The March 2009 Health Gazette Ezine Edition will be published on time, on March 1st. A copy will be available in the archive for subscribers’ convenience.

This month’s edition encourages readers not to be a bowel cancer (or colorectal cancer) statistic. This lifestyle-related disease is a major killer in western society. The featured article goes beyond the simple and orthodox symptom list and screening recommendation to add a proactive means of prevention.

Are you at risk? Do you have symptoms that should be investigated? Do you know what preventative actions you can take? Find out in this month’s edition.

Don’t forget palliative careAs populations age in the United States, chronic illnesses create an uncertain medical future. By 2030, a fifth of the U.S. population will be over 65, and many will face the challenges of managing one or more chronic illnesses for a significant number of years, including physical and psychological distress, functional dependency and frailty, and a need for support.

Traditional care systems are not particularly well equipped for this situation. For example, our medical system focuses almost exclusively on curing illnesses and prolonging life — goals shaped by the hard-charging interventional past. But in the new order, these two worthwhile goals become hollow if they’re not pursued simultaneously with goals of improving quality of life, relieving suffering, and providing physical and emotional comfort.

The palliative care movement addresses this concern. Palliative care, which focuses on supporting the needs of the chronically ill as they approach the final phase of life, is as much a life philosophy and value position as it is a caring revolution.

Two leaders of the movement recently noted "The aim of palliative care is to relieve suffering and improve the quality of life for patients with advanced illnesses and their families."

The process of getting there is as important as the goal itself. Palliative care calls for an extraordinarily inclusive team effort with a strong emphasis on planning.

This philosophy of care begins with physicians eliciting the concerns of the patient and loved ones. What is important in the patient’s life? What more would he or she like to achieve? Is there something he or she fears worse than death?

Concerns expressed during this conversation help define the patient’s value system. Studies have found that patients almost always express the desire for more effective communication with a care team that is comfortable dealing with uncertainty and complexity. It’s important for the care team to tailor care to the patient’s individual needs.

Palliative care is remarkably focused and pragmatic. If I place myself in an elder patient’s shoes – multiple diseases, some compromise in capacity, but an uncertain prognosis – priorities become more obvious. What would I need? What would I ask of my caregivers? First, relieve my suffering. Second, improve the quality of my life. Third, manage my pain and other symptoms effectively over a long span. Fourth, while you are caring for me physically, don’t abandon me psychologically or spiritually. Help me grieve my losses. Fifth, be sure to coordinate my care as a team effort, remembering that my family and I are part of the team.

At the end of the day, the patient seeks enough comfort to contribute to loved ones’ lives, enough resources to not be a burden to family and friends, and enough strength and capacity to control one’s own life.

Many people are dealing with these issues with their loved ones now. It makes sense to plan ahead for a time when this generation will have multiple medical conditions themselves but will not yet be in the dying process. For more information on palliative care, The Center to Advance Palliative Care, Brown University’s Center for Gerontology and Health Care Research, and the National Consensus Project for Quality Palliative Care are three good sources.

Where do hospice services fit in with palliative care? Hospice care has a remarkable track record in supportive, holistic, end-of-life care. In the United States, however, it has been primarily associated with terminal care of cancer patients. Insurance coverage for hospice services requires physician certification that a patient has only six months to live. Such certification in non-cancer chronic diseases is difficult.

But slowly, around the world, care systems are beginning to absorb the teachings of hospice in the form of chronic-disease management, team coordination, and a holistic, patient-centered care approach. When successful outcomes are well defined, everyone benefits. For example, patients should be able to voice their personal needs and define their long-term and short-term goals. Evaluation should be thorough on the front end and take into account what patients define as an excellent outcome. Care should be well planned, based on these expectations, and discussions should be summarized in a treatment directive, leaving little to chance. And a trusted health care proxy should be identified, in case the patient becomes incapable of making his or her own health decisions. With this road map, care execution and coordination manage the complexity of the situation, helping to simplify a patient’s remaining time.

