Monday, September 28, 2009

A Conversation with Dr. Pandey on Healthcare Transformation

Dr. "Ravi" Pandey is president of BIPRO Inc., a consulting company, which focuses helping organizations across the globe to achieve sustainable growth in performance and consumer satisfaction. He is an expert in performance improvement and strategy, and has strong ideas about healthcare reform, which he expresses on his Healthcare Transformation blog.

I've known Ravi for over a year and respect his intelligence, knowledge, experience, and dedication. We engage in weekly discussions about key issues focused on transforming our healthcare system. Following I reconstruct a conversation we've been having about healthcare policy and strategy.


Dr. Beller: What are your thoughts about the healthcare reform debate these days in our country?

Dr. Pandey: Oh, don't get me started on it. I was very optimistic earlier. Now I see lots of talk but no substance. If we can pull off something meaningful, it would be a miracle. I mean, think about it, we don't even have a clearly defined goal? What would an ideal healthcare system be? And yet we are already arguing about cost.

Dr. Beller: Some people believe that you should know the cost first, so that you can decide what the goal should be. What's your take on it?

Dr. Pandey: It is all tricks to confuse and distract us from the real issues. How can you talk about cost unless you have a clear vision of the goals and the effort needed to achieve them? When I say goal, I don't mean it in terms of universal healthcare, or single payer, co-ops, or anything like that. Instead, let's say our goal is to achieve world-class healthcare; then what does it mean? We need to clearly articulate that. Then, we can debate about how to achieve it.

All this discussion about cost is premature...It's a silly discussion to have at this time. Let me ask you this: We all agree that our healthcare system is too expensive, correct? If that is the case, then wouldn't spending more money make it more expensive? We already have the money, we need to utilize it better.

Our healthcare system costs 30-40 percent more than it should. By the way, this I also heard on CNBC program. Sen. Frist was saying the same thing that we have about 1/3 of money is wasted. That's more than 700 billion dollars of waste. This is not a cost issue. It is an efficiency, policy, and management issue.

Dr. Beller: We'll come back to this cost issue later. Let's focus for the time being on the policy and politics. Lots of people are saying that the government can't do anything right. If they run healthcare they will screw it up, too.

Dr. Pandey: Again, that is just a scare tactic. We should ask those people if they are living in the best country in the world or not! WE are the government. If government is not good, we have made it that way. I mean the federal government is one of the biggest employers. Many of us Americans are working there. Now if we say it is unproductive system, then we are basically saying that many of us are no good and are wasteful.

I also think we beat up the government for everything. Let me ask you this, which of the following has given demonstrated spectacular performance Enron, AIG, WorldCom, the Big 3 auto makers, private health insurers? I have seen the private sector up close and personal. I am not sure if their performance is anything to boast about..

Dr. Beller: So, are you saying we should have a government controlled healthcare?

Dr. Pandey: No, that's not what I'm saying! I have expressed my own ideas in bits and pieces on my blog, the Healthcare Transformation.

When it comes to healthcare reform, what I see now is more of a patchwork being done. It is not a reform bill and it is not a healthcare for all bill. Instead, it's a "healthcare for more bill"... more people and more money. Secondly, there is too much finger pointing and distortion. That's because our system is built upon adversarial forms of competition. Unless you create a law where no one can provide misleading information, insurance companies, the AMA, hospitals, big pharma, and medical device manufacturers have the power to derail the whole thing through blame shifting and misinformation. Remember the ads in 90s against healthcare.

For any healthcare reform to work—which I would rather call "healthcare transformation"—we need to create a system that takes into account the needs of everyone, including patients, doctors, insurers, etc. This can be done by creating a competitive collaboration.

Dr. Beller: What do you mean by "competitive collaboration?"

Dr. Pandey: In a traditional sense, when we compete, we not only try to do better, but also we try to hurt the competition. Creating a public option to compete with private sector insurers could do that. There's another way to slice the market. Let government be more focused on wellness care. The PCPs [primary care physicians] would serve as health managers, that is, they would focus on managing their patients' health…keeping them well and making sure they get the right care when sick. There should use evidence based guidelines and use performance metrics, such as a wellness index, that measures care quality and cost. And the insurance industries could provide the supplemental insurance.

In that way we are not competing, but complementing the market needs. This is what I call competitive collaboration. You work together to succeed by leveraging each others strengths. Not by undercutting each other.


Dr. Beller: Back to the money issue. If we do what you said earlier and define the goal of healthcare transformation, will there be enough money to pay for it? Where will that money come from?

Dr. Pandey: Of course there is. Let's start with administrative cost for insurance management, the cost of treating over a million avoidable injuries, malpractice premiums, over-testing and excessive treatments, under-utilized capital, and so on. In addition, insurance administration and profits add up to 30% of the premium payments, compared to 3% that Medicaid and Medicare spend. There's plenty of fault and inefficiency to go around and hospitals have too many managers and bureaucracy, which means there is huge opportunity for productivity improvement.

