The HIT Transition Weblog

Why Quality Doesn't Matter

Oops. I meant that headline to read, "Why Quality Scoring Doesn't Matter."  Oops.  My bad.

I've maintained a skepticism about the value of so-called "quality transparency" scores when it comes to comparing one hospital/clinic/lab/doctor to another. My queasiness is mostly related to the problems of measurement and sample selection: Won't the toughest cases get routed to the best doctors and facilities?  And if so, won't that be reflected in higher mortality rates relative to those who take the more mainstream cases?  Yeah, I know about acuity adjustments, etc., but when it comes to life and death situations, I'd rather rely on the professional opinion of someone I trust -- say, the family doctor I've had for the last ten years -- than rely on my own reading of a spreadsheet with unknown risk adjustment tweekage criteria.

The Flying Fickle Finger of Fate
And further, I see the "foam finger" reduction of even those impressive tables and charts into marketing one-liners: "We're Number One! (with an asterisk)."  (So if your comparing trauma units, do you look for "Number One with a Bullet?")

Now Matthew Holt points out another, perhaps more compelling, weakness: The numbers themselves aren't significant.  As in "statistically significant."

It turns out that only for CABGs (coronary artery bypass grafts) are there enough cases performed to have statistical confidence that a hospital has that poor a record compared to the national average.

Holt cites a presentation by Joe Newhouse of Harvard Medical School, who pulls data from a 2004 JAMA article by Dimick, et al. 

Adder Up
Okay, so if we've known these statistics are crap for three-going-on-four years, what's all the fuss about using these quality numbers to drive policy, even revenue?  Holt suggests that even bad numbers can lead to improvements, sort of like college linebackers comparing Basket Weaving grades.

I'm not so sure. If I were a hospital administrator, I'd want to bank my paycheck on a more reliable team...

RHIO Riposte

My response to the flurry of premature RHIO obituaries has been included in today's Health 2.0 blog.  I was grateful they accepted my request to guest author, even though there are probably a lot of Health 2.0 types who would prefer the industry pursue a commercial model for health information exchange.  Maybe even their commercial model.

I'm actually a very 2.0 kinda guy -- pushing out a collaborative intranet site in the late nineties, publishing various blogs since aught-one and even scheming to accelerate HIT standards adoption with a hare-braned collaborative environment of my own design.  I even ran an industry collaborative project on 2.0-ware without telling anyone until it was over.

Cripes.  It's been four years since I gave that 2.0 testimony.  Maybe I better get busy again.  Sounds like people are paying attention now.

Meanwhile, to show that 2.0 might work even for nonprofits, put your comments over on the H20 version of my editorial.  You don't even have to agree with me.  In fact, it's sorta better if you don't.  "Me too" is so 1.0, ya know?

How Much Would Universal Coverage Save?

Earlier this morning I made a point that has been clear to me for a long time: Universal coverage will cost less.  This opinion has evolved over a long period of time, starting with my college studies in economics, which were focused on another domain impacted by the interactions of individual, societal and natural forces: the environment.  My career in healthcare, particularly in its focus on business operations and financial interactions, made it clear that the cost-shifting shell game we play in America is what is causing the system to spiral out of control both in terms of economics and quality: Letting people get sick costs more than helping them stay well.

Sometimes the urge to put this all into a single analysis is paralyzing, distracting me from my "real job" of merely trying to help the industry do health IT right.

Thank goodness someone appears to have done it for me.  They even put a price tag on the profligate ways of our dysfunctional "free market" (NOT) system: $1.5 trillion.

That's what the Commonwealth Fund's Commission on a High Performance Health System report, Bending the Curve: Options for Achieving Savings and Improving Value in Health Spending, says we can save over 10 years by covering everybody and making wise, systemic changes to the way the elements of the healthcare system interact.  I'm just popping it open now, but it seems they are not "anti-market," but rather seek to employ market forces within the context of correcting known dysfunctions, for instance, by setting prices based on outcomes rather than on procedures, using collective purchasing power to drive down drug prices, etc.  Pharma's just going to love this one.

