Monday, December 28, 2015

Make Health Care Great Again

Click here to view: Reading of the Donald J. Trump children's book by Jimmy Kimmel
We don’t win anymore in health care. After repeatedly drilling in our heads that America’s sick care system is a disaster, that those who care for the sick are incompetent and stupid, and that the sick themselves are losers, Meaningful Use was advertised as the means by which technology will make health care great again. The program has been in place for 5 years and the great promise of Meaningful Use is just around the same corner it was back in 2011. The only measurable changes from the pre Meaningful Use era are the billions of dollars subtracted from our treasury and the minutes subtracted from our time with our doctors, balanced only by the expenses added to our medical bills and the misery added to physicians’ professional lives.

Meaningful Use, a metastasizing web of mandates, regulations, exclusions, incentives and penalties, is conveniently defined in the abstract as a set of indisputably wholesome aspirational goals for EHR software and its users, which stands in stark contrast to the barrage of bad news flooding every health related publication, every single day. Health care in America used to be the best in the world, but now our health care is crippled. Meaningful Use of EHR technology will improve quality, safety, efficiency, care coordination, and public and population health. It will engage patients and families, and it will ensure privacy and security for personal health information. With Meaningful Use leading the way, health care will be winning so much that your head will be spinning. You won’t believe how much we’ll be winning.

Be afraid, be very afraid

Bombastic? Laughable? Easily dismissible by educated people? Not so fast. According to Dr. David Blumenthal, president of the Commonwealth Fund, and former National Coordinator for Health IT, “we probably have the worst primary care system in the world”. Yes, worst system in the whole wide world, worse than Niger, Malawi and Somalia. Probably. According to a hobbyist “study” that extrapolates its “results” from a handful of other studies based on an admittedly inaccurate tool intended for different purposes, 440,000 people are killed in hospitals due to preventable errors each year – “that's the equivalent of nearly 10 jumbo jets crashing every week”. Or, with a little more math, half of all hospital deaths, and one in six US deaths, are due to negligent homicide perpetrated by psychopathic doctors and nurses.

How is that for buffoonery? I suspect that the beautiful minds appalled at populist or outright racist fear mongering rhetoric claiming that thousands of Muslims were dancing on rooftops on 9/11 in New Jersey, have zero problems with self-servingly stating that “hospitals are killing off the equivalent of the entire population of Atlanta one year, Miami the next, then moving to Oakland, and on and on”, based on equally valid he-said-she-said evidence. Both virulent strains of outlandish demagoguery are insisting that they, and only they, can keep us safe from things that go bump in the night. Supersizing the ghoulies and ghosties and long-leggedy beasties makes us more likely to relinquish control of our lives to those who might deliver us from terror.

The Meaningful Use program rests on a narrative where medicine is witchcraft, our doctors are murderers, our hospitals are cesspools teeming with death, our citizens are Lemmings unable to wipe their noses, and the machines of the illuminati are our only salvation. When the premise of an action is delusional, one cannot expect the outcomes to be anything but.

Smoke and mirrors

When you read “studies” advertising that Meaningful Use increased the rates of mammography by 90% in three months, you should assume that the only thing that was increased is the rate of ticking boxes for stuff that was not documented before, and practically no material changes have occurred. When you feel vindicated by the 99% rate of patients given a clinical summary after each visit, keep in mind that the vast majority of those summaries were posted to a portal that nobody uses, or just fake-printed to PDF, and the few actually given out were dutifully tossed in the recyclable trash bin. When you read about the billions of dollars in tax money successfully spent on Meaningful Use, you should understand that this is just the tip of the iceberg, and the indirect costs to each and single one of us are larger by orders of magnitude.

For most of us simpleton believers, who mistook fiery demagogues for brave-hearted visionaries, the disappointment is a throbbing daily humiliation, manifesting itself in polite low-energy petitions to powerful bureaucrats to take pity on us and roll back some of the most onerous aspects of the program. There are signs indicative of some forthcoming acts of mercy, but those are as disingenuous as the original false narrative of Meaningful Use. After five years of Meaningful Use of EHR technology, the initial hope has failed to translate into promised change. Or has it?

From its inception, the Meaningful Use program had two sets of requirements. One set defines what EHR vendors must build to stay in business, and another set specifies what doctors and hospitals must do to collect gratuity payments from Medicare. Over time these requirements sets began to diverge. Once clinicians became conditioned to compulsively collect data, overt reporting is being replaced with covert extraction through the backend (i.e. application programming interfaces, or APIs). The Certified EHR Technology mandated by the program was never intended to extend abilities of clinicians as much as it was designed to generate standardized measures of their performance. Administrators and regulators cannot control an industry from afar without incessant measurement and the power to reward and punish individual practitioners. Meaningful Use is designed to enable remote control of medicine, its doctors and the people they serve.

We are not alone

Back in 2001 our rulers identified another field where America was losing big time. Education was a disaster, a huge mess with rampant disparities and across the board low quality. Like health care, education of small children is an ideal place for intervention if your aim is to control populations and increase the value derived from each person. With overwhelming bi-partisan support the ruling class passed the No Child Left Behind Act, mandating that all children are above average by 2014. An avalanche of funding for computers, measurements of schools and teachers and incessant standardized testing of students descended upon our schools. For the last fifteen years, schools were engaged in life and death accountability games of reward and punishment, and our children became merely biometric indicators for school and teacher performance assessments.

As 2014 came and went, with many children still stubbornly below average, with multitudes of teachers still burnt out, and education morphing into a misnomer for the standardized testing doomsday machine consuming all but the rich and privileged, the federal government took a step back and passed the Every Student Succeeds Act of 2015. Leaving aside the downright idiotic terminology used for naming acts of Congress, the new legislation is reluctantly beginning a process to diminish federal control of schools. Considering the cumulative damage to our education system, perpetrated by toxic bureaucratic ineptitude which is  crowding out the ability of real educators to address real problems, this halfhearted attempt may very well be too little too late.

Failure is not inevitable

I don’t know about you, but I am getting tired of having to live up to Winston Churchill’s image of America. We don’t always have to try everything else before we do the right thing. We shouldn’t have to wait fifteen years before declaring that in retrospect Meaningful Use was meaningless. We know now that it is. Removing a few reporting requirements for physicians, while beefing up patient scoring measures, is not enough. Playing with reporting periods at the last minute and granting ad-hoc exclusions to make people shut up, is not enough either. Randomly linking physician fees to Meaningful Use EHRs may be enough, but it’s beyond disgusting.  The Meaningful Use program must end. Plain and simple. And most importantly, the underhanded EHR certification schemes must be halted immediately.

Standardization, quantification, computerization, gamification, engagement, and infantilization of the populace in general, do not produce better educated or healthier citizens. Education reform has failed us on a grandiose scale. Health care reform, to which Meaningful Use is foundational, is based on the same failed concepts as education reform. It will also fail in due course and spectacularly so. It is actually failing as we speak and with the exception of elite institutions, which are benefiting financially from as much health care reform as can possibly be inflicted on the rest of us, we all know it’s failing badly. 2016 presents the perfect opportunity to demonstrate to the entrenched perpetrators that in America accountability is a two way street, and value is a freely defined personal concept.

American health care has been hijacked by very bad people, and it’s time for us to quit being sad little losers who just sit there and bitch. It’s time to take our health care back and it’s high time to deliver to those horrible people the thorough schlonging they so richly deserve. It’s time to make American health care great again.

In 2016, resolve to go out and vote. Vote in the primaries, vote in local and general elections, ignore the propaganda, educate yourself and as old Harry Truman advised us all, vote for yourself, for your own interest, for the welfare of the United States, and for the welfare of the world.

Monday, December 7, 2015

Bingo Medicine

It was a dark and stormy night. My computer didn’t catch fire while typing the previous sentence. No alarms were triggered warning me about the quality of such opening. I wasn’t prompted to select subjects and predicates from dropdown lists. I typed the entire sentence, letter by letter, not at all dissimilar to its first rendering back in 1830. Computer software in general, and Microsoft Word in particular, magically removed the hassles of quills, ink, paper, blotters, sharpeners, ribbons, whiteout, carbon paper, dictionaries, and all the cumbersome ancillary paraphernalia needed to support authoring, but made no attempt to minimize the cognitive effort associated with writing well.  Authoring great literature today requires as much talent and mastery as it did in the days of Edward Bulwer-Lytton.

For several decades, software builders have tried to help doctors practice medicine more efficiently and more effectively. As is often the case with good intentions, the results turned out to be a mixed bag of goods, with paternalistic overtones from the helpers and mostly resentment and frustration from those supposedly being helped. Whether we want to admit it or not, the facts of the matter are that health IT and EHRs in particular have turned from humble tools of the trade to oppressive straightjackets for the practice of medicine. Somewhere along the way, the roles were reversed, and clinicians of all stripes are increasingly becoming the tools used by technology to practice medicine.

