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April-26-2010

15:40
Over the last couple of weeks I have been running across various success and failure stories of EMR implementation in various settings, ranging from small practices to large hospital wide implementations. 

The number one factor in a successful EMR implementation from all the read reports have been due to physician/surgeon buy in.  Makes sense, after all these are end users of the applications and if you don't have anyone on the provider side vying for a successful workflow adaptation, there is no reason to implement an EMR.  Also, if you have an M.D. as your champion, won't the rest of the staff have to buy in for fear of replacement of someone who will?  I know in other occupations, what the boss says, goes.  The true is same in healthcare, no?

The next seemingly most important factor is the ability to customize the application in a way that will best benefit the providers.  This is absolutely a main component in the success factor of an EMR in my opinion.  Vendors have to do what they can to include everything in their system that a practice, clinic or hospital may use.

In a hospital system, this problem is very clear.  A hospital system has to be a nightmare to the specialists who use it.  Why would a provider want to sift through literally thousands of medications when they typically only prescribe certain ones for their patients.  This is where careful planning and delegating comes in.  The customer needs to understand that the hospital system is meant to meet the needs of all providers in the entire system.  It is recommended that each specialty department within the community appoint select staff to create a list of "Favorites" within the medications, procedures, diagnosis, orders etc. tabs.  This way, time will be saved when completing a patient visit.

In a smaller setting, I have to recommend going with a specialty specific vendor.  In doing this, the provider will have a more robust system specifically catered to their needs and will not include any additional data fields that they will never have a need for.  The specialty specific vendors are also more likely to already have certain reporting tools already preloaded in the system to generate specialty specific and relative reports, such as those required for Centers of Excellence.  Exemplo Medical (www.exemplomedical.com)  is one such company that develops specialty specific software.  For example, Exemplo's application for Breast Cancer, eMD for Breast Centers, is an application designed in conjunction with Breast Surgeons and staff that only shows pertinent workflows that a typical Breast Center or Practice may use.  The workflow includes specific data fields for patient visits, orders, medications, procedures and so on.  They even have a specific report that automatically generates a NQMBC report that is easily submitted to the National Consortium of Breast Centers for their COE compliance.

Of all the success stories these two themes: provider buy in and customization seem to be at the top of the list and perhaps the easiest to attain.  Some may disagree with that statement of being "easy to attain" however if a provider has been given a clearly painted picture of the benefits of EMR implementation, then it should be a no brainer on their end.  As for the customization...providers do your homework, there are wonderful systems out there that you will be amazed to find how easily adaptable they are to any practice.


December-16-2009

9:52
Two studies were published in the Archives of Internal Medicine this past Monday showing "The risk of cancer associated with popular CT scans appears to be greater than previously believed".

I originally read this article in the WSJ and they included a nifty graph showing the increase in CT scans over the years (1993-2006, and included projected 2007 numbers). I can't say I was shocked. Obviously there will be an increase, population increases year over year.

As expected, the American College of Radiology (ACR), released their own statement in response to the recent studies. The ACR statement was wonderfully put together and basically stated that if an imaging center abides by the standards put forth, then there should be no increased risk as the benefit of the scan outweighs the risk. Seems like common sense to me.

This is where I believe that patients need to take more responsibility for their own health by asking questions instead of just going along with whatever their physician says. After all, when you break it down, its a business that strives to make a profit. I am not putting down all clinicians who perform CTs, I am putting down the clinicians who abuse the system to make the money to pay for their fancy state-of-the-art equipment. Those machines come with a hefty price tag and the ROI must be met somehow. Some clinicians go about it the right way, others don't unfortunately. They are human after all.

Now for the other issue with this...clinicians have to protect themselves. If a patient comes in complaining of a mild condition that a CT may show, its up to the doc to determine the severity of the situation. This is a very fine line due to the liability involved. Unfortunately we live in a world of money hungry individuals who are willing to sue if their coffee if too hot. This is where the relationship of the physician and patient comes into play. There has to be a level of understanding and trust for the situation at hand.

Personally, I have a wonderful relationship with my GP and others specialists that I see because I feel comfortable with them. If you don't feel comfortable asking the hard questions with your provider, maybe its time to look into a different one. Good ones are out there, more good than bad fortunately for us. But it is up to us to sift through the population to find one that fits best. Unfortunately for doctors now a days, it is getting harder and harder to make money and that is unfortunate because I believe that some of the "good" docs may be susceptible to becoming more focused on business side rather than patient care, which I can't say I don't necessarily blame them, they have bills to pay too, big ones like student loans, salaries, mandatory EMR adoption etc.