It's not a piecemeal effort by any means, though.  They actually attack the problem at the national level, and identify ways that different policies can work together to control costs.

Nice present to put under your tree.

(Michael says I need to remember, though, that our company is not a non-profit enterprise, so this time I'm going to put in our little ad for the Health IT Grant Resource directories he worked so hard to assemble.)

http://hittransition.com/flashpoint/ad_rhio2.htm

Uninsurance Is a Deadly Sin

In what should be a no-brainer for anyone who has thought deeply about US healthcare, Matthew Holt over at The Healthcare Blog cites some fresh statistics that prove that not having insurance can kill you.  Quoting this new study by the American Cancer Society, he offers a dark truth: "For all cancer sites combined, patients who were uninsured were 1.6 times as likely to die in five years as those with private insurance."

Is it that they can't afford those expensive surgeries and heroic interventions?  Perhaps.  But most of it seems to happen earlier -- they don't get the screenings they need for early detection.

Women without health insurance are about half as likely as those with private health insurance to have received a mammogram in the past two years (38.1 percent of uninsured women versus 74.5 percent of insured women age 40-64), a pattern seen for all race/ethnicities studied (white, African American and Hispanic) at all levels of education.

As a result...

Twenty to 30 percent of uninsured women were diagnosed with late stage (stage III/IV) breast cancer, compared with ten to 15 percent of privately insured patients.

What the study doesn't seem to address is the financial impact, either to the individual or to the nation.  I'll fill you in on something I learned back in my days at the hospital: Sicker patients cost more to treat.

We don't spend more on healthcare despite not covering all our citizens.  We spend more on healthcare because we don't cover all our citizens.  The moral case and the economic case come up with the same answer.

Seeking Sustainable RHIO Forest; View Obscured by Non-profit Trees

Health Affairs just published a study by a team of Harvard researchers that has cast a pall on the sustainability of Regional Health Information Organizations (also referred to as Health Information Exchanges). The report, The State Of Regional Health Information Organizations: Current Activities And Financing, by Julia Adler-Milstein, Andrew P. McAfee, David W. Bates, and Ashish K. Jha, seems to imply that the maladies suffered by RHIO efforts around the country might be fatal, at least if you read the many news stories and blogs that are talking about it.  I say "seems to" because our analysis suggests that the industry echosphere is still missing quite a bit of the big picture.  Let's take this step by step, starting with the Harvard study and moving into the invisible economy and the nature of the RHIO challenge.

First, the "scary facts" presented by the researchers:

• 25% of previously-listed RHIOs seem to be "defunct"
• Only 20% of the remainder reported exchanging significant volumes of clinical data
• Most of the data they were exchanging falls into the categories of lab results, inpatient data and medication history
• A majority reported receiving in-kind donations, about half reported grants or financial contributions and slightly less than half reported no financial contributions

You might look at these factoids and come to the conclusion that the current generation of RHIOs are unsustainable.  The quote lifted from the report that has been frequently cited to support this conclusion says: "if RHIOs are to succeed as small businesses, they must be built around sustainable business models, which requires both profitability and value creation for participants."

Red Tuesday: Jan 1 2008

On our Black Swans list for 2008, one of the biggest birds will swoop in on the very first day of the year: January 1.  That's when a huge number of health plan enrollments roll over, and the move to the High Deductible Health Plan model is going to hit providers hard in the pocketbook.  Hence our suggested name for the eventful date: Red Tuesday.

Forecast for the Rich: Richer
The Nashville Business Journal cites unnamed analysts in guessing 2009 HDHP enrollment will double from January 2007's 4.5 million.  But one named analyst is more specific, calling HDHPs "the best idea I've seen for a health plan in 25 years." I guess that's great news if you're a health plan.

