Casalino LP, Dunham D, Chin MH, Bielang R, Kistner EO, Karrison TG, Ong MK, Sarkar U, McLaughlin MA, Meltzer DO. Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results [Internet]. Arch Intern Med. 2009 Jun 22;169(12):1123-1129.[cited 2009 Jun 26 ]

This is a wonderful and well-timed study that has significant implications in the era of the Electronic Health Record and the Personal Health Record. As well done as it was, I would have loved a section of inquiry to be added about “the impact of patient and family access on test result notification.” Read on…

It’s impressive that in 2009, believe it or not, there really aren’t firmly established processes for handling information about test results. A lot of what is done today is bred from custom, such as the infamous “no news is good news,” which the authors found was the protocol in 8 out of 19 medical practices studied. Everyone who likes this approach to test result notification, please raise your hand….

With that background the study team started at a very low baseline, thinking about what kinds of test results patients should be informed about, in what period of time they should be informed about them, and then analyzed medical records (5305 in all) to see if theoretical best practices were carried out., and about 7.1% of the time, on average (up to 26.2% in one Academic Medical Center practice), information to patients was not furnished about their abnormal test results. We can imagine what that might mean in a practice whose policy is “no news is good news.”

The authors looked at the impact of having an electronic medical record and found that practices with a “full” electronic medical record were no more likely to have gaps than one without IF they had a good process for managing test results. So, process and workflow trumps technology in this case.


What’s missing in good process?

So, the number of abnormal test results in this study not communicated to patients is alarmingly high. At the same time, I immediately drifted to what’s missing in the process. The authors listed these steps as a good way to manage test results:

1. All results are routed to the responsible physician
2. The physician signs off on all results
3. The practice informs patients of all results, normal and abnormal, at least in general terms
4. The practice documents that the patient has been informed
5. Patients are told to call after a certain time interval if they have not been notified of their results.

Maybe this is good practice today, but what do our patients and families want in the era of the personal health record and full transparency (73 cents style)? How about this:

Good process for managing test results, patients and families at the center

1. All results are routed to the responsible physician and the patient and their proxies, if specified, at the same time
2. The physician and the patient and their proxies, if specified, sign off on all results (in a current PHR installation, this might mean verification that the patient has viewed the result…read on)
3. The practice informs patients and their proxies, if specified, of the meaning of all results, with specific recommendations to be made based on the information
4. The practice documents the shared decision made by the responsible physician and the patient based on the information obtained from results
5. Without 1-4 above, the practice reaches out to the patient via the most appropriate means (letter, telephone, secure e-mail) to achieve notification and shared decision-making.

If we think about it – in the era of the personal health record, do we really want to tell patients if they haven’t heard something within a certain time interval, they should call us?

Do we really want to continue a “no news is good news” policy, at the risk of “no news” meaning 7.1% of the time someone may be hurt in the process of care?

I think it’s important to remember that the ultimate reason a test of any kind is ordered in health care is for one reason – “to reduce uncertainty.”

It would be great in a future study to analyze the impact of patients having access to their test results in real-time or near-real time, to see what the rate of failure is, and also dig deeper, at the rate of understanding of what test results mean. This is the sweet spot for physicians and nurses, who excel at using test results to reduce uncertainty in the context of a patient’s overall health.

In terms of whether or not the new/improved “Good process” is more time intensive or not than the regular “Good Process,” I don’t think it is more time intensive. I think this is a great item for discussion in the comments. Let’s talk about the cost-benefit of doing things differently.

It’s worth noting that in the first quarter of 2009 alone, 5,078,442 test results were viewed by Kaiser Permanente patients and/o their proxy individuals on KP’s My Health Manager personal health record. In many of those instances, the test results were delivered to the patient at the same time as the physician. That’s a lot of experience both to tap into, and to understand that the old process is already changed forever for lots of Americans and the teams who care for them.

With thanks to the authors for a timely and useful investigation into an area of health care where we all want to improve.

What Only the CEO Can Do, A.G. Lafley, Harvard Business Review, May, 2009

I used to spend a lot of time struggling with this question, and I see many people still struggling with it, especially in Health Information Technology. I see a focus in a lot of places on making sure physicians are happy in order to be successful. The struggle is normal, this is a controversial idea. This article from HBR says that it’s the E=MC2 of customer loyalty.  

