Top Ten Reasons Why Electronic Medical Records Are Here to Stay

Electronic medical records (EMRs) are a hot discussion item these days. Their widespread adoption is seen as critical to higher quality and more affordability in health care. And while I don’t want to underestimate our national collective ability to screw things up, I think we have a good chance for some success on this one. So in order to make a point I want to offer up my “Top Ten Reasons Why Electronic Medical Records are Here to Stay.”

  1. EMRs are in just about every presidential candidates briefing book on health care. (‘cept maybe Fred Thompson)
  2. Medicare, Medicaid and federal employees want them. (the feds can’t get enough of this stuff)
  3. Private health plans want them. (finally getting on board!)
  4. The technology industry wants them. (big, big bucks to be made here from deep, deep pockets)
  5. Walmart wants them. (new Wally Mart clinics supply-chain management tool)
  6. Newt Gingrich wants them. (big neo-con transformational to-do item thingie)
  7. India wants them. (lots of data-entry workers to employ)
  8. China wants them. (needs one unbelievably ginormous system)
  9. Consumers think they want them. (like iPods!)
  10. Doctors don’t want them. (usually a good motivator for the rest of us)

Given these most excellent reasons, how can we miss?

Medical Errors Study Results Delayed

In December of 2006, the Public Library of Science (PLoS) published in its peer-reviewed open-access online journal a study on medical errors sponsored by the National Institute for Occupational Safety and Health (part of the US Centers for Disease Control) and the Agency for Healthcare Research and Quality. The study found that sleep-deprived medical residents and interns reported higher incidents of medical errors, some resulting in the deaths of patients.

While the results are not surprising given previous research cited by the authors, the study apparently motivated the U.S. House Energy and Commerce Committee to launch an investigation into preventable medical errors and whether overly long work shifts and sleep-deprivation among physicians, medical residents, and interns are causing serious threats to patient safety, according to an April 11 statement.

All this attention is quite necessary if we are going to get the country to focus on the problem. Even though the study had its limitations (appropriately noted by the researchers) it served its purpose. But what caused me some concern was this little line in the notes appending the article.

“Received: January 5, 2006; Accepted: September 29, 2006; Published: December 12, 2006″

This article — one dealing with errors possibly leading to deaths, and one that has had a national impact — took over 11 months to see the light of day. I know, I know, this not a new issue, and there are all sorts of reasons why this kind of delay takes place including the nature of the peer review process. Journals continually have to be on the lookout for poor quality studies, significant findings not reported and even medical research fraud. And, the PLoS does makes a great contribution to the distribution of scientific knowledge. ( I also do applaud them for showing us the metric here). But given the extraordinary talent and information technology we have in the medical industry, we should be able to do better than this. The review process needs to be examined and rethought. There was a time when this kind of delay for publication was normal and acceptable. That time has passed. Welcome to the future.

500,000 Die Annually in China from Hepatitis B

Previous postings (here and here) have pointed to incidents of social discrimination against persons with Hepatitis B in China. Today we see the report that of the 120 million Chinese who have tested positive for Hepatitis B, nearly 500,000 die annually, according to Wang Zhao, head of China’s Hepatitis Prevention Foundation.

With these kinds of numbers, the mounting evidence of social stigma should be a cause of even greater concern. People fearful of the consequences of revealing their illness will often avoid whatever care and treatment options they have available to them. This is a challenge not only for China’s health authorities, but for the world at large, since infectious diseases such as Hepatitis B do not respect our cherished national boundaries.

Obama Moves Cautiously on Health Care

First an admission: Hawaii (where I’m writing from) has a special connection to Barack Obama. He was born here in 1961, left for a while, and then returned at the age of 10 to attend Punahou School, a private school (where my own son attended). So if I am less than critical about his candidacy for the Presidency or on his positions, just chalk it up to a friendly local bias. But putting that confession aside, and stating for the record that I’m not necessarily or unconditionally a fan of his, I think Obama is approaching health care in exactly the right way.

Let’s do a quick review of the facts. Over the past few months in stump speeches from New Hampshire to Iowa, Obama’s been clear that he wants affordable health care for all Americans. At the same time he’s been cautiously working–or at least saying he’s working–to forge a national consensus. He’s noted “that in previous campaigns, presidential candidates have offered detailed proposals without building that political support, only to see the issue fade after the election.”

Commentators have been trying to figure him out, feeling that maybe this is a simply a feigning to the right, and that his single payer sympathies will eventually win out. Others think him hypocritical, or worse yet, hopelessly naive.

But I’m going to take him at his word–that is he is genuinely trying to come up with a national approach we can all get behind. My view is that Obama is smart enough to see health care is just too important to quickly jump to the traditionally divisive and ideological “partisan” solutions.