The Doctor Will See You Now, Mr. Wimpy
Will providers notice?  Not from what I'm hearing.  Physicians, clinics, hospitals, labs, etc., may be "concerned" about the migration of a big chunk of A/R from a few hundred points of cantankerous collections (i.e. health plans) to tens of thousands of points of empty and slow-paying pockets (i.e. patients), but they're not generally looking at the numbers that matter: Patient Responsibility as a percent of total billing (not "revenue" -- that assumes the money will be collected).  And multiply that by the likelihood of collecting any patient receivable, factoring in that their bill just went up by a thousand percent.

You Mean I'm Going to Stay This Color?
Maybe they will get the picture after the month closes?  Make that Fuscia Friday (Feb 1, 2008), or maybe give them three business days to close and call it Ruby Tuesday (Feb 5)?  Probably not. Months aren't trends.  January's always a slow month, right?

Maybe they'll look at the results after the first quarter.  That would be about April 3.  Surely they should be able to see how much money they are losing by then.  What color should we give it? Thrush Thursday!

But wait.  They won't even bill most of their January patients until the claims get settled by the health plans, and that takes at least 50-60 days.  January's patient payments won't even be overdue by the end of March.  They'll cash their refund checks on April 16, then buy that new Buick, and...

Ice, Ice, Very Ice....

We hear our local weather made the BBC.  Yow.  A-yip-tye-o-ee-yay!

We took in a number of refugees, being the last house among our chosen family to have power.  Then the lights went out at about 4 pm yesterday.  The office is only a half-mile away, and there we have both lights and net, hence this post.

I want to reassure you that this meteorological Black Swan is not going to keep us from doing our webinar tomorrow.  Still, if you have an extra box of double-ought swan cartridges, we could use a little more ammunition.  A rick of seasoned firewood would be nice, too.

Meanwhile, yes, we are going to have something to say about Deborah Peel's attack on her local hospital for daring to store patient records electronically, and even more to say about the premature RHIO obituary that seems to have been published in Health Affairs.

Right now, we're kinda chillin'.

http://hittransition.com/flashpoint/ad_rta.htm

The Revolution Will Not Be Commercialized

In a paradigmatic parry to the revenue-model driven rush to build HIT companies, a trio of universities have created a project to put the skills of undergraduates to work in building Free and Open-Source Software solutions for humanitarian purposes.  Trinity College, Wesleyan University, and Connecticut College set The Humanitarian FOSS Project in motion, but are already connected with an emergent infrastructure that has addressed real-world problems with low-cost solutions.

How does this win me? Let me count the ways:

• Undergraduate students with youthful passion and optimism get to work with real people to help solve real problems
• The FOSS bottoms-up development process becomes the initial template against which they will measure all other methodologies
• They'll network with people outside their institutions and emerge from college with people in positions of influence who actually know what they can do.
• People with big problems and little money will be the customers.

Involving the Users -- Isn't That Cheating?
I'm from the old school "code-first-ask-questions-later" development mindset, so to me, FOSS is more a foreign land than native territory.  Flashes of the entrepreneurial lightbulb can still be seen going off over my head in late night BS (that's "brainstorming") sessions and overlong cross-country airline flights. So before I go completely moony-eyed about some new, democratic, user-oriented development methodology, I have to go out and seek some dollars-and-cents, large-scale success stories that tell me I'm not just fantasizing that non-trivial FOSS solutions can compete with, or even outperform, traditional commercial software platforms. 

Like this, for instance.

http://hittransition.com/flashpoint/ad_rta.htm

Is 5010 a Year?! Why HIT Standards Take So Long...

You thought I was just being clever last week when I quipped, "These umbrage-and-edit timelines rachet out to make the electronic claim standards developed three years ago available for widespread adoption sometime after the the turn of the decade, even with optimistic dependency scheduling."

Oh, no.  I had inside information.  And that information became public this week.  The North Carolina Healthcare Information and Communications Alliance and The Workgroup for Electronic Data Interchange have been working on a real live MS-Project-based timeline to show regulators and industry analysts just how much time is consumed in developing, adopting and implementing HIT standards.  The equation for the 5010 version of the electronic claim and other ASC X12 administrative transaction adds up to 2014 -- that's seven years from now to implement a standard I helped smarter people finalize almost three years ago. 