A common misconception is that EHR designers produce lousy software because they don’t understand how medicine is practiced. The real problem is that many actually do, and the practice of medicine is precisely what they aim to change. These high clerics of disruptive innovation would have you believe that “resistance to change” is equivalent to the resurrection of paper charts, thick ledgers, and medical information coded in secretive hieroglyphs. The truth is that physicians want to use modern computers, but they resent being used by computers. And the truth is that if we shed the orthodoxy imposed on us by self-serving “stakeholders”, computer software can indeed help address various problems in health care, some in the here and now, most in a distant future.

One thousand and one elements

This may sound strange to some, but the first step towards putting EHRs back on the right track should be to stop trying to help physicians practice medicine. Clinical decision “support” in the form of alerts, disease specific templates, mandatory checklists, required fields and rigid workflows are some of the things that must be removed from EHRs for two reasons. First, most of these “features” don’t work very well anyway. Second, more often than not, the real purpose of said support is not clinical in nature. For example, alerts about generic substitutes for brand name medications, data fields that must be filled and checkboxes that must be clicked to satisfy billing codes, PQRS or Meaningful Use, and the wealth of screens to be traversed before an order can be placed, have no clinical value.  And in most cases the opposite is true.

Some experts argue that EHRs are failing because they are nothing more than an old paper chart rendered on a computer screen. Many others are outraged by the fabled lack of interoperability (dissemination of information) or the lack of EHR usability, i.e. number of clicks, visual appeal, color schemes and ease of information retrieval. I would suggest that these dilemmas are peripheral to the one foundational problem plaguing current EHR designs – the draconian enforcement of structured data elements as means of human endeavor.

When Google mapped the Earth, it did not begin by mandating how to build and name roads and buildings. When we indexed and digitized books and articles, we did not require that authors change the way they write prose or poetry. When we digitized music, we did not require composers and performers to produce binary numbers at equidistant time intervals, and we did not make changes to musical instruments to allow for better sampling.  We built our computerized tools to ingest, digest, slice, dice and regurgitate whatever humanity threw at us, without inconveniencing anybody. This is why good technology seems magical.

EHRs on the other hand, are obnoxiously demanding that people change how they think, how they work, and how they document their thoughts and actions, just so that the rudimentary software prematurely thrust upon them can function at some minimal level of proficiency.  People don’t think in codified vocabularies. We don’t express ourselves in structured data fields. Instead of building computers that elegantly adapt to the human modus operandi, EHRs, unlike all other software tools before them, demand that humanity adjust itself to the way primitive computers work. The self-appointed thought leaders, who are taking turns at regulating the meaningful clicks of EHRs, are basically demanding that we discard the full spectrum of human communications, in favor of gibberish that supposedly serves a higher purpose.

All the pretty horses

What is the purpose of EHR documentation templates? There is practically no EHR in use today that does not include visit templates. Visit templates are a list of checkboxes, some with multiple nested levels, which allow documentation by clicks instead of by typing, writing, drawing or dictation. Visit templates are created for each disease and contain canned text for findings judged pertinent to that condition by template creators. In all fairness, many physicians like documentation templates because with just a few clicks you are able to generate all the documentation required nowadays to get paid for your work, pages and pages of histories, review of systems, physical examination, assessments and plans of care. Do doctors like templates because they believe this extensive documentation is necessary, or do they like templates because the checkboxes alleviate the pain of typing thousands of meaningless regulatory words? I suspect the latter.

Clinical templates, along with the automated clinical decision support they enable, are advertised as time savers for physicians. The time saved is the time previously spent with patients, and most importantly the time spent thinking, analyzing, and formulating solutions. For most, it’s also the time spent rendering thoughts in a manner that can be understood by another person. Furthermore, when your note taking is template driven, most of your cognitive effort goes towards fishing for content that fits the template (like playing Bingo), instead of just listening to whatever the patient has to say. Even in “efficient” practices where staff does the clicking and physicians have the luxury of asking “open ended” questions, the patient story, the quirky details that are irrelevant to the template, are not documented (highlighted, circled, noted on the margins, etc.) anymore. Is this a good thing?

If we proceed on the assumption that IBM Watson and the likes are eventually going to be artificially intelligent enough, and big data are eventually going to be big enough, to respectively analyze and represent a complete human being, then yes, we can safely dispense with old fashioned human expertise. However, we are most certainly not there yet, and regardless of industry rhetoric, we are not certain that we will ever be there, and we are not even sure that we want to ever be there. While this utopia (or dystopia) is portrayed by interested parties as “inevitable”, chances are that for at least several generations we will be forced to contend with imperfect digital renditions of medicine, instead of allowing EHRs to follow the growth of underlying technologies. This is akin to summarily confiscating and shooting all the horses, on the day Henry Ford rolled the first Model T off his assembly line. Where would America be today, if we did that on October 1, 1908?

Furthermore, what type of doctors are we producing when we teach medicine by template, supported by clinical decision aids based on the same template, and assessed by quality measures calculated from template data? Medicine does not become precise just because we choose to discard all imprecise factors that we are not capable of fitting into a template. Standardization of processes and quality does not occur just because we choose to avert our eyes from the thick edges were mayhem is the norm. Dumbing physicians down is not the optimal strategy for bringing computer intelligence closer to human capabilities. EHRs should not be allowed to become the means to stifling growth of human expertise, the barriers to natural interactions between people, or the levers pushed and pulled at will by greed and corruption.

Bildungsroman style

Instead, EHRs could be the scaffolding for IMB Watson and other emerging contraptions to grow and become truly useful tools for both doctors and patients, and yes, also for legitimate and beneficiary secondary uses of clinical information. Instead of mandating that doctors think and work in ways that serve Watson’s budding abilities, we should require that Watson learns how to use the normal work products of humans. Instead of enforcing templated thought and workflows, whether through direct penalties for doctors or indirect certification requirements for software, we should work on teaching Watson how to parse and use human languages in all their complexity. Watson should grow up to be the multi-media scribe behind the computer screen, the means by which the analog music composed by physician-patient interactions is digitized into zeros and ones without loss of fidelity and without interference with actual performance.

Billions of years of evolution endowed the lowliest human specimen with cognitive abilities that machines will most likely never attain. The glory is in the journey though. We need to accept delayed gratification, and we need to accept that the challenge will span centuries, not just one boom-bust cycle of a fleeting global economy. We need to accept the fact that we will all die long before the ultimate goals are achieved, instead of declaring victory whenever each negligible incremental step is taken. If we are going to create a new form of intelligent life on earth, we need to assume the same humility Nature, or God, has been exercising since the dawn of time and counting. Otherwise, we are all just a bunch of hacks looking to make a quick buck on the backs of our fellow men and women.

Tuesday, November 10, 2015

The Middle-Aged Consumer in the Coal Mine

Whenever you read a health care article, paper, book, blog post or even tweet, that substitutes the term consumers for patients, and the term providers for doctors, or physicians, you should inherently assume that the authors are advocating for something that will not benefit you or the people you care for, something that will most likely harm you financially and if you happen to be less than independently wealthy it will harm you physically in real and immediate ways. These advocacy pieces usually come dressed in the sheep clothing of empowerment, liberation, convenience, savings and democratization, but underneath it all, and often unbeknownst to the authors themselves, there is always an ominous incarnation of the wolf of Wall Street.

Whenever you read something emanating from selfless, do-gooder (usually public or supposedly not-for-profit, but certainly for-revenue) institutions, alliances, consortia, coalitions, and such, note how you are always addressed in the third-person plural. There is no “we” in what passes as enlightened health care conversation. As Dr. Victor Montori astutely observed, there is no “sense of a shared fate. Of a shared journey with our kin.” The wolves of Wall Street, and the hyenas of Silicon Valley dancing at their feet, have no kin and no intention of sharing in our fate.

Consumers and providers are a uniform mass of transactional entities, neatly described by a finite number of discrete financial events. Consumers and providers are hence computable entities. You don’t often see articles about consumers being sad or happy, consumers laughing or crying, consumers falling in love or dying. Providers are never sued for malpractice, never accused of fraud, never disillusioned and they never commit suicide. The vocabulary used for consumers and providers requires that we strip everything human from the subject matter, and leave all that is mercenary and precisely quantifiable in dollars and cents. As the consumer/provider vocabulary is ported to health care, the entire endeavor by necessity is divesting itself of human considerations, including kinship and any remaining sense of a shared fate.

Consumers, although sometimes patronizingly described as savvy, are not assumed to possess any particular wisdom. The only discriminatory behavior ascribed to consumers is the ability to discern cheap from expensive. Consumers are expected to incessantly shop for consumable stuff, like so many rats frantically searching for bits of cheese in a carefully constructed maze. We are expected to shop when things are hunky dory and when things are down in the dumps. We are ordered to shop in the face of national tragedies, and now we are ordered to shop when personal tragedy strikes as well.  We are ordered to shop for life saving medicine. We are ordered to shop for surgeries, and we are ordered to shop for “relationships” with our “providers”. We are effectively ordered to shop for dear life, and to “share” and “rate” our shopping “experience” to better inform the maze designers.