Additionally, I heard this guy on CNBC panel discussion say that if you can create a wellness program and reduce people's weight to pre-1991; it will save about a trillion dollar. I am not sure where he is getting his numbers from; but there is at least conceptual validity to his argument. He was also quoting about some study that a Japanese ethnic group is twice more likely to get cancer in US than in Japan. It's due to our eco-system and life style.

So, I think money should be the least concern. What we need is to define clear strategies. I bet you could achieve all the objectives and still save some money.

Dr. Beller: How do you suggest this be changed in order to create an efficient healthcare system that works?

Dr. Pandey: The people working in healthcare system cannot change it. It is not about their competence, it's about a system that has become incredibly complex. We have to redesign the system.

I mean healthcare is a relationship between doctors and patients. You improve their productivity by using nurses and technicians. Then you might add some diagnostics equipment. Would you not think everything else is a waste? It is a simplistic view to make a point. However, what I mean here is that these are the logics you can use to see what should be the cost of an ideal system. There's your benchmark then.

Dr. Beller: But wouldn't productivity be more greatly improved if those doctors knew how to deliver the most cost-effective care and were rewarded for doing so?

Dr. Pandey: Yes. That is the reason I was talking about creating a new system that incentivizes the right behavior. And we need to spend resources on research. You know that we do not have enough information to individualize medicine. We launch a product and often times we find months later that it needs to be taken off the shelf. Why are we failing? Where are we failing?

A major burden is not on doctors, but on the pharmas. They should be doing their research properly. Doctors prescribe based on what they have been told. So a better correlation between medicine and an individual will improve the care delivery effectiveness. I think though it is long way away.

Dr. Beller: What about health IT and informatics?

Dr. Pandey: They have a big role. However, these are only platforms. Unless we changed the process and behavior, the IT will only accelerate the bad things. I have been a big critique of most of the products being sold today. I was glad to see recently an article where Dr. Blumenthal's office was quoted as saying that the current EMRs are not up to the standard since they do not take into account of the needs of the stakeholders.

In my view, these products are piece-mealed together. In a sense, they were developed and then people tried to fit them to meet the healthcare industry's needs rather than understanding the needs and then developing the software. There are lots of horror stories about implementing informatics products. To be fair, we also need to improve the quality of processes and project management. We will succeed if we first focus on building the process frame work for healthcare delivery and management. And then create IT products to automate it. Right now we just keep on adding functionalities in existing products and it keeps on getting worse and worse.

Take the example of EHRs and PHRs. Why do we need two systems? It creates unnecessary confusion and duplications. Personal health, as you know, is a combination of genetics, medicine, habits, environments, etc. So if the solution to wellness is a holistic approach, then why not create systems that support the holistic needs.

I think a great system that can be implemented with relative ease and can be developed in about $1 billion or a bit more. Over $20 billion being allocated by the white house will end up in the same hands that have spent years to develop a non-workable system. They are smart, but they do not know how to get out of the maze that has been created. IT culture of product development isn't suited for product design for healthcare industry due to its critical nature. They need to bring some outside experts to help develop their products. When MS Window crashes, it is not a big deal…but you do not want those kinds of issues. Our IT system has to transform its own attitude towards product quality.

Dr. Beller: How would you summarize what should happen?

Dr. Pandey:

  • Create a clear definition of ideal healthcare system. And create strategies around that.
  • Create a culture for healthy living.
  • Improve the quality and efficiency of medical research.
  • Demand a cost reduction of over 30% across the sector.
  • Create a tiered system of coverage...basic provided by government and advanced through private insurance.
  • Implement a new system for handing malpractice claims.
  • Scrap the entire health IT system and will save tons of money.


This concludes the first part of our discussion. Check back for more.

Evidence-Based Practice and Psychotherapy

An e-mail recently sent to members of raised three questions about the implementation of evidence based practice (EBP) in the field of psychotherapy.

As a clinical psychologist and health IT inventor, I've been focused on this issue for the past 25 years. In the mid to late 90's, there was heated debate about psychotherapy outcomes research and the science of EBP. I argued that such research and EBP implementation are essential if our field is to become increasingly cost-effective (i.e., ever higher value to the patient/consumer), but I was condemned by those believing that psychotherapy is more of "an art than a science," as well as by those rejecting the clinical use of computers.

Following is my reply to the three questions.

1. If change at the provider organization is key, how do we increase systematic approaches to EBP implementation?

First you need by-in by practitioners and organizational leaders. Based on my past experience, this won't be easy. Next, collaboration between clinicians, researchers, patient/client representatives, and health IT technicians is important. The focus of such collaboration should be on defining meaningful measures of treatment efficacy and convenient ways to collect data in everyday clinical practice (as well as in controlled research studies).

