JAMA Article on How to Increase the Involvement of Physicians Falls Short

Writing in the latest issue of JAMA, Drs. Erica Spatz and Cary Gross of Yale's Robert Wood Johnson Clinical Scholars Program share their insights on the immediate and concrete steps that physicians can take to improve the health care system.

They also unwittingly demonstrate the atrophy of higher order cognitive brain functions that result from the reality deprivation that afflicts many of our finest medical schools. Non-inhabitants of the academosphere that read JAMA may think these bright docs speak for the avant-garde of the mainstream physician community. That would be a mistake and would only make the Disease Management Care Blog's migraine worse.

The Disease Management Care Blog summarizes Drs Spatz's and Gross' suggestions below.

1. Work Daily to Provide High Quality Care - physicians should adopt 'new approaches' to measuring and improving quality of care.

2. Control Costs - physicians can act locally/think globally and 'consider' the costs of medications, tests and treatments.

3. Improve Communication - this can be achieved via electronic records, information exchange systems. giving lists to patients and 'shared decision making.'

4. Become Involved Locally - physicians should get involved or even volunteer in 'community based programs.'

5. Help Implement Creative Payment Reform Solutions - the 'several testable options' underway for control costs and increasing quality cry out for physician participation.

6. Talk About Reform With Patients - patients trust physicians to give them the insights they need about 'why change is needed.'

7. Minimize Conflicts of Interest - with the 'pharmaceutical' industry.

While the DMCB agrees with the technical merits of each of these seven points, they are astonishing for their their emphasis on the traditional role of the physician that still continues to be perpetuated by an unresponsive medical education system. Maybe the folks at Yale haven't heard about the emerging consensus on teaming, health consumerism, systems of care, increasing complexity of insurance designs, growing sense of alarm over health care costs, novel approaches to physician reimbursement, coming heavy-handed involvement of the U.S. government and work that remains in making health information technology useful.

The DMCB wishes that JAMA's editors had demanded more on behalf of their physician readers.

Anyone paying minimum attention to what is going on in health reform knows there is far more to the story at the bedside, the clinic and the community:

1. Work Daily to Provide High Quality Care - like it or not, physicians need to adapt now to new expectations and changing work roles that increase the delivery of high value. For example, they need to become experts in optimizing local work flows and the 'systemness' of leading non-physicians in ways that help their assigned patients maximize self-care.

2. Control Costs - physicians need to be responsible for helping patients and insurers navigate through increasingly complex insurance benefit designs with increased out of pocket costs. For example, they need to demand that HIT decision support also helps patients make decisions about care options that are aligned with their personal values and their pocket books.

3. Improve Communication - this can be achieved not only via electronic records, information exchange systems, giving lists to patients and 'shared decision making,' but through web-based and 'push' cell phone technologies, support of personal health records and better coordination with resources that include, but are not limited to, insurers and community groups.

4. Become Involved Locally - physicians should not only get involved or volunteer in 'community based programs,' but communicate with their elected representatives, join at least one organized medicine group (there are options that range from the AMA to PNHP to PSR), write letters to the editor and serve in one or more advocacy groups - and that's just for starters.

5. Help Implement Creative Payment Reform Solutions - physicians need to be highly skeptical that any of the pilots and demos will be enough to reconcile escalating health care costs, limitless demand and ballooning government deficits. If there are any good ideas out there, now is the time to talk about them.

6. Talk About Reform With Patients - it's time for physicians to trust and listen to their patients so that they can gain better insights about 'why change is needed' and how to make it happen

7. Minimize Conflicts of Interest - physicians need to decide which is worse: the appearance of being fixated on preserving income while being played like puppets on a string by a government incapable of fixing the Sustainable Growth Rate, or, taking a huge cut in income that is likely to occur sooner or later anyway while preserving our self respect. Right now, the DMCB can't tell which is worse for the profession.

The Latest Cavalcade of Risk Is Up

During its residency training, the Disease Management Care Blog participated in an annual party in which it and its fellow trainees would put on a show with a series of skits mocking the faculty, the administration and the other specialties. Everyone knew, however, that the worst fate for the individuals in our very target-rich environment was to go unmentioned.