Now for my cynical comment....I wonder which diagnostic test or treatment or whatever will be next to take some heat in order to cut healthcare costs? Keep in mind this is at the expense of the public who desperately wants change, but I have to ask, at what price? So far it has been more about money than human lives.



December-11-2009

11:43
The National Consortium of Breast Centers (NCBC) has just released their position statement regarding the recent mammography guideline changes:

“The National Consortium of Breast Center's Board of Trustees has given their consent to the following position statement reflecting their stand on the issue of mammographic screening, in response to the recommendations made by the US Preventive Services Task Force.

National Consortium of Breast Centers, Inc.

Position Statement regarding the Mammography Screening Recommendations of the United States Preventive Services Task Force (USPSTF)

The National Consortium of Breast Centers (NCBC), the largest national organization devoted to the inter-disciplinary care of breast disease, requests the USPSTF rescind their new position on mammography screening.

The U.S. Preventive Services Task Force (USPSTF) published a paper detailing model estimates of potential benefits and harms to women screened for breast cancer with mammography.1 They provided an updated USPSTF recommendation statement on screening for breast cancer for the general population that alters currently accepted guidelines for women over 40 years old.2

The NCBC opposes the new guidelines as written. We cite specific evidence that screening mammography leads to early detection which leads to improved survival.3 In every country starting population screening, mortality declines coincide with onset of screening, not systemic therapy. These USPSTF models are not based on sound data, namely different denominators in the “harms” vs. “benefits” groups leading to invalid comparisons. Recent data from randomized controlled trials reveal significant mortality reductions evident approximately five years after screening programs were initiated. The reductions in age-adjusted, disease specific mortality (30-40%) since 1990 define screening program benefits not seen in the prior six decades. In the United States, these mortality declines continue at a rate of approximately 2% per year. 4 This mortality improvement counts as a remarkable public health achievement.

In addition, the USPSTF panel (comprised almost exclusively of primary care physicians) did not include breast imaging specialists nor was it represented by any of the multiple other specialists who collaborate to optimize patient outcomes. These specialists include pathologists, surgeons, medical oncologists, radiation oncologists, reconstructive surgeons, technologists, geneticists, nurse navigators, educators and others.

The NCBC does not understand the assumptions used by the USPSTF to value human life. We note the cited literature was selective and failed to acknowledge equally powerful and credible peer-reviewed literature, which supports currently accepted breast cancer screening guidelines.

We would also like to note that quality of life has a significant value, not just survival. It is well established that if we discontinue mammography for women in their 40’s, the cancers eventually detected will be larger, more likely need more aggressive surgery, more likely need chemotherapy and more likely lead to other significant socio-economic concerns.

The NCBC requests input into future guideline development and vows to work with government, scientists and industry to keep the process transparent and keep the focus on the patient. We recommend further efforts target screening, risk assessment, education and awareness regarding the implications of positive and negative screening findings. Funding for further research is imperative and supported by the controversy these articles have generated.

Finally, we note the USPSTF article states, “whether it will be practical or acceptable to change the existing U.S. practice of annual screening cannot be addressed by our models.”1 The NCBC agrees with this comment and finds their screening guideline suggestions unacceptable. The NCBC believes many women’s lives will be placed at risk if current screening guidelines are altered. We respectfully request the Task Force rescind their position on this specific women’s healthcare screening policy.

# # # #

About NCBC: The National Consortium of Breast Centers (NCBC) is the largest national organization devoted to the inter-disciplinary care of breast disease. In keeping with our mission, to promote excellence in breast care through a network of diverse professionals dedicated to the active exchange of ideas and resources including: 1) To serve as an informational resource and to provide support services to those rendering care to people with breast disease through educational programs, newsletters, a national directory, and patient forums; 2) To encourage professionals to concentrate and specialize in activities related to breast disease; 3) To encourage the development of programs and centers that address breast disease and promote breast health; 4) To facilitate collaborative research opportunities on issues of breast health; and 5) To develop a set of core measures to define, improve and sustain quality standards in comprehensive breast programs and centers.