I’m not sure I agree, though.

I last did some deep-dive business study research on this a few years ago and came to the conclusion that patient happiness and doctor happiness are probably co-mingled. My work experience in several places has always worried me that excessive focus on the happiness of one population (doctors, nurses, allied health, anyone) puts patient happiness at risk, so why not just focus on their satisfaction as the key to everyone else’s?

In the article Employee Happiness Isn’t Enough to Satisfy Customers , the authors state:

The idea that employee satisfaction simply rubs off and benefits the company is wishful thinking.

And then go on to state that there’s no evidence that satisfied employees equal satisfied customers.

In the feature article, What Only the CEO Can Do, A.G. Lafley, chairman and chief executive officer of Proctor & Gamble notes throughout his interest in customer satisfaction first, in crafting the role of the CEO (much of it based on Peter Drucker’s philosophy)

Drucker also wrote that the purpose of a business is to create a customer. P&G’s purpose is to touch and improve more consumers’ lives with more P&G brands and products every day. Of all our stakeholders, both outside and inside, the primary one is the consumer.

And

As for employee stakeholders, we believe that P&G people are the company’s most valuable assets. Without them we would have no P&G brands, no P&G innovation, and no P&G partnerships. However, putting employees ahead of external stakeholders, especially consumers, would result in a more internal—and, arguably, more short-term—focus. P&G people are inspired by the company’s purpose and motivated by how they can personally touch and improve consumers’ lives.

In the article, Lafley talks about how the CEO shapes values and standards, and how in his role, he shifted the values more toward placing the customer’s needs first, as he felt that values prior to his tenure had evolved to place employees’ needs ahead of consumers. It’s an interesting read throughout to discover how the metrics of P&G are based on customer loyalty and penetration of P&G satisfaction into consumers’ homes.

I like articles like this because they connect the philosophies of some of our best health care organizations, like Mayo Clinic, where it is said,”The best interest of the patient is the only interest to be considered.”

I connect all of this to working with physicians through the understanding that physicians are passionate about helping patients succeed and often put this success ahead of their own emotional success, because they will do whatever it takes, however inefficiently or indirectly they must do it in the systems they work in.

If I/we can allow them to fulfill their passion, to support patients where they live, work, and play, in being successful, as efficiently and directly as possible, their emotional success will ensue, or as it said the Employee Happiness article,

…engage employees by giving them both reasons and ways to please customers; then acknowledge and reward appropriate behavior.

So I know this is a controversial idea, and my research may not be as deep as anyone reading this post – I welcome your comments.

Full Text, ARRA

My approach to regulations and legislation in health care is to enjoy and savor them by reading the actual text. For me, summaries tend to obscure the problems that people who create these are trying to solve. This is what makes this part of the job fun.

I’ve read Title XIII-Health Information Technology with an eye toward the things I am most interested in and will quote those passages below, for informational purposes. Remember that this is a blog which means that corrections and improvements are welcome in the comments. And I’m not an attorney, this is for informational purposes only, and there’s good information in here.

Subtitle A – Promotion of Health Information Technology

Section 3000 Definitions

Health Information Technology includes uses by patients:

‘‘(5) HEALTHINFORMATIONTECHNOLOGY.—The term ‘health information technology’ means hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for or support the use by health care entities or patients for the electronic creation, maintenance, access, or exchange of health information

Section 3001 Office of the National Coordinator For Health Information Technology

Support for patient/consumer groups

‘‘(7) ASSISTANCE.—The National Coordinator may provide financial assistance to consumer advocacy groups and not-for- profit entities that work in the public interest for purposes of defraying the cost to such groups and entities to participate under, whether in whole or in part, the National Technology Transfer Act of 1995 (15 U.S.C. 272 note).

Section 3002 HIT Policy Committee

The sections of this Committee’s charge that cover things like patient access and empowerment are listed in “Other Areas For Consideration.” At least they are there at all.