When palliative care plans are successful, what do we find? More joy and pleasure, less pain and worry. We also find less hospitalization, fewer nursing home placements, greater patient and family satisfaction, greater caregiver health and well being, and, in the end, a greater likelihood of a peaceful death, surrounded by loved ones, at home.

For Health Commentary, I’m Mike Magee.

See Also

• Summit on Integrative Medicine and the Health of the Public
  This summit will explore the science and practice of integrative medicine, and how it can be effective for health care reform.

The February Health Gazette Ezine Edition will be published on time, on February first. Subscribers will also find a copy in the archive for their convenience.

This edition focusses on taking action and getting the health foundation right. The main article is titled "Bowel Cleansing: Path to Inner Detoxification and Real Health" and it challenges readers to follow 8 rules for their consumption of food and fluids over the next month. Those who do will be rewarded with improved health and knowledge of how to make great improvements to their bowel health and how to gently but effectively detoxify.

The February Health Gazette Ezine Edition will be published on time, on February first. Subscribers will also find a copy in the archive for their convenience.

This edition focusses on taking action and getting the health foundation right. The main article is titled "Bowel Cleansing: Path to Inner Detoxification and Real Health" and it challenges readers to follow 8 rules for their consumption of food and fluids over the next month. Those who do will be rewarded with improved health and knowledge of how to make great improvements to their bowel health and how to gently but effectively detoxify.

Science has given us a new understanding of how cardio-metabolic disease works

Magee family and the passage of timeWatching President Obama’s speech today, as I was doing an emergency repair of my grand-daughter’s doll house in Cumberland, RI, I was very conscious of the passage of time, and the meaning of this historic event to various family generations. For Trish and I, born in the late 40’s, high schooler’s at the time of JFK’s assassination, young Americans who grew up in turmoil – Martin Luther King, Robert F. Kennedy, Vietnam, Kent State – so hopeful and yet so dashed of hope, this arrival has great meaning. It means that in our lifetime, there is the possibility of reaching for the potential and idealism that was shattered before our eyes many years ago. But as joyful and hopeful as this is, we are older now. Our children, born in the 70’s are no longer children. And our grandchildren – Anabella, Fiona, Lila, Amelia, Benjamin and Quinn – range from 7 years to 3 months, with four of them one year old or less.

It is clear that our new President is speaking to all us with an expectation that together, through service and ingenuity and caring, we might allow America and our human race to reach its full potential. But in our President’s determination to look forward rather then backwards, I believe he uniquely appeals to the young, as once John F. Kennedy did for us. This morning our daughter Meredith posted this comment on her blog as she watched the inauguration with her baby. She says so well what we felt so many years ago:

“I hear babies cry and I watch them grow. They’ll learn much more than we’ll know and I think to myself, what a wonderful world.

"It is hard to express with words how emotional this day is. I’m overjoyed for my son that he gets to begin his life with a president who I believe truly not only wants our world to be a better place, but understands the importance of rolling up our sleeves and getting dirty in order to make the world better.

"Even before we began trying to have children, I always knew that I wanted service to be part of their lives. I want them to understand how blessed they are to have new clothes, food on the table, a comfy bed to sleep in, vacations to go on, and the unconditional love of a family. I want them to understand that when you lead a life of privilege you are born with a duty to serve others. It is this basic concept of service that energizes me when I think of Barack Obama being sworn in today as our 44th president.

"Obama has made it clear; he cannot change our world alone. He is our motivator, our facilitator, but it is all of us, it is my son, who has to be willing to put in the hard work if change is to truly take place. And it is my job, and I believe the job of all parents, to make sure our children understand that they have been called to duty.

"It is only when we all start owning up to the truth that we are the deciding factor on whether or not our planet survives and humanity is restored that the change actually begins.”

Change is Here.

The article below was submitted by Barb Feick. It is published here because:

• the observations and reasoning it offers are essentially sound, and
• it represents a fine example of the kind of critical enquiry that consumers need to develop

References would strengthen the article but none were submitted. To follow up on the article make a comment below or contact Barb Feick directly via her site.

