes of Health (NIH)-sponsored Tele-HF trial are in, and the findings are worth considering . The results are counter to most of the findings of other studies examining telemonitoring for heart failure and at face value are disappointing to us, and the industry. Upon closer examination, however, this study offers us an excellent opportunity for further innovation, refinement of solutions and continuous improvement. It also provides a snapshot of how significant the challenges remain in transforming U.S. healthcare – from a system that is episodic, reactive, acute care based to a system of care that incorporates proactive, interactive, continuum-based chronic care management. 

The genesis for this study stretches back nearly 10 years, from conceptualization to the results we see reported today. This randomized, controlled multi-centered trial was designed to compare an automated, daily symptom and self-reported weight monitoring technology with “usual care” in reducing hospital readmissions and mortality among patients recently hospitalized with decompensated heart failure. The boldness of vision should not be underrepresented: Tele-HF is the largest study of a non-pharmacological intervention for heart failure ever conducted. 

At a high level, the results showed “no significant differences” between the group receiving usual care and the group randomized to receive telemonitoring. I cannot say that these are the results we were hoping for. However, I urge those in our industry and other key stakeholders to take a closer, more informed view, and to reach their own conclusions and insights. 

The Details

First, I want to thank and acknowledge the great work of the investigators, study sites and everyone involved in this trial. It was a long process and everyone worked with the utmost integrity and professionalism. We were privileged to have been selected for participation.  I also want to acknowledge the value of conducting large, multi-centered, randomized, controlled trials in terms of advancing medical science. 

The patient interventions in this study took place in 2006-09 and omit many of the processes and techniques Pharos uses today to achieve the necessary critical mass of physician and patient involvement. Here are the limitations of this particular study – from my perspective:  (more…)

vs.

The debate is highly controversial and nuanced. There are “experts” on both sides.

My point today is not to take sides (although I’ll admit my canine partiality to the open web), but rather:

• to point out that the debate is occurring 
• to explain what the discussions are about
• to suggest that competition between walled gardens vs. the open web is creating healthy competition and providing consumers with great choices (e.g., Apple iPhone as a walled garden vs. Google Android OS as a more open approach)
• to point out that health care has not had much to say in this debate…until very recently.

A while back I started writing a series “Healthcare Crosses the Chasm to the Network Economy” . This essay continues that series. (more…)

As I’ve written before, the Big Idea behind ACOs (Accountable Care Organizations) is the notion of accountability, not the specifics of organizational structure.

The purpose of the ACP position paper is to address the gaps that exist in care coordination when a physician refers a patient to a specialist. The obvious and logical answer proposed is to develop “Care Coordination Agreements” between primary care physicians and referring specialists, and the position paper takes 35 pages to explain why and how.

A simplified way of thinking about Care Coordination Agreements is that they recognize that coordination of care is a team sport, that specialists are part of the team, and that this paper proposes rules of the game about how primary care physicians and specialists should play together on behalf of their common patients.

However, there’s a great big CAVEAT buried in the position paper.  I don’t doubt the earnestness of the authors, but I do take this caveat as a Freudian slip recognition that not all specialists will be eager to play on the team and to play by the rules:

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• Extended Network Connectivity – As a network of networks, Surescripts will support and enable the exchange of all types of clinical messages between EHRs, HIEs and health systems that, today, are not connected with each other.
• Net2Net Connect – Allows health systems and technology vendors that already support clinical information sharing within their network to connect to Surescripts in order to receive and send clinical information outside their network (December 2010).
• Message Stream – Secure messaging tools for health systems and technology vendors to enable their physicians to electronically exchange clinical information (December 2010).
• Clinical Message Portal – Simple connectivity tools intended for providers that, today, do not have an EHR system to send and receive clinical messages. (January 2011).

Many others have recapped the new Surescripts network, so I’ll simply point you to a few of these resources:

• Surescripts press release
• Surescripts website — Clinical Interoperability Services
• “Surescripts, a Defacto NHIN”,  John Moore, Chilmark Research
• “Surescripts goes beyond e-prescribing” John Halamka, Life As A Healthcare CIO
• “Surescripts launching online health-care records network”, Washington Post
• ”Push for better ways to share e-health records”, Washington Post

Here are my 6 first-take reactions. (more…)

This is a short story about Blood Pressure Chart – a web-based tool used to manage, analyze and share blood pressure records. The old saying, “necessity is a mother of invention”, is almost applicable here. Almost, because coming up with an idea to store whatever records in a web app is hardly inventive. Certainly not in 2010. Strangely, a moderate set of requirements could not be satisfied by any preexisting solution.

For at least the past decade, I’ve been hearing about my country’s health care going digital. Millions (billions?) of taxpayers’ dollars later, I was given a paper notepad to record my blood pressure.

Having seen a doctor using a typewriter recently, I wasn’t really surprised, but simply had to find a better way. Few hours of googling and checking out a few desktop apps and one web app made me realize that nobody has taken it seriously so far. “I could make something much better in a week”, I thought to myself… but ideas for new functionality kept on coming and around a month later the site was ready.