The government of the United States wants us to shop for health insurance every twelve months. Health insurance companies want us to shop for cheap services all through the year. ProPublica and the unparalleled paragon of social beneficence called Yelp, are volunteering to help us do a better job at shopping for “providers”. Glitzy startups like Amino, will “harnesses health Industry data for consumers”, to show us some information about some doctors, for no particular reason and free of charge, because “the initial goal is to create an appealing product, and then figure out a business model later”. Yes, it makes perfect sense that Mr. Vinod Khosla and company would sink almost $20 million in something not projected to have any returns. After all, the entire Silicon Valley Empire was built this way, and now the time has finally come to fully align health care with Silicon Valley and Wall Street ways of doing business.

A fundamental shift in how we are being programmed to think about health care is therefore underway. The rather recent term “consumer-centric healthcare” is now brazenly accompanied by musings on who will be “herding” consumers’ medical records. Following the subtle transformation of health care to “healthcare”, we are beginning to shift the conversation to just “health”, because the “care” part seems redundant. Health care is not too expensive because insurance companies operate like Columbian drug cartels and pharmaceutical companies are essentially drug cartels. Health care is not too expensive because hospitals are coalescing into regional and national monopolies, unchecked and undeterred by the perpetually fund-raising legislative and administrative corps of career politicians. Health care is not too expensive because people who work for a living haven’t gotten a raise in decades. No siree, Bob!

Health care is too expensive because consumers lack the wisdom to be healthy, and providers, i.e. the nondescript entities tasked with pushing “appropriate” processes and products to consumers, are failing to keep consumers healthy (a.k.a. profitable). Consumers must be reformed to be healthier, and providers to be more productive producers of health. To prime the pump, health care itself needs to be transformed from a quirky personal service to a standardized population management industry ripe for plunder (a.k.a. disruption). And then, who better to reform consumers than the high tech propaganda machine? Over the years we were reformed to happily ingest every edible poison known to mankind. We were reformed to bash the brains out of fellow consumers every Friday after Thanksgiving. We were reformed into a trembling mass of righteous fear and indignation that can only function (when properly medicated) in “safe spaces” devoid of intellectual ambiguity.

We were reformed to not just accept, but clamor and pay a premium for the right to carry consumer profiling devices in our pockets, which are used to chart our future in minute detail. Healthcare “futurists” are painting for us abstract visions of healthcare where “health is primary”. Futures where medicine is devoid of hospitals, human doctors and human patients. Futures where you buy genetic analysis from 23andMe on your TV, and fixing your baby in utero is a weekend DIY project. Futures where we need not care for each other because the iPhone Gods are caring for us all. Will we be happy? Will we be free? Que sera, sera….

But our health has always been affected mostly by social order, and less so by health care. As Silicon Valley and Wall Street are taking command of our health, what will be, will be affected by factors far removed from the myopic analysis of our healthcare experts. Fortunately, we are bringing our canary on the journey down this shaft. Unfortunately, the canary is dying.

Mortality rates have began to rise for white, middle-aged Americans without a college education, arguably the people most vulnerable to the mercantile siliconization of life. They use mostly alcohol and opioids to numb the pain and eventually they numb it for good. Unless we find our way out of these toxic dungeons where life is money and money is life, right here, right now, most of us, consumers and providers alike, will suffer the same fate. This is the real clear and present future of consumerized health.

Wednesday, October 14, 2015

The Quantified Doctor-Patient Relationship

In a previous post we explored the doctor-patient relationship, which according to many is an important factor influencing the health care trifecta of quality, outcomes and cost. So far the doctor-patient relationship escaped rigorous quantification, because “relationship” is largely a nostalgic quantity, and because “communications” was deemed to be a reasonable substitute. There are various tools and instruments for subjective measurement of communications with one’s doctor, with the most common being the ubiquitous patient experience survey. However, if we accept a broader definition of the doctor-patient relationship, such as the 6C’s proposed by Dr. Emanuel, a more objective measurement of the relationship seems not only possible, but desirable even for those who may be questioning the value and purpose of quantification in general, and obsessive measurement in particular, present company included.

Let’s take the 6C’s from the top, leaving out communications and compassion, which are subjective quantities. The intent is to create an accurate picture of relationships patients can expect to have with a physician within the boundaries imposed by their financial circumstances. Most suggestions presented here are not attempting to score the physician directly, since relationships are always affected by more than just intrinsic qualities of the two parties relating to each other. For example, a relationship with the most compassionate and articulate physician may turn into a disastrous affair if conflicts of interest dictate how communications are conducted and how and when compassion is expressed. Ideally, a patient specific “scorecard” composed of the criteria below, would be compiled by a non-biased third party, or by physicians themselves, and made available to patients.


For patients, this means choice of practice type and settings, primary care physician, specialists, hospitals, and choice among treatment alternatives. Surely the degree to which these choices are available to patients can be objectively calculated, rated and ranked as is now fashionable. For example, where patients are assigned to physicians by third parties, the relationship would score a big fat zero. A point or two would be awarded to a vertically integrated system where patients can choose from the physicians employed by the group. Scores would be proportional to network size and variability for more traditional plans, with Medicare fee-for-service and cash-only practices getting the highest scores. Obviously, patients will need to account for individual scenarios for incrementing or decrementing scores.

Choice of specialists and hospitals can be inferred from the same variables as measured above, but adjustments will need to be made to account for hospital privileges and referral patterns of the primary care physician. This too can be measured and scored pretty accurately from easily obtainable hard data. Choice among treatment alternatives is a bit trickier, particularly in primary care. Using process measures, sample documentation and insurance plan policies, one could derive an individualized measure of choices available to patients. It is important to note that here we are not measuring “appropriateness”, “stewardship of scarce resources” or how “wisely” people choose, nor do we measure “education” about options. We measure the actual availability of treatment options.


How does one measure physician competence? Arguably, all current “quality” measures, public reporting and board certifications are aiming to quantify and ensure precisely the competence of doctors, in a roundabout way that is failing to measure anything of consequence. If we describe a competent physician as one who stays up to date, has good technical and diagnostic skills, exhibits good clinical judgement and is cognizant of his or her own limitations (as Dr. Emanuel did), we could devise better ways to assess competence. Staying up to date is trivial to measure. Technical and diagnostic skills, as well as clinical judgement, are very difficult to assess objectively, and perhaps this is why all our faux measuring schemes seem woefully inadequate.

We can certainly envision physicians assessed by their peers (perhaps anonymously or through virtual grand rounds collaboratives), but competence cannot be discussed until we quantify the prerequisite time variable. It makes little difference whether a physician is competent or not, if the patient rarely sees the doctor, or if visits are limited to a few minutes of furious typing, clicking and scrolling. So here is one variable that can be objectively and rather easily quantified: time spent with patients by severity of chief complaint, patient health status and vulnerability. We can get fancy and measure frequency of visits and total time spent per patient per year, adjusted for a host of variables.

Another factor closely related to competence in primary care, and not explicitly addressed by the 6C’s framework, is comprehensiveness. This too can be measured objectively. The range of conditions treated by the physician, and the list of those routinely referred out can be compiled, ranked and assigned relative scores accounting for frequency of occurrence, along with patient characteristics. For example, a physician treating large numbers of elderly diabetics with multiple comorbidities, would garner more competence points than a physician who spends most of his time taking telemedicine calls for minor and limited ailments.  A physician who admits and manages her own patients when hospitalized would rank higher than physicians who never set foot in a hospital.


Continuity of care is another word for long lasting, comprehensive relationships, and it can be accurately quantified with very little effort. Both PCMH and standard patient experience surveys include vague attempts to quantify continuity, but those could be misleading. Continuity of care is now applied loosely to teams of clinicians, such as residency groups, and it does not account for how appointments are conducted. When the patient is seen by a team member, and the billing doctor sticks his head in for a few seconds to say hello, does this count as continuity? When any and all patient interactions that do not involve a face-to-face visit are “handled” by other team members, and never the physician, does that count as continuity? How about outsourcing complex care management in between visits altogether, which is the “unintended” consequence of the new Medicare chronic care management fee?

It is important not to confuse continuity of care with continuity of medical records, or care coordination, when quantifying this aspect of the doctor-patient relationship, but other than that this may be the easiest factor to quantify objectively. A physician who always sees his or her patients, is always available in between visits to provide clinical advice, and has maintained this relationship with individual patients over long periods of time, would score high on this factor. Almost by definition, solo practitioners and many direct primary care physicians should top the charts on continuity. Similar to the quantification of patient choice, here too we must account for the vagaries of health insurance marketplaces which are increasingly empowered to break any relationship at any time on a whim.

