2009 a Year of Surprises and Change for the EHR Technology Market

2009 a Year of Surprises and Change for the EHR Technology Marketby DAVID C. KIBBE and BRIAN KLEPPER"Oft expectation fails, and most oft thereWhere most it promises; and oft it hitsWhere hope is coldest, and despair most fits." All's Well That Ends Well (II, i, 145-147)2009 began with a bang for legacy Electronic Health Record (EHR) vendors, promising strong sales and windfall profits

The Patient Centered Medical Homes and Wellness: Can Physicians Really Respond?

Check out this '...but I wouldn't want to live there' posting in the Turn to Stone blog. You might be inclined to dismiss this as another off beat critique of the Patient Centered Medical Home (PCMH), but this one is from Robert Stone. Bob is not only an experienced health care executive with years of experience in population-based care management, he's also a co-founder of the disease management company Healthways. When he speaks, the Disease Management Care Blog has learned to listen.

He raises some good points:

• 'Wellness' activities such as exercising and pursuing a healthful diet have yet to be intelligently 'medicalized' in any meaningful fashion. Consumers don't look to their local hospitals and doctors for wellness. What's more, hospitals and doctors don't have the resources (and in many instances the knowledge) to provide wellness services. Last but not least, retooling the overwelmed primary care system to adopt wellness in their busy clinics is a stretch.



• It is doubtful that today's average physician wants to be in the wellness business. After four years of medical school and additional years of postgraduate training, they are trained and socially conditioned to diagnose and treat disease.

Supporters of the PCMH would point out that their care model doesn't rely on the physician personally providing the services. Rather, their job is to be 'doctors' while simultaneously overseeing a team of health professionals that support wellness and prevention. Unfortunately, that key concept may be getting lost as the 'medical home' enters the mainstream. Early buyers of 'medical homes' may be disappointed when they're met at the PCMH door by Nurse Marcia Wellness instead of Doctor Marcus Welby.

The Disease Management Care Blog is more alarmed by Turn to Stone's second point. If docs haven't had a lot of personal professional experience to intelligently deal with nutrition, exercise and all the other forms of non-traditional medical consumerism, how in the world are they supposed to supervise it?

The answer may be to totally 'outsource it.' The DMCB wonders if docs will be inclined to do that and if companies such as Healthways will be able to serve that market.

Time will tell.

hello again

I'm back.

All is well here, I just used up all my writing mojo in November writing a novel (more on that experience in a future post).

Then I took a few days off to hang out with a wonderful friend and, well not write for a few days,

And while I was gone from the blog November 24th (the anniversary of my diagnosis of metastatic breast cancer) and December 2nd (the anniversary of the night I found the first lump) came and went. I noted both events in passing, took the time to breathe deeply and be grateful, and then got on with my day.

It's been four years since I found the lump. It's been three since the cancer spread to my liver. And it's been two and a half years since my first clean scan.

I had an appointment with my oncologist yesterday. I had nothing to tell him. He said, "Shall we keep dragging you in here every few months just to say 'hi'?"

I readily agreed.

I have chemo next week. They've been building a new treatment centre for what seems like years. I have often jokingly pointed in the direction of the new building and said, "They're building that for me."

Yesterday, I discovered that the new building is open and the chemo room has been moved. No more listening to the sounds of construction during treatment. No more listening to the intimate details of the constitutional issues of the patient beside me. There will be a little more light and a little more room and hopefully, a little less noise.

I'm kind of excited.

And yes, that is somewhat ironic. I have lived long enough to be excited about getting chemo in the new building.

Good For Orszag--Budget Director Discusses Cost Containment in Dem Bills

I was encouraged by remarks White House Budget chief Peter Orszag made in Washington yesterday.There has been substantial debate in recent days about whether the pending House and Senate bills have the kind of robust cost containment we need to really "bend" any health care cost "curves."Readers of this blog know of my concern that these bills amount more to expensive entitlement expansions than

ICD-10: A Win for Physicians, Care Management and the Patient Centered Medical Home

The ever virtual Disease Management Care Blog has recorded another webinar. This time it was about ICD-10 and the implications for care management. You're welcome to listen to its commentary here. Feel free to email if you want a copy of the PowerPoint presentation itself

So what did the DMCB have to say?

While the mandated future implementation to ICD-10 from the current ICD-9 coding system has been equated with 'Y2K,' the End Of Days, a planet killing asteroid or the return of certain Republicans to power in D.C., the DMCB has decided that the change will be well worth it for physicians, researchers, disease management organizations and the patient centered medical home.