Ironman of Political Calculations takes an opposite tack in the latest Cavalcade of Risk and mentions everyone with a fabu assessment system that mimics bond ratings. If you're looking for capital at low interest rates, you don't want digits other than the treasured A, a or 1; if you're looking to avoid the delicious insults that come from being off topic, making readers stoopid or having painful writing, you don't want digits like C, c or 3.

AND as an extra bonus, Ironman offers an on-screen calculator that reconciles your income, projected tax penality and the cost of a health insurance policy to help you decide whether to pay or play Massachusetts style.

The Disease Management Care Blog? It has an Ironman rating of Aa2.

The DMCB is also proud to report that it was also mentioned in a host of resident skits after it became a faculty member.

Health Affairs and Their Issue on Health Information Technology: Your DMCB Helps You Take A Tour

If you're mystified by the continuing folderol over electronic health records (EHRs), you may want to head over to your closest medical library and take a look at the latest April 2010 issue of Health Affairs. It has a good spectrum of informative articles on the Feds' efforts to promote adoption of EHRs, the debate on meaningful use, some of the usual pro-EHR fluff, what's going on in physician practices nationwide and - and kudos to the HA Editors on this - some warnings about where this technology falls short. You can read more about the issue at the Health Affairs blog.

Alternatively, since you are one of the thousands of savvy Disease Management Care Blog readers, all you really need to do is get a cup of an appropriately caffeinated beverage, adjust your monitor, sit back and quickly scan this encapsulated summary. THEN you can decide which articles warrant use of your precious time for closer inspection:

In her opening article, Editor in Chief Susan Dentzer points out that only 6% of hospitals and 2% of physicians rely on EHRs and that the Feds are banking on a combination of sticks and carrots to encourage them to adopt "meaningful use" EHRs. She notes the taxpayer's $29 billion investment in the HITECH legislation hinges on getting the definition of meaningful use right.

There's a Health IT Gold Rush Underway, says Nancy Ferris, thanks to HITECH's $750 million in grants and contracts going to 40 States and 30 non-profit organizations that, in turn, are supposed to facilitate health information exchanges and technical assistance. There'a another $225 million going to train people in information technology, courtesy of the Department of Labor. That's just for starters, and a pittance compared to the more than $14 billion that will go to physicians (as in $18,000 per doc per year) and hospitals. You can also get her summary of the five key goals of HITECH and wonder if it will be enough to prod physicians into spending an estimated $30,000 apiece for a functional EHR.

Want a screen shot of what the docs at Kaiser Permanente see when they're taking care of patients? It lists chronic conditions, immunizations, vital signs (including obesity), care suggestions ("flu shot due, Active tobacco use, advise quitting"), recent lab tests and a list of medications.

What happens when you put an ex-national coordinator for health information technology with the current coordinator for health information technology in the same room? After reading this exercise in mutual admiration and closed circular reasoning, the DMCB asks who really cares?

John Halamka is the blogging CIO Beth Israel and Deaconess and likes what he sees in the emerging definitions of meaningful use, but has some suggestions about increased governmental guidance without stifling innovation. Those suggestions include content specificity, creating better vocabulary subsets, better approaches to data transmission, and heightened secruity and quality reporting. This article - by someone well versed on how to use the written word - gives some insight as to why getting into the weeds of health information technology is not easy.

Sean Hogan and Stephanie Kissam of RTI International suveyed 4,484 physicians with a 2,758 responses (an impressive 62% rate). They found that 18% have at least a basic EHR and, depending on the which part you ask about, about 75-85% meet the various individual meaningful use criteria. The DMCB asks how many physicians met ALL criteria simultaneously, a number that was apparently not mentioned in the report. The DMCB also wonders if the other 82% of physicians, after reading this paper, might think they made a smart move by waiting.

James Ralson and other colleagues from Group Health report on that organization's experience with the system-wide implementation of an EHR, a patient centered medical home model of care and a web portal through which patients could view their test results, request medication refills and email their physicians. Before you take the time to read this, the DMCB warns there doesn't seem to be any new insights on how to pull this off outside of integrated delivery systems.