Consider that in an APA Monitor (10/93) article, Robert Perloff, a past president of the American Psychological Association, described his "dream of a clearinghouse where clinicians can report observations and hypotheses and give ideas to researchers, who design clinical trials the practitioners can use. Electronic communications with computers and telephones could be used, and the whole project would be in the public interest." Sixteen years later, this vision remains unrealized!

2. What provider systems are 'best in show' for effective implementation of EBPs?

I claim that it is too early to select best in show systems since objective #1 has not been achieved. Nevertheless, what we need are low-cost, convenient, secure, and useful health IT systems that collect and analyze comprehensive biopsychosocial data (that take into account one's physiology, psychology, and mind-body connection). This data collection and analysis ought to be done at the beginning and end of treatment for assessing outcomes of different patient/client cohorts (groups), as well as periodically during treatment to assess care processes. The information on each patient resulting from these analyses should be presented to the practitioners and patients in a manner that fosters effective and efficient treatment planning and delivery. In addition, predetermined data sets should by de-identified (to protect patient privacy) and shipped to research organizations where they are aggregated, studied, transformed into evidence-based practice guidelines, and disseminated to the practitioners and patients in understandable language. And there should be ample opportunities to study novel therapeutic approaches.

I know how to do this technologically, but technology alone cannot create and evolve the guidelines.

Consider that in an APA Monitor (5/94) article entitled, "Outcomes Measurement is Debated by Profession," Michael Lambert, Ph.D., professor of psychology at Bringham Young University, found that " in 348 outcomes studies done over a period of five years, researchers used 1,430 distinct outcome measures 840 of the measures only once." This, the article went on to say, makes it difficult to compare studies, creates " an atmosphere of 'chaos,'" and evidences a great need to " find the most sensitive way of measuring change." In the same article, Larry Beutler, Ph.D., professor of education and psychology at the University of California, Santa Barbara, underlined the importance of " developing consensus on what to measure and what criteria tests should meet to ensure compatibility of [research] results."

Yet, some 15 years later, we're back to having the same discussion!

3. In an era of resource constraints, how do we change reimbursement to support the implementation and continued use of EBP?

For one thing, practitioners and organizations ought to be compensated for collecting the data and using the information they yield to guide clinical decisions. Second, practitioners and organizations delivering high-value services--cost-effective care (higher quality at lower cost)--ought to be paid more than those providing lower-value care.

This is easier said than done because we simply don't know what treatment approaches are of greatest value to particular patients. The situation hasn't changed much in the past 15 years. Consider the following:

The issue of treatment decision-making was addressed in an APA Monitor (10/95) article entitled, "What Treatments Have Proven Effective," in which David Barlow, Ph.D., head of the Phobia and Anxiety Clinic the State University of New York at Albany, said, "We are far from the notion of specific treatment for specific problems."

In a Consumer Reports Magazine (11/95) article entitled, "Mental Health: Does Therapy Work?," a survey of four thousand readers yielded mostly favorable results. These findings, however, were marred by the fact that they could not answer the question, "When a person needs psychotherapy, how much do they need?" According to the report, "That has become a critical question both for clinicians and for the insurers that pay for therapy. And it's a hard one to answerWhile brief therapy often helps, there's no way to tell whether 30 or 40 sessions, or even more, would be even more effective."

Bottom line

Meaningful change doesn't come easily. There are many things that can be done to continuously improve psychotherapy's value, but widespread resistance can only be expected, and a good deal of work is required to hammer out the details. In the long run, practitioners and organizations who embrace the effort will come out on top, and so will their patients.

But is the mental health field up to the challenge? I really don't know!

American Values and Healthcare Reform

Chris Fleming of Health Affairs recently posted and article about American values and health reform at this link. In it he writes:
During the current health reform debate, both Democrats and Republicans have often made their case in terms of values such as liberty, justice, and equality…philosopher Paul Menzel…argues that this apparent conflict between justice and liberty can be addressed by considering liberty "in its fullest context, bound up with responsibility – where both are connected to fairness and justice."…[And Thomas Murray, Hastings Center president] argues that"…simplistic understandings of values are deceptive and harmful to private insight and public discourse. Liberty, properly understood, is not the opposite of equality; justice, not the opposite of liberty; and responsibility, both personal and social, is crucial to the full realization of liberty and justice. Efficiency, an instrumental value rather than an end in itself, is intimately related to quality, solidarity, stewardship, and justice. Core American values, rather than existing in ineluctable tension with one another, form a sturdy, mutually reinforcing foundation for health reform."
I agree that personal and social responsibility, liberty and justice, efficiency and quality are (or at least should be) core American values that guide the healthcare reform debate. They fit in perfectly with the four criteria and eight objectives for judging how likely any government policy will create a sustainable healthcare system, which I wrote about last week at this link. And they are consistent with an article I posted last month at this link about a principled and pragmatic approach to healthcare reform that emphasized empathy and compassion.
Related posts:

Thursday, September 24, 2009

Personal Responsibility: A Thorny Issue in Healthcare Transformation

In my last post—Criteria for a Sustainable Health System—Cindy Weinmann made this excellent comment about personal responsibility.