Barb’s article follows:

The is a summary of peanut allergy info so far Posted in Health, Peanut allergies on January 13th, 2009 – A basic review of what I’ve covered in my previous blogs concerning peanut allergy which can be deadly.

The Obama health care team should consider a wide range of useful, innovative health IT options[By David C. Kibbe & Brian Klepper]    Yesterday we tried to put EHRs into perspective. They’re important, and we can’t effectively move health care forward without them. But they’re only one of many important health IT functions. EHRs and health IT alone won’t fix health care. So developing a comprehensive but effective national health IT plan is a huge undertaking that requires broad, non-ideological thinking.

As we’ve learned so painfully elsewhere in the economy, the danger we face now in developing health care solutions is throwing good money after bad. We don’t merely need a readjustment of how health IT dollars are spent. We need to reboot the entire conversation about how health IT relates to health, health care, and health care reform. To get there, we need to take a deep breath and start from well-established and agreed-upon principles.

Most of us want a health system that, whenever possible, bases care on knowledge of what does and doesn’t work – i.e., evidence. We want care that is coordinated, not fragmented, across the continuum of settings, visits and events. And we want care that is personal, affordable and increasingly convenient.

Most of us also agree that, so far, we have not achieved these ideals. In fact, health care continues to become costlier, quality is spotty, and the gap between the health care we believe possible and the current system is widening.

We believe that most health care professionals are acutely aware that more health IT alone cannot resolve these problems. Despite billions of dollars in health IT investments by health care professionals and organizations, the gap persists and is widening. Many physician practices have expanded their health IT functions, moving beyond electronic billing systems – a necessary asset to be paid by Medicare – toward EMRs and from paper to software systems.  About a quarter of US physicians use EHRs from commercial vendors. Hospitals and health plans – larger, corporate organizations with more dedicated capital resources – have implemented health IT more quickly. Even so, the tools implemented have typically been focused on record-keeping and transactional processing, not decision-support. Health care clinical and administrative decisions have not yet become more rational, less tolerant of waste and duplication, or more congruent with evidence.

We don’t need simply more health health IT; instead, we need an array of specific health IT functions and capabilities that can facilitate better care at lower cost, and the adherence to evidence-based rules.

What would those empowering health IT products look like, and what would they do?

Focusing on Decision Support
Most important, new health IT would help patients, clinicians, managers and purchasers make the best possible clinical and administrative decisions. This includes identifying risks and following the best path to lowering them whenever possible. Health IT should help people stay healthy and avoid illness through active clinical decision support, and make sure that the system recognizes value. Which patients, according to past data, have acute or chronic conditions that need care? Which, do the data show, are the most effective (or high value) doctors, hospital services, treatments and interventions – so that the market can work to drive efficiency.  Given a particular set of signs or symptoms, lab test results, or genetic test, what is the best next step in care?

Technology and information engineering is readily available to do this. Car technologies now help drivers understand when a problem is occurring, or is likely to occur, monitoring and communicating fluid levels, tire pressure, maintenance appointments, and location in case of emergency. Banking technologies can flag suspicious credit card purchases and can instantly invalidate charge cards. Recently, Google trended flu searches to help estimate regional flu activity; their estimates have been consistent with the CDC’s weekly provider surveillance network reports.

By comparison, most health IT is relatively unsophisticated. In general, the prevailing front line tools do not yet help clinicians identify individual- or population-level health risks. They do not yet provide guidance with evidence-based approaches that can best mitigate those risks, create alerts and reminders, or help monitor adherence to care plans, even though the data are now clear that most Americans die and we pay the most money due to easily preventable and managed conditions.

In short, we monitor our cars and bank accounts better than we do our health. We can change this.

