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Healthcare Policy & Reform

The week in Government HIT: May 7, 2010

- Monday, May 3: The HHS Office of Civil Rights releases a request for public comment on their effort to expand patient notification rights in the event of a protected health information (PHI) disclosure. This contemplative commenter sees this effort as an important balance to the HITECH project, insofar as it increases patient confidence in electronic health information–and sometimes shows when this confidence is unwarranted. Now who could be against that? Well, anyways there are some parts that might be operationally problematic, but we’ll point those out as appropriate.

- Tuesday, May 4: The Beacon Communities are awarded! The final shoe drops in HITECH grants with the award of $220 million to 15 communities that are to be the pillars of excellence in healthcare IT. The list of awardees is a sample platter of healthcare stakeholders. Some of the awardees are already ‘beacon’ communities (Mayo, Geisinger, IHIE, Intermountain), but ONC made some inspired choices as well. Love the Piedmont project, or at least as much as I can tell from a paragraph. RIQI’s project with Blackstone Community Health Centers tackles my favorite topic: PCMH. And it’s hard not to get teary-eyed thinking about the good that the Louisiana Public Health Institute will do in empowering patients with health information. Among them all, here are the big topics that stood out to me: sustainable health information exchange (HIE), diabetes care management, telemedicine, patient engagement and personal health records. Who knows what brilliant, bountiful brainstorms of beneficence come out of these guys, but it’s been fun horse race to see the field whittled down from 190 to 15! (Though probably not as fun for the 175 stallions that weren’t selected.)

- Tuesday, May 4: Physicians Reluctant to Adopt EHRs: It appears some doctors are still not convinced about the benefits of electronic health records and are willing to accept a decrease in Medicare reimbursement. There has been pushback on the meaningful use standards with many groups asking to see the program extended to 2017. However, in Massachusetts the drive to educate physicians about the benefits of EHRs continued last week at a conference hosted by Governor Deval Patrick.

- Wednesday, May 5: Four more state Medicaid agencies get matching funds for EHR incentives for CHCs and pediatricians: Missouri, Washington, New Mexico, and Oregon. As this cunning correspondent pointed out a month ago, each of these Medicaid agencies will dramatically affect the appropriate distribution of incentive funds in their state. Set the bar too low, and patients don’t benefit from the technology; set the bar too high, and deserving groups won’t seek to improve because of administrative overhead and reporting requirements. Botch the reporting or standards setting entirely, and they’ll end up with a lot of wasted money. Our hats are off to them in hopes that they are successful.

Spotlight on: Health Reform – The California Perspective

Many of the health reform provisions – such as the creation of health insurance exchanges and the requirement that most U.S. residents purchase health insurance – won’t take effect for several years. However, there is quite a bit that goes into effect this year that likely will have an immediate impact in California. Here’s a rundown of the upcoming changes and how they affect the California marketplace.

One of the largest challenges California faces, along with many other states, is the expansion of the Medicaid program. The health and human services system in California is overwhelming. It takes four immense computer systems to process claims, determine eligibility, track beneficiaries and distribute billions of dollars in benefits. Try this on for scale: about one-third of the state’s human services caseload is concentrated in Los Angeles County. That one county provides services to 2.2 million people, at a cost of about $3 billion a year. But the computer system that crunches the numbers for that weighty system is nearing the end of its useful life, state officials say. That’s especially important now with California preparing to increase eligibility for Medi-Cal as called for in the federal health reform law. This article goes into more detail and estimates the cost of rebuilding the system at $530 million.

Healthcare Policy & Reform

NY Times Bits Blog on athenahealth: a “Web-based insurgent”

Last week, CEO Jonathan Bush sat down with reporter Steve Lohr of The New York Times for a cup of coffee during a break in the action at the Innovation 2010 event in Dana Point, Calif. Jonathan offered his view that federal HITECH Act payments for “meaningful use” of electronic medical records will help perpetuate obsolete solutions rather than spur innovation. 

From the article:

His argument is that the government incentive program, which begins next year, will, given its size and complexity, serve to subsidize traditional health software, which resides on the hard drives of personal computers and servers.

The big, old-line vendors like General Electric, Allscripts and Cerner, he contends, stand to gain more than the Web-based insurgents, like Athenahealth and others.

 “Established technology is being given a federally funded new lease on life,” Mr. Bush said. “Traditional health software now is on Medicare, being kept alive like grandma.”

 Read the rest of Lohr’s piece here and more HIT pieces by Lohr here, here and here.


If I Were as Sexy as Atul Gawande

Jonathan BushWhile I don’t much feel sorry for myself these days (I used to, but that was years ago now), I had a recent pang of it reading Atul Gawande’s new book The Checklist Manifesto.