References:

1. November 17th edition of the Annals of Internal Medicine, Vol. 151, Number 10, 738-747.

2. November 17th edition of the Annals of Internal Medicine, Vol. 151, Number 10, 716-726.

3. Tabar L, Vitak B, Chen HT et al. Beyond randomized controlled trials: organized mammographic screening substantially reduces breast cancer mortality. Cancer 2001; 91: 1724-1731.

4. American Cancer Society, Breast Cancer Facts and Figures, 2009-2010.

All content and design © 2009 by the National Consortium of Breast Centers, Inc.”


As mentioned in the recent post, "Scrapping the Barrel to Support Health Reform", it seems like the current Health care reform plan is costing the nation a trillion dollars yet is taking away money from preventative care of deadly diseases, mainly its been cancer that has been hit the hardest.


The optimist in me at first said that with these changes, maybe techniques and other medical procedures will be forced to improve based on this change. I still believe this will be the case, but does one outweigh the other? The best approach would be to do both of course. Maintain the guidelines that have been proven effective through various published trials, and allocate ARRA funds to increase R&D of new treatments or improved quality of current techniques. Who knows, there may be money left over from the HITECH stimulus funds by ARRA if physicians are unable to collect the 44k in order adopt EMR.

Once improved procedures allow for a change in the guidelines, then the change is warranted. If not, guidelines should not be altered.

The National Consortium of Breast Centers (NCBC) is currently the largest national organization devoted to the care of Breast Disease. Through their quality measures program, the National Quality Measures for Breast Centers (NQMBC), breast care centers have the opportunity to collect and standardized data to the NCBC in hopes to improve clinical care of Breast Cancer Patients.



December-7-2009

12:57
As usual, its been a busy few weeks in the Health IT world and things continue to get shaken up with many recent announcements.

In a press release on 10/22/2009 the Certification Committee for Health Information Technology (CCHIT) announced that they are seeking candidates to serve as Trustees and Commissioners.

Another press release on 11/13/2009, announced that CCHIT's well known Chair, Mark Leavitt will be retiring in March of next year after 5 years of service.

Once the first press release came through on my feed, I thought it was only a matter of time before this happened. Changes need to be made by the CCHIT to gain acceptance by many skeptics. Then I received the second feed, an interesting decision made by Dr. Leavitt to announce his retirement, especially since the CCHIT has been under major scrutiny lately for being the sole certifier of EMR systems and carrying a rather large price tag, so large in fact that most of the smaller vendors are unable to afford the certification. I'm just not sure if leaving his organization now, especially announcing it, was the greatest business decision for the CCHIT.

The CCHIT has also been accused by it's critics for catering to the larger EMR vendors that also conveniently sit on their Board of Trustees and Commissioners.

I find it quite coincidental that after undergoing such a large amount of scrutiny for favoritism that the CCHIT is now holding interviews to replace some of it's Board Members. I know that you are probably thinking, damned if you do damned if you don't. Thats not where I'm headed. I want to give kudos to the CCHIT and Dr. Leavitt for their accomplishments in the past years as well as the realization, or wake up call, that changes need to be made their board, specifically the board member ratio, which I'm sure will be affected. The positions are open to members of physician practices and hospitals, payers, health care consumers, vendors, safety net providers, public health agencies, quality improvement organizations, clinical researchers, standards development and informatics experts and government agencies. I would imagine that the vendor to healthcare provider ratio will be severely affected.

As for Dr. Leavitt leaving, personally I don't think this is the greatest time the CCHIT during this critical time, especially when the certification business is open for business according to Health and Human Services. Who know's, maybe its a career move...he would be a perfect candidate to head up a start-up certifying company.

That brings me to my next topic, the Drummond Group may prove to be a worthy alternative. They had their own press release on 11/02/2009 that they will submit to become a certifying body. I haven't heard of any progress, but if anyone out there has heard anything, please let me know. For those of us who are new to the Drummond Group, they are a company specializing in interoperability testing. Rik Drummond, CEO of Drummond Group was quoted in the press release saying, "Drummond Group has been supporting Fortune 500 industries and government by certifying the transfer, identity and cybersecurity of their internet information flow over the last ten years. We have also done testing for the CDC, DEA and GSA. Certification of EHR is a natural extension of our testing program, and we believe we can provide great value for the medical community. We look forward to the publishing of the ONC requirements in the days ahead so we can get started."

There seems to be a lot of progress within the Certification realm. My only other questions and worries are targeted towards getting everything in place in time for physicians to get their reimbursements.