Untethering Patients with Easily Accessible Personal Health Information
High value health IT would improve care by making summary personal health information available to providers and patients, increasingly independent of location and time. Most health records are still tied to a health care organization’s data center, supporting an outdated business model in which the patient must come to a centralized, expensive location for even the most routine tasks, like history-taking or lab testing. Most current EHRs don’t change this, in large part because they aren’t connected to the Internet yet. Web-enabled patient information would untether the patient, and make increasingly standardized care more readily available anywhere. De-coupling health information from health care providers is the first step in the development of new business models that will offer team-based care services wherever one is located, saving money and increasing convenience.

Empowering Patients Through Online Linkages with Clinicians and Other Patients
High value health IT will link patients with clinicians, will match problems with the most appropriate solutions, and will use social networking to increase access to patient- and condition-specific information, knowledge, and guidance. This class of health IT applications and services will be particularly useful with chronic illness, shifting more of the condition’s monitoring and management to the patient and his/her family and peers, with diminished reliance on the office-based physician and the single visit model of care. Bringing advances like these to fruition will require much broader implementation and access to broadband and mobile technologies, as well as standardized health record formats that use XML, like the Continuity of Care Record (CCR).

Supporting Participatory Medicine: Bridging the Medical Home and Web-Based Care
As Kibbe and Kvedar recently wrote, much of the health IT we’re describing here bridges the divide between two powerful trends: Health 2.0 (or user-generated health care ), and "the medical home." It is now clear that, while most health care consumers want to be more actively engaged in their own care management – e.g., using Web-based search and joining patient communities – they also want to be connected to their physicians for questions and care when appropriate. The way forward here is Participatory Medicine that combines and remixes health information and knowledge – some from experts and some from the crowd – in the interest of helping us live healthier lives.  Here is a very good description from Neal Kaufman, MD, a practicing pediatrician and the CEO of DPS Health, about how this will work:

…organized medicine needs to provide the day-to-day support patients need to prevent disease and to self-manage their conditions if they are ill. In the connected era that means just in time delivery of the personalized and up-to-date data and information a person needs to have the knowledge to make wise choices. It means supporting patients to easily and accurately keep track of their performance. It means providing tailored messages and experience that speak to each person based on their unique characteristics, their performance on key behaviors and their needs at that moment in time. It means helping patients link directly to family and friends for critical support, and link to their many providers to help integrate medical care with everyday life.

Making Data and Accountability the Routine By-Product of the Use of Health IT
Health IT can help make all health care professionals and organizations – physicians, hospitals, other providers, health plans, drug firms, device firms – more accountable stewards for quality, safety and cost results, and for the engineering required for continuous improvement. We can learn from our current supply, care delivery and finance processes in the same ways that Toyota and Wal-Mart monitor their internal business processes. 

But we need to design data aggregation into the products from the start, not as an afterthought. The problem is not just that we lack some important data elements to carry out these analyses now. More to the point, we have not committed nationally to aggregating, analyzing, and reporting the massive amounts of health data that we already have. Similarly, due to a lack of incentives and competing interests, most professional and organizational health care players have resisted using data to improve the quality, safety and cost of American care. 

Interoperabilitiy of various EHRs is absolutely critical to the ability to cost-effectively collect, manage, and report outcomes data.  All health IT products used in the care of diabetic patients, for example, ought to be required to export performance data relevant to care of diabetes in standardized formats.  All research of any kind depends on this capability.

Removing the Complexity and Cost Associated with Multi-Payer Claims Administration
Health IT ought to make claims payment, eligibility look-up, co-pay verification, and other administrative processes simpler, easier, and faster for providers, patients, and family members.  There is no good reason why we don’t currently have an all-payer clearinghouse for patient administrative and financial information that is standards- and web-based. There also is no good reason why, in the era of PayPal, physicians and hospitals experience Days in Accounts Receivable of 36 and 55, respectively. As Rick Peters has written recently, it is time for us to build a scalable, XML, and cloud-based claims adjudication, public health, and quality reporting system to replace the entire archaic mainframe systems at CMS and their fiscal intermediaries. "Make the winning solution open source, implement it for Medicare and the CDC, and offer it free to every state Medicaid program and all the commercial payers," he says, and we agree it is time to use updated technology to resolve the inexcusable claims administration mess.