According to Holt Anderson, Executive Director of NCHICA,

“Our estimate is based on the key assumption that a proposed rule on 5010 will be published in June 2008, and if only minor revisions are made, a final rule will be published in 2010. It is projected that it will take three years to move to limited production of new standards and one year to move to full compliance, bringing us to 2014.”

Don't believe it?  Check out the details on the WEDI/NCHICA site devoted to the study.  And if you still don't believe it, download the MSP file and plug in your own assumptions. Heck, join in the conversation on their listserv!  The link says "membersonly" but it's supposed to be open to everybody.  If you have any difficulty subscribing, shoot me a note and I will inform the powers-that-be.

AHIC is Behind Medicare HIT Stick

In yesterday's post, I critique HHS Secretary Mike Leavitt's directive to congress to tie any restoration of the Medicare Physician fee schedule to EHR adoption. In it, I question where such a mind-bending solution originated: The idea that you can create a positive incentive for HIT out of an essentially punitive approach.

Diana Manos at Healthcare IT News points the finger:

Leavitt's call for incorporating healthcare IT adoption into a physician payment fix bill follows pressure last month from members of the HHS healthcare IT advisory panel, the American Health Information Community, to force adoption.

Craig Barrett, chairman of Intel Corporation said after 17 meetings of AHIC, doctors are no closer to adoption.

No kidding?  A score of CEOs and bureaucrats meet in Washington for a year and a half and the problem isn't solved yet?  I guess those doctors need to understand you mean business.  Why not threaten them?  That always works. [continued]

Leavitt Ties Medicare Carrot to IT Stick, Beats Docs

I tend to be a market-oriented sort of guy.  Not just the so-called "free" market, which exists largely in pundits' brains, on commodity trading floors, and on e-bay Hummel figurine auctions, but real markets, public and private, where people and organizations act and interact collectively in a world of imperfect (and often withheld) information, unknown risks, and externalized cost transfers, both accidental and manufactured.  As such, I recognize that when the actions of one party (say the gathering and organizing of information by a physician practice) creates benefits largely for another party (say a private or governmental payer), then market forces will tend to bring about a way for the party of the second part to provide an incentive to the party of the first part to do more of said activity.

Put more simply: It makes economic sense for payers to give money, resources, educational materials, etc., to get doctors to adopt electronic health records.

So I ought to be glad to get the news today that HHS Secretary Michael Leavitt has announced plans for a strong financial incentive to Medicare providers to adopt EHR, right?  Not so fast....

Grant Roundup for 12/05/07

"Disruptive Innovations" Entrants Invited to Apply for Grants
The Robert Wood Johnson Foundation is looking for ways to shake up healthcare, and they may have found some. Among the projects invited to compete for funding:

• Project ECHO: Knowledge Networks for the Treatment of Complex Diseases in Remote, Rural, Underserved Communities - University of New Mexico Health Sciences Center
• Instant Birth Control - Planned Parenthood of the Columbia Willamette
• Develop a universal technology framework for registries focused on capturing outcomes data for cardiovascular disease -- American College of Cardiology
• Clinical Research Information Exchange - CRIX International
• Health Futures Markets - New York University
• The EpiSurveyor Project: Lowering the Barriers and Raising the Bar for Data Collection - The Datadyne Group
• Space age medical care for use on Earth - Henry Ford Hospital
• Rethinking What a Health Insurance Package Can Be - Working Today-Freelancers Union

Colorado Trust Awards $3.9 Million: Some Room for CDSS, eMAR?
Grants totaling $3.9 million to help strengthen patient care and safety in hospitals around the state. Supports the Five Million Lives Campaign, an initiative of the Institute for Healthcare Improvement (IHI) intended to build safeguards against hospital-acquired infections, ADEs, surgical errors and other complications of patient care.