(non) Conflict of interest

This is arguably the most important factor in the doctor-patient relationship, and other than random incendiary headlines, there are no serious attempts to measure or even shed light on the mushrooming conflicts of interest systematically inserted into the traditional doctor-patient relationship. Ideally, physicians would always act solely in the best interest of the one patient in front of them. Most people still believe that this is the case and most physicians will insists that regardless of circumstances, this is what they strive to do, but there are objective data points that could more precisely quantify the alignment of interests between doctors and patients.

We all know now that accepting the smallest gifts from pharmaceutical companies represents a conflict of interest. But how about directly tying salaries, and other compensation for labor, to corporate revenues? How about enforcement of corporate protocols and suppression of “disruptive” behavior? How do these things jive with the clinical judgement required by our “competence” factor? How about coercive “reimbursement” rates that force physicians to limit time spent with patients, and exclude certain patients from their practice? How about participation in incentive programs that pay doctors to substitute the interests of “society” for the individual interests of patients (as “misguided” and “wasteful” as those may be)? These are precisely quantifiable data.  

Ideally, I would love to see a comprehensive, and frequently updated, list of all potential conflicts of interests for each physician, by health insurance plan, publicly displayed in every practice and on every practice website. Why? Because conflict of interest, whether by choice or externally imposed, affects the most basic ingredient of any relationship: trust. If you were charged with a crime, would you trust a lawyer who is payed to keep society safe from criminals? Would you trust an accountant who is paid to increase IRS revenues?  Would you trust a hair dresser paid a fixed fee per client per year? Would you trust a mechanic who gets a little kickback from your insurance company to use the cheapest replacement parts for your car? Same goes for doctors.

In summary, there is absolutely no reason why we should not collect objective data, which is readily available in quantifiable formats, and combine it to create an informative picture of each physician and the environment in which he or she is practicing medicine. We may not be able to come up with a simplistic single score on some artificial scale, and we may not be able to punish or reward doctors for the “relationship measure", but people have a right to know what lies behind studied communications and standardized compassion, and most of all, people have a right to know how health care reforms are affecting a physician’s ability to maintain relationships with patients. If I’m not mistaken, this is what transparency is all about.

Monday, September 28, 2015

The Crisis Masters of Health and Death

There are three visions of peace in the seemingly never ending, but really rather brief, Israeli-Palestinian perpetual crisis. One peace features two independent countries living in collaborative harmony on a piece of land approximately the size of New Jersey. Another peace yearns for a messianic Jewish state stretching from the blue Mediterranean shores to the Jordan River, and possibly beyond. The third and final peace is expected to materialize after the Zionist entity has been permanently erased from the face of this earth, or at least from the face of that New Jersey size holy piece of land.  Each definition is amenable to slight compromises in form, but not at all in substance.

There are three visions for the future of medicine in the seemingly insurmountable, but really rather minor, perpetual health care crisis in America. One future of medicine sees physicians unencumbered by useless administrative tasks, wielding sleek and useful technology tools, offering the best medical care to all patients who need and want attention. Another future is yearning for the revival of chickens and charity as bona fide methods of payment for whatever medical care the free market wishes to bestow on the less fortunate. The third and final future is one devoid of most middling and often faulty doctors, where the health of the nation is enforced by constant computerized surveillance with fully automated preemptive interventions.  Each definition is amenable to slight compromises in form, but not at all in substance.

Years ago I used to walk the streets of East Jerusalem, buy dates in the open air markets of Jericho, and search for the perfect plate of hummus in Ramallah. Everywhere I went people wanted the same things I did. They wanted the rain to stop, or the hamsin to break. They wanted their coffee hot and strong and their bread soft and warm. I said shalom and they said salaam and we all meant the same thing, because ironically people in the Middle East always wish peace upon each other, and people like us, who buy and sell cheap jewelry or dates or hummus, actually mean it.   

Years ago I used to hang out with software programmers, writing code for hospitals, doctors, nurses, billers and schedulers. Everywhere I went these strange looking techie nerds wanted the same things I did. They wanted the overhead lights in the office to be off, and the whiteboards to be bigger. They wanted their Java to compile without error and their curly braces to be perfectly aligned. They worked days, nights, weekends and holidays to keep the lab printers running on every floor. They managed to convince themselves that somewhere in a hospital far away, a patient may get better sooner, or a doctor will see something he may have missed, and an exhausted nurse will breathe a sigh of relief, if they managed to get the face sheets to look just right.   

There is always some effort underway to fix the Israeli-Palestinian problem. Many such efforts have gotten as close to an equitable solution as Moses got to the Promised Land, only to discover that the last barrier is insurmountable. What’s to become of Jerusalem? Who owns the holy ruins of past civilizations, and the tombs of dead prophets? Whose religion bestows the ultimate rights of ownership over rocks and boulders that are coveted by all religions? Should it be the religion that started it all? Should it be the religion with the biggest cathedral, or the religion with the biggest guns? Is possession nine-tenths of the law? Perhaps ownership is the wrong way to think about this. Perhaps access is a more pertinent concept and the historical manifestations of God on this earth should become the commons of all religions. Perhaps, but not today.

There is always some effort underway to fix health care in America. Decades of legislative, regulatory and business driven efforts have gotten us almost universal access to the most unaffordable health care system in the world, only to discover that “information blocking” is a barrier to health. Information is power, but aggregate information is also a tool for amassing wealth, and massive information, of the big data type, is practically legal tender. What’s to become of this seemingly self-generating big data? Who owns the streams of life once they are transformed into data? Whose role in the digital extraction process bestows the ultimate rights of ownership over the monetary value of people? Should individuals own their digital emissions (defeating the entire purpose of this exercise)? Should the collectors own the data? Should the purveyors of data containers own what’s being accumulated inside? Is possession nine-tenths of the law?  Perhaps ownership is the wrong way to think about this. Perhaps access is a more pertinent concept and our aggregate digital lives should become the commons of all people everywhere. Perhaps, but not today.

Jerusalem is not the real problem. There will be no resolution for the Israeli-Palestinian crisis until hate is defeated, or at the very least silenced. Standing with your back against the deep sea and listening to incessant drumrolls of death, dismemberment and extermination is enough to ruin the best gin and tonic at the best club on the most beautiful night on the Tel-Aviv promenade. Deep down you know that the people you met in Jericho, Ramallah and East Jerusalem would much rather get drunk with you in the club, than blow themselves up at the door, but that doesn’t seem very comforting tonight. Jerusalem and all its holy ghosts will be solemnly shared only when everybody benefits from this arrangement, including the millions of people whose lives are at stake here, and excluding the fiery tongued hate mongers who pass as leaders in some parts of this world. Until that day comes, Jerusalem will keep taking our lives, our children, and worst of all, our humanity, in the biggest hoax ever staged by mankind.

Information blocking is not a real problem. There will be no solution to our health care crisis until greed is defeated, or at the very least tightly controlled. Siphoning hard cash in the form of “information” from medical facilities into the coffers of third party data processors, seeking to supplant traditional medicine with computerized cost-benefit analysis, cannot possibly be met with enthusiasm by the doomed. Serenading the public with psychopathic prophecies of eternal health, while stealing their personal information to more accurately find and extract money from their wallets, and to curtail all freedom of choice, is not helping either. Information will flow freely only when everybody benefits from the torrent, including the millions of people whose lives and liberty are at stake here, and excluding the smooth tongued wealth extracting machines which we call leaders. Until that day comes, information will flow haltingly, under duress, in the biggest jail ever created by mankind.

There is an old saying in Hebrew stating that a dead fish stinks from the head, but there is also an old saying in Arabic promising that each dog shall have his day, so there may still be some hope. We the people who are happy and satisfied with hot coffee, a loaf of bread, a nice whiteboard and a little less light shining on us, have no use for crises of any kind. It is the power drunk, greedy and shamelessly opportunistic (mostly) men calling themselves leaders, who manufacture crisis after crisis, to justify their own miserably exalted existence, because crisis and leadership are like a nightmarish version of the chicken and the egg dilemma.  There is no material difference between the rough lunatics, preaching fear of thy neighbor, and promising boundless paradise in return for mindless violence in this world, and the sleek captains of industry, preaching fear of natural life, and promising boundless health on this earth in return for mindless submission to infallible algorithms for the duration.

The crisis masters of Middle East death and American health are both driven by the same “selfish and boundless thirst for power and material prosperity” (to put it delicately). The former manifests itself in the lucrative fire and brimstone raining over that hapless portion of the world since the day Abram chose to change his name to Abraham. The latter is how we the people of the new world go gentle into that good night.

Tuesday, September 22, 2015

How much is that PCMH in the Window?

Much has been written about the Patient Centered Medical Home (PCMH) model of primary care, both complimentary and critical. Most evaluations and opinion pieces refer to the particular PCMH flavor defined by the National Committee for Quality Assurance (NCQA), since this is by far the most widely adopted model, and all other models are just minor variations of the same. Practically all reviews, studies, opinions and assessments pertain to the ability of PCMH practices to improve “quality” measures and generate savings for the system, and in all fairness both evidence and opinions are mixed. One aspect of the PCMH that is rarely discussed, is the cost incurred by the practice for sustaining PCMH operations over time.