Closing the Collaboration Gap
Finally, a new generation of health IT platforms and services will close the "collaboration gap" that exists between the system’s many sequestered players, who as a result perform so much less effectively and efficiently than they otherwise might. Clinicians, for example, diagnose disease and set up treatment plans but often are isolated from helping patients cope, manage, or adhere to these plans. Patients, once diagnosed, are motivated to manage their illnesses but often have few tools or methods to assist them. Purchasers and payers want to see clinicians use the most efficacious resources, but typically do not have a way to inform and reward evidence-based purchasing processes. In every case, health IT can facilitate a more collaborative experience that is tailored to the user’s purpose, no matter what role that user plays in vast health care space.

Health IT presents enormous, unprecedented opportunities to improve the quality of care, to dramatically reduce the waste and cost inherent in our current approach, and to culturally transform physicians and patients so both become more actively engaged in improving health and health care. Bringing the fluidity of health information and knowledge that is just starting to fruition will allow us to leverage the true power of information engineering, and that can take many forms.  We think the name "clinical groupware" is more appropriate to this new class of health IT products and services than is the term "EHRs."  In any case,  the real health IT challenge to the Obama health care team is to step back, take stock of the kinds of applications that are emerging in the domain of health IT, including EHRs, and create an expansive, open policy structure that can leap beyond the status quo and really change the way American health care, in all its facets, works.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies. Brian Klepper PhD is a health care market analyst and a Founding Principal of Health 2.0 Advisors, Inc.

To get its health care infrastruction buildout effort right, the Obama team should think more broadly than EHRs

Electronic health records would be the easy-but-wrong emphasis of an Obama health IT effort[By David C. Kibbe & Brian Klepper]   It seems likely that the Obama administration and Congress will spend a significant amount on health IT by attaching it as a first-order priority to the fiscal stimulus package. We take the President-elect at his word when he recently said:

“…we must also ensure that our hospitals are connected to each other through the Internet. That is why the economic recovery plan I’m proposing will help modernize our health care system – and that won’t just save jobs, it will save lives. We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year.” (December, 6, 2008)

Whether the health IT money is well spent will depend on how it is distributed and what it buys. Most observers suppose that federal health IT investment dollars will be used to help doctors’ offices and hospitals acquire and implement electronic health record systems (EHRs or EMRs). These are commercial software suites for entering, storing and managing patient health data within a practice or health organization.

We agree that some of the federal health IT money should go to purchase EHRs, especially to doctors and hospitals in rural and under-served areas, which otherwise could not afford them.

The Easy, Wrong Solution
The easy solution would be to spend most of the health IT funds on EHRs. The EHR industry has made it easy by establishing a mechanism to "certify" EHR products if they incorporate certain features and functions.

But the easy solution would not be the right one. EHRs still are notoriously expensive. Often, practicing physicians do not consider many of the features and functions to be useful or important.  It can cost as much as $40,000 per physician in a medium size medical practice at the beginning of an EHR implementation. Even that regal sum may not completely cover the hardware and technical support necessary.

EHRs can be difficult to implement, upsetting practice workflows. In general, physicians’ practices have not adjusted quickly or smoothly to the disruptive nature of the switch from paper to electronic systems for patient care. Implementations can take months or even years to stabilize.

And the turmoil associated with the implementation can often have negative revenue repercussions for the medical practices they are intended to help. Physicians routinely report that, during the adjustment period, the number of patients they can see and treat in a day drops by twenty to thirty percent, with a commensurate decline in revenues.

Nor is there conclusive evidence that the use of EHRs improves patient care quality.

Finally, EHRs from different vendors are not yet interoperable, meaning that patient information cannot yet be easily exchanged between systems. If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the Babel that already exists.

These barriers to adoption are well documented; they form the wall that has kept physician EHR adoption overall to less than 25 percent in this country. Even if a hefty federal subsidy reduced the exorbitant cost of the EHRs, many practices would suffer severe negative business impacts, and primary care access could temporarily be reduced on a national scale.