Principles are interesting and to an extent transparent to systems. But focusing on individual responsibility has to take into account societal context of that responsibility. Want people to eat better diets and exercise more - well, Americans lose over 40 hours of vacation a year because they're afraid to take time off from work; average American commute is 3 hours. Add that up and you have a lot of stressed out Americans eating dinner in their cars - a recipe for hypertension, obesity, cancer, and heart disease. Oh wait! Isn't that part of the problem? I don't hear anyone agitating for more vacation days and shorter work hours!

Just as important might be: reducing the 50% of health care costs attributable to waste, according to Price Waterhouse Coopers - out of $2 trillion plus - over $1 trillion wasted. About the same as insuring everyone, huh?

As Cindy points out, personal responsibility is a thorny issue. I've written about this several times in the past, including these four blog posts:

In the first post (Apr. 2007), I discussed the dilemma modern consumers confront in this era of "personal responsibility" by presenting three stories about the difficult position patients and other consumers face: One has to make difficult treatment decisions when there are no clear-cut answers, another has to decide on a health insurance policy from among dozens of confusing alternatives, and a third is being treated in a trauma center after a catastrophic event. The conclusion:

…consumers need valid, understandable information about the risks, benefits, and costs of different treatment options. But often that's not enough. Consumers also need the motivation, resources and skill to comply with chosen plans of care. In other words, they must be mentally, emotionally and physically able and willing to carry out their healthy living strategies, and do it effectively and efficiently.

Obtaining the needed information can be difficult because information found on different web sites, instructional pamphlets and expert opinions often offer conflicting, inadequate, irrelevant, unclear, and/or invalid information.

In the second post (Sep 2007), I followed up on a discussion that offered answers to the questions: Who is worthy of having adequate health insurance and high-value (safe, cost-effective) care; what makes them deserving? And who, on the other hand, is unworthy; what makes them undeserving? Following are excerpts from a subsequent conversation with a reader who commented:

Everyone deserves unobstructed medical attention for illness and injury; curable, chronic, and/or terminal. In that I see an absolute fulfillment of the constitutional mandate to see to the 'general welfare'. One step beyond that is preventive care, more opinionated and intellectually based; but I none the less would consider that the 'general welfare'. Every other service for everyone associated as medical service should remain privately financed and marketed (like child bearing and voluntary procedures).

The critical issue within that position is how to deal with self induced health impairments. This health class should have a name, definition, and social remedy. Let's call it IHIs. It's tough because it's smoking, poor diet, drug addiction, STDs, poor dental care, high risk sports, etc. I'm thinking IHI classification puts an individual into a special insurance category requiring addition premium or mandatory savings both during and for some time after such circumstances.

I replied:

Yes, dealing with the kind of self induced health impairments (IHIs) is a thorny issue.

A logical case can be made for having those with the financial means pay out of pocket for at least a portion of treating health problems clearly determined to be voluntarily induced. That is, delivering care to people with adequate maturity, knowledge, intelligence and rationality, but who make a conscious decision to engage in high-risk behaviors and suffer the consequences, would cost them more, so they are held accountable for their actions.

Unfortunately, many (most?) of these people are either (a) immature (e.g., teenagers enticed by tobacco and alcohol marketing, as well as peer pressure, and then get hooked); (b) ignorant, confused or unintelligent (they don't fully realize or understand the risks of eating too many greasy french fries and failing to exercise regularly, or they have trouble self-managing a chronic condition requiring a complex medication regimen and lifestyle changes); (c) irrational (e.g., they deceive themselves into believing they can stop taking drugs, or they are self-destructive due to a psychological problem); or (d) they lack the funds and support needed to live a more healthy lifestyle (all their time is taken working day and night at minimal-wage jobs, or they lack affordable transportation, to visit the dentist every 6 months, or they can't afford fresh fruits, vegetables and lean meats when pasta is a fraction of the cost). Or, they just might be unlucky (e.g., the got an STD because the rubber broke).

In other words, this is a complex issue and a great deal of thought should go into defining the conditions for the kind of punitive costs you propose.

Also consistent with your suggestion would be a policy of taking punitive action against the manufacturers, distributors, retailers and marketers of unhealthy foods and ineffective medications and supplements. And what about tobacco companies and alcoholic beverage producers who promote their products to college students, and even the promoters of dangerous sports?

