Health System Ed

The New York Times called attention to a horrific death in a NYC hospital earlier this month. It raised a plethora of issues about our right to privacy, as well as how, when and what types of technology, are appropriate to record patient encounters. And it is a pathetic example that calls our use of technology in healthcare on the carpet.

I won’t use any more adjectives. Here is a description by another blogger whose post called my attention to this, Glenna Crooks, PhD:

According to the stories, without their consent – in fact, without their knowledge – husband and father Mark Chanko was filmed for a national ER reality-show television episode while he received care. Until the segment was aired 16 months later, the family did not know a camera was present, that Mr. Chanko’s death was filmed and that the physician who delivered the news was wearing a microphone when he did.

According to the articles, their pleas rest on claims the hospital violated Mr. Chanko’s privacy and on those grounds, they may not win. The Chanko’s are not the only victims, though. The spirit of privacy protection laws like HIPAA may well become a victim to the letter of those laws and how they are interpreted by attorneys and the courts today.

Read Dr. Crooks’ complete post.

She followed this blog with another that enumerated the policy issues that this kind of invasion invites. I recommend it. Read it here.

Her questions demonstrate the wide range of legal and policy issues raised by this kind of behavior. I imagine years of lawyers’ time spent arguing these issues! But in my heart, this situation requires us to examine deeper issues, such as the dignity of the person and the nature of the doctor-patient relationship. The plethora of policy issues arising from this incident reveal how far we’ve left behind the humanity of the healing exchange. Now society is the arbiter of what some might still argue should be a private, personal and intimate situation – our health, our diseases, our dying.

My mind reels with the policy implications, but my heart hurts for our humanity.

Reality TV is a symptom of how harsh and undignified our culture has become, and nowhere is it more evident than in these most private moments. As I recall journalism school lessons from a time long ago and far away, this case seems to violate a basic premise that we were taught to respect the dignity of private moments, and leave them out of the news. There were certain things that stayed with the family, especially with people who didn’t meet the legal definition of public persons. Sometimes, depending on the situation, common decency required restraint even when people did meet those criteria. Has our Instagram culture made all of us public figures, eschewing legal definitions for all practical purposes? Have we unwittingly – or witlessly! – allowed ourselves to lose our right to privacy by our un-private behaviors?

From a pure health policy perspective, Dr. Crooks raises issues that need to be addressed. One layer deeper, as a human being, you have to ask yourself: How did we get here? I suppose if the state/government is paying the lion’s share of the bills and the health plan bears most of the risk, the piper gets to call the tune. In that case, the payers can require that it is all about the regulations.

As a patient, as the mother of patients, as the partner of a patient, as the daughter of patients, as a family member and friend of patients, I wish we had a healthcare system in which people could be assured that their personal health and well-being was the primary interest of their treatment team.

You know what they say about wishes – if frogs could fly, they wouldn’t womp their butts…

By Peggy Salvatore

Given the geometric pace of change, the electronic health record systems of today are horse-and-buggies rapidly in the making. The pace of recent change means that your typical EHR will not experience obsolescence from the amount of time it took to invent the horse to the time it took to invent the horseless carriage – which is a few millennia.

Actually, EHRs are horse-and-buggies in the making from the time of the launch of HITECH in 2010 to the discovery that Meaningful Use cannot be implemented along any timeline because it has become obsolete before it hit its deadlines.

Wearable technology is galloping way ahead of the pace of regulation, and its uptake is rapid. Fitbit was the big Christmas (or Hannukah /Festivus/Winter Solstice) gift this year. A friend is monitored 24/7 after cardio ablation surgery last week. Her doc can see every beat of her heart. If your healthcare provider’s electronic patient system isn’t recording all this information to learn about you and the state of your health, it is already obsolete.

One of my favorite books, Future Shock by Alvin Toffler circa 1970, chronicled some of the early intelligence on the pace of technological change and its effect on society. Fast forward, four decades. I spent part of this holiday break reading MONEY Master the Game by leadership guru Tony Robbins who dedicated a chapter to the incredible future of medicine and technology – and he pointed out that “The Future is Brighter Than You Think”.