So important as EHRs are, at this point there are far better ways to invest in health IT for the doctor’s office and hospital. These approaches are low cost and would have immediate high impact on the quality and safety of care. They could build on and utilize existing health IT infrastructure, and be relatively non-disruptive to practice workflows. These factors would encourage adoption by minimizing risk for the doctors, their staffs, and their patients.

E-prescribing As A Model
The success of e-prescribing – as health technology and as public policy – makes it a model for future efforts. E-prescribing uses computing devices to enter, modify, review, and communicate prescription information. The entire process can be automated, from a prescribing doctor’s fingertips on the keyboard to the receiving pharmacist’s view of the medication order on his/her monitor. All this is possible through the use of standards- and web-based software that is free or inexpensive to the medical practice.

The only technology required of the doctor is Internet connectivity and access to one of the popular browser software programs, like Internet Explorer or Mozilla Firefox, which are already present in most offices and clinics around the country. E-prescribing takes advantage of this existing infrastructure, which is why its adoption is growing rapidly, particularly after CMS authorized an incentive payment to e-prescribing physicians of 2 percent of their total Medicare allowed charges during 2009.

E-prescribing has succeeded because it is an incremental and low-risk health IT that made it easy for physicians and pharmacists to electronically share prescription data, and because it was encouraged by financial incentives. E-prescribing produced significant benefits to physicians over the short term, but simultaneously provided a pathway to more comprehensive IT use over time. It also avoided a sharp decline in access to primary care.

More Bang, With Less Turmoil, for the Buck
We believe that the Obama administration could leverage IT spending in similarly inexpensive ways. Smaller, incremental steps would likely impact a larger number of medical practices in the short-term, benefiting patients while limiting the disruption to doctors.

Here are three suggestions:

1) Referral Management. No patient ought to be referred from a primary care provider to a specialist unless the relevant personal health data are available. Yet, as often as half the time the paperwork arrives, if it arrives at all, after the patient’s specialist appointment. This wastes time, results in duplication of tests, medications and procedures, and may imperil personal health.

Care can only be coordinated and continuity assured if information follows the patient wherever the next care event will occur. The solution is relatively easy and no more difficult than e-prescribing.

Create financial incentives for the implementation of simple tools that allow doctors and practices to share health data and communicate with other doctors. It should start with the specialists to whom they refer patients, and include the specialist when (s)he returns the patient to the primary care physician. A 1-2 percent bonus to doctors who e-refer would significantly increase continuity of information among doctors, which would translate to better continuity of care for patients, and lower costs to the system.

2) Patient Communications. Patients want and deserve to communicate through secure email with their medical home practices. They also increasingly want to use the Web to schedule appointments, pay bills and view portions of their medical records, such as lab results. These online services are not expensive for medical practices to provide through companies that offer them as “web portals” and they offer more than convenience to patients.

These communication tools are a means of closing the “collaboration gap” that exists between busy physicians and their busy patients, allowing routine tasks to be moved outside the rushed seven-and-a-half-minute office visit. This gives consumers time to digest and reflect upon how best to meet their health and wellness goals and offers doctors the luxury of better-informed patients. While some consumers are willing to pay their doctors an additional monthly fee to obtain these online services, a small payment from Medicare similar to that offered for e-prescribing would make the business case for doctors’ adoption of these patient-friendly online services. Adoption would surge.

3) Infrastructure Build-Up and Maintenance. Nowhere is access to the Internet more essential than in health care. We must assure that broadband Internet connectivity reaches every medical practice and every home in America, no matter how rural a region or how low income a neighborhood. Currently there are too many areas in the country where cable and DSL do not reach, often due to the small numbers of subscribers and the consequent barrier to investment by network carriers this imposes. The federal health IT initiative should subsidize both the establishment of broadband service in those areas, and the subscription fees for low income and health disparity populations that could benefit the most from Internet connectivity with health care providers and online care services.