November-20-2009

10:41
What a past couple of days in the Healthcare realm. First of all, the Health Reform bill passed in the House with a price tag of $1 trillion. The money has to come from somewhere and it seems like it is coming down to the preventative care of women as for now. In other releases, separated by one day each, new guidelines came out for mammograms and pap smears. Another release just came out regarding a 5% tax on non-elective plastic surgery procedures.

I have to wonder who is influencing these recently altered guidelines and their research findings. I have my opinions on research...data can be manipulated to prove a desired point. I have to assume this is what is going on in these recent releases regarding the preventative care for serious cancers that specifically target women. For the past year I have heard more news to promote preventative care than ever before. Why? Because it saves lives and yes money too. So now, why are they changing these guidelines that promote a higher level preventative cancer? Has anyone thought that the numbers may be down because of the preventative measures that have been in place?

With a $1 trillion price tag, one has to wonder is its to free up funds to pass this bill. Unfortunately, these changes are going to be just the beginning I believe.

As for the elective plastic surgery procedures, in 2008 it was reported that $10.3 billion was spent on these procedures. People choose to get certain procedures to benefit their quality of life in some way, which can ultimately change certain mental conditions such as depression and anxiety which both play an enormous factor in the progression of other serious health factors. Not everyone who elects to get plastic surgery are the typical "trophy wife" getting a different nose every 5 years, its also those people that have little money to pay for a procedure to correct something that may have been caused by an accident for example. Now, these people who have to spend thousands of dollars, that may have had to scrape it together, are expected to spend 5% more. Is that fair to the little girl who was in a car accident and suffered injuries to her face that left her scarred for life without plastic surgery? This is just an example, but it is also a reality of how people are going to be affected by this health care reform push.

I believe something has to change in Healthcare, but at what cost? Certainly not time, after all the current administration is rushing this thing out without the proper time to think of how it will actually pan out in the future.

Its going to be an interesting couple of years to say the least.



October-19-2009

11:11
Since the inception of ARRA, there has been mixed emotions of whether or not throwing money at a situation will benefit the struggling incumbent health care system. Having only worked in Healthcare IT for a limited amount of time I believe I can shed some light on the subject from an outsider's perspective rather than a biased, perhaps jaded, insider's view.

First lets talk some basics. Approx $19.2 bill in incentives available to physicians who adopt a certified, meaningful use EMR system. This breaks down to around $44k/provider on up to $64k/provider depending on Medicaid/Medicare patient ratio (the more CMS customers, the higher stimulus awarded). Incentives start this 2010 and penalties start 2015.

The main debates have been lying in the "certified" and "meaningful use" or simply "MU" realms. Let's first talk about certification. The only certifying body to date is the CCHIT which was spawned off of HIMSS and even has a former HIMSS member as its leader. For those of you that are new to this area, the Certifying Commission on Health Information Technology (CCHIT) is a non-profit group based out of Chicago, near HIMSS HQ, that is comprised of different executives who have vested interest in the large EMR vendors...because they run and/or work for them. That is all I will rant about for this post on the CCHIT.

The next big issue, which needs to be radically simplified is MU. Every practice and specialty are different. Meaningful use may vary from specialty to specialty. This needs to be a simplistic model, not a complicated matrix that was originally released, for everyone to understand. There also has to be a lot of gray area as well in this definition to allow for proper payment if a practice is able to show that they use MU.

These 2 criteria, certification and MU, have yet to be decided on. Deadlines are set, but as we all know and have experienced, they may be moved again.

So back to the original question in the title, has the stimulus money caused a boom for HIT or has it been a bust thus far?

Certain areas of the HIT market has seen an increase due to the stimulus funds for HIT for sure, but on the same note, many HIT vendors have seen a lull in sales. Why, when there is at least 44k on the table and adoption needs to happen quickly in order to qualify for the 1st and biggest stimulus handout.

The stimulus money has put providers on a bit of a "wait and see" mentality. There are far too many providers who do not see the value of EMR. Should this stimulus money have been allocated differently? Should more money have went to education and research rather than purchase and implementation?

EMR is not a thing of the future. It is a technology that has been around and in use for over a decade. They have time over time proven effective, efficient and reliable. I am not going to go into detail because the case studies are out there. The only problems that I have seen are due to bad matches between vendor and customer, not the idea or technology itself.

Look at our world now, smartphones that allow us to answer emails while out of the office, telecommuting from home to save on overhead costs etc. Technology will continue to improve upon quality. Be it quality of care or quality of life.