A new article published in the Annals of Family Medicine estimates ongoing PCMH costs to be approximately $105,000 per physician FTE per year, in personnel costs only. Data was collected through interviews and staff surveys at 20 primary care practices, 8 owned by an academic institution in Utah, 7 private practices and 5 sites of a Federally Qualified Health Center (FQHC) in Colorado. Only the Colorado practices were recognized by NCQA, while the Utah practices had their own proprietary definition of PCMH. The authors reached their shock and awe inducing figure by adding self-reported increases in time spent by staff on each task listed in the NCQA PCMH 2011 Standards, and then priced this incremental effort based on staff compensation.

Unfortunately, the cost of individual PCMH Elements and Factors is not available, but even in aggregate form, the analysis is perplexing. The average $105,000 per physician per year is not an absolute number. It is the incremental difference, according to the authors, between running a “traditional high-performing” practice and running a PCMH practice. As such, the dollar amounts depend on how one defines the baseline. The article does not provide an exact definition for the “traditional high-performing” primary care practice baseline and this is obviously problematic. The authors mention that not all PCMH Elements were fully implemented in the surveyed practices, but an exact list of implemented functions is not available either.

Basically, we don’t know what the starting point was, and we don’t know what the end point is, but we are told that it takes an outlandish $105,000 worth of work to get from the former to the latter. Outlandish, because any independent solo practice faced with half of those costs would go bankrupt in six months or less, and in spite of that, there are many solo practices recognized by NCQA at the highest possible PCMH level, which is more than the practices in this study have accomplished. Here is a riddle for you: how does a micro practice, with one physician and no staff, sustain the highest levels of PCMH operations when according to this study, one would need to add approximately 2 FTEs to the traditional model?

The answer is that the lump sums presented in this article are meaningless. For example, the highest incremental expenditure for the studied practices, to the tune of $3,000 per physician per month, was attributed to NCQA Standard 3, which deals with providing medical care to patients. There are several items selectively listed by the authors in the description of Standard 3, so let’s assume that those are the tasks that generated incremental effort and costs. The first task on the list is the notorious daily huddle. This is most certainly a new PCMH construct that wasn’t there before. However, would the daily 5 or 10 minutes spent on huddles in a PCMH, not be spent on the same exact tasks peppered throughout the day in a traditional practice? Did the study account for such considerations? We don’t know.

Another item listed for this Standard is implementation of evidence-based guidelines. What does this even mean? Should we presume that traditional high-performing practices are not practicing evidence-based medicine? Were they using magic 8-balls to diagnose and treat patients prior to PCMH implementation? The same can be said for multiple other items, such as medications reconciliation or monitoring patients on high-risk medications or making sure that lab orders are resulted at some point, and a host of other tasks routinely performed in any practice, although in different form and perhaps in a more ad-hoc fashion. Of course, we can only speculate here, since the details behind the $105,000 figure are not available, but these seem to be typical examples of the rampant misconceptions regarding the meaning of PCMH operations.

What sets the NCQA PCMH initiative apart from your run of the mill data collection and reporting programs, such as Meaningful Use, PQRS and even ACO, is that it provides a holistic framework for improving practice operations without being narrowly prescriptive on how to accomplish that. It is a comprehensive tool for the practice to examine its inner workings once every three years and brainstorm on ways to improve its processes. There is nothing in the NCQA PCMH framework that does not occur or should not occur in a modern “high-performing” practice. With the exception of some Meaningful Use measures, I would challenge anyone to point out to even one PCMH factor that cannot, or should not, be implemented in a way that benefits patients and the practice itself. And it all starts with the initial recognition process.

Much has been written about the trials and tribulations of obtaining NCQA PCMH recognition, from the extensive documentation requirements to the onerous costs of labor and expertise. There are two approaches to PCMH recognition that generate these types of complaints, and later on may generate the theoretical $105,000 costs. One approach common in large institutions is to view PCMH as a top down initiative managed and executed by a central office, with little or no input from practice staff, including physicians.  The other extreme is the small practice chugging through each PCMH factor, trying its best to generate mountains of screenshots and reports with no particular strategy in mind other than getting enough points to pass the “test”. Both models may get you PCMH recognition, but with much frustration and zero benefits to the practice.

And then there is the right way, which harnesses the PCMH recognition process to benefit the practice and its patients. Forget about “readiness assessments” and “culture change” indoctrination. You were ready and fairly well cultured the day you finished residency. The question you should ask yourself is not whether we do this or that thing, but whether we are doing it well. You may have some pink colored slot on your schedule called same day appointment, but is it where it should be? Is it solving a problem, or is it creating one, or is it there for decoration purposes only? How are you planning to stop the upcoming hemorrhage of patients to non-descript retail clinics and iPhone “doctors”? Should you maybe use this opportunity to revisit your 10 years old scheduling process?  This is not about NCQA. This is about dollars and cents for your practice.

How about “implementing evidence-based guidelines”? Should you be deeply offended because someone dares to ask you to implement clinical practice guidelines for a sore throat? Or should you look at this as an opportunity to write some standing orders for your staff, so that you don’t have to go in an out that exam room more than once, and maybe, just maybe, you can squeeze in a couple more minutes with your little patient, and notice that mom seems to be unusually worried and distracted? And maybe you'd want to ask her about it. And maybe that’s what “patient-centered” is all about. And maybe all the administrative PCMH stuff you do, should be purpose built by you to make this possible. And maybe this is not about recognition, but about creating a safe little space where you can be the doctor you always wanted to be.

We don’t know how the PCMH was implemented in the study. We just know that it was implemented to a certain degree. We don’t know if the missing pieces are minute or crucial for practice financial health and patient care. We don’t know if the physicians in these practices were given the opportunity to build their own medical home, or if someone else decided how to shuffle the deck chairs. We don’t know if the subjective incremental effort reported by staff on each factor was offset by reduced effort elsewhere, or if it represents better use of previously underutilized positions. We have no objective numbers for “before and after” payroll expenditures, although those should be rather easy to obtain for large facilities. There is more than enough missing and undisclosed data in this study to render the $105,000 suspect.

Are there ongoing costs for a PCMH practice? No doubt, there are plenty, but these costs are no different than the costs of running a traditional (or non-traditional) high-performing practice, because PCMH is just another name for high-performing practice. Perhaps the most useful conclusion from this paper is that high quality primary care costs more than mediocre or outright irresponsible primary care, and those who decide how much primary care doctors get paid, should bring this largely self-evident fact into account, when defining physician fee schedules and future payment schemes.

[Disclosure: I am the founder of BizMed, a company whose mission is to support the viability of independent medical practice, and to that end it offers free software and tools to reduce administrative complexity in private practice in general, and for PCMH recognition in particular]

Monday, August 24, 2015

Measuring the Doctor-Patient Relationship

Sixty years ago, before he became a controversial figure in the field of psychiatry, Dr. Thomas S. Szasz co-authored an article for the Archives of Internal Medicine (now JAMA Internal Medicine) on “The Basic Models of the Doctor-Patient Relationship”, which is well worth reading today, particularly for those who believe that patient empowerment/engagement is a novel and disruptive innovation of our digital times. The paper is describing three distinct relationship models (i.e. active-passive, guidance-cooperation, mutual participation) and how they flow and morph into each other based on patient ability/preferences, physician characteristics, and illness circumstances. Dr. Szasz is addressing all the contemporary hot buttons of paternalistic doctors, patient values and shared decision making, but more important is the realization that doctor-patient relationships were a concept debated before most of us were born, in much the same way they are debated today.

Since Dr. Szasz made his contribution to the philosophy of medicine before hidden agendas and political correctness dictated how ideas are phrased, he was free to observe that “each of the three types of therapeutic relationship is entirely appropriate under certain circumstances and each is inappropriate under others”, without the compulsory need to assign blame to either the patient who prefers passivity or the physician who complements those preferences in “an interlocking integration of the sick and his healer”. And when a mismatch arises between the preferences of doctor and patient, the relationship is dissolved, “and so life goes on”. But the days of laissez-faire medicine are over, and today we feel compelled to define the, one and only, ideal physician-patient relationship.