It seems to me, therefore, that establishing a reasonable two tier system--one for folks who self-manage their health effectively and another for those who don't--is a daunting task, but one worth examining.

In the third post (Nov. 2007), I wrote:

Turing to personal responsibility. People who abuse drugs or alcohol start do so for many reasons--often due to psychological problems, bad living environments, genetic predispositions, family problems, marketing & advertising influences, peer pressure, our society's worship of short-term hedonism and self-indulgence (conspicuous consumption that drives our form of capitalism), and other such factors related to human frailties. And these folks tend to start down that negative path when quite young and more susceptible. A similar case can be made for smokers and even obese people. This doesn't "excuse them" for their poor decisions, but it does explain why humans sometimes act foolishly. That is, there's a heck of a lot more to it than can be attributed simply to "personal choice," like choosing a Coke over Pepsi (or visa versa). What we should be doing is working to change the things in our culture that precipitates such self-destructive behaviors, providing more effective psychological and rehabilitative services, investing more in preventive care and ways to motivate adherence to healthy lifestyles, etc. I find it rather heartless to say: "Too bad…it's your fault you're sick and can't afford excellent healthcare…we don't care why…but since you can't afford it, you don't deserve the same level of care that I do!"

Now, I'm not dismissing the claim that there may be some "deadbeats" out there who are psychologically stable and able to work, but wish to live in poverty just to get free medical care and be able to sleep all day, even though their health is more likely to be worse than others and they must do without the pleasures money can buy. But since 80% of our healthcare costs are for 20% of the population (i.e., old people near end of life and folks with certain chronic conditions), I don't think the deadbeats account for much of the utilization, even though you can certainly make a case that they are "playing the system" and ought to be required to pay back any publicly funded care they receive.

In the fourth post (Dec. 2007), I wrote:

To be responsible, people ought to take good care of their health by, for example:

  • Eating foods lower in fat and carbohydrates, not smoke tobacco, avoid drinking much alcohol and using dangerous drugs, breath clean fresh air, stay out of the sun, exercise, etc.
  • Earning good money, invest it wisely and save in order to afford treatment should they someday have a catastrophic or chronic condition.
  • Rejecting short-term pleasures that have a potential negative health consequence.
  • Going to the doctor, dentist, therapist, etc. only when necessary and selecting providers and treatments that are the most cost-effective.

And, it is only sensible that our culture, government, and economic system more likely that our citizens do such responsible things by making radical changes, such as:

  • Making junk food more expensive than high-quality food
  • Making tobacco and alcohol extremely expensive, while discouraging advertising to young people
  • Putting businesses that blatantly pollute our air and waters out of business
  • Down-playing the vanity of a sun tan
  • Stopping the use of TV as the opiate of the masses, which creates so many "couch-potatoes," and start promoting more physical activity
  • Rewarding healthcare providers for delivering high-value (cost-effective) care and preventive services, and insurers for offering high-value policies, as well as enabling consumers to select them through robust transparency of quality and cost
  • Being role models of responsible money management, such as balancing the Federal budget rather than pushing incredible debt onto our children
  • Making wise investing something that anyone can do rather than making the system so complicated and full of underhanded practices that it's so easy to get ripped off and make poor financial decisions
  • Encouraging business to focus on long-term societal benefits rather than short-term investor returns
  • Increasing the incomes of the working poor, so they have a chance to save for the future and purchase health foods, etc.
  • "Leveling the playing field" so the disparity between the haves and have-nots aren't so drastic (the top 5 percent currently have more wealth than the remaining 95 percent of the population combined)
  • Linking profit to value for the patient/consumer
  • Putting at least some of the money currently being spent on political pork (estimated to be over $50 billion per year) and war (now about $500 billion and expected to go to $2 trillion) into improving our healthcare system.

Bottom line: There's a heck of lot to consider concerning when judging healthcare reform policies in terms of their focus on promoting personal responsibility!

Related posts:

Wednesday, September 23, 2009

Criteria for a Sustainable Health System

On his blog, Vijay Goel, M.D. posted five criteria for a sustainable health system. He wrote:

Sustainable health reform requires a solid foundation…unfortunately the proposals we're seeing out of Washington create a more elaborate house of cards, as we continue to create an elaborate health care ponzi scheme. The House that built Medicare has already saddled our country with Trillions in unfunded liabilities. The proposals we see look to continue to reward a medical-industrial complex that creates and manages diseases rather than focusing on optimizing the health of people.

His criteria are:

  1. Individuals receive fair value for premiums
  2. Health Insurance is actual insurance (i.e. doesn't insure pre-existing conditions)
  3. Comprehensive services exist to Actively Manage Chronic Conditions: Chronic conditions (pre-existing) need active management
  4. Subsidies occur Transparently
  5. Retail Competition based on Differentiation.