EMR is a way to do both. The incentive from ARRA is there yes, but treat it as a bonus for adopting a new way of patient care and reporting to improve the overall quality of care and patient health for futures to come by adopting and embracing a sound technology that you may, or may not, get some extra cash from.



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January-19-2012

8:09

I was convinced that Milt Freudenheim's glowing, uncritical puff-piece about Epic in the NYT would not provoke any critical blow-back (see: Digitizing Health Records, Before It Was Cool). I was certainly not expecting any criticism from hospital CIOs and CEOs who are anxious to stay within the good graces of the company and are contractually constrained from any visceral outbursts. However, Vince Kuraitis, who blogs over at e-CareManagement, has informed me via a comment that there is a heated discussion going on at Google+ about the NYT article and Epic in general. You may also want to refer to my recent blog note about Epic (non)-interoperability (see: A Reader Comments on Epic Interoperability and Care Everywhere). Here is Vince's comment:

FYI, there is heated discussion going on about Epic (non)-interoperability on Brian Ahier's Google+ post.

Here are five snippets from the ongoing Google+ dialogue selected on a semi-random basis:

  • It's almost as if Milt Freudenheim avoided doing any research. It borders on contradicting anything that people who are actually work with Epic, as a company or as part of their workflow, will tell you about their experience. I know that Epic has their fanboys and girls, but come on... Really? (Nathan DiNiro)

  • The article says it draws programmers that might otherwise take jobs at Google, Microsoft or Facebook. I can't imagine there are many of those. Let's see, work on MUMPS in Wisconsin or some newer technology in the Bay area. Yeah, I'm not seeing many making that choice. I also love that it says that Epic is sharing data with other systems. I'd love to see examples of this. I hear that Epic will have a spot in the interoperability showcase at HIMSS. Maybe we'll find out more there. (John Lynn)

  • I was going to write a post but apart from all the good things about Epic, the [four] things Milt Freudenheim doesn't know that would have made a balanced article
    • Technology is old and laughable outside HC (MUMPS or Ruby on Rails--you be the judge).
    • Competition is pathetic (Cerner is the best.....McKesson? IDX/GE? pah).
    • Buyers are America's dumbest corporations (hospitals) who like overpaying and overcharging....
    • Epic doesn't even interoperate with Epic [and] there's no such thing as a standard install, My daughter's pediatrician in the Sutter System has Epic--NO Consumer access. Whereas at Palo Atlo Medical Foundation, which is Sutter AND has Epic, you can view your own record. Do you really think you cold move data from one to the other?

I guess the sad thing about American health IT is that this -- so far -- is the best we got (Matthew Holt)

  • ....How much did Northern California Kaiser go over budget on their Epic implementation? $3 billion? Epic has the big dumb hospital/ foundation players by the short hairs and is milking it for all they can. And they have no intention of playing nice with other technologies or even their own kludgy systems. Of COURSE they argue that monopoly is the only valid solution... just like a privately-held corporation with a highly proprietary, closed-source solution should. (Paul Abramson)

  • Epic is the antithesis of the type of open IT architecture that will be needed to achieve accountable care. Epic is enterprise centric, not patient centric. (Vince Kuraitis)

OMG! All of this anger can't be healthy. However, don't expect much to change in the real EMR/EHR world as a result of this discussion. Link to Google+ if you want to read more in this thread.

One more thing. Has the NYT totally lost its way amidst the Epic adulatory mist? Here's what I think happened. Judith Faulkner NEVER gives interviews to the press. I suspect that Milt Freudenheim was advised by his editors to pitch only softballs to her in exchange for this exclusive audience. I know that the paper maintains that it never cuts such deals but why don't you read the article and judge for yourself. There must be some teeny, weeny problems somewhere in Verona that Milt could have uncovered.

January-18-2012

9:41

In response to a recent note about Epic's Care Everywhere (see: Sharing Medical Records across Hospitals with Epic's Care Everywhere), a reader (Open Standards) posted a comment which I thought was instructive and worthy of promotion to the level of a note. I present it below in its entirety:

Per the Epic technical manual, Epic's Care Everywhere is [described in] the following [way]: 1. For Epic institutions, it is an XML file containing Epic proprietary extenstions to the continuity of care document. 2. For non-Epic institutions, it is an XML file containing the standard continuity of care document. Both of the above are variations of the same theme: the CCD document, an XML marked up document with the demographic, medication, medical history, and most recent encounter data abstracted from the EMR.

