The Buzz for 2012

December 30, 2011

What’s “change fatigue?”

According to a fun article by Cheryl Clark in a recent Healthleaders column, change fatigue is one of the top new buzzwords we’ll be seeing in 2012. She explains

“There’s change in leadership, areas of responsibility, accelerated workload and expectations, and requirements for new skills and training in people who may not be prepared for it or want it.

“Some providers have expressed frustration with this ‘new flavor of the month’ attitude. Now managers are trying to find productive ways to make these transitions, so there is enough stability and constancy mixed in to prevent change fatigue.”

Another buzzword cited is “accountable care skimping.”  Clark reports

“In the Medicare Shared Saving Program’s final rule released in October, the word “skimp” comes up four times.

“Officials for the Centers for Medicare & Medicaid Services used the word to address a concern that when physicians in accountable care organizations are paid to avoid unnecessary expenses, they may—unconsciously or not—avoid necessary expenses for their patients. Heaven forbid, they may ‘skimp on care.’

I think that skimping is just another word for rationing. The concept of rationing care is understood and accepted in countries such as Canada and the UK which have national health care system. Rationing has become a taboo word in health policy in the US.

Another buzzword noted by Clark is “positive deviance or disruptive innovation.”

She explains

“In healthcare settings, these two phrases, which have different origins and meanings, can be used to express the same idea. They imply a strategy in which providers look at peers—be they controversial individuals or entire institutions—that function differently, but still achieve excellent results.”

This is a good way to explain certain phenomenon, although the term positive deviance will be hard for many people to grasp.  The terms deviance and deviants (a homonym) have some strong negative connotations, not only in healthcare but in political and social thought as well.

Will anyone  champion skimping as a disruptive innovation?

2012 Crystal Ball

December 23, 2011

The last week of December always features predictions for the coming year. In the past week we’ve seen good articles from Hospitals and Health Networks, Health Data Management and many others.

One can categorize them in two broad areas: technology (e.g. new software, hardware) and policy.

HHN notes several key events: the continuing struggle over the deficit, the implementation of the Affordable Care Act and the Supreme Court ruling on the law’s constitutionality.

From the business standpoint, Helen Darling, President and CEO, National Business Group on Health, notes that employers are employers are struggling to provide health benefits at an affordable cost at a time when employees and dependents are “not as healthy as they used to be” and “younger workers are joining the work force with significantly more risk factors.”

Darling points out that employers will also face growing administrative burdens due to the ACA, she said.  ”For some employers, especially small employers, the option to obtain coverage through (health insurance) exchanges may be a better choice.”

If, however, the economy stumbles and health costs grow at the projected 7.2 percent rate, “we will watch our standard of living decline and consumers will have even higher out of pocket costs.”

For some good news, readers can turn to predictions about new technology.

Bill Crounse, MD, Senior Director, Worldwide Health at Microsoft, predicts that “Broadband internet, computers, gaming systems, and digital television merge to become a platform capable of delivering on-demand health information, instruction and medical services into our homes.  Much of this has already happened.  In other words, the platform and technology already exist.  What’s needed to make it mainstream are the business drivers and incentives that will bring it all to life.”

In his blog (http://blogs.msdn.com/b/healthblog/archive), Dr. Crounse  says that if the right regulatory and reimbursement reforms are implemented, the market will deliver “more cost-effective modalities for both preventive services and care.

“That will increasingly include the delivery of health information and medical services directly into the home whenever possible.  So much of what healthcare providers do is focused on the analysis of signs, symptoms and results, dissemination of information, and prescriptions for treatment.  Much of this can, and increasingly will be done, virtually.”

Remember the adage, “water, water everywhere and not a drop to drink?” In healthcare 2012 we may have “technology, technology everywhere, but not a business model to use it.”

Raison d’etre for health care

December 15, 2011

“The medical profession has no raison d’etre apart from patient care. No patients, no medical profession.”

This statement was contained in a comment by a physician who was complaining about the usability of EHRs in a response to an article in Healthcare IT News.

My first reaction was this was an insightful, true statement (and a good use of neat French phrase). Then I realized that it is noble-minded, but basically flawed. There have  been patients since humans evolved on the plains of the Serengeti two million years ago. The rise of the highly compensated medical profession, however, has come in the last 50 years.

Consider the statement “No diners, no restaurant industry,” or “No new cars, no auto industry.”