In this bestseller, he points out that much of what ails us in health care is the lack of good checklists.  Not just the lists of course, but the fact that much of health care is now rote stuff that we already know how to do. What we need to do is accept that and stop treating the work like it’s a craft-brewed, once-in-a-lifetime invention. We need to start treating it like a complex set of tasks that needs to be done well, in order, every time and preferably by technicians specially trained to repeat the list.  This Gawande guy is so smart, good-looking and bloody silver-tongued, that he gets to saunter out with what athenahealth has been trying to say and do for the last decade—only he gets published right off! I just know he’s gonna get one of those ooey gooey softball interviews with Terry Gross and even get to meet Obama over it.   I feel like the guy on the FedEx commercial who didn’t get credit for the idea because he didn’t “go like this —” when he offered it.

OK, enough whining. Spilt milk aside, Gawande is right.  What he suggests is what all the innovators in health care that I like are doing.  In general, we start with the very lamest junk first and then work our way into the complex.  In athenahealth’s case, we started with the billing process, of all things.  Most practices and hospitals treat it like it’s one of the dark arts when it’s actually just a complicated process problem that needs to be broken into checklists, hopefully in 6th grade English, and then served up in the moment of truth to those doing the work. It could be a scheduler, a nurse, a doctor, every single conversation in healthcare can contribute to a clean claim—or break it. The Internet has been a terrific aid for us in this task.

athenaNet®, since it is web-native, is available everywhere and usable by everyone.  You don’t need much training or specialized skill to use web-apps these days. We are still missing a lot but we now have the checklists necessary to make it so mostly every claim in every specialty glides right through. It has taken us a decade of updating our checklists and we have found over 40 million (no kidding!) reasons why medical claims can go wrong AND we still have miles to go. But we are well on our way.

With billing under some semblance of control, we were able to move about five years ago to medical records documentation and management.  Here the work was initially only about filing. It was not about complex protocols for treatment of chronic disease, it was just about not losing faxes.  Did you know that almost everything that the average doc gets today about patients comes via fax …EVEN IF HE OR SHE HAS AN EMR??! The average provider on our network gets over 1,100 faxes a month!! I got three during all of 2009!

We have put tens of thousands of hours of software and analytics into getting those faxes read and filed correctly—and of course into finding the senders and introducing them to this neat thing called the Internet.

Next, we found that there was money for doctors in executing on certain chronic care checklists. They are called Pay-for-Performance (P4P –cute moniker eh?) programs.  So now we are building checklists in that same 6th grade English into every conversation about scheduling, every intake with a medical assistant, every exam and of course every physician order. Ahh, those humble beginnings in the claim worlds are starting to show up in the exam room!  We aren’t docs. Never will be. Don’t want to be.  We just want to clean up after them and keep track of all the checklists that they need to stay safe and productive.

Now we are onto patient communications.  Same gig here. When are people ready to deal with their appointments? Their lab results? How do they want to deal with the financial aspects of health care?

athenaNet is learning the answers to those questions. We are learning literally millions of lessons in this pursuit.  Little eeny-teeny lessons, yes, but they add up.  Because all our clients do their billing and medical records and patient communications on ONE instance of one web-native application, we can push each teeny learning out to all our clients as they need to know it in real time.

Drop by drop, we are draining the medical confusion swamp revealing only the hard, and important, stuff. That’s the stuff for which we don’t know the checklist, the stuff that makes up (or should make up) the REAL practice of medicine in 2010.

So congratulations Atul, you sexy SOB.  You are onto the answer to what docs need in this book… but pack a lunch! There is a long, hard slog left in getting those checklists together and useful to the point where they take the drudgery and absurdity out of doctors’ work and let them focus on the important stuff.

PS—In order to get people DOING those checklists there has to be a market for the work in them. More on that next time.

All Things EMR | Practice Management

EMR Reveals “Actual Work of Primary Care”

The Wall Street Journal’s Health Blog—one of our recommended reads—does an excellent job of itemizing and outing the “invisible” work in the typical day of a primary care doctor. It lays out the phone calls, emails, refills, paperwork and other such tasks that keep doctors from patients. 

The recent post is based on a report in the New England Journal of Medicine by Richard J. Baron, M.D. entitled, “What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice.” At his five physician internal medicine practice in Philadelphia, he used an electronic health record through 2008 to log practice work outside the exam room and found his doctors swamped with information management.

It concludes:

At a time when the primary care system is collapsing and U.S. medical-school graduates are avoiding the field, it is urgent that we understand the actual work of primary care and find ways to support it. Our snapshot reveals both the magnitude of the challenge and the need for radical change in practice design and payment structure

We couldn’t agree more!

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