There is nothing particularly innovative about Epic's Care Everywhere. In fact, it is a Mearningful Use requirement for any EMR vendor to have CCD export capability. In this regard, all the 400+ MU certified EMRs in the U.S. have this functionality. A CCD document is vastly different than an HIE, which is an independent server that acts as a translation broker. The whole point of the CCD is to enable point-to-point transfer of a common standard machine readable summary of the patients data as a handoff document between any and all EMR.

In this regard, EpicCare specifically breaks the standard CCD form, and makes it incompatible with the rest of the 400+ EMRs in the USA by adding their proprietary extensions. This is consistent with Epic's proprietary, one-vendor-shop, non-interoperability stance. The statement that "any hospital can interoperate with Epic's Care Everywhere - just so long as they are an Epic institution" aptly summarizes this. Again, the proprietary extension to the CCD by Epic means that the 400+ certified EMR's in the USA won't interoperate with Epic's EMR, because these 400+ EMRs adhere to the government mandated open standard CCD XML form and Epic doesn't.

I would appreciate any further comments if this comment is erroneous or misleading in any way. On this basis, it would not be correct to describe Epic's Care Anywhere as a type of HIE. The name of the product is misleading but that nothing new in the software industry. It seems to be a proprietary version of CCD export capability -- a continuation of the Epic's "walled garden" software model.

January-16-2012

8:00

There are a number of factors contributing to the financial pressures being placed on community physicians. One of the most significant is that the federal government, the most important payer of medical costs, tends to favor inpatient and ambulatory care delivered by hospitals. A recent story provided the details (see: Doctors going broke). Below is an excerpt from it

Doctors in America are harboring an embarrassing secret: Many of them are going broke. This quiet reality, which is spreading nationwide, is claiming a wide range of casualties, including family physicians, cardiologists and oncologists. Industry watchers say the trend is worrisome. Half of all doctors in the nation operate a private practice...."A lot of independent practices are starting to see serious financial issues," said [ a consultant to physician practices]. Doctors list shrinking insurance reimbursements, changing regulations, rising business and drug costs among the factors preventing them from keeping their practices afloat. But some experts counter that doctors' lack of business acumen is also to blame....[A cardiologist] said recent steep 35% to 40% cuts in Medicare reimbursements for key cardiovascular services, such as stress tests and echocardiograms, have taken a substantial toll on revenue. "Our total revenue was down about 9% last year compared to 2010," he said. "These cuts have destabilized private cardiology practices," he said. "A third of our patients are on Medicare. So these Medicare cuts are by far the biggest factor. Private insurers follow Medicare rates. So those reimbursements are going down as well."....Also on his mind, the impending 27.4% Medicare pay cut for doctors. "If that goes through, it will put us under," he said.Changes in drug reimbursements have hurt [oncologists] badly. Until the mid-2000's, drugs sales were big profit generators for oncologists. In oncology, doctors were allowed to profit from drug sales. So doctors would buy expensive cancer drugs at bulk prices from drugmakers and then sell them at much higher prices to their patients. "I grew up in that system. I was spending $1.5 million a month on buying treatment drugs," [an oncologist] said. In 2005, Medicare revised the reimbursement guidelines for cancer drugs, which effectively made reimbursements for many expensive cancer drugs fall to less than the actual cost of the drugs.

There is no question that cutbacks in Medicare and Medicaid reimbursement are hurting many physicians in private practice. However, I also agree with the statement above that part of the problem is many doctor's "lack of business acumen." When times are flush and reimbursement is at a high level, faulty business practices can be glossed over. The same rule does not apply to current conditions. It's easy to manage a business on the way up and hard to manage one of the way down. Physicians spend many years in training but spend almost no time learning how to run a business.

I have posted a number of notes about the so-called oncology concession whereby oncologists purchase expensive cancer drugs at a wholesale price to treat their patients and then mark up the prices when they are administered (see: Academic Oncology and the "Chemotherapy Concession"; The Oncology Concession Under Attack by Health Insurance Companies). I have been told that it's easier to manage the expensive, limited-shelf-life chemothrapy inventory in academic oncology infusion centers with a large number of patients than in smaller private practices. Large cancer hospitals also benefit from the discounted volume purchases of such drugs.

The bottom line is that movement toward Big Medicine (Big Health Systems, Big Payers, and Big Pharma) persists unabated (see: Health Insurance Company to Purchase Troubled Pittsburgh Health System; Hospitals Use Their Medical Schools, Residencies for Later Physician Recruitment).