These are all good tactics!

From a broader perspective, we've identified at least 4 goals that any government proposals ought to focus on achieving; and the proposals can be judged based on degree to which they address these 4 goals. That is, we ought to be assessing how much do the proposals focus on promoting greater:

  1. Self-Discipline?
  2. Personal Responsibility?
  3. Empathy and Compassion for the least advantaged (Social Responsibility)?
  4. Public Accountability (Transparency)?

In addition, there are at least 8 objectives that relate to those achieving those goals; and a proposal can be judged by how likely they are to achieve these objectives:

  1. Balance Investment & Spending
  2. Balance Savings & Borrowing
  3. Balance Conservation & Consumption
  4. Balance Endowments & Entitlements
  5. Connect Ends & Means (Resource Availability)
  6. Connect Should/Must Dos & Can Dos (Priorities)
  7. Preserve Security/Protection
  8. Preserve Rights/Freedoms (Opportunity & Liberty).

I suggest that the most sustainable proposals are those that focus on achieving those goals and objectives by fostering ever-increasing value to the patient/consumer through the cost-effective prevention, (self-) management, and treatment of health problems.

Continued at this link.

Tuesday, September 22, 2009

Kudos to Dr. Blumenthal!

As reported at this link in a new items item titled "Blumenthal calls for more study on uses of health IT," Dr. David Blumenthal, the national coordinator for health IT, said much more research is needed to determine the effectiveness of health information technology while it's being deployed with support of stimulus monies.

According to the article, Blumenthal indicated that more documented research will help providers put their systems into practice and use it effectively because, until now, research about health IT (HIT) has been limited. It went on to say:

To be eligible for increased Medicare and Medicaid payments, the stimulus requires that healthcare providers be meaningful users of health IT. Meaningful use will result in a more accountable healthcare system and one that produces more value, Blumenthal said.

The Health IT Policy Committee, which Blumenthal leads, has laid out the steps providers must take by 2011 to use health IT to collect data for improved patient management, care processes and to assure better outcomes for patients..Blumenthal called for building an infrastructure for continuous clinical improvement through the use of decision-support technology that can bring research results and new treatment information to a clinician's fingertips.

"One thing we haven't done is apply the scientific method in the practice of healthcare and medicine," he said.

Well said! Dr. Blumenthal wants HIT to be used meaningfully in a way that supports decisions and promotes scientific research to bring greater value to the patient/consumer. EXCELLENT!

I've been echoing these sound principles over the past few years on this blog and on our Wellness Wiki. Take, for example, this two-part post on meaningful use of HIT starting at this link in which I wrote:

Meaningful use, to me, means using HIT in ways that are of great value to the patient and other healthcare consumers. It doesn't matter what types of software tools are used, what communication infrastructure is used, what standards are used, or what certifications are used. It just means that the using HIT should result in ever more effective and efficient (i.e., ever greater value) care delivery…This definition raises the bar over other definitions being offered because it focuses realizing the benefits of ever-increasing care value (effectiveness and efficiency), which is something mainstream HIT does not do.

I then cited a recent report by the National Research Council of the National Academies, which addresses the issue of decision support. It concluded that a serious gap in HIT today is the failure to deliver patient-centered cognitive support. According to the report:

During the committee's discussions, patient-centered cognitive support emerged as an overarching grand research challenge to focus health-related efforts of the computer science research community, which can play an important role in helping to cross the health care IT chasm...Today, clinicians spend a great deal of time and energy searching and sifting through raw data about patients and trying to integrate the data with their general medical knowledge to form relevant mental abstractions and associations relevant to the patient's situation…The health care IT systems of today tend not to provide assistance with this sifting task…[We need] computer-based tools [that] examine raw data relevant to a specific patient and suggest their clinical implications given the context of the models and abstractions. Computers can then provide decision support—that is, tools that help clinicians decide on a course of action in response to an understanding of the patient's status. At any time, clinicians have the ability to access the raw data as needed if they wish to explore the presented interpretations and abstractions in greater depth…The decision support systems would explicitly incorporate patient utilities, values, and resource constraints…They would support holistic plans and would allow users to simulate interventions on the virtual patient before doing them for real.

In addition to debating ways to insure all Americans, we ought to be discussing how exactly we will bring ever-greater value to the patient/consumer, including the kind of HIT innovations we desperately need to help achieve this vital objective.