Center for Community Health Leadership: $3 Million Grant for Connected Healthcare
Organization sponsored by Misys Healthcare Systems commits $3 million to the 3 million-population Tampa Bay area.

North Dakota Woman Has A Global Impact
This busy lady was over and above her fair share with her work for rural clinics and working with public safety groups. But then the Navajo nation wanted to track diabetes using PDA/blackberry technology...

Your Grant Dollars At Work: Rochester RHIO Goes Live
The upstate New York RHIO, funded by a $4.4 million state grant and $2 million from local businesses, has started training 20 participating physician office's staff members. Cork the Champagne!

Surprise! Siemens CEO Touts "Big HIT" Solution

In an announcement that should surprise no one, Siemens CEO Erich Reinhardt is advising hospitals to go with a single source for their Healthcare IT software, as well as, guess what? their heavy and pricey diagnostic equipment.  Reinhardt's appearance at the Radiological Society of North America (RSNA) annual meeting was covered by Digital Healthcare and Productivity.

Regular readers of this blog should know by now that we don't do off-the-cuff vendor endorsements -- nor do we take pot-shots at particular companies or products.  Unless, that is, one of their executives says something that sounds a bit unwarranted.

I really don't know Siemens product line -- I know some very smart people that work for the company, and have no reason to doubt they are doing a great job at whatever.

Denial Engines Still Lack Response from Provider Vendors

It's been almost two years since I published my piece on a new segment of payer software tools that offer a suite of editing tools so sophisticated that it basically allowed payers to tune them to whatever percentage of revenue retention they thought providers would tolerate.  I dubbed the tools Denial Engines and suggested that provider vendors had been seriously outflanked and needed to up their game.

This new category of vendors digs deeper, into the literally millions of edits available.  They employ various ways to improve on the previous technology, such as greater selectivity (applying edits to some providers and not others), longitudinal comparisions (i.e. based on patient history), and pattern matching (i.e. upcoding).  Regardless of the approaches they choose, these vendors make the sale based on the fact that they can recover more money than the payers' existing edits, and they provide the analytics to prove it....The "best" of these denial engines point to independent sources for the edits.  This helpful feature allows providers to learn from their mistakes. Such evidence may also tend to keep providers from pursuing appeals that will ultimately prove unsuccessful.

In my research since then, I've learned a lot more.  Some of these DE tools will go so far as to edit against best practices published in medical journals, and integrate a link to the citation in the automated defense. 

Worse, DE tools are being used by Recovery Audit Contractors (RACs) to do commission-based re-adjudication of old Medicare claims.  They're not just subtracting from what they owe you, they're taking back money you thought you'd earned years ago.

Leaving Money on th--Hey!  Where's My Table!?
I even suggested that there were (software) revenue/market opportunities to had, if provider vendors could just alert their clients that they were having an additional 4% or more of their payables systematically denied, and come up with an effective response mechanism.  I even architected a potential solution and showed it to a few of them.

Adding 2.0 to HIT Alphabet?

I've been tracking the Health 2.0 buzz generated by Matthew Holt's blog-boosted thought machine.  The idea that HIT can help remake healthcare, instead of just automate its dysfunctions, has a significant appeal. Marty Tenenbaum's post suggests the creation of a new convening entity, akin to the CommerceNet alliance that bootstrapped web-based commercial exchanges. 

Early CommerceNet members included startups like Netscape, Yahoo, and Amazon as well as established organizations like Visa/Mastercard, FedEx and IBM. The members of CommerceNet collaborated on initiatives like search, catalogs, security, payment, and shipping/fulfillment, leading to complete end-end transactions where one could actually locate a product, buy it, pay for it and get it delivered. Not only was overall market growth accelerated; many business deals resulted, generating a lot of wealth.

Um, yeah.  I guess from an insider's view, though, the deal of creating yet another HIT collaborative after the explosion of alphabet soup bowls we've seen thrown at the walls of US healthcare for the past 10 or 15 years leaves me a little, well, lukewarm.  And sloppy.