At least I hope so. The proof of this leap-of-faith will be in how quickly he comes to a policy conclusion, and what that conclusion is. Should he waffle, and decide to fall on the single payer sword, let the bells ring and the boxing begin. But let’s all hope his pragmatic approach reframes the national debate, and moves the country to a national policy for the uninsured that provides excellent coverage and doesn’t break what’s right about the existing system. The country, Hawaii and Punahou deserve no less.

The Coming Consumer to Physician Disconnect

“Consumers want physicians to provide more cost and quality information than they are willing or able to offer.” That’s one conclusion from a Harris survey of consumers and physicians sponsored by Booz Allen Hamilton. Survey respondents also indicated they were dissatisfied with the quality and cost information they do get, and that they also expected doctors to compete on quality.

Physicians mostly agreed with consumers that they would be competing more on quality of care in the future. Yet according to the doctors surveyed, few intended to make available the quality and cost information patients want, or use it themselves when referring their patients to other physicians.

This emerging disconnect between consumers and physicians is showing up again and again. Now, consumers may still insist “on the right to choose a poor-quality physician” (WSJ  subscription required), but they are becoming less tolerant of being in the dark when serious health issues are involved. Partially, that’s because they are continuing to read media reports like this new study by HealthGrades, an independent health care rating organization. Their research revealed about 1.2 million hospitalized Medicare recipients experienced preventable medical errors, amounting to nearly a 3 percent incident rate during 2003 through 2005.

The challenge for health care reformers will be to negotiate a new social contract between patients and physicians to bridge this widening chasm.These tough discussions will prove vitally important to the future of quality health care.

On Covert Philosophers and Marxists

I’ve found out lately that a number of people I know in health care were philosophy majors in college. Probably not unusual, but certainly interesting. They often reveal this charming little secret surreptitiously, first in slight hints, such as a brief quotation by Hegel (or other classic sages) murmured under their breath. It’s just a quick quip, mind you, not meant to call attention to itself. But if you choose to pick up on it, then a full and revealing confession often follows. Some seem embarrassed by being flushed out in the open this way and I can understand why.

Once upon a time, as a college student, they had eyes opened to a journey that promised the intellectual keys to the kingdom. Along the way something happened and that something led them to here, the present. But deep down, they still cling like an adolescent lover to that first rush with PHILOSOPHY. Often mixed with this practiced admission is a grudging recognition of the status of philosophy in the “real world”, which is to say, zero. Thus, the slight embarrassed shyness that accompanies the tale.

My own student background was in political THEORY, which I’ve always considered to be a kind of blue collar philosophy. So I sympathize with the confessions of our more philosophically-minded members of the health care community– especially when a quiet remark about the “petit bourgeoisie” reveals their inner Marx.

But I was recently reminded that philosophy and theory are still quite important, especially when they conspire to dethrone PHILOSOPHY and THEORY. This reminder came in the form of some rather comic reflections on French philosopher Michel de Montaigne by Alain de Bottom (see my earlier post). Although quite learned, Montaigne held the contrarian position that if we allowed GREAT BOOKS to “define the boundaries of our curiosity,” they would hold back the development of our minds. These authors were “too clever for our own good,” having said so much that they always “appeared to have had the last word.” They inhibited the “sense of irreverence vital to creative work in their successors” (that’s us). Thus, after the GREAT BOOKS, everything else is just notes in the margins.

“There are more books on books than on any other subject: all we do is gloss each other. All is a-swarm with commentaries: of authors there is a dearth.”

And this was written in the 16th century.

Pondering these issues got me navel-gazing about blogs. In the health care blogosphere, we have our great THINKERS. And although constantly discussed, they find little respite from critique. Blogs are definitely “a-swarm” with irreverent commentary, much of it by everyday folks. Montaigne would have liked that:

“Were I a good scholar, I would find enough in my own experience to make me wise.”

“We are richer than we think, each one of us.”

On the other hand, much of this discussion occurs in an echo chamber, so we are still subject to his lament that “of authors, there is a dearth.”

But I’m comfortable with that. The scale of the healthcare blogosphere is so huge, that it’s sort of like Little League for writers– we are nurturing a few truly great players out there. These blogs are a training ground, of sorts, where “many are striving for wisdom, but never far from folly.”

Internists Survey: Majority Oppose Public Reporting of Quality Scores

Physician resistance to public reporting of their quality performance scores remains high and will be a continuing obstacle to health care transparency and reform. (see my earlier post). Lawrence Casalino (University of Chicago) and colleagues reported in the most recent issue of Health Affairs (subscription required) on their survey of 556 general internists from across the country about pay for performance and public reporting of quality scores. They indicated that “although a large majority of respondents supported financial incentives for quality, a large majority opposed public reporting, especially reporting of individual physicians’ performance.” More specifically, only one third supported public reporting of individual quality scores while slightly more (45 percent) supported public reporting at the medical group level.

