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.

AMCP.org – Comments on Standard SIG – The NCPDP was working on the standard for Med Sigs – a little background

• The Happy Hospitalist: This Deserves The Middle Finger – I guess it is controversial (the RUC report on Medical Home Reimbursement)
• AMA (RBRVS) RUC Medicare Medical Home Demonstration project recommendations – RUC and Medical Home. Might this be controversial?
• reportonbusiness.com: Asking ‘why’ again and again is harder than you think, but it works – Good description of the 5 Why's Exercise
• What is Hypertension? – WrongDiagnosis.com – Factoids about Hypertension, useful in planning a community intervension
• Cigna clients seek answers after expiration –
• Cigna ends pact with hospitals, leaves thousands in the lurch – This local story has not made the national news. I wonder why?

• Pattern Recognition » Blog Archive » I really hate Zotero – Like the concept, wants to improve the implementation
• Medical Home | Solution to Chronic Care Management? | Health Care | Disruptive Innovation for a New Primary Care Model | Center for Health Solutions – Deloitte LLP – Very nice overview of Medical Home, particularly with the rundown of stakeholders in the back, plus the medical home cost model.
• WordPress ? Support » Tags Import As Numbers, Not Words – Importing issues Wordpress
• Web 2.0 Expo San Francisco 2008 ? Co-produced by TechWeb & O’Reilly Conferences, April 22 – 25, 2008, San Francisco, CA -
• Compare Accounts | YouSendIt – Store and forward service for the times when e-mail isn’t so efficient. I use XDrive.
• Convert Your Paper to iPaper | Scribd – An ambitious project to convert paper , no extra charge
• John Furrier Says Google?s CIO is Leaving for EMI – Interesting change of employer, could the same thing happen if a Google employee was recruited to run a health care organization?
• Twitter – A Teaching and Learning Tool | ICT in my Classroom – Nice discussion of the uses of Twitter in education
• VoiceThread – Group conversations around images, docs and videos – An interesting image, video, voice annotating service. What are the applicaitons in medical group training and patient involvement

• Apple Digital Fitness Companion System? – Mac Rumors – It was/is only a matter of time. Hello Health2.0, courtesy of iPhone
• The computer will see you now | Economist.com – A nice biographical piece about Larry Weed, father of the problem oriented medical record.
• EMC, Partners collaborate on hypertension program – Daily Business Update – The Boston Globe – An employer that thinks about population health and sets up a PHR in concert with a health system. Interesting…..
• Subscribe to ringtones via iTunes – Easy way to get ringtones – a ringcast?
• Mashable?s Guide to Upcoming Web 2.0 Conferences – A plethora of get togethers to get up to speed on the latest in Web 2.0.
• leanblog.org | Lean Blog: The Waste of Handwritten Notes | Lean Manufacturing | Lean Healthcare | Toyota Production System – Yes, Leadership. From patients and their families too. The kind of leadership that brings the patient perspective into every conversation.
• Apple – Support – Downloads – MacBook, MacBook Pro Software Update 1.1 – Help with keyboard freezing issues caused by Leopard
• Healthcare 360 -
• GHI – GHI Medical Home Pilot – I think this is very promising for supporting EHR adoption and patient access to their own clinical information. Ties in very nicely with NYC’s PCIP project.
• Public health system struggles to reach gay ?hidden population? – Washington Blade – Another vulnerable population that could benefit from outreach – many are underserved even when well insured.
• Cocoa Programming for Mac OS X – The resource for programming on MacOSX, and iPhone as well

• The ‘World Wide Computer’?Another HAL? – Businessweek’s Review of “The Big Switch” – I used it for comparison
• NPR: Doctor Blogs Raise Concerns About Patient Privacy – I agree with points raised – a patient should never seek care and then discover that they have been written about on a blog. Instead, they should receive a copy of the medical record that has been created about them. At the same time, physician bloggers are doing something very important – they are testing the boundaries of transparency, to support a more accountable health care system. If anyone saw the 60 minutes story about Dennis Quaid and his family, the rationale for this become very clear.
• What Every Physician Should Know About the RUC – January 2008 – Family Practice Management – The information is useful. As primary care providers I think we need to be careful to include our specialty colleagues in the conversation, not distance themselves from it. As a member of a large multispecialty medical group, I know that there is interest across the physician community in supporting community health and the best experience for patients.
• MindBlizzard blog: Virtual Healthcare 2: Palomar Pomerado Health – All right – More news about the utility of Second Life – testing a hospital before it launches
• What is the ROI on employee suggestion systems? – A nice example from the toothpaste industry. But not necessarily one that supports the evidence, that far less toothpaste than people think is needed to protect teeth…..Maybe a customer suggestion system might be in order.