David Bates and Asaf Bitton of Brigham and Women's have some thoughts on how health information technology can be configured to better support the patient centered medical home. While they think the two are inseparable, they have some specific suggestions on how to achieve better clinical decision support, registries, communication capabilities that enable teaming, tracking of hospital discharges, patient friendly personal health records, enabling of remote monitoring and support of quality reporting. The DMCB agrees wholeheartedly, because much of this is already being used to great success in commerical disease management programs.

"Warning!" says Rushika Fernandopulle and Neil Patel, who describe How The Electronic Record Did Not Measure Up To The Demands Of Our Medical Home Practice. With great expecations, AtlantiCare started up a PCMH in New Jersey and found they were stymied by computer slow-downs, e-prescribing security glitches, inabilities to import lab data, clinical alert fatigue, increased physician busy work, too much effort reconciling medication lists, having to rely on an outside vendor, lack of a registry and inflexible on-screen templates unsuitable for non-physicians and group visits. They eventually turned to other software solutions to operate in parallel fashion.

Using "Analtyica 4.1 modeling software", Colene Byrne and colleagues from the "Center for It Leadership" performed a cost-benefit analysis of the Veteran Administration's $7.16 billion VistA EHR. Thanks to projected reductions in adverse drug events, diminished duplicate lab testing, reduced work, decreased operating expenses and more freed space, the cumulative yield in benefits net of costs was $3.09 billion. Before you take the time to read this, the DMCB again warns there doesn't seem to be any insights on how to pull this off outside of the VA, even if you accept the black box analysis.

Catherine DesRoaches and other colleagues from Mass General, George Washington University and Harvard find a poor correlation between hospital adoption of electronic health records and measures of quality. In a companion piece, Jeffrey McCullough and colleagues from the University of Minnesota found a better correlation in hospital quality but many of the outcomes failed to reach statistical or even impressive clinical significance. After reading this, the DMCB wonders if the other 94% of hospitals waiting on the sidelines are thinking they are doing the right thing.

But the debate about hospital-based computerized physician order entry (CPOE) is over, right? Well, maybe not exactly. While previous studies have shown CPOE without a full fledged EHR can reduce medication errors and save lives, Jane Metzger et al show the systems aren't perfect. Using a simulation tool in a sample of hospitals that volunteered to go through this, only 53 percent of the medication orders that would have resulted in fatalities and 10–82 percent of the test orders that would have caused serious adverse drug events were detected. Uh oh.

Oh, never mind says Susan DeVore and Keither Figlioli of Premier health care alliance. They surveyed their hospital members and found the road to EHR installation is lined with gradual implementation to account for objections and work-flow hiccups, clinical champions, lots of staff training, meaningful quality-based decision support and reporting, high security, clear policies and budgets that can handle the unexpected and pay the clinical champions.

Phyllis Torda, Easther Han and Sara Hudson Scholle of the NCQA interviewed 'knowledgeable people" about the implementation of EHRs and found no problem cannot be solved by assistance, consultants, trust, engagement, expertise, sophistication, realism, operational excellence, program redesign, selection of the right software and hardware and sustainability. See... it's that easy! Check out the list of insider knowledgeable people and you'll see why.

Alan Hinman and David Ross go back to the fundamentals and review the building blocks of EHRs, health information exchanges and immunization registries, suggesting the latter may be a good way to tie everything together. The DMCB thinks there may be something to this learn to walk before you run approach.

Good grief you made it to the end of this summary. If you are that interested in the topic, the DMCB suggests you head on over to Vince Kuraitis' e-CareManagement Blog where he has inaugurated a series of very informative posts on HITECH.

Disease Management: A $2.3 Billion Industry That Speaks to the Wisdom of Markets

Looking for a way to convince naysayers that the disease management industry is not only surviving, but thriving? Look no further than this well written 'DM Grows, Though Under Fire' article appearing in Managed Care Magazine. Despite an awful economy and decreases in covered lives, DM industry revenues in 2009 increased to $2.3 billion. Compared to previous years, the percent increase was 'only' in the single digits.

Despite the deserved success of DM, the article hints that the Disease Management Care Blog's friends in the industry are continuing to fret about their second class status among academics and policy makers. Be of good cheer, says the DMCB: Chris DeMuth may have it right. It should be no surprise that the evidence-based dons would be unmoved by DM's prosperity. After all, they favor centralized rationality as the answer to organizing health care and view markets as an antiquated impediment to their plans for the proper, appropriate and approved application of science.