Health care is fundamentally different from other industries such as food, retail and banking. The customer rarely pays for his services; the check is usually picked up by a third party (the government, an employer).

If people had to pay 100% out of their own pocket for healthcare, we would not have 400 MRI machines in Los Angeles County, nor would we have cancer drugs that cost $600,000 per year.

These are not bad developments; when I need an MRI or a new drug, I’m glad it is available (I have good insurance) without flying 500 miles or mortgaging my house. The point is how physicians define good patient care is very different from payers define it.

That brings us to EHRs. Why are EHRs being mandated? Who will benefit?

In the short run, adopting a new EHR system may be an inconvenience for many solo practitioners. The EHR mandate is being driven by the need to control costs. The old business adage “if you can’t measure it, you can’t manage it” applies here.

Will a new EHR system in a small physician practice lower costs for the patient or raise revenues for the physician? Maybe, maybe not. But that is not the raison d’etre for EHRs. The data that is captured and analyzed will improve overall health quality and lead to efficient delivery of care.

Ca fini.

Brickless Clinics

December 9, 2011

Here’s a clever new healthcare buzz phrase we will be hearing a lot in the future: brickless clinic.

This phrase was mentioned by an Intel executive in an address to the mHealth Summit in Washington DC last week. Several publications including iHealthbeat and the Chilmark Research newsletter had very interesting articles about the conference.

According to iHealthbeat:

“Rick Cnossen — director of worldwide health information technology at Intel — said he believes in the next 10 years 50% of health care could provided through the “brickless clinic,” be it the home, community, workplace or even car. Cnossen said the technology – such as mobile tools, telehealth, personal health records and social networking – already exists to make this possible. He said, “We have the technology. … It’s time to move out on it.”

And why has mhealth adoption been so slow to date? The iHealthbeat article reports that

“Cnossen said, “The challenge is not a technology problem, it’s a business and a workflow problem.”

This last statement can be applied to every single sector of the U.S. healthcare industry: mhealth, clinical diagnosis, billing and payment. It is never a technology problem, it is always a workflow problem. In our fee-for-service delivery system, one person’s workflow problem, whether it is a series of unnecessary tests, a too-long hospital stay or hours of transcription and billing by paper, can also be an important revenue source.

The other issue is the imperfect state of wireless connectivity. An anonymous comment posted at the end of the iHealthbeat article captured the problem brilliantly:

It’s time to apply some common sense here.  Ever had a battery problem with an iPhone? Ever had a problem getting consistent WiFi reception or had a call dropped or had a problem with the 3G network? Wanna bet your life on Dr. Topol’s iPhone reception in, say, Manhattan versus his stethoscope?

MU2: Win for Pioneers

December 2, 2011

HHS has removed some of the uncertainty and confusion around meaningful use with its announcement that the start date for Stage 2 has been moved back from 2013 to 2014. In addition, HHS said that providers who attested in 2011 and those that attest in 2012 can both wait until 2014 to start Stage 2.

In addition, “pioneer providers” (early adopters) who attested in 2011 can now get three years of Stage 1 incentive payments.

This fact is very important for the “pioneers,” the several hundred hospitals and medical practices who have attested so far in 2011. They were about to face a penalty: they would have to comply with the (still unannounced) Stage 2 requirements in 2013. Under the old rule, providers who waited until 2012 to qualify for MU Stage 1 would have had until 2014 to comply with Stage 2.

HHS judged (correctly) that a significant number of medical groups and hospitals were postponing Stage 1 adoption to obtain an extra year for Stage 2 qualification.

It is important to remember that the final rules for Stage 2 standards have been hotly debated and are now scheduled to be unveiled in June 2012. We don’t know exactly what will be in the Stage 2 rules, although it is certain they will be considerably tougher than Stage 1.

I was at a HIMSS Southern California meeting on Thursday. One of the main presenters, the CIO of Cedars-Sinai, noted that the HHS had “misjudged” the difficulty of meaningful use. He said he welcomed the postponement because hospitals and medical groups face a “perfect storm” of deadlines with coming Stage 2 and ICD-10 deadlines, along with preparing for ACOs and other IT-intensive initiatives.

Although the PR messaging from HHS and the ONC has been consistently upbeat about the meaningful use program, the hard numbers show the MU program is off to a painfully slow start. Although more than 10,000 physician practices have “registered” for Stage 1, less than 500 had actually qualified as of September 1.