guest blogging!

I was honoured to be asked to be this week's guest blogger for the Ottawa Regional Cancer Foundation (the folks who organized my recent makeover).

Let me know what you think. I even like the photo they're using! 

How Did the Disease Management Care Blog Do With Its Predictions for 2010?

Calling Dr. Blumenthal's faulty augury to task is one thing, but applying the same exacting standard to itself is another. While other bloggers are making predictions for the coming year, only the brave Disease Management Care Blog dons a retrospectivescope to conduct a post-mortem on its own soothsaying and ask: how did the Disease Management Care Blog do with it's ten predictions for 2010?

This is what the prescient DMCB foretold:

1. Things are not going to change much. When the sun goes up, insurance rates will increase, busts for Medicare fraud with continue, the academic elite will continue to publish clueless articles and the number of uninsured will remain stubbornly high.

The DMCB modestly suggests it nailed this one. Why else would Ms. Sebelius recast herself as a cost-fighting poly-state insurance commissioner, stuff like this is no longer suitable as front page news, the staid New England Journal is unable to stop itself from saying the Feds can do no wrong while the pro-reform Kaiser Health News would let this see the light of day?

2. The battle has only just begun. Whatever bill gets passed, look forward to continuing mortal combat over the regulations that shape the real authority when it comes to the Fed’s foray into its new vistas of health care.

While the DMCB had it right on the regulations and mortal combat, it didn't predict the scorched earth warfare of "repeal and replace," defunding, and the prospect of hostile hearings spiced with a level of partisanship that includes dancing on the graves of your enemies.

3. Disease management will continue to thrive in its niche. Or rather multiple niches, offering a cafeteria-style suite of low cost and mostly remote care management, prevention and wellness offerings for commercial insurers and self-insured companies. Prevention and wellness will lead the way because most insurers and employers want it but few know how to deliver it. They already have the disease management and will want to keep it.

Here's an example of what one insurer is doing, which is what greater than 95% of all insurers are doing. The Care Continuum Alliance is still going strong and had a 2010 blockbuster meeting. Even the skeptical Vince Kuraitis had nice things to say about disease management.

4. Registries will emerge as a source of new medical knowledge. The rise of terrabyte servers containing all (and the DMCB means all) demographic, claims and medical data will enable startling insights about correlations that were impossible last year and will become routine the next year.

Maybe not routine, but the Institute of Medicine would still agree. The inability to get at the unorganized and largely text data contained within the EHR is one factor that got in the way of succesful multi-source registry development. The DMCB underestimated the EHR's ability to gum this up.

5. The line between insuring and providing will continue to blur. Insurers will provide care services that could be done by the providers in their networks, such as case management and home monitoring. In the meantime, providers will assume partial levels of risk that put them on the financial hook if claims expense exceeds target thresholds.

The DMCB nailed that one too. It's called Accountable Care Organizations and shared risk. Care to predict what the DMCB will have to say about the ability of provider organizations to manage risk? Stay tuned!

6. The advent of PCMH Ver 2.0 or rather Ver 2.a-z. The PCMH will remain more of a concept than any implementable or operational model of care. As the return-on-investment bloom comes off this rose in the many national pilots, its architects will appropriately scramble to tweak the model, perhaps by adopting some of the lessons from disease management.

As of this writing, the DMCB is still unaware of any good studies that conclusively demonstrate that a fully configured PCMH consistently, meaningfully and statistically reduces health care costs. That may be one reason why smarter states are looking at shared service designs that borrow heavily from modern versions of disease management.

7. Social media will expand. Docs will ‘tweet’ each other in hospitals, insurers will push all sorts of web-enabled messaging and the disease management industry will find ever novel ways to combine industrial psychology with cell phone communications.

Well, maybe this has a way to go before it becomes routine, but that didn't stop the enthusiastic DMCB from increasing the concept's visibility.

8. Little to no insurer consolidation. Barring the usual short-term hiccups, the fact that it will be a crime to not buy what the health insurers are selling will give all insurers some breathing room.

The DMCB got this right. As of this writing, profit margins are holding steady and only Dr. Renault would be shocked over the insurance industry's silence over the constitutionality of the ACA's insurance mandate.

9. Republican allegations of the unconstitutionality of health reform bill will have legs. Speaking of which, the DMCB suspects there may be an outside chance that the courts will get in the way of a bill that requires U.S. citizens to buy insurance.

While health reform supporters were initially tut-tuting this DMCB scenario, what better evidence of its credibility than Kaiser Health News' publication of this?