In the meantime, according to the 'DM Grows' article, nimble DM companies are finding ways to engage patients in achieving evidence-based approaches to care with motivational interviewing, assessing readiness to change, focusing on medication compliance, tackling undetected depression and coordinating care for more and more diseases. Faced with plenty of successful anecdotes from an appreciative workforce, rigorous in-house assessments of financial returns and a greater appreciation for the value-creation that comes from health, the 'steely-eyed, green-shaded CFOs and actuaries of corporate America' are buying it: figuratively and literally.

Who can blame them? Compared to what the Feds will be spending between borrowed Yuan and American tax dollars, they've calculated that $2.3 billion is a good investment.

If readers are looking for a way to convince more companies and insurers that they should invest in DM,the DMCB suggests giving them a reprint of this article. When they see what their competition is up to and why, they'll quickly change their minds.

And hopefully, our academic friends will stay out of the way.

Congress Passes a Health Law: Use "Humor" and the "Internet!"

Not to be undone by the swarm of lobbyists, lawyers, strategists and entrepreneurs picking through the bloat of the health reform legislation passed by the 435 Congressional Medical Directors, the Disease Management Care Blog came across this (edited) provision spanning pages 1130-32:

"The Secretary of HHS shall provide for the planning and implementation of a national public–private partnership for a prevention and health promotion outreach and education campaign to raise public awareness of health improvement... that describes the importance of utilizing preventive services to promote wellness, reduce health disparities, and mitigate chronic disease (through a) media campaign (that) may include the use of television, radio, Internet and other commercial marketing venues... and may include the use of humor and nationally recognized role models."

"Internet?" "Humor?"

One only need to go to a CDC (for example), NCI (for example) FDA (for example) or the NHLBI (for example) web site to see just how humorless, sterile, boring and Web 1.0'ish Washington has been when it comes serving the information needs of health consumers. The DMCB suspects that that's not only due to the moribund inertia of our Federal bureaucracies. It's also due to the legions of lawyers, educators and other faceless professionals who are devoted to making sure the organs of government violate no regulation and inconvenience no constituency.

The DMCB isn't very optimistic about the campaign's chances of having any meaningful impact. The disease management industry learned long ago that cleverly produced web site/video content does little to change behavior. The discovery by members of Congress of the "Internet" and "humor," let alone passing a law about it, is testimony to the plodding inability of government to grasp the modern array of communication styles and channels that undergird consumer engagement.

What's more, they'll be going up against the marketing campaigns that have been successfully promoting lifestyle sins for decades. If the taxpayers are lucky, we may get to see some cleverly produced public service announcements that are broadcast at 2 AM or posted in some corner of a government web site.

There is one good thing though. The bill goes on to say that...

The Secretary shall ensure that the campaign implemented under paragraph (1) is subject to an independent evaluation every 2 years and shall report every 2 years to Congress on the effectiveness of such campaigns towards meeting science-based metrics.

The DMCB looks forward to seeing THAT report.

Tut tut you say? The DMCB is being a hypercritical weenie naysayer? While it denies ever being hypercritical, the DMCB does admit that it may fancy a special kinship with Newt Gingrich's Center for Health Transformation. That's why it modestly offers this amendment language for the Republicans to consider under a simple majority reconciliation process after they seize control of Congress this fall:

"The Secretary of HHS shall provide for a national competition of entities experienced in the professional production and design of consumer-based advertising campaigns that raise public awareness of health improvement... that describe the importance of utilizing preventive services to promote wellness, reduce health disparities, and mitigate chronic disease. Competitors must use television, radio, Internet, cell phone and other current and yet to be developed commercial marketing and communication channels. The Secretary shall fund no less than four finalists' campaigns and select a winner of a prize of a) $10,000,000 and b) being prominently featured on the Disease Management Care Blog, based on the effectiveness of such campaings toward meeting science-based metrics as well as the ability of the campaign to use humor by poking fun at members of Congress and the Administration.