As the managed care era descended upon us in the 1990s, Dr. Ezekiel Emanuel felt it necessary to define an aspirational goal for the ideal physician-patient relationship based on six fundamental components (the six C’s):
  1. Choice – For patients, this means choice of practice type and setting, choice of primary care physician, choice of specialist or facility for emergencies and special conditions, and choice among treatment alternatives.
  2. Competence – Physicians should stay up to date, have good technical and diagnostic skills, exhibit good clinical judgement and be cognizant of their own limitations.
  3. Communication – First, physicians should listen and understand symptoms, values, family, jobs and other health related patient concerns. Second, physicians should be able to explain the disease, the diagnosis, treatment alternatives and how those affect patient values, guiding patients through issues raised by their illness, while respecting patients’ preferences for how much they want to know.
  4. Compassion – This is about empathy and helping patients feel supported.
  5. Continuity – Here the paper recognizes that the “ideal physician-patient relationship requires a significant investment of time”, and that frequent changes of physicians undermines such relationship. It also acknowledges that “relationships that endure over time may be more efficient” both by helping doctors treat the patient in more appropriate manner and by fostering patient trust and confidence.
  6. (non) Conflict of interest – Personal and financial interests are emphasized, but the expectation seems to be that “a physician’s primary concern will be his or her patient’s well-being, even though physicians may have obligations that conflict”.
The remainder of his paper explores the many ways in which managed care is positioned to attack all six components, and concludes by stating that “the physician-patient relationship is the cornerstone for achieving, maintaining, and improving health”.

Dr. Emanuel’s definition of the doctor-patient relationship is very broad, and with a few minor additions and deletions, it can also serve as a definition for what we now call patient-centered care. Perhaps it is not by accident that the term “patient-centered medicine” was introduced into common parlance by Enid Balint, the wife and collaborator of Michael Balint who was one of the earliest researchers of the dynamics between doctors, patients and illnesses. Michael Balint went as far as to suggest that the doctor himself was actually a therapeutic “drug”, while Enid Balint envisioned the skills needed in the practice of patient-centered medicine to be “in the way that the doctor allows the patient to use him, rather than in the way the doctor responds to the patient by his interpretations and theories”.

Whereas the contemporary definition of the physician-patient relationship (and subsequently patient-centered care) consists of a rigid set of presumably ideal physician characteristics, the Balints, and to a certain extent Dr. Szasz, saw the physician as a tool to be personalized by each patient and further customized for each illness situation. It is difficult to imagine a more egalitarian or participatory relationship than this one. In fact, Dr. Emanuel’s six C’s can be seen as just one particular facet of the malleable relationship proposed by Enid Balint. In a perfect world, we would concentrate on creating an environment where physicians are able to allow themselves to be used by patients, and trust that good things will happen to both parties as a result.

But in our current world of ingrained distrust and defensive measurements, we feel compelled to digitize, tabulate, rank and rate the doctor-patient relationship, just like we measure everything else. First, the ubiquitous patient experience surveys provide a coarse measure of how patients experience the communications component of the relationship. It is interesting to note that patients are not asked about their preferences, but whether the “provider” did this or did that, presuming that this or that are what the patient wants the “provider” to do in all situations. Can we infer from a highly scored experience survey that the patient has a useful relationship with her doctor? Not really.

Then we have the periodic surveys asking patients to rank the importance of physician attributes, which always include physician compassion and communication patterns, but rarely other components of Dr. Emanuel’s six C’s, and never the chameleon abilities proposed by Ms. Balint. The presumed intent here is to impress upon physicians that they should focus on the highest ranked attributes of the relationship because they matter more often to more people. Some researchers went as far as to define frameworks for measuring the relationship itself, and formal screening instruments to score it from a patient perspective. Those tools seem a bit more pertinent since the questions are about the patient and her perceptions, instead of inquiries about sanctioned physician activities, and because no assumptions are being made regarding the “right” kind of relationship (a Dutch example is depicted below).

Perhaps a combination of the former and the latter, along with objective information, such as assessment of choice, conflict of interest and competency, can get us closer to a meaningful measure of the doctor-patient relationship. Careful analysis of result sets would allow us to answer two basic questions: are patients getting what they value most, and are those fortunate enough to have the relationship they desire experiencing better medical outcomes. Examining the characteristics of both patients and doctors, could yield actionable insights into optimal practice models. Strangely though, in spite of the billions of dollars spent on “patient-centered” research to date, I am not aware of any such study, or serious attempts at anything remotely similar. One can only wonder why.

Although there is ample rhetoric about the doctor-patient relationship and patient-centered everything, much of what we do in health care today is in stark contradiction to Dr. Emanuel’s ideal six C’s, not to mention the revolutionary ideas of the Balints. Patient choice is being curtailed by a bewildering array of narrow network health plans and wholesale clinical decisions made by corporate CEOs. Competence is being redefined to include care provided by non-physicians, non-clinicians, and algorithmic software. Continuity of care is being discouraged in favor of cheapness, convenience and continuity of medical records, while conflict of interest is inherent in all so called value-based arrangements. Compassion has been scripted by marketers, and communication, precisely codified for the eclectic, self-managing, highly educated, financially secure, and largely healthy, patient segment, has become the second most important factor defining the interaction between patients and the health system. The premier factor is of course, access to all of the above.

I don’t think I can agree with Dr. Emanuel’s opinion that the physician-patient relationship is the “cornerstone” of health, but it might very well be the cornerstone of healing. I don’t know how healing the sick affects the myriad measures we are currently collecting, reporting and analyzing with such zest. Some argue that a satisfactory doctor-patient relationship is conducive to patient adherence, increased ability for self-management, and decreased utilization of hospitals and emergency services. If these assertions are even partially true, then the doctor-patient relationship has serious implications for the most important aspect of health care in this country: money. And as such, defining, supporting, and, yes, formally measuring and analyzing the doctor-patient relationship may present a rare confluence of interests between corporate greed and basic human dignity.

Monday, August 3, 2015

The DoD EHR: Ah Hell, Let's Try Again

The health information technology (HIT) world has been hit by a watershed event like no other. The Department of Defense (DoD), widely respected for its indiscriminate generosity to contractors, has awarded the most coveted prize in recent HIT memory – the Defense Healthcare Management Systems Modernization (DHMSM) contract. And the winner is... Leidos, the contractor formerly known as SAIC. A couple of years ago, when the race for the DoD contract began, Leidos/SAIC selected Cerner as its EHR of choice for this contract. The smart money though was on Epic and its Big Blue partner because they are and seemingly always have been the safest procurement choices for top brass in any large organization.

A stunned HIT “community” initiated its favorite game of providing post facto authoritative explanations ranging from cute to grotesque. Here are the most common and least specious opinions. The interoperability lobby offered Cerner’s recent and vocal leadership in organizing a national information exchange as the reason for the DoD choice. Others, who may have been bothered in the past by the prices Epic was able to command, suggested that the relative cheapness of Cerner must have tilted the balance. The technically inclined opined that the Cerner architecture is more modular and hence a better fit for DoD needs. These theories and more may all hold some truth, but what we all seem to forget is that the DHMSM contract was awarded to Leidos, and Cerner is just a subcontractor.

In September 2013 the Science Applications International Corporation (SAIC), one of the largest defense contractors in the U.S., changed its name to Leidos Holdings, Inc. and spun off a smaller entity that retained the SAIC name. The split was explained as a way to avoid conflict of interests and get more business. The classic SAIC expose, written by Donald L. Barlett and James B. Steele, and published in Vanity Fair in 2007, should be required reading for anyone trying to understand why the DHMSM contract award was pretty much preordained. Epic lost the day it partnered with IBM, and Cerner won the day it selected, or was selected by, SAIC.

Back in 1988 SAIC was awarded a $1 billion dollar initial contract to design, develop, and implement the Composite Health Care System (CHCS). When the first version of the CHCS turned out to be lacking, SAIC was awarded a contract to replace it with CHCS II. Over 27 years SAIC has evolved the CHCS into the current Armed Forces Health Longitudinal Technology Application (AHLTA) through design, redesign, rip-and-replace, integration and deployments in military facilities of all types around the globe. The DoD was very proud of the new $1.2 billion AHLTA back in 2005, but in time it became fondly known as an acronym for “Ah Hell, Let's Try Again”. Nevertheless, SAIC kept raking in support and development contracts for AHLTA, since according to the DoD, SAIC “is the only vendor capable of supporting functional and technical system changes due to their unique experience and familiarity with the system”.

After CHCS and AHLTA, now comes DHMSM, and there is absolutely no reason to believe that the DoD changed its opinion regarding SAIC’s unique capabilities. Spending billions of dollars on one failed solution after another does not seem to be a problem for defense contractors, or government contractors in general, and in all fairness SAIC does have decades of experience in the unique deployment needs of the military, which are vastly different than your typical posh academic center in the homeland. Perhaps throwing a decent commercial EHR in the mix will finally break the perpetual cycle of failure the DoD has become accustomed to paying for. One can only hope.

The more interesting question for non-military HIT is how the DHMSM contract will affect the orders of magnitude larger commercial EHR market. Will Cerner leapfrog Epic and become the EHR of choice for large health systems? Will Cerner be so bogged down in military work that it will start losing ground in the private market? Will Epic repent and submit itself to the Cerner led CommonWell interoperability (data collection) bandwagon? Or alternatively, will Epic snap out of its self-imposed silence and mount an aggressive marketing and PR campaign? Will distant competitors somehow be able to take advantage of the turmoil and take the market by storm? Or maybe, just maybe, once the headlines die down in a few weeks, and we move to the next big thing, nothing will have changed.