‘(iii) Telemedicine technologies, in order to reduce travel requirements for patients in remote areas. ‘‘(iv) Technologies that facilitate home health care and the monitoring of patients recuperating at home. ‘‘(v) Technologies that help reduce medical errors. ‘‘(vi) Technologies that facilitate the continuity of care among health settings. ‘‘(vii) Technologies that meet the needs of diverse populations. ‘‘(viii) Methods to facilitate secure access by an individual to such individual’s protected health information. ‘‘(ix) Methods, guidelines, and safeguards to facili- tate secure access to patient information by a family member, caregiver, or guardian acting on behalf of a patient due to age-related and other disability, cog- nitive impairment, or dementia. ‘‘(x) Any other technology that the HIT Policy Com- mittee finds to be among the technologies with the greatest potentiof health care.

There is support for patient involvement on the HIT Policy Committee (nominees were sought recently for this Committee):

‘‘(G) 13 members shall be appointed by the Comptroller General of the United States of whom— ‘‘(i) 3 members shall advocates for patients or con- sumers; ‘‘(ii) 2 members shall represent health care pro- viders, one of which shall be a physician; ‘‘(iii) 1 member shall be from a labor organization representing health care workers; ‘‘(iv) 1 member shall have expertise in health information privacy and security;

Section 3003 HIT Standards Committee

Membership to include consumers:

‘‘(2) M.—The membership of the HIT Standards Committee shall at least reflect providers, ancillary healthcare workers, consumers, purchasers, health plans, technology vendors, researchers, relevant Federal agencies, and individuals with technical expertise on health care quality, privacy and security, and information.

Tomorrow, Part II of Title XIII

Hawn C. Take Two Aspirin And Tweet Me In The Morning: How Twitter, Facebook, And Other Social Media Are Reshaping Health Care [Internet]. Health Aff. 2009 Mar 1;28(2):361-368.

Note: the article no longer requires a subscription for access (3/14/09)

The much anticipated health information technology issue of Health Affairs, and in it is an article written by Carleen Hawn about Social Media in Health Care. The links above to to the Health Affairs site, but it appears a subscription will be required to view it, so hopefully readers have access to an institutional or other subscription to read it.

The genesis of this article was a discussion that was started in July, 2008, at the American Board of Internal Medicine’s forum on Patient Centered Care, where i presented about some of these concepts. This was followed up with discussions with myself and other leaders in the field, such as Jay Parkinson, MD, from HelloHealth, Bob Coffield, a well known legal expert in the area of social media, as well as real patients.

I actually attended the briefing announcing the release of this issue in Washington, DC, and was pleasantly surprised to see that the article is billed on the front cover of a very full catalog of scholarly works. Who would have thought 4 years ago that an article about social networking/media would be front cover material for the Health Affairs issue on Health Information Technology. This says a lot about the impact that social media, or perceived impact, in this area of health care! At the same time, I think Matthew Holt correctly points out that there’s a part two (and three and four) to be written covering what’s below the tip of the iceberg.

In addition to the information mentioned in the article, Carleen Hawn also consulted with some of my favorite innovators in health care, including Scott Shreeve, MD, and the team at the Kaiser Permanente Sidney Garfield Center for Health Care Innovation.

In addition to these contributions, I would also mention the contribution of the California Healthcare Foundation, whose leaders, including Veenu Aulakh, MPH, Sophia Chang, MD, MPH and Sam Karp, stimulated the development of the crowdsourced definition of Health2.0 mentioned the article with a simple question to me: “Ted, what is Health2.0?” (my answer was, “I don’t know, let’s ask the crowd.”)

And, I would also like to mention that innovation like this comes from health care organizations and systems that are able to say,”Not everything has been tried before,” and in my case this is/was Group Health Cooperative, who have learned from our early blogging experience and now bring their physicians and staff online for the world to learn about what they are doing to reinvent primary care. I’ve been engaged in maybe a few conversations over the past few years about why health care organizations should be transparent and it’s helpful for everyone to have an example of why this works well for everyone.

Thanks again to Carleen Hawn, The Health Affairs Team, and The American Board of Internal Medicine Foundation for taking the time to explore this topic for America’s patients (that’s all of us).

Adolescent Access to Online Health Services: Perils and Promise. Journal of Adolescent Health. [cited 2009 Feb 3]

One of the authors of the article and former colleague from Group Health Cooperative, David Grossman, MD, tipped me off to its publication, and I’m glad he did.

This piece adds to a growing volume of work that doesn’t ask “why?” patients should have online access, but work that asks “why not?” for patient online access. Unfortunately, the peer reviewed literature lags significantly behind what is known in the world about patient online services – it points to some of the deficiencies of peer review in a Web 2.0 world that I an others have written about previously.