While they can’t explain this resistance, the researchers speculate that “it is possible that respondents believed they were unlikely to lose much from having financial incentives for quality but feared that a poor public quality rating would be humiliating and might lead to losses of patients and of peer approval.” No kidding. And yet this sentiment describes exactly the motivational forces that policy wonks believe will drive the future of quality improvement in health care.

Note to my internists friends: Sure there are probably reasons upon reasons to question current quality measures. But come on guys, fundamentally you got to get on board with this. The demand for transparency is not going to go away. Get over it.

Top Ten Reasons Critics Say “Value-Based Competition” in Health Care Won’t Work

Or, Why You Can’t Get There From Here.

The blog debate continues to rage over the arguments in Michael E. Porter and Elizabeth Olmsted Teisberg’s book, Redefining Health Care. For the uninitiated, these authors argue that health care reform should be about ensuring market competition that focuses on three principles: 1) the goal is value for patients. 2) medical practice should be organized around medical conditions and care cycles, and 3) results — risk-adjusted outcomes and costs — must be measured.

Distinguished policy wonks on the Health Affairs Blog have come out in force on the book over the last several months including James C. Robinson, Uwe E. Reinhardt, Alan Maynard, and Gail R. Wilensky. And they’ve been followed by notable contingent of commentators on related issues.

After digesting the book for a few months and taking note of the blogging frenzy, I’ve come up with my own “Top Ten Reasons Critics Say ‘Value-Based Competition’ in Health Care Won’t Work.” So here goes:

  1. Their ideas are too politically naive and not realistic. (A conversation stopper by reality insiders.)
  2. Health care is way too complex for these notions to work. (So many variables, so little time.)
  3. The private market can’t and won’t do it. (What does Enron and single payer have in common?)
  4. Fees and incentives rule provider behavior, not value. (We all know that right? Right?)
  5. Health results are really damn hard to measure. (Gosh, this is tough!)
  6. They don’t appreciate the conditions under which real health care decisions are made. (Emergencies don’t wait. But colonoscopies?)
  7. The Medical Industrial Complex really doesn’t care about this adding-value-to-health-care crap. (O, ye of so little faith.)
  8. The docs will never buy into value-based competition. (See #4.)
  9. Consumers aren’t demanding value-based competition anyway. (Patients don’t read the memos or anything!)
  10. Authors are annoying carpet-bagging Harvard professors too new to health care to be taken seriously. (Who do these guys think they are?)

There are other criticisms floating around but these top ten go a long way to persuade me that Porter and Teisberg must be on to something. Stay tuned.

The “Nothing-left-to-lose” Edwards Iowa Campaign

I’ve been encouraging people (see earlier post) to keep an eye on Salon’s Walter Shapiro who has been closely following the Edwards campaign. He’s noticed the candidate’s appetite for political risk has changed. Says Shapiro: “since Elizabeth’s heartbreaking diagnosis, this is truly the nothing-left-to-lose campaign. Whatever his ultimate political fate, John Edwards is unlikely this time to end up with regrets about being too timorous a candidate in the race of his life.”

Asked by Shapiro why things had changed Edwards pointed to the deterioration of everything from the Iraq war to the “dysfunctional” health care system. Watch out–this may be the campaign that shakes things up a little. Edwards’ credibility in health care is growing and drawing crowds in Iowa. Since he’s just put some meat on the bones of his universal health care proposal, there’s something for voters to chew on as well.

West Funds China Health Care Projects

Beijing, China — Two financial contributions of note mark the increasing support of China’s health care reform from western sources. The German corporation Siemens kicked off a $10 million, five-year rural health care project in China on Thursday. The project will be rolled out in Yan’an, Northwest China’s Shaanxi Province. Siemens will equip the county-level hospital with a full range of diagnostic imaging equipment including ultrasound, X-ray and CT machines. The project is part of Siemens’ contribution to the Clinton Global initiative to support the development of poorer areas in emerging countries

On another front (see my earlier post), the “Toward a Smoke-Free China” public campaign has been launched with $125 million donated by New York City’s Mayor Michael Bloomberg. The two-year campaign will be run by the Chinese Center for Disease Control and Prevention (China CDC), Peking Union Medical College, the Johns Hopkins Bloomberg School of Public Health and will cover about 20 pilot provinces. The day following the announcement, The China Daily, which often communicates the Chinese government’s position on public issues, came out with a strong editorial supporting smoking “eradication”. The editorial focused especially on children.

“Can we expect our children to do as we say when we continue to smoke? Will schoolchildren trust their teachers when they tell them about the harm of smoking in class but drag hard on cigarettes after class?”

Private sector projects like these demonstrate the possibilities when world attention is focused on China’s critical health care challenge. Let’s hope they continue.