10. The Electronic Health Record (EHR) will continue to disappoint.

It's too early to tell if the HITECH luster of tens of thousands of dollars will finally push docs past the digital divide and into buying EHRs, but there is no shortage of illuminating papers like this and this and this despite Dr. Blumenthal's serene confidence.

Improving The Health Law In 2011: Realistic Ways To Reach Bipartisan Compromise

This post originally appeared at Kaiser Health News.The new health care law can be changed in ways that would make it acceptable to a bipartisan majority in the new Congress -- and, therefore, to the American people. But to find this elusive middle ground requires consideration of the competing philosophies at the heart of the nation's political divisions regarding this sweeping measure.For

why i love twitter

People often ask what it is I love about Twitter. I tell them how useful it is to get advice and share information - about resources, local business, good things to read, etc. I also love the quick exchanges of ideas, the wit and the humour.

Twitter is fun.

And last week, I found a new reason to love Twitter. Trading. Check out the two exchanges below in which I gained a Canada Reads book from the author and the best quiche that I've ever eaten. Read each conversation from the bottom up (sorry it's so small and blurry - click on each image to make it larger and much easier to read).

Postcript: When I couldn't figure out how to capture and embed Twitter conversations, I turned to Twitter for help. I got several great responses and, in the end a friend who I met via LibraryThing and got to know on Twitter, actually the capturing forming and sent it to me as an email.

The blurriness is my fault but it's thanks to her I got it done.

I love social media.

Here's a Whopper of a Prediction from National Coordinator Blumenthal About the EHR That Hasn't Quite Worked Out

'Tis the month when journalists, pundits, bloggers, wonks and the other denizens of the commentariat examine past predictions and make new ones. So, when a new research article on the merits of the electronic health record (EHR) came out, the Disease Management Care Blog couldn't help but recall this whopper of a forecast:

"The widespread use of EHRs in the United States is inevitable. EHRs will improve caregivers' decisions and patients' outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers. Hundreds of thousands of physicians have already seen these benefits in their clinical practice."

That's from national coordinator for health information technology David Blumenthal writing in an August 2010 issue of the New England Journal. The Disease Management Care Blog can forgive him: as a Czar presiding over our national medicaltechnologic complex, cheerful blather is part of the job description and part of the Washington m.o.

Facts, on the other hand, are a different matter. The latest example that EHR adoption is not the Utopian panacea that the HIT weenies would have you believe is this RAND article authored by Spencer Jones, John Adams, Eric Schneider, Jeanne Ringel and Elizabeth McGlynn (yes, THAT Elizabeth McGlynn) titled "Electronic Health Record Adoption and Quality Improvement in US Hospitals."

The authors cross-referenced survey results (including having a basic or more advanced EHR system in place) from the Health Information and Management Systems Society (HIMSS) with the quality data from the American Hospital Association's Hospital Compare. The hospitals used for the study were the 3971 nonfederal general acute care hospitals. The quality measures assessed treatment of a heart attack, heart failure and pneumonia. If Dr. Blumenthal's above bluster is correct, more EHR in each of these US hospitals should translate into clinically and statistically significant increased quality, right?

Not exactly. From 2004 to 2007, there were 4-16 point performance increases in treatment of heart attack, heart failure and pneumonia in the 62% of U.S. hospitals that didn't have an EHR in place. Compared to these "no EHR" hospitals, there was no difference in the hospitals with a basic EHR or an advanced EHR - with one exception (treatment of heart failure was better among those with a basic EHR).

But wait, it gets worse. Heart attack and heart failure quality scores statistically improved less among hospitals that adopted an advanced EHR compared to hospitals that did not adopt an EHR. What's more, heart attack and heart failure quality scores improved significantly less in hospitals that upgraded their basic EHR compared with hospitals that maintained their basic EHR.

To their credit and to Dr. Blumenthal's minions' relief, the authors point out that their study was short term, was limited to a narrow set of quality measures in select hospitals; it didn't capture all possible quality measures in all health care settings. In addition, the authors note that there's a difference between having an EHR and fully as well as correctly implementing it. It's possible that a well implemented EHR does lead to real quality. It's also possible that measures of quality in heart attack and pneumonia may have reached their ceiling, making it more difficult to detect any meaningful changes one way or another. Last but not least, the authors speculated that the considerable work of installing an EHR distracted the hospitals over the short-term from continuing to work in quality improvement and that there will be a pay-off in the coming years.

Despite these limitations, the results should give pause to policymakers that have bought into the notion that EHRs will "inevitably" fix all that ails U.S. health care. In