• Frist Advocates Higher Medicare Payments for Doctors Who Use EHRs – iHealthBeat – An idea to promote network preference among physicians who adopt HIT.
• Marissa Mayer’s 9 Principles of Innovation | Fast Company – I love number 5
• The Curious Genius of Twitter – Evan Williams – Tweet | Fast Company – Will Twitter go the way of friendster? I think there could be applications of Twitter in Health Care (really)
• Area Tap Water Has Traces of Medicines – washingtonpost.com -
• Farm Workers Service Wheel – Services for farm workers in Sonoma County. Showing that the Internet can serve everyone

Commonhealth » Blog Archive » A NEW AND DIFFERENT WAY TO PAY FOR CARE by Andrew Dreyfus

At the level the information is presented it sounds promising – that delivery systems might have more lattitude to use all of the tools available today to coordinate care (including patient access to their records online). The details are not listed, though. I wonder what about the plan would enable a more patient centered approach to implementing health information technology. Would a delivery system under this plan be spurred to promote personal health record adoption?

As we found when we visited Boston recently, adoption of relatively robust patient access systems has been less than desired, especially compared to systems where incentives are aligned. Maybe this might help?

I’m posting this as a trackback to the blog post to see if more information might be shared about this, either here or on the original blog. How does this new payment methodology stimulate patient access to health information technology and non-visit based care?

• DC Moves for Safer Sidewalks – Get There – Washington government takes a step toward promoting walkability. Sidewalks stay open for business.Walkers rejoice!
• Apple //c – a photoset on Flickr – The OOB experience of an unopened AppleIIc computer. Remember when technology was fun? It still is. And I never even learned to program in Pascal.
• Ryanair’s Changing Altitude – Efficient cost management and charging for everything keeps margins high at RyanAir – a great example of “copy how we think” in terms of being like Southwest
• Running a hospital: More on fetching and work-arounds – BIDMC launches an improvement methodology called SPIRIT. Looks like it’s at least partially based on LEAN?
• The Health Care Blog: Bad Medicine: How The AMA Undermined Primary Care in America – Brian Klepper – Analysis of RBRVS and impact on primary care.
• The ethics of CEO blogging – Nice discussion from Paul Levy about the approach that a CEO takes to blogging. I’m in support!
• Insurers Begin To Reimburse for Online Visits, Concerns Remain – Nice profile of Kaiser Permanente’s program.
• Marriot Rolls Out Web-Based PHR System to Employees Nationwide – iHealthBeat – An employer-sponsored PHR. Will the lack of connection to the health care team be an issue?
• KUOW: Program Archive: Patient Safety, January, 2008 – Dr. Matt Handley, from Group Health Cooperative, is featured
• Best Companies 2008 – FORTUNE Magazine’s Top 100 Employers to Work For – The 2008 list is out. From an HR/Leadership perspective, it is interesting to look at some of the most important qualifications for being on the list, such as support for diversity.

• Prometheus Payment, Inc. – A new payment model that supports outcomes, evidence-based care, and transparency
• The music industry | From major to minor | Economist.com – “Then they had the money and could have built the competence by buying concert agencies and merchandise companies,”…Now it may be too late.
• Coverity Incorporated Scan – Company working with the US Govt to harden open source code for use by agencies including Homeland Security. They are finding bugs and the bugs are being fixed.
• Online Real Estate Sites Work To Get A Listing Standard – Another industry that is seeing the benefits of standards, and the challenges of disruption
• Gone Indie ? Thought Palace – Interesting insight on the work environment at Apple. LEAN production? You decide. I will say, though, that even though Apple is not embracing Web 2.0 like other companies are, I have solved many problems using their hosted discussions. These actually work well on Apple’s site I think because they do a great job of leveraging their loyal customer base. Yet another blog “goodbye” to an employer.
• Lean Manufacturing Blog: 1 Hour Kaizen – Excellent template and approach to small improvements. Just takes an hour. Can we have physicians shadowing nurses and vice versa?