The DHMSM contract is very large by comparison to private EHR contracts, but it is not as large as it looks. The initial award is for $4.3 billion over the next 10 years. Multiplying by at least 2, since after all this is a Pentagon contract custom built for SAIC, we are looking at approximately $860 million per year on average, over the next decade for SAIC, Cerner and dozens of other subcontractors. An optimistic estimate of Cerner revenue would be around $80 million per year (HIStalk estimates a more conservative, and probably more realistic, $40 million per year). To mere mortals this may seem like a lot of money, but considering that typical hospital EHR implementations run anywhere between tens to many hundreds of millions of dollars, and considering that Cerner has annual revenues of around $4 billion, the DoD contract seems like a modest contribution to an already gigantic EHR powerhouse.

Speaking of money, it does seem rather excessive to spend so many billions of dollars on a piece of software. Nobody knows how many billions will end up being spent, but we do know that $4.3 billion is the absolute minimum over the next 10 years. Is that a lot? The DoD has 55 hospitals and more than 600 clinics, and it has aircraft carriers, submarines, helicopters and all sorts of personnel carrying vehicles where the EHR will need to be used, not to mention remote caves in foreign lands, and theaters of full blown war. Neither Cerner nor any existing EHR, including VistA, has those capabilities out of the box. Certainly lots of new code will need to be written by Cerner, but the bulk of the money will go to integration and deployment. That money is SAIC money and is independent of EHR choice (this is a good place to go back and read that Vanity Fair article).

There is however no doubt that the DoD contract is a huge marketing win for Cerner, and this is amplified by the fact that Epic does little to no public marketing of its own. The Cerner award will also have beneficial effects on the CommonWell data exchange platform. The already significant influence Cerner exerts on government agencies, such as ONC, will likely increase and that’s a very good thing for Cerner’s commercial business. More important though is Cerner’s foot in the door at the Department of Veteran Affairs (VA), just in case they decide (or are forced to decide) to keep up with the DoD and replace their VistA EHR.

So far the experts and the media have been kind to Cerner, and will continue to be so as long as the DHMSM project moves successfully through its milestones. However, as a subcontractor, Cerner has limited control over the project as a whole, and considering that in the world of SAIC, success is defined as extracting the largest possible annuities from the government, whether its deliverables are fit for purpose or not so much, Cerner is running a significant risk of having its otherwise respectable reputation tarnished through no fault of its own. Not sure why, but my feeling is that Cerner has a much better chance of surviving inside the shadowy defense contractor culture than Epic would have ever had, so things may turn out just fine.

Health care nowadays is like the ticker tape of a hyperactive stock market gone mad. Everything is huge, disruptive and transformative for a few days until the next seismic shock rolls in. Since nothing means anything in particular, everything means exactly what each expert wishes it would mean. For some the DHMSM exemplifies the triumph of interoperability and the demise of information blockers. For others it is clear proof that the future belongs to platforms and substitutable modules. Many are just thrilled to see a previously unbeatable contender take one squarely on the chin. And a few feel personally persecuted because a big iron EHR vendor was selected instead of something from the app store. Truth is that the DHMSM means very little to anybody in the EHR industry, other than Cerner of course.

Sunday, August 2, 2015

Excerpts from a Doctor's Personal Journal


4/18/13 …finally certified as a PCMH with NCQA. We’re meeting Meaningful Use requirements and are busier than ever. It seems I’m staying at the office later and I haven’t seen any of the expected profit yet, most of the increased reimbursements have barely offset the added costs as far as personnel and IT, but now we can prove the quality of the care we provide…

4/25/13 …at dinner with the family I realized how chaotic my home life is, no structure like at work. I was late getting dinner ready, Thursday is my night to cook, and I didn’t have all the ingredients so I had to run to town and still forgot to buy milk. I needed to pay bills but hadn’t transferred any money to the checking account and had used up the last of the checks without ordering more…That night the twins Annie and Amy were pestering my wife Kate about soccer camp, and Glen was talking about his latest baseball game, he made the varsity baseball team as a sophomore playing first base. Kate, who runs her own business as a florist, observed that at work she has systems to track orders and deliveries, but at home we can run out of milk and no one says anything. It got me thinking…

5/16/13 …after dinner the kids had finished their homework and were starting a game of Monopoly and Kate was about to settle down with her book when I called everybody together for an impromptu family meeting. I proposed that we build a Family Centered Personal Home (FCPH) based on the same principles of the PCMH I had learned at work. I suggested we could have written family procedures and protocols for all the important stuff, and we could track our progress if we digitized and automated as much of it as possible. We would develop a team approach with everyone functioning at the top of their abilities. The kids were excited when I told them we would each need our own IPad connected with the home computer, but Kate was skeptical and wondered how it would help and what it would cost.  Eventually my enthusiasm prevailed and Kate agreed to try. I know that if we can collect enough data and use the right quality metrics we can optimize the FCPH…

8/22/13 …it’s taken all summer but I think we’re ready to begin in time for the start of the new school year. I used all the spare time I had this summer writing protocols for everything from paying bills to homework and piano lessons. I took the money we would have spent on weekend outings and invested in a new home computer and IPads for everyone. I had an IT guy at work help me modify some basic software and spreadsheets to structure our initial data collection, later I’ll need to invest in better software to help interpret the data we collect…

8/29/13 …Ready to roll! I explained tonight that the new computers are tools and not toys, we’re going to use them to track our progress. I showed each of the children how to use the preloaded spreadsheets to track their time spent on homework, chores, piano and violin practice, school attendance using GPA as an outcome metric, and so forth. I included detailed procedures for everything from teeth brushing to basic hygiene and meal prep, expectations for laundry, vacuuming, dishwashing, and lawn mowing... Glen was excited to see I’d included a program to track his baseball batting average. It’s important for children to have some unstructured time to pursue their own interests and hobbies so I built that into the detailed preloaded schedules customized for each of them. For Kate and me, we have the added responsibility of tracking household finances, kitchen and pantry inventory, transportation expenses maintenance and repair, etc. I mirrored some of the children’s software on our computers too so we can have reminders of important events like recitals and soccer games….

8/30/13 …today I introduced the family to the rest of the team, just as with the PCMH Kate and I can’t be expected to do it all, so I’ve hired some surrogate help in the form of tutors, nanny, personal trainers, gardener, and housekeeper. I have outsourced accounting, IT development and most home maintenance responsibilities. Extended family can step in to fill some functions when Kate or I aren’t available. I’ve had to forgo any retirement savings this year and we might miss a mortgage payment or two, but it will be worth it in the name of quality…

9/2/13 …I had to password protect the Intimate Relations protocol and data set on the shared server, it was generating too much interest. I need to talk to Kate about measuring quantity as well as quality as a metric…

10/10/13 …pulled Amy aside tonight and had a stern father-daughter chat, she just hasn’t been tracking her data like the rest of us. She complained it was too much work, that all the data entry was actually keeping her from performing the tasks she is supposed to track. I explained that I completely understand, and that based on my experiences at work the documentation is always more important than anything else so sometimes you have to fudge a little bit in order to get everything done. Without the data we can’t measure how well we’re doing and if we can’t measure it how can we improve? She cried and tried to argue that sometimes the intangible things in life are more important, but in the end she saw things my way and promised to try harder…

12/12/13 …During dinner tonight everyone was quiet, the cacophony of conversations we would have heard last year at this time is gone, instead everyone has their head down rapidly pecking away at their computer screens documenting their activities of the day…we don’t seem to be interacting nearly as much but the pantry is well stocked and the oil/filter in the pickup was changed on time for once…

1/16/14 …reviewed the children’s report cards from fall term and Annie’s grades have fallen. Looking through the automated reporting features of our user friendly software it appears she has been keeping up with her homework, and the chore tracking feature reveals 100% performance, everyone else is tracking around 65% to 80% with a performance incentive set at 72.3%. My personal observations make me question the veracity of Annie’s outcomes, but it’s hard to dispute the data…

2/13/14…Glen is in the front yard playing catch with Nathan his personal trainer, the twins are at the kitchen table with Brenda their mentor working on their algebra, both tasks I used to have to do. This has freed me up to do more important things… I just discovered all the tires on our mountain bikes are flat, they’ve probably been that way for months and nobody noticed, I’ll need to add a bicycle tire pressure monitoring protocol to Glen’s garage inventory and maintenance duties, maybe I should sell the bikes, we haven’t used them in almost a year…

3/27/14 …spent the first couple of days of spring break tweaking our protocols and procedures for the FCPH and letting the kids catch up on their reporting. Was surprised to learn that Glen isn’t going out for baseball this year, he says he just doesn’t have the time…

5/15/14 …Amy is still having a hard time, tonight she complained that our relationships are suffering, she observed that we haven’t played a game of Monopoly in over six months and our dinner conversations are curtailed as we all rush to finish the meal and clean up so we can complete all the documentation needed for the FCPH. It was difficult for me but I had to explain to Amy that in any endeavor like this sacrifices are necessary. At the office before we became a PCMH I used to think that my relationship with my patient was paramount and that I could effect a better outcome by getting to know and bonding with my patients respectfully. Our transformation to the PCMH taught me that I wasn’t doing such a good job. Some of my patients that I’d been treating for years weren’t following my advice and were skewing the metrics used to incentivize me so they had to be discharged from care. I explained to Amy that just as I’ve had to sacrifice any antiquated notions about relationship building in clinical medicine in order to optimize my outcomes, so too must she jettison any such unreasonable expectations as we perfect the FCPH…

6/18/15 …our household is running like a well-oiled machine, and I can prove it! We had to let the housekeeper and gardener go so we still have some issues in those realms, but everyone has very well defined roles and responsibilities… sometimes there can be a lot of finger pointing when things go wrong. I haven’t talked to Amy in weeks, there are still some discrepancies in Annie’s data and actual outcomes I haven’t put my finger on yet, and Kate seems more distant somehow. Glen no longer talks about going to medical school after college. On the computer I can show you how we’ve improved on so many metrics in the last two years, I can’t imagine trying to run a household without the FCPH…

The author is a family physician in solo practice.