Since ICD-10 has a far greater level of detail, physicians will be able to expect and demand a) better matching of payment to their work effort, b) more accurate risk adjustment in any bundled payment systems, c) increased payments under pay-for-performance reimbursement, since their performance should be more apparent to the payer and d) the payment system will have greater transparency.

Researchers will win also. Since randomized controlled clinical trials are time consuming and expensive, ICD-10 will permit better 'virtual' matching of patients in quasi-experimental studies with and without the diagnosis, treatment or intervention of interest. Armed with increasingly powerful desktop computers, more researchers will be able to plumb the claims data sets for insights that aren't possilble in the ICD-9 current claims and EHR-based systems.

Despite the huge costs of retooling their claims systems, insurers will also see some gains. Thanks to the greater 'granularity' of ICD-10 in defining the underlying drivers of cost trends, the risk associated with certain populations will be more accurately underwritten. Having actuaries who can use this information will turn out to be a competitive advantage.

However, the DMCB thinks the care management industry may end up seeing even greater benefit:

• One key measure for assessing the change in the status of a population is the 'R squared,' which can be thought of as a mathematical measure of how much of an observed change can be accounted for by known factors. Since what is known will increase thanks to ICD-10, there will be better definition of the chronic care and disease management organizations' contractual risk corridors and an increase the accuracy of their predictive modeling.
  
  
• Speaking of predictive modeling, the DMCB has always followed the 'sweet middle' rule of population-based care management. The trick is to not dedicate a lot of resources on the patients that have a mild burden of illness and are destined to do well, or on the patients that have catastrophic illness and are destined to not do well. ICD-10 will help find those population segments that have a moderate burden of illness and will not do well without nurse-based care management.

The Patient Centered Medical Home should do well also under ICD-10. As understood by the DMCB, Medicare is currently contemplating two payment levels for patients who are cared for in a medical home setting. Patients with a Hierarchical Condition Code (HCC, which is a method of risk adjustment) that is low will be associated with a lower monthly payment than those patients with a higher HCC. ICD-10 will hopefully force Medicare to recognize that patients and physicians deserve a better level of granularity in the reimbursement levels. There should be more levels of payment and ICD-10 may help that occur.

ICD-10? Despite the pain of transitioning to this effective Oct 1, 2013, the DMCB says bring it on. Its message for the disease management industry is to start planning for this now and do everthing you can to help your customers make it happen. It's in your - as well as your customers' and your patients' - best interest to do so.

The Latest Cavalcade of Risk is Up!

That' right, it's at the Insurance Copywriter Blog. Yours truly is leading the way in this #93 summary of the latest best submissions from the world of risk-related bloggery.

Air Passenger Travel and Population Based Health Care, Managed Care and Disease Management: Overlaping Terminology

The Disease Management Care Blog spent the day being victimized by our air transportation system and noticed many an uncanny resemblance between the healthcare and airline industries. So much so that some of the terminology used by the DMCB in past posts can be easily applied to the average passenger’s experience.

To wit:

System Inertia: What happens when a customer with a complicated itinerary has a flight delay with connection problems and hogs the attention of the gate agent.

Stakeholder: Anyone who plants or ‘stakes’ both elbows on the counter of a gate agent while dealing with a complicated itinerary. See ‘system inertia.’

Maximizing Outcomes: the jostling of the experienced travelers to get on the plane first so that they can be first to access the overhead bins with their generously sized carry-ons.

Disparities: the unfavorable ratio of available space to carry-on luggage volume for persons unable to maximize outcomes.

The Underserved Population: first time travelers who are baffled by garbled overhead announcements, opaque seating systems and how First Class passengers are always allowed to board ahead of everyone else - even when they get in line with them.

Outlier: the inexplicable tendency of underserved populations to remain in the aisle and not get in their seat while tending to the countless last minute details of traveling, like checking their ticket one more time, getting their food out, dealing with disparities and chatting it up with other underserveds.

Chaos Theory: the sudden and noisy unwinding of a toddler’s patience with being confined in a aluminum tube at 35,000 feet. More likely to manifest itself during descent thanks to narrow Eustacean tubes.

P value: the superior status of the lavatories in the front of the airplane thanks to the requirement that passengers restrict themselves to their ticketed cabin.

Regression to the Mean: the over-response of the DMCB spouse to the perfectly reasonable possibility that her frequent flying husband could get a coveted upgrade to First Class without her.

Withholds: the DMCB spouse’s solution to her husband’s continued willingness to go to First Class without her, despite Regression to the Mean.