When Toffler wrote the first edition of his classic book, Steve Jobs and Steve Wozniak were two college-aged geeks who hadn’t yet met. Fast forward 2014, and here are passages from Robbins’ book about the state of technology today:

• There’s…a “bio-pen” that allows surgeons to draw healthy cells on layers of bone and cartilage. The cells multiply and grow into nerves, muscle, and bones, healing the damaged section. The technology allows the surgeon to place cells wherever he or she wants them, in an instant.

• When (Easton LaChapelle) was 14, he decided to build his own robotic hand. Hey, why not? …he scoured websites like Instructables and Hack It! to teach himself electronics, programming, and mechanics. Then he used objects he had lying around – Legos, fishing line, electronic tape, small hobby motors, and a Nintendo Power Glove – to build a prototype. By the time he was 16, he had refined his design by getting access to a 3D printer and creating a mechanical hand out of layers of plastic…he met a seven-year-old girl with a prosthetic arm that cost her parents $80,000….So what do you think his new invention costs to make as opposed to the $80,000 limb…How about $250!

• 3D “printers” are actually minifactories that use computer files as blueprints to create three-dimensional object layer by layer. The printers can use at least 200 different liquefied or powdered materials, including plastic, glass, ceramic, titanium, nylon, chocolate – and even living cells. What can you make with them?…human tracheas, ears and teeth.
So, while we’re trying to get electronic health record systems to talk to each other from one healthcare provider’s location to another, inventors and even patients themselves are not waiting around to see how that works out.

Why are these stories important in a book about money? Quite simply, Robbins points out that as technology advances and proliferates at head-spinning speed, the costs of technological advances are coming down and the possibilities are growing geometrically.

By extension, while we fret about the cost of healthcare, the definition of healthcare is changing and the cost of the technology to achieve previously unimaginable levels of healing and wellness are dropping from unattainable to pennies a day.

By the time we get interoperability according to the regulations set forth by CMS, the definition of interoperability will most definitely have changed. And that, for my money, is a good thing.

By Peggy Salvatore

In the never-ending quest to balance the cost-access-quality triangle, the healthcare system led by the federal government has pursued many variations of payment incentives.

Pay more to get them to do it. Pay less to get them to stop. Only pay after the fact. Only pay before the fact. Only pay for certain incidents and don’t pay for other incidents at all.

The incentive dance continues. Accountable Care Organizations (ACOs) are the latest variation on the theme of incentivized payments with a healthy dose of disincentives thrown in just to scare you. CMS has just drafted rules holding off for three more years a disincentive plan that was scaring providers away from getting on board. To learn more, click here, here and here.

The bloggers, pundits and policy hounds are engaging in betting whether the ACO model has the potential to be viable and effective. Does pay-for-performance really work under the ACO plan? Will disincentives motivate them if the incentives don’t drive them to achieve accountable care?

A Rose by Any Other Name

ACOs, like its predecessor HMOs, and all the bundled and capitated models begat by HMOs, is about capping payment to achieve an outcome. Underneath all the reimbursement formulae is an accountant shifting the risk to providers to get them to control costs and still deliver all necessary care. In some variations of the HMO model, some savings were achieved by some organizations with certain populations and strong prior authorization in place.

There are policy purists who would disagree with my comparison of ACOs and HMOs and all the related sons-of-HMOs. As far as payment incentives and disincentives, ACOs walk much like a duck. What is wholly distinctive about ACOs is that it is a model derived in an environment where the data exists to be much more precise about outcomes and the ability to calculate payments.

That said, ACOs have the potential to achieve their full potential when all the systems are in place to deliver both real-time patient data to treat the patient in front of you and retrospective data to decide if the methods to treat achieved their goals.