Opinions expressed by "On Health Care Technology" guest bloggers are their own.

Tuesday, July 28, 2015

Back to the Future Garden of Eden

The very first thing Adam and Eve did after acquiring the wisdom to distinguish between good and evil was to cover themselves up and hide from view. Privacy was the first concern of a newly enlightened humanity. The punishment for acquiring this peculiarly human self-awareness was harsh, swift and unforgiving. Yes, it is legend, but you should never underestimate the genius of an author whose collection of stories has been the number one global bestseller for almost six millennia and counting. Today, a new legend is forming. If we agree to take off our loincloth and step out from the shadows of our privacy, the eternal punishment of blood, toil, sweat and tears will be rescinded by a new generation of supreme beings.

Is it possible for us to unbite the proverbial apple? Is it possible for us to revert to naked grazing among the magnificent bounty offered by the new gods, completely oblivious to benevolent surveillance and unobtrusive discipline? Our government thinks so. The billionaire class thinks so. And many of us agree and think it’s for the best. After all, honest people have nothing to hide, nothing to be ashamed of, and privacy has no tangible benefits anyway. Better yet, a little less privacy, and a little more supervision, for criminal elements and people we don’t like, is probably a good thing. Insisting on an archaic “right to be let alone” in a globally interconnected world, other than being laughable, is hindering the democratization, simplification, cheapification and commoditization of all life’s endeavors, including prevention of disease and curing cancer. Privacy is the last barrier to an eternal life of leisure and joy.

There is currently a well-coordinated, well-funded and extremely successful campaign to help us shed the ball and chains of privacy. Whereas three quarters of a century ago we realized that work made us free, today we recognize that sharing our private information will bring us personal liberty. Freedom and liberty, contrary to what you may have learned in kindergarten, are earned by hard work and individual publicness. Since the innocent days of prancing naked on the banks of the Euphrates, we learned the hard way that free markets are the engine, the heart and soul, of humanity, and free markets are hampered by the original sin of privacy, which introduces an information asymmetry that makes the markets anything but free. To liberate ourselves, we must liberate our markets first.  

America, as usual, is leading the way in liberating international markets. Our unique form of government with its three famous branches of corporate, lobbyist and executive is best suited for freeing humanity, because our government has evolved from representing a small group of citizens to representing global markets. For those too old to see the glory, rest assured that there are large checks flowing freely between the three government branches and balances are meticulously calculated by our leaders. The Singularity, you see, is not a nebulous prophecy about cyborgs. The Singularity is here and now, as this is the precise moment in human history where governance, technology, apathy and savvy leadership are perfectly aligned to take us back to the future Garden of Eden.

On Friday, July 10, 2015 the 21st Century Cures Act was passed by the House of Representatives of the U.S. Congress with overwhelming bipartisan support. Relatively speaking, the bill is rather short and concise at 362 pages, so one can be certain that our wise representatives have read every syllable and understood all the technical intricacies of this groundbreaking legislation before casting a vote. Having been a skeptic in the past, I must admit that I am particularly awed by the mathematical prowess of our legislators who empowered the Secretary of Health and Human Services to require that scientists use Bayesian statistics in their pharmaceutical research.

The Act that will cure us in the present century is the culmination of a gigantic effort by the corporate and lobbyist branches of our government to bring potentially lifesaving medicines to the market faster, in larger numbers and at lower costs to the manufacturers. To accomplish this the Act is cutting through the useless regulatory red tape of the Food and Drug Administration (FDA) and bypassing the obsessive scientific insistence on rigorous clinical trials, which can take decades to produce an approved medication, while people continue to needlessly die. Instead, an iterative and more agile process is being put in place by the Act. Do a little research, a little testing, a little checking and regulating, fail soon, fail often, and pivot quickly based on post-market laboratory surveillance.

Sure, people will continue to die (not necessarily the same ones and perhaps a few more), but now they will die for a good cause. The road to heaven, you know, is paved with necessary atrocities. Privacy of course is not congruent with the needs of a learning laboratory system, and the Act has taken the first steps to remove some of the anachronistic obstacles erected by the privacy sections of HIPAA. Once the Cures Act becomes the law of the land, personal health information will become shareable for research purposes, and the cumbersome need to obtain informed consent from human research subjects will be waived if illustrious researchers estimate that the experiment poses “minimal risk” to those experimented upon. Illustrious researchers have always been humanitarians first, and scientists second (savage sadists was a distant third), so we should be fine.

Less than a fortnight after the Cures Act swished through Congress, the lobbyist branch came up with a whitepaper to guide the next steps in our road to redemption.  Calling it as Oracle, IBM, Intel and PhRMA, all esteemed members of the corporate branch, see it, the lobbyist prescription is to dismiss any shreds of privacy and self-determination laws left standing, including the Common Rule which protects the rights of human subjects of medical research. The Common Rule is the American implementation of the Declaration of Helsinki, which was developed by the World Medical Association, following the peculiar events that led to the creation of the Nuremberg Code. The Common Rule is thus a relic, an overreaction to a bunch of idiots who thought they could somehow engineer a perfect race of humans, and among other things engaged in ample exploratory research. Stuff like that cannot happen anymore, because now we have Internet, so it’s time to get over it, put it all behind us and move forward.

Privacy rules, you see, have “opportunity costs” for the corporate branch of government, and as such are strongly affecting the movement of checks between the branches, and the size of balances everywhere. The lobbyist whitepaper is making an exceedingly compelling argument for permitting unchecked collection and trade in all sorts of personal information, not just medical or genomic. The banks have been doing it forever and it's all working just fine, other than a little innocuous leakage into marketing databases. Why should other corporate clients be treated differently than the banks? It’s simply not fair, and “lives are being lost” because of our failure to equally protect all corporate members from undue regulatory burdens. A stark example of unfairness is the preferential treatment afforded to the Centers for Medicare and Medicaid Services (CMS). 

On November 13, 2014, the CMS published a final rule regarding its physician fee schedule for 2015. Tucked neatly inside it, there is a little section promising to “provide clear legal authority for Health Insurance Portability and Accountability Act (HIPAA) Covered Entities to disclose any required protected health information” to the CMS. The “required” disclosure is for information ranging from clinical to “health behaviors” to a catchall “other data”, such as “participant employment status, participant educational degrees pursued/achieved, and income”, all “with identifiers that allow linkages across time and datasets”. The subjects of said disclosure are all entities “participating in the testing of past, present, and future models” funded by the CMS, including people not covered by the CMS, which is pretty much all people in this country.

The CMS needs the information to evaluate results of research projects, which by its own admission could have adverse effects on participants, with no mention of informed consent being needed from test subjects. How is this fair? If the CMS is asserting such latitude, why shouldn’t the corporate branch enjoy equal opportunities? What has the CMS done for you lately? If you are going to trust someone, why not trust a good solid brand-name, like say, the Coca-Cola polar bear, or the Marlborough man? If somehow doctors came to your mind in this context, the lobbyist whitepaper is quick to point out that, by winning Jeopardy, IBM’s Watson proved once and for all that “doctors are no longer the experts they once were”. And no whitepaper can be complete without reminding us that if we don’t get our act together quickly, China is going to eat us for lunch.

So that as they say is that. We must comply. Yes, for some of us it will be a little awkward in the beginning, but many have already made the transition, and frankly they seem to be just fine. This is after all an inevitable stage in human development. After losing our innocence, we began eking out a meager and perilous living by scratching food from the dirt beneath our feet. We looked underneath the dirt and discovered carbonized dead vegetation and digging deeper we found other fossilized lifeforms. We sustained ourselves comfortably on the dead bodies of those who came before us. For a brief moment, we looked up and considered the infinite bounty of the universe, but that seemed too hard.  The disruptive innovation of our times is to fast forward to a distant past and turn on each other to extract untold fortunes from mass digital cannibalism.