The new Administration and Congress are about to throw a lot of money at the health IT problem, and the conventional thinking is to buy everyone an EHR of his/her choosing. While we enthusiastically applaud the vision that this represents, a more measured approach would create a smoother and more productive transition. At the same time, it would signal the EHR industry that, for national deployment, they need to come to terms with issues they have avoided so far, like interoperability and cost.

David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies. Brian Klepper PhD is a health care market analyst and a Founding Principal of Health 2.0 Advisors, Inc.

7 VISIONS to guide the build-out of a new health care system

As we move toward a new administration, and our new leaders and their challenges are laid out before us, it is useful to ask ourselves, "Do we know what we want to build?" For health care, I’ve given this question some serious thought over the past 24 months, and come up with "7 VISIONS" to guide our health care future. I call them "TransVisions," value-driven aspirations capable of bridging our country from its segmented, exclusionary, interventional past to an integrated, inclusionary preventive future. Here are my thoughts, which I invite you to share with others.

The December 2008 edition of the Health Gazette will be published on schedule, today, December 1.

In this month’s edition Dr Jenny Tylee gets physical with details about how to strengthen your pelvic floor. Don’t know what your pelvic floor is? …or what it does for you? Then you need to read this article.

Free subscription is available via most of our websites. For example, you could use the form found at our Health Products Site to subscribe. Click here for the Health Gazette Subscription form.

The jury’s still out on whether EHRs reduce cost, but it appears they enhance value.

Note by Brian Klepper: Today the actuarial consulting firm Milliman is convening a town hall meeting in Seattle focused generally on health care reform, but specifically on Electronic Health Records (EHRs). The larger Seattle metropolitan area is a hotbed of health care innovation, with Virginia Mason, Costco, Starbucks, Boeing, Premera and other forward-thinking firms. The conference will have representatives from CMS, Microsoft, the VA, Group Health Cooperative, and Milliman, and is open to the public. Should be an interesting session.

To kick it off, here’s a little piece on EHRs by Jeremy Engdahl-Johnson, Managing Editor at Milliman.

By JEREMY ENGDAHL-JOHNSON

Of all the initiatives endorsed by outgoing Secretary of Health Mike Leavitt, few are likely to be met with as much agreement by his likely successor, Tom Daschle, as the need for wider adoption of electronic health records (EHR). While there is general agreement on the need for this technology investment—both presidential campaigns included EHR in their health platforms—the cost ramifications are still up for debate. Will electronic health records reduce costs? There are compelling reasons to answer both “yes” and “no.”

“Yes, electronic records decrease costs”

Our system of care is fractured, and EHR is one way to tie it together. Doing this is more than just a convenience. It could save money. Why? For one, the cost of some conditions are compounded by the presence of other conditions, creating expensive co-morbidities that are not treated well in a fractured system. On a monthly basis, asthma costs $390 per member per month, but in the company of depression it costs $940. This co-morbidity is not always diagnosed (only 16% of the time even though it is expected 45% of the time among asthma patients), and while the cost of treating the diagnosed comorbidity is high, the cost of the undiagnosed comorbidity is higher. When physicians use electronic records, they are more likely to provide effective treatment because they can coordinate care with other physicians and also with nurses, therapists, technicians, and other organizations, cutting across care silos for the good of the patient.

Furthermore, patients with chronic conditions have more to gain from a personal health record. Their treatment plan is often self-administered and reliant on the correct information. If they can facilitate the kinds of questions and discussions needed to properly care for their condition without office visits, they can reduce the cost of their care. That’s why the medical home model, of which EHR is a cornerstone, is receiving more and more attention.

But it’s not just about chronic conditions. Despite the common assumption, the cost trends for nonchronic care are actually rising faster than those for chronic care. All patients have something to gain by tapping into the growing body of medical science. Evidence-based guidelines—the best of which have some 15,000 scientific references and can chart better paths of care—can bring that science to the bedside and to the home health environment.