Until then, providers who buy into the ACO game are doing it with one eye covered. Most of them understand that they are data-challenged, so they either have opted out of playing or, if they are particpating, about 95% have agreed to partake in the incentives but declined to play the disincentive game just yet.

Accountable to Whom?

The true value in Accountable Care Organizations lies in the premise that ACOs make providers accountable to ensure that patients get the very best outcomes. The value does not lie in providers having to prove to regulators that they have provided adequate care in a way that saved dollars.

When ACOs are focused on the patient to whom they are truly accountable, the cost savings are likely to follow. That will best happen when all the data is available in real time, and trackable retrospectively, to provide high-quality care wherever the point of care may be.

By Peggy Salvatore

The changes at CMS have been stunningly breathtaking over the past few months, particularly those related to health IT.

The top two biggies are personnel and mission refocus at the very top. Those high-profile changes signaled this most recent development which is the establishment of the Office of Enterprise Data and Analytics or OEDA (let’s pronounce it “oh-da” until we hear otherwise).

Niall Brennan is the First Chief Data Officer at OEDA, and the first best thing about Mr. Brennan is that they did not make him our First Data Czar. I was relieved about that. The title “Chief Data Officer” sounds more like a military assignment for someone in a position of responsibility and accountability. It’s likeable and trustworthy, and the title gets my vote of confidence.

The man even more so.

Mr. Brennan comes over from the CMS Office of Enterprise Management where he was acting director. According to the CMS Leadership website, he oversaw “a number of efforts related to data, e-health, business operations and project management across the CMS enterprise.” Before that, he was the Director of the Office of Information Products and Data Analytics “where he oversaw agency efforts on data storage and dissemination, analytics and the creation of information products.” And, oh by the way, CMS picked him up from the Brookings Institute where he “directed a range of efforts to better measure both the quality and cost of healthcare. And there’s more impressive stuff in his CMS bio which you can see here. He knows the terrain; in fact, it sounds like he was in charge of a good piece of the terrain outside the public eye.

The Mission

HealthData Management’s Greg Slabodkin interviewed Mr. Brennan who explained:

OEDA, which was formed last month by CMS to improve data collection and dissemination, is the “culmination of how the agency has been increasingly placing data and analytics as part of its core mission” as it has “evolved from a passive payer of claims into a value-based purchaser of care” over the past couple of years. With significant growth in the volume of CMS data and data users—both internally and externally—ensuring that the data is timely, relevant and accessible is critical, he argues.

The HealthData Management interview explored the current state of data within CMS, and the challenges and the goals for use of the data. It also defined one Mr. Brennan’s – and the healthcare system’s – greatest challenges: data integrity.

“We’re absolutely committed to transparency, not only transparency but also accuracy. There’s no point in being transparent if your numbers aren’t accurate,” asserts Brennan. “These are generally early days for transparency in healthcare and we are at the forefront of that effort. It’s not entirely surprising that if you look across our entire suite of publicly available products that some may not check everybody’s box of what actually constitutes useful information. We’re constantly striving to make our publicly available datasets better.”

Data integrity is critical for Mr. Brennan, CMS, providers and payers to do their jobs – that is to provide the best treatment, the first time, at the lowest cost, consistently for the patient. In fact, ECRI just released its annual Top 10 Technology Hazards for 2015 . Once again this year, alarm hazards topped the list. But right up there at #2 was Data Integrity; Incorrect or Missing Data in EHRs and Other Health IT Systems.

A big piece of getting data integrity right is making sure that the technology is integrated seamlessly into the workflow. Mobile devices and the many wearable, wireless technologies are beginning to make data available in real time and in real world settings. Data integrity is more than a panacea; the pieces are beginning to fall into place as the engineering catches up to the way we live and the way we interface with our healthcare system.

Between Mr. Brennan’s extensive understanding about parsing the data to achieve value and advances in collecting accurate data, it’s an exciting time, and Mr. Brennan quite possibly has one of the most central positions in making possible the world we will live in tomorrow.