One disclosure is that I am an acknolwedgee and was one of the individuals interviewed by the author, although I was not involved in any significant way in the content or conclusions reached by the author.

The article covers online patient access for a vulnerable population, teens, and the author makes an astute observation about their vulnerability in today’s health system, which parallels their vulnerability in online health systems:

Adolescents, as a group, do not typically advocate on behalf of their own health care needs, and generally are not the primary subscribers on health insurance plans. As a result, teen needs may not be among a health care organization’s highest priorities.

From my experience, many of the online programs that exist for adolescents are there because of the support of a handful of dedicated pediatricians and family physicians as well as their nursing and allied health colleagues who care for this group. That’s changing, though, as parents who enjoy this access for themselves are asking how their entire family can participate.

There’s a very nice table in the article about what, specifically, leading edge organizations are doing to provide teen access. This table alone should serve as a guide to understand what conventional limitations are. However, I would stress the word “conventional,” because as the authors point out, much more should be possible in the care of adolescents, so organizations out there looking to implement teen access hopefully would use this information to provide even more service – this is the foundation of innovation after all!

In addition to the useful summaries of potential beneficial uses of teen access, the article includes a fairly good review of the benefits of personal health records in general.

The other thing I liked (and like in any article like this) falls into the category of what I call “myth explosion,” which is where a critical eye is applied to assumptions made about how things might work if some thing new is tried. (In my LEAN work, I used to say, “not everything has been tried before.”) This includes concerns about parents coercing teens to provide passwords to their online health information, which is successfully challenged as a concern, in my opinion. Beyond thoughtful analyses like this, I think patients and their families are the best at myth explosion and do it quite readily. With that in mind, a great follow-on to this article might be one written about the experiences of teens and parents involved in the adolescent access programs now underway.

The one other idea that comes to mind is the fact that the recent HIPAA guidance put out by the Department of Health and Human Services has no information in it regarding adolescent access. I think it might be useful for the next chapter of that guidance to include this group, to make something that seems difficult to so many not seem so.

Thanks to Megan Moreno, MD, for her work to change the question from “should we?” to “how and when?” Hopefully, soon. If there are any teens or parents out there using this access or want to use it, please feel free to comment on your experience as it is or as you would like it to be.

Johnson KM, Chark DM, Chen QP, Broussard A, Rosenbloom STM. Performing Without a Net: Transitioning Away From a Health Information Technology-Rich Training Environment [Internet]. Academic Medicine. 2008 ;83(12):1179-1186

This article caught my eye because it’s the first look (that I’ve seen anyway, let me know if there are others) of what I have been calling the “California effect.” No, not the California effect of passing laws that limit patients access to their own medical data online (which has been ineffective). This is the California effect that was effective, around banning smoking indoors. What happened after that was that a whole generation of children grew up and moved to other places in the U.S. and asked their communities, “why is this place that allows smoking indoors so abnormal?” I saw a hint of it at Group Health Cooperative as well, where patients leaving the health system would ask their next doctor, “Where’s your EHR/PHR?”

This study doesn’t study patients, though; it studies doctors. Ones that have been trained in a technology-rich environment at Vanderbilt University, and who then begin working in a diversity of environments that use and don’t use Health Information Technology tools. The authors chose to study the electronic health record component, and not the personal health record component. More on that later.

328 physicians out of a total of 679 graduates were surveyed. The authors excluded people who had undeliverable addresses in the denominator, but I would prefer to look at “intention to survey,” so depending on your approach, at least more than a 50% response rate was obtained. It’s important to note that 54 percent of the respondents reported working at an academic medical center, so there’s a heavy sampling of AMC work environments here.

Absence of HIT was associated with lower perceived quality of care in many domains surveyed, including safety, efficiency, and system learning. Of considerable note, this group reported having less confidence in their knowledge about drug interactions and drug management than they did during their training, even months after changing institutions. Additionally, many respondents felt weakened in their ability to prescribe medications safely.

That’s the headline. However, looking deeper. There are a few curiosities:

1. Only 23 percent reported HIT as a “positive” factor in the decision to practice in the new institution. 11 percent reported it as “negative.” The luke-warmness and negativity could be dependent on the specific implementation of HIT at the “new” place, of course.
2. “I was better able to interact with patients/families” was not statistically significant, meaning that people with “Less HIT” didn’t feel that they were better able to communicate with patients and families at Vanderbilt.