January-13-2012

8:00

John Lynn, who blogs over at EMR and EHR, had this to say recently about a company called Emdeon (see: Emdeon’s EHR Lite)

I’d been meaning to do a post about Emdeon‘s EHR lite ...since I first heard about it at MGMA. While I think that EHR Lite might be some good branding, I’m not sure you can really classify Emdeon’s EHR as lite. I’m sure they’re just trying to differentiate themselves from the 300+ EHR companies out there....I think I found the thing that most differentiates Emdeon from many other EMR companies. it’s their network. Here’s a summary they sent me of their network. Emdeon’s network encompasses:

  • 340,000 providers
  • 1,200 government and commercial payers
  • 5,000 hospitals
  • 81,000 dentists
  • 60,000 pharmacies
  • 600 vendor partners

....I strongly believe that healthcare will be a very heterogeneous environment. ...EHR software is still going to have to connect with hospitals, pharmacies, labs, payers, government entities etc. An EHR is going to be key to integrating with these other heterogeneous software as I do believe the EHR will be the “Operating System of Healthcare.” Today a silo’d version of an EHR is not an issue at all. However, the writing on the tea leaves that I read is that healthcare providers that have a well connected EHR are going to be at an advantage. We’ll see if Emdeon can use their current connections as an advantage in this way.

It's quite clear that hospitals need to be interconnected via multiple networks for the exchange of both clinical and financial information. Whether or not the leading EMR companies will move in this direction and function more as as "operating systems" is another story. Epic, for example, might appear to function as an HIE with its Care Everywhere module (see: Sharing Medical Records across Hospitals with Epic's Care Everywhere). However and given that this interconnectivity is provided only to Epic clients, the software would be better called Care with Epic Clients.

In my opinion, Epic has little interest in mobilizing healthcare information electronically across hospitals within a region that are not its clients. The company is all about domination of the higher end of the hospital market and modules like Care Everywhere have been developed to provide additional client functionality and not to serve as a HIE utility across all hospitals in a region (see: A Fresh Look at Epic from a Financial and Strategic Perspective). Epic's business model can be described as a "walled garden" whereas, I think, Cerner is envisioning the development of an interconnected community with its Winona project as one prime example (see: A Different Paradigm for Analyzing the Competition between Cerner and Epic; The Winona Project: Is This a RHIO Success Story?; Cerner's Winona Health Project Featured on the PBS News Hour).

I have posted notes before about the need for a national, agnostic lab network (see: Interpreting the Tea Leaves: Ten Hot Trends in Healthcare, Lab Medicine, and Pathology Informatics; Predicted Migration of "Some" LIS Functionality from Pathology to Central IT). For the labs, a national network is useful for the exchange of lab data but also as a means to access expertise and talent which may be lacking or insufficient locally. Community hospitals labs, and even academic departments, have always turned to regional and national reference labs to provide esoteric testing services that they can't supply. Any lab or hospital national network needs to be agnostic in the sense that it's open to a variety of companies and service providers. Such an approach stimulates competition on the basis of quality and price and is the antithesis of the walled-garden, vertically-integrated approach which is all about domination of the market by a single company (see: iPhones, Physicians, and the Dilemma of the "Walled Garden").

January-11-2012

9:50

Cleveland Clinic established a ban on hiring smokers more than two years ago and similar policies are now spreading to other hospitals (see: Want a Job at the Cleveland Clinic?: Smokers Need Not Apply; Tobacco-Free Hiring Takes Hold; Both Smoking and Smokers Excluded; The Financial Stakes Escalate for Employees Who Smoke). Geisinger Health System has now introduced a similar policy (see: Hospital Quits Hiring Smokers, Introduces Nicotine Tests For Medical Workers). Below is an excerpt from the story

Smokers in the medical field now have another reason to quit as a Pennsylvania hospital has said it will no longer hire smokers and is introducing nicotine tests in order to enforce the rule....Those exposed to second hand smoke will be exempt from the test, which screens applicants for cigarettes, smokeless tobacco, snuff, nicotine patches, nicotine gum and cigars. For those who fail the test, the hospital says applicants can reapply after six months....According to CNN, Pennsylvania is among 19 states that allow employers to screen job applicants for signs of smoking. While there's certainly an incentive to keep employees healthy for work, the economic benefit of having non-smokers on the payroll is also notable. The U.S. Centers for Disease Control and Prevention (CDC) puts a $3,391 price tag on each employee who smokes: $1,760 in lost productivity and $1,623 in excess medical expenditures.