Six Reasons Why the Senate Republican Leadership Should Approve Dr. Berwick's Nomination to Lead CMS - An Open Letter

Dear Senate Republican Leadership:

You have the Disease Management Care Blog's sympathy. Despite your Verdun-style stand, Mr. Obama and his Democratic allies passed health reform and, to add insult to injury, convinced some voters that they may know how to govern after all. In the meantime, there's the toxic contamination of those wacky tea baggers, expensed soirees at clubs of dubious reputation, Sarah Palin’s unending media presence and generalized voter animus. Under these trying circumstances, who can blame you for planning to hunker down until the November election and lob filibustering daisy cutter neutron bombs that uniformly kill all Democratic-inspired appropriations, deals, legislation and nominees.

Yet, on the matter of Donald Berwick MD's apparent nomination to CMS Administrator, you may want to calibrate your scorched earth approach.* The DMCB is at your service with some unsolicited advice on three reasons why you may have no choice but to go along. Be of good cheer, however, because the DMCB says are three ways to turn this to your advantage.

No Choice

1. It's hard to underestimate St. Berwick's standing in the healthcare community. Don't be fooled by their faux-cooperation with the President, who is holding them hostage with the repugnant SGR threat and back-room deals. They don't like the Democrats but, if you block the nomination, they will be again reminded how little they like you.

2. You're trapped. Dr. Berwick's tireless advocacy on behalf of consumers is a David vs. Goliath story that will used by Mr. Axelrod et al to portray you as being on the wrong side of history. While letting the nomination go though may end up making you look feeble, the political calculus suggests you need to take the lesser of two evils.

3. The Medicare Constituency. Most Americans couldn't care less about the filibustering or recess appointment of nominees for offices like the Under Vice-Secretary for Budgetary, Fiscal and Dress-Code Affairs at the Office for Import and Lavatory Safety and Integrity in the Deparment of Commerce. In fact, we think it might actually save money. Medicare, however, is different. Blocking a CMS Administrator may needlessly provoke the seniors who are paying attention.

Turn this to your advantage by.....

1. Being Clinonesque. Recall how your nemesis co-opted your ideas when "he took the center?" While Dr. Berwick is by no means a centrist (more on that below), announcing that Dr. Berwick's selection for CMS Administrator fits with your vision for America will help you regain the center. Mr. Obama will not be helped when you publicly congratulate him and his advisors for finally making a selection that fits with your conservative principles.

2. Considering it as a non-event? CMS is a huge bureaucracy and, thanks to the passage of health reform, has an impossibly unwieldy mandate. On top of that, Dr. Berwick has little experience in health insurance and will have an imperial boss. While the last confirmed CMS Adminstrator showed how powerful the office can be, it's possible that kicking Dr. Berwick upstairs into CMS bureaucracy will dilute any negative impact he might have. The DMCB doesnt think so, because it is......

3. Banking on Dr. Berwick being a greater long-term risk for the Administration. The DMCB says this with only the greatest respect. but there must be a reason why he had to start his own not-for-profit. Don't be fooled by the left's elitist ardor for him: this is an apolitical extremist maverick that is fed up with many of the same dysfunctions in the health system that also vex the Republicans. With his ascent into the head office at CMS, Dr. Berwick will undoubtedly discover much of the truth behind the The Gipper's famous quote. When he does, the DMCB suspects he'll be a bigger headache for his handlers than for you.

In fact, the DMCB thinks it's not unreasonable to believe that if we had a Republican Administration and majorities in both Houses of Congress, you could have just as easily nominated Dr. Berwick to the irritation of your Democratic opponents. Comfort yourselves by pretending it is so and cheer him on.

Oh, one more thing. Last but not least, politics aside, Dr. Berwick simply represents a right thing to for Medicare and Medicaid beneficiaries. If he lives up to his potential, we'll all be better off for it.

Sincerely yours,

The Disease Management Care Blog

*Hat Tip to Maggie's HealthBeatBlog

The Latest Health Wonk Review is Up!

If you think health reform is over, you're mistaken. While passage of 'The Bill' makes great grist for the blog mill, the good and the bad of health reform will continue to be debated in the midterm elections and there are trillions of words of regulatory language to be written. And what better place to learn more about this than the latest Health Wonk Review, hosted by Rich Elmore's Healthcare Technology News? Check it out!