And this interesting summary statement:

One implication of this study is that if HIT reduces error rates but is not yet ubiquitous, administrators at technologically sophisticated environments might need to expose their junior physicians to unsupported and less safe care environments as learning experiences.

The implication of the above is that resources should be spent on introducing physicians-in-training to paper based practice to support safety in a potentially unsafe environment.

The authors asked about the impact of HIT on communicating with patients and families, and the study shows that there wasn’t a significant one attributed to HIT in the Vanderbilt institution, a place that is advanced in the area of personal health records (from my limited knowledge, someone please add information about that if you have it).

Even if we assume that a HIT-enabled environment is always “more safe” than one that isn’t (and you could read the Health Care Renewal Blog to challenge that assumption – safety is not inherent in HIT, it’s in the system that it’s a part of), I think the resource should go to training skills that work in any environment, HIT or not. I am speaking of process improvement, collaborative/enterprise thinking, and patient centered care. This includes things like analysis of clinical workflows to look for and eliminate waste, learning how to write to patients and involve them and families in their care and understanding of their medical information, and leadership/support of entire care teams. On the process improvement work, there is much that can be done in a paper environment even before HIT is implemented. It’s likely that doing work that reduces waste and increases standardization makes HIT easier to implement. At the very least, creating a culture of looking for problems and focusing on the impact to the patient is as important within a HIT-enabled environment as one not-so-enabled.

Speaking from a LEAN (Toyota Management System), problems are gold, and this study is very helpful. I think it points to an early “California effect” with regard to HIT. It’s possible that clinicians trained in these environments will be more observant of not just HIT, but well-implemented HIT. The study also points out that we may still be thinking of Health Information Technology as a physician endeavor. I think it would be interesting for a large health system that has a fully deployed personal health record to survey patients who have left and ask about their confidence in managing their health and staying healthy.

“Know Your Numbers, Outlive Your Diabetes: 5 Essential Health Factors You Can Master to Enjoy a Long and Healthy Life (Marlowe Diabetes Library)” (Richard Jackson, Amy Tenderich)

For the last several months, at least since Amy Tenderich, Jane Sarasohn-Kahn, and I served on a panel for the California Commonwealth Club, when people have suggested I read this book or that book, I have said, “Amy Tenderich’s book is at the top of my list, that’s what I’m reading next.”

And I stuck to that promise.

Why? The medical literature I read usually talks about patients (people) in the abstract/third person, which is great for focusing on the science (sort of, I’m not sure anymore), but maybe not the art. That and the fact that before Amy, Jane, and I went on stage, I noticed that Amy checked her blood glucose and had a protein bar ready to go in preparation for our hour-long discussion. There are things I am not going to understand about patients’ health experiences if I don’t listen to their experiences to start with.

I decided to combine the reading of this book with 2 experiments for myself. One, to use Twitter to write notes to myself about the book, two, to complete a board certification module for my specialty (Family Medicine) after reading the book. For the first experiment, there’s a good record of the first several chapters here. Part way through I thought that this was probably not as relevant to people following my Twitter feed as me, so I stopped. I would do it again, though, because the notes are helpful, maybe from a different account.

As you can tell from the linked notes on Twitter, I enjoyed the book and think it added a lot to my knowledge. Believe it or not, there are some details about some of the things we do as doctors that are not really explained to us except in the experiential part of doing what we do, such as how to organize the care of a condition, from the big picture. The authors laid that out extremely well using the diabetes health account concept. Diabetes was never taught to me that way – it was kind of a jumble of all the different diseases a patient can get and how to prevent them, not about how to organize and focus efforts. Leave it to a patient to do that because they don’t just have to tolerate having these conditions – they live with them.