Friday, September 18, 2009

A Novel Way to Exchange Patient Health Information

An interesting post on THCB by Margalit Gur-Arie—titled "What if I Had to do HIT All Over Again?"—critiques the very large, very expensive and very clunky monolithic EMR/Practice Management/Billing system currently dominating the market. She concluded the post this way:
"So if I had to do it all over again, I would take a hard look at Microsoft Office. I would build multiple useful applications, like Word, Excel, Power Point, etc. I would make sure I can export data from one to the other. I would make sure that the user interface is consistent between them. I would allow others to create templates and integrate their software into my tool bars."
I replied:
Wow, Margalit, that's exactly what we done! We've actually just presented the first live public demonstration of a prototype of our system to doctors, educators, and insurers. It went very well!
The demo showed, in real time, how this MS Office based system enables:
  1. Primary care physicians (PCPs) to send personalized referrals to specialists
  2. The specialists to reply to those referrals
  3. The PCPs to respond to the specialists' acceptance reply by sending them XML-based continuity of care documents (CCD) and other supporting data files
  4. The specialists to access and view the resulting patient information
This is all done with encrypted e-mail attachments and a small software program and macro routines that process the e-mails automatically. They automatically encrypt, zip, and attach the files to e-mail and put them in the outbox; as well as retrieve the email from the inbox and unzip, decrypt, format and display those files, and store them encrypted in the recipient's computer.
It requires as few as 5 mouse-clicks per end-user for the entire process. No need for central servers (or any other infrastructural build-out), there is little if any need for IT support, and there are no other costly complexities.
And all the data are stored locally in encrypted files, which areautomatically retrieved and rendered any time via a few button clicks. From a technical perspective, it's a simple node-to-node (peer-to-peer), publisher-subscriber, and asynchronous decentralized desktop solution that uses Office macros, .Net, and SMTP. It is literally the easiest, most convenient, and least costly way I know to exchange and present patient health information securely between any EHRs in a way that promotes care coordination.
Another reader (Alexander) commented:
Margalit, what you describe, basically, reflects the principles, on which the proposed NHIN infrastructure is based. The only difference is that it is supposed to connect RHIO's rather than separate EHR systems. Without a nationwide patient ID, though, it is going to be very challenging to find and link all medical records on the same person since some important data fields used by matching algorithms can be empty or contain incorrect values. Besides, as I mentioned before, it is much more difficult to predict availability of EHR systems installed in small medical offices or hospitals, unless they use cloud-based applications.
To which I wrote:
Margalit - What do you think about the use of a biometric index to create a unique patient identifier (medical record number)? It would negate the necessity to establish and connect to a central repository, and it would enable the fluid exchange of patient health info between any nodes in a mesh network architecture, which is similar to the way communication is done in telephone networks (see
And she responded:
Dr. Beller, I think a biometric ID is probably a very good choice, short of implanting a chip :-)
The NCVHS has been tinkering with this for over a decade, but nothing happened. There seems to be some reluctance on the part of most people to have such identifier. I'm not sure why, since we all get SSNs immediately after birth and think nothing of it.
I think the technology is available for biometrics and the logistics are not insurmountable (put a machine in every DMV).
Alexander, I know that availability is an issue with the current crop of EMRs, but I strongly believe that SaaS is the future. Besides, as Dr. Beller mentioned, we all use phones without the operator having to patch calls through anymore and without having to run to the telegraph office to send something. Technology changes fast and I can see a device or an executable installed in every office to ensure availability.
I'm not ruling out RHIOs or other intermediaries, but I believe the actual data need not reside anywhere other than the provider system.
I replied:
Yes! I suggest that important roles for RHIOs, HIEs, etc. would be:
  • To aggregate de-identified patient data
  • To make those data available to authorized research organizations (universities, etc.) who study the data to help develop and evolve evidence-based preventive, diagnostic, self-maintenance/management, and treatment guidelines that focus on bringing ever-increasing value (i.e., cost-effectiveness) to the patient/consumer
  • To disseminate the resulting guidelines to all parties.
In this scenario, using the decentralized node-to-node architecture, the patient data would be stripped of patient identifiers and shipped to a centralized research data warehouse. The stripping and shipping would be done by the nodes having direct access to where those data are stored, that is, to the nodes belonging to the clinician/provider that access the data from their EHRs, and to the patient nodes having access to their PHRs. Nodes having direct access to the research data warehouses would then receive the de-identified patient data. In other words, the clinician and patient nodes would implement their publisher (sender/transmitter) function to transmit the data, and the RHIO/HIE's data warehouse nodes would implement their subscriber (receiver) function to retrieve the data. And the resulting guidelines would be shipped via the RHIO/HIE nodes by implementing their publisher function; the guidelines would be received by the clinician nodes implementing their subscriber functions and subsequently be presented through clinical decision support software programs.