A few interesting points are brought out in this article relating to the exclusion of smokers as new hospital hires. A twist that was new to me in the article is that a prospective employee can claim an exemption from the hiring ban on the basis of second-hand smoke. I assume that the applicant would show a weakly positive lab test that could be explained by a smoker in his or her household or even in a car pool. I believe that the preferred test for a history of smoking continues to be cotinine (see: Saliva and Urine Tests for Smoking). Secondly and in the article, it seems that there needs to be enabling state laws in place to enable a hospital to pursue a smoking restriction; 19 states currently have such laws in place. I suspect that most of the states that have not yet fallen in line with such legislation will do so shortly. Smokers are becoming an endangered species.

Lastly, there is data presented at the end of the excerpt above that place a cost to employers for employees who smoke, providing convincing financial evidence for the soundness of a "no smokers, no smoking" policy for hospitals. It seems to me that there are three health system that usually take the lead regarding innovative clinical and organizational policies: Cleveland Clinic, Geisinger, and Kaiser. You can now expect many other hospitals, initially in the 19 states, to launch similar policies.

January-9-2012

10:04

Hepatocellular cancer (HCC) is a common neoplasm in Asian countries because of the high incidence of hepatitis infection. Here are the three most common risk factors for (HCC):  (1) alcoholism; (2) hepatitis B; (3) hepatitis C that causes 25% of causes globally (see: Hepatocellular carcinoma). Although HCC has been relatively rare in the U.S., the incidence is now rising quickly (see: Mayo Clinic Studies Identify Risk Factors In Rising Trend Of Liver Cancer). Here's more details from a recent article:

Doctors have known for years that the incidence of deadly liver cancer is on the rise, but what is causing that trend has remained a mystery. Two recent studies...offer a clearer picture of the rise of hepatocellular carcinoma (HCC), or liver cancer, which has tripled in the U.S. in the last three decades and has a 10 to 12 percent five-year survival rate when detected in later stages....[One] study found the overall incidence of HCC in the population (6.9 per 100,000) is higher than has been estimated for the nation based on data from the National Cancer Institute ....The study also found that HCC, which two decades ago tended to be caused by liver-scarring diseases such as cirrhosis from alcohol consumption, is now occurring as a consequence of hepatitis C infection. "The liver scarring from hepatitis C can take 20 to 30 years to develop into cancer," [one study author said]. "We're now seeing cancer patients in their 50s and 60s who contracted hepatitis C 30 years ago and didn't even know they were infected. " Eleven percent of cases were linked to obesity, in particular fatty liver disease. "It's a small percentage of cases overall," [the study author said]. "But with the nationwide obesity epidemic, we believe the rates of liver cancer may dramatically increase in the foreseeable future." Another study looked exclusively at the Somali population, which is growing in the U.S., particularly in Minnesota, where as many as 50,000 Somalis have settled in the last two decades. The East African country is known to have a high prevalence of hepatitis B, a risk factor for HCC. Researchers investigating records in the Mayo Clinic Life Sciences System confirmed that hepatitis B remains a risk factor, but they were surprised to find that a significant percentage of liver cancer cases in the population are attributable to hepatitis C, which had not been known to be significantly prevalent.

What I took away from this article is that the incidence of HCC is rising precipitously due to chronic hepatitis B and C infections in our native-born population, immigrants coming to this country carrying the two viruses, alcoholism, and obesity. It's a "perfect storm." Here's some more information about the relationship between obesity, diabetes, and HCC (see: Obesity and hepatocellular carcinoma):

Both obesity and diabetes are frequently associated with nonalcoholic fatty liver disease, and case reports have shown progression of nonalcoholic fatty liver disease to cirrhosis and hepatocellular carcinoma. Although no study has clearly tied all of these variables together, it is likely that the association of hepatocellular carcinoma with obesity represents the progression of underlying nonalcoholic fatty liver disease to cirrhosis. The mechanism most likely involves replicative senescence of steatotic mature hepatocytes and compensatory hyperplasia of progenitor (oval) cells as a reaction to chronic injury due to ongoing nonalcoholic steatohepatitis and resultant hepatic fibrosis.

Also see: Bristol bags hot hep C drug developer Inhibitex for $2.5B.

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