Why is this science important? Much has been said about healthcare consumerism, and the suggestion that being more responsible for your health will create an economic incentive for staying healthier, a seemingly important carrot in a country with a 35% (and rising) obesity rate. Does the consumer-driven theory work? Maybe. Like them or hate them, consumer-driven health plans are shown to save 4.8%. This is in spite of the relative scarcity of good consumer health information … which is where dispensing medical science comes in. Most people don’t even know what health consumer information looks like. We’re only beginning to see healthcare equivalents of Consumer Reports. Many people know more about the different brands of canned goods available to them than they do about their different healthcare choices. Sources like WebMD have begun to change this, and health surveillance tools like Google Flu Trends are promising if unproven. Regardless of whether the consumer-driven model wins out, it seems likely that an information-driven approach can help improve care and perhaps reduce costs.

Throw in the most frequently cited virtue of EHR—a reduction in unnecessary administration—and you have a compelling case for the cost benefits of this technology.

“No, electronic records increase costs”

But there is cause for skepticism. From the small family business to the biggest multinational organization, technology deployments routinely cost more than anticipated. Going overscope and overbudget is almost a rite of passage. And now is seemingly a bad time for that kind of investment, when the country can scarcely pay off debts already incurred. Who picks up the tab for EHR during a recession?

Then comes the question of effecting change. Efforts to legislate IT have encountered mixed results. HIPAA implementations cost more and took longer than expected. They had the benefit of happening during a robust economy that was already investing heavily in technology. Today is different, and we’ve seen more resistance to legislated IT investments. Just look at ICD-10: The mainstream press poses questions about cost and doctor groups suggest this is one investment that can wait. The mandated 2011 conversion deadline is an interesting trial balloon for nationwide EHR requirements.

The final verdict?

We can’t know for sure whether electronic records will increase or decrease costs. As a purely cost-based argument, the debate can go on indefinitely. Ultimately, the quality argument may win out for a reason independent of cost—because it is deemed the right thing to do. The idea that healthcare has grown too complicated, becoming “too much airplane for one man to fly,” is often invoked as justification for surgeons’ checklists and better use of tools built on evidence-based medicine. It’s not that our doctors aren’t good; it’s that there are too many details and too many scientific improvements to keep track of.

The quality imperative—now emboldened by an administration that claims to be intent on change—may clear the way for other changes, generating the will to make a pervasive electronic health environment a reality.

Find out more at www.healthcaretownhall.com.

We at The Health Gazette recognze that health is unavoidably political. It affects people, it costs individuals and governments (public funds) a lot of money — how could it not be political?

So we were interested to read a statement by Congressman Ron Paul (R-Texas), Republican Presidential candidate for 2008, under the title "Health Freedom". Here it is:

Americans are justifiably concerned over the government’s escalating intervention into their freedom to choose what they eat and how they take care of their health.

http://www.Turakij108.com/cgi-bin/mail/starter.cgi

The March Ezine Edition of The Health Gazette will be published on time, March 1st, 2008. The featured article this month is a little different from usual. It is titled: Mind-Body Connection: The Medical Blind Spot. It is one of those classic cases of a huge gap between medical rhetoric and the realities of practice. The article briefly traces this problem to the historical roots of Cartesian thinking and the erroneous beliefs about modern science.

Another issue addressed in the edition is the use of natural antibiotics. We answer a reader’s question about natural antibiotic use for dental infections.

The April edition of the Health Gazette Ezine was published on schedule, today, April first 2008. It has been emailed already and is also available to subscribers in the archive.

This month we discussed the importance of healthy fats and oils. Many people have been told to cut fats from their diets and unfortunately, that’s exactly what they have done! Care must be taken when modifying dietary fats to ensure that ample essential fatty acids are still consumed.

In this edition we explain what good fats and bad fats are. Naturally, we don’t just peddle the orthodox lines about cholesterol. Do you know what good and bad fats are? Do you know the risks from consuming bad fats? What about the risks from not consuming good fats? If you could use a few more details then why not subscribe to the Health Gazette Ezine — it’s free. Go here to subscribe to the Health Gazette. Just complete the form.