I also noticed that a book written for and by patients doesn’t start with pharmaceutical therapy, it starts with knowledge, which may be the opposite way health care thinks about approaching condition management. I have to further celebrate Amy’s approach to thinking about diabetes in non-militaristic terms. The war analogy is pervasive in health care management (”front line staff,” “triage”) and I think it sets up the wrong type of relationship behavior with patients behind the scenes. It is great to see a patient confirm from their experience that it sets up the wrong type of relationship behavior with their condition:

People often refer to experience with a disease as a battle, such as “her battle with cancer..”…We think think this reference is wholly inappropriate for diabetes – one of the few chronic diseases with which patients have the power to both feel physically well day to day, and to live a long and healthy life….If you think of your diabetes as a battle, you’ll always be stuck in a miserable war. Make peace with your diabetes, and you’ll be at peace with yourself.

(let’s also stop using battlefield terms behind the scenes, we are not at war with patients, we are at peace with them)

As helpful as this book is, I think there’s great potential for a sequel (with Amy’s perspective). There’s new information about the value of home blood pressure monitoring, and new ways to check for retinopathy that don’t require a trip to the eye doctor. In addition, there’s now information about some of the newer drugs mentioned that may cause their harms to be underemphasized in the book. And I think Amy would be well suited to expand on some of the Web tools that are out there, including her very own, Diabetes Mine, and how they are helpful, from the patient perspective.

These are minor critiques, and actually not critiques of Amy, because it’s the job of doctors to have the most up-to-date information (and provide it to patients) in actual health care experiences. This brings me to a closing thought, which is that reading about the work of Amy and other leaders like her makes it clear that Health2.0 is not about shifting the power away from anyone, it is more about valuing the contribution of each role. As Amy and I discovered after our talk at the Commonwealth club (”you mean, you didn’t know the answer to that question either?”), neither of us is the true expert on everything, but we are both necessary, and I think it’s very valuable for a health professional to know how necessary the patient is by listening to their experiences.

Now that Amy has done a great job (truly!) in making it clear what someone with diabetes needs to focus on most, my follow-up is to look at some of the online tools available to help with that. Amy’s approach seems to lend itself well to a tool for health that’s as straightforward as mint.com is for finances. I will write on that in a future blog post.

Network Citizens: Power and Responsibility at Work

Not long ago I was ordering coffee and needed to wait a few seconds for the person taking my order to end a personal cell phone call. Once the call ended, she was extremely courteous, warm, and service oriented. I now realize that she was tapping into her social network, using her own information technology, at work.

There’s an ongoing conversation in many workplaces that starts with “(name your social network) is blocked by by my employer.”

This white paper, written by Demos, which bills itself as the think tank for every day democracy, delivers a broad look at social networking, and goes beyond, “your company should allow access to social networks.” On that point, though, here is what is said:

First, smart businesses recognise that ‘social’ networking is not neatly separable from ‘professional’ networking. Attempts to control employees’ use of social networking software in the office may end up damaging the organisation in the long run by depleting its network capital. Of course, bans on Facebook or YouTube are in any case almost impossible to enforce; firms may as well try to put a time limit on the numbers of minutes allowed each day for gossiping. A network permissive culture requires a degree of trust on the part of managers and responsibility on the part of employees; but to the extent that networks add internal economic value, this is usually a risk worth taking.

So, controlling access to networks in the workplace is futile (think about the coffee employee’s cell phone) and has negative consequence on recruitment, retention, and innovation among other things. At the same time, there’s an interesting conversation about the risks of networks, and not the kind of risks most people commonly think of:

Networks can build meritocracy, openness and democracy – but then can also exclude and discriminate. They can help to diffuse power away from hierarchical structures – but they can hoard power for themselves, too.

The authors point out that most social networks are opaque, compared to the transparency of the organizational chart. It’s easy to look at these and see who is connected. This is where responsibility comes in. Organizations should “go with the grain” of social networks and those engaged in social networks should be good network citizens and use the power they get from the network to further the goals of the organization. This comes together in the creation of a kind of network “constitution” or social contract, which supports good relationships, rather than hard rules. I think some companies, like Sun Microsystems, are starting on this journey through the creation of progressive social networking policies.

Some organizational approaches are to create Bespoke services, which are internally supported social-networking-like applications, and these carry some risk, as pointed out in one of the case studies:

The issue with our company is that the answer to every problem is a database. The problem is actually time – this utopian vision of being able to look up all this information and draw it down from the database is a bit unrealistic. – Interviewee, large professional services firm

I think Bespoke services can be successful if their purpose is thought of carefully and not as the solution to every problem. Every organization will likely need a portfolio of tools to support the needs of employees of today and tomorrow. The paper has a high philosophical tone, and the social networking analysis is very interesting ( I have to try that soon ). The idea here is to support the exploration of what those are in an open environment.