This scenario is an example of a hybrid mesh node network architecture in which both centralized and decentralized networks work in harmony. BTW, another example of a hybrid mesh is when a multi-site healthcare organization with a centralized EHR system (behind a firewall) connects via nodes to the EHRs and PHRs of other parties outside their organization (beyond their firewall).
Margalit added:
Dr. Beller, it seems other folks are starting to think the same way It's a start.....
And Alexander added:
P2P communication works great when a PCP refers a patient to a specialist or
orders a test. And there are already exchange formats widely used for that, such
as HL7, CCD and CCR. But in order to get all patient EHR's through P2P
connections, (1) the requester has to somehow find out, which peer systems have
that information, (2) make sure they are connected, (3) send a request to each
of them. And every EHR application must have its own authentication and
authorization module to handle external requests... I just don't see how this
may work without an intermediary.
To which Margalit replied:
I agree Alexander. It won't work on a very large scale without an intermediary
or a super node or a translation gateway, whatever we end up calling it.What I
like about eCW's announcement is the change in the way vendors are thinking.
Exchanging information is finally becoming a worthy goal. As long as they are
moving in that direction, every small step is an achievement.
I responded:
I also agree that an intermediary would be useful for larger scale P2P
implementations so that each peer/node can find other peers/nodes during the
publisher-subscriber activation process (i.e., when two nodes connect with each
other for the first time, which includes authentication and authorization). A
RHIO/HIE would be an ideal intermediary supporting such P2P connectivity
regionally. A Federal government agency, or even a “supra-RHIO/HIE” node that
connects the regional ones, could do this nationwide.
Another reader (a physician) then commented:
The interesting thing is that the only 'standard' that clinicians use in the
daily care of people is English. I think this is unlikely to change, Dr. Beller.
And I replied:
I'd go one step further: I believe our country should be engaged in international collaboration and research, so English isn't even a universal standard.
In any case, using a pub/sub node-to-node architecture, there can be one or more nodes between the publisher and subscriber that serve a data translation/conversion function via mapping methodology. That is, if the publisher uses a local terminology standard “A” and the subscriber uses local standard “B,” then the data can be sent to an intermediary node where corresponding terms are translated into the subscriber’s parlance. This would not only improve communications between clinicians in different regions and facilities, but also in between clinicians in different disciplines. Likewise, the terms could be translated into layman's language when communicating with patients!
Another physician responded:
Interesting thread... Some thoughts...
1) The last post about A and B getting translated by an intermediary pretty well describes the desire behind RxNorm (input Multum, First Databank or other and translate to RxNorm or one of the other systems) -- Good idea, would be even better if the Government would create an open wiki or similar to create a crowd-sourced comprehensive drug-drug interaction system (Would cut about $20/Doctor/Month off the cost of e-prescribing, now paid to Drug Data manufacturers).
2)The Pub/Sub Node with some reporting central store - describes well Carol Diamond's and lots of others architecture for an HIE / NHIN infrastructure (eg hybrid federated - pub/sub node and centralized - central clinical repository).
3) The Vermont Blueprint and VITL exchange that Governor Douglas (Vermont Gov, also Chair of National Governors Assoc this year - different topic, but look at his RxReform platform for accessible, affordable accountable healthcare - pretty interesting) -- Anyway, the exchange started generating data for reporting and for community coordination by doing 2 things - 1) Agreeing on transport (started as CCR, then moved to CCD - both work, but as Phil Marshall from WebMD stated in his HIT Policy committee testimony - CCR is easier to use unless one needs to use CCD for standards reasons) and 2) Agreeing on a LIMITED semantic dictionary - make sure to collect a few important things in a structured, easy to manage fashion, and the system can be used by lots of parties.
Bottom line feels as if designing to solve the GOAL of the PROJECT or TASK ends up with a simple, effective solution - the heart of the original post - it was right on target.
To which I replied:
Concerning CCD vs. CCR, I think their reliance on XML makes them both more complicated and inefficient than is necessary. I say this because the data they contain can more easily be laid out in a comma separated value (CSV) file (including any parent-child hierarchies, although they are rarely, if ever, required for health data exchange).
In fact, I've developed an open source app that uses an MS Excel VBA macro to convert a CCD into a much slimmer and much more human readable CSV file at Note that the CSV could be used instead of the CCD for transmitting data from node to node. Nevertheless, CCDs/CCRs are today’s standards and thus cannot be dismissed.
BOTTOM LINE: As our country struggles to transform healthcare into an efficient and effective system, there is great need for a convenient, low-cost, resource conserving, and secure way to exchange any electronic data residing anywhere that doen not require those data to pass through a central server or reside in a central database. This is precisely the kind of decentralized peer-to-peer mesh network architecture, publisher-subscriber communications, and desktop (standalone) applications that I've been describing. It's good to know others are beginning to see the wisdom of this approach!

Note that, while this system currently takes advantage of the power and ubiquity of the MS Office platform, it is not dependent them since the same funcitonality can be built on other platforms.