When you create pretty much anything, it’s good to start by asking yourself a few questions before you touch any tools. Who is going to use it? What do they want to use it for? What are strengths and weaknesses of competing solutions? What non-standard functionality can we offer to enhance user experience?

First and foremost, I’m competing with a simple paper notebook. (more…)

Federally supported “Beacon Communities” are at work now defining how health information technology will support accountable, evidence-based care in communities – especially for care of chronic conditions. Backed by $235 million in federal grants, 15 communities across the country are serving as Beacon Community pilots for eventual wide-scale, performance-based use of technology to improve our health care delivery system.

The goal of the webinar is to address

• The fundamental nature and vision of the Beacon Community Program
• How the Beacon Program will influence nationwide delivery system reform and be a guide-path toward developing community infrastructures
• Other implications for the future of healthcare delivery

Why You Need to Know About Beacon Communities (more…)

Mike Miliard did a great job in capturing highlights and key points of my presentation at the Mobile Health Expo conference earlier this week. You can read his story here.

Please write me at vincek@bhtinfo.com in you’d like a copy of the PowerPoint presentation.

Update:  Neil Versel of FierceEMR also wrote up the presentation.  Here’s a link to his concise, on-target article ”HIE, mobility, open platforms start to knock down ‘walled gardens’ of proprietary EMRs.”

“Track who is on a care team — and share info with the patient.”

That’s just one of the summary recommendations coming from expert testimony given in a recent public hearing on how to improve care coordination through the use of health information technology. The Meaningful Use workgroup and Quality Measures workgroups are now wrestling with how to translate this recommendation into meaningful use criteria for HITECH Stages 2 and 3.

Seems like a good idea — simple, straightforward — perhaps even obvious. The EHR (electronic health record) could be a great tool for keeping care team members in the loop and on the same page about a patient’s care.

But then I thought about this for a few minutes, and the complexities started dawning. This seemingly simple recommendation — “Track who is on a care team and share info with the patient” — is the proverbial can of worms.

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When a major, multinational company does a complete turnaround on its operating and business model, it’s worth noting and examining the reasons behind the switch.

Wireless Week reported on a presentation made at the CTIA conference this week by Verizon COO, Lowell McAdam:

In a nod to the future, McAdam also said Verizon Wireless will scratch its “walled garden” approach because “in a 4G world, we need to turn that guarded model inside out.” The operator will transform its business model, he said, because it realizes that innovation in applications and use will come from outside the company.  Verizon will open its network, applications and location technologies to outside developers…[emphasis added].

Ars Technica reported further on McAdam’s commentary: 

I think collaboration and openness will be the operating platform for the future if we’re to bring the full promise of what 4G LTE brings. That’s really the new paradigm, the new model for operating in the entire wireless industry.

“Now I know that some of you in the audience are saying, ‘C’mon Lowell, you guys are the poster child for walled garden.’ What I’d say is that for the first 25 years that garden approach of closed systems served the industry pretty well. But in a 4G I think we need to turn that garden model inside out.”

How big a deal is this? Here’s an imaginary comparable statement that might be made by Judy Faulkner, CEO of Epic:

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In many communities, hospitals (delivery systems) will be the “natural” organization to lead an ACO. Hospitals bring management expertise, IT, capital, and community relationships to the table as important assets.

Questions about Hospital-Led ACOs

I’ll try to keep an open mind, but I question whether hospitals are best positioned to lead ACOs:
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Last week I attended and participated in an excellent conference — the National Reducing Hospital Readmissions Forum sponsored by World Research Group.

One of my main take aways is to observe a simple — yet huge — difference in mindset between hospital executives and vendors.

Over the past few months I’ve heard many vendors with diverse health care offerings talking about building readmission avoidance “programs” that they want to sell to hospitals.  Their idea here is to put together a soup-to-nuts offering of technologies and services — a “program” that hospitals would mostly outsource to a 3^rd  party vendor.

This concept has never quite sat right with me. Having spent the first 15 years of my career in and around the hospital world, I’ve often observed a “not-invented-here” aversion to anything brought in by outsiders.

My suspicions were confirmed at the conference.

The hospital mindset is NOT “we’re looking for an outsourced program from a vendor that will solve our readmissions problem.

While hospitals are in various stages of planning, here’s my sense of how hospitals have thought about readmissions:

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Accountable Care Organizations (ACOs) are today’s cure-du-jour for reforming the health care delivery system. Bob Berensen, MD of the Urban Institute strongly questions whether the shared savings model under current legislation provides enough economic incentive for hospitals to disrupt their existing core business of acute, inpatient care.

The dialogue took place at HSC’s 15th Annual Wall Street Comes to Washington Conference. Here’s the conversation from the transcript — I actually went back to dig this out of my trash:

Paul Ginsburg: Actually, let me just pose a devil’s advocate question. You know, I could see why ACOs might be attractive to a large —- an IPA because there’s this opportunity to reduce hospital use and be rewarded for it. But what’s the motivation for a hospital because the rewards from the ACO are likely to not measure up to the loss of volume from more efficient delivery. Is there any response to that? (more…)