In this context, the fact that the person taking my order for coffee after tapping into her social network doesn’t bother me at all. I have a feeling it will help them and the organization they work for provide even better service in the long term. I hope this paper and blog post might help some have the conversation about whether (social networking tool) should be blocked or not.

Feel free to comment with your experiences in your organization, of course.

Delivery System Reform Action Steps and Pay-for-Value Approaches, joint perspective from Intermountain Healthcare, Kaiser Permanente, Mayo Clinic

This is a white paper published on the Mayo Clinic Health Policy blog about approaches to delivery system reform, with a significant focus on reimbursement. I read it because I’m joining colleagues from Kaiser Permanente at the World Healthcare Innovation and Technology Congress (and if you’d like, you can hear a podcast of CEO George Halvosron here).

The reason I decided to post this paper on my blog is I think it’s an accessible (easy to read), basic and reasoned approach to changing the way we deliver care in our patients’ interest. It goes beyond medical home thinking (while including those principles) to include more aspects of care, including inpatient and outpatient care, and includes what I think is a pretty reasonable timeline for this happening.

There is a section on “Patient-Centered Use of Information Technology” that says information must be made available to “doctors and patients.” I think the people who read this blog and others can further flesh out the details of a fully accountable health care system. I also really liked the discussion of “Episode-Based Payments for Hospitalized Patients.” I think this would enhance care coordination, and I have seen the impact of hospital care reimbursement being isolated from the overall hospital care episode, which doesn’t end when the patient leaves the hospital.

Some of the recommendations are to be expected considering the organizations who provided the perspective, such as support for group medical practice. At the same time, I think the paper has good relevance and offers realistic ideas for all care environments, which is why I’m posting it here. It’s pretty manageable lengthwise, so I’d encourage others to read it and post their thoughts on it – do the ideas look reasonable/rational in whatever care system you work in/ get care from?

Here’s the link to the post on the Mayo Clinic Health Policy blog if you’d like to post your comments there (and feel free to post there instead of here)

Baker LC, Atlas SW, Afendulis CC. Expanded Use Of Imaging Technology And The Challenge Of Measuring Value [Internet]. Health Aff. 2008 Nov 1;27(6):1467-1478.[cited 2008 Nov 27 ]

The quote in the title of this post is the paraphrase of a conversation I have had more than a few times with someone who has asked me, “Ted, what’s the return on investment for web services for patients?” The answer I have usually gotten when I ask the question back is usually no answer.

Two papers just published in HealthAffairs provide a little more background for that conversation. The first is about the growth of the use of imaging technology in the United States. As you might expect, it is growing, and more with every new scanner put in operation.

To put things in better perspective, I created this graph from the data, showing the increase in the number of scans/beneficiary. In 2005, there were 547 CT scans per 1,000 Medicare beneficiary, or about 1 scan per 2 beneficiaries. What the article doesn’t mention is that the radiation load from a CT scan is high, anywhere to 15 – 100 times the dose of radiation from a chest X-ray. Medicare reimburses, on average $308 for a CT scan, $713 for an MRI.

A basic return on investment analysis is performed for abdominal aortic aneurysm (AAA) screening, which shows that as more people are screened using CT, less are screened using catheter angiography (which is more invasive). This is good, except, the reduction is less than 1:1, so there is overall expansion of screening to more people, and more procedures to fix AAA associated with this. The problem is that there isn’t data on whether this is overall a good thing or not from a cost/benefit perspective.

Because CT and MRI are a physician preference item, reimbursement and use is typically physician directed, which can create conflict (see Jaime Robinson’s paper in the same Health Affairs issue for more about this).

It’s interesting that the adoption curve of CT/MRI looks a lot like the adoption curve of personal health records in organizations that prioritize them, like Kaiser Permanente and Group Health Cooperative.

Currently, Medicare pays $0.00 per certified empowered/activated patient (potentially defined by more than 2 accesses to a comprehensive personal health record in 6 months).

So we know from this is example that it’s possible for health care to adopt technology. How can we recreate the magic of the CT/MRI adoption curve for something that’s patient directed? I have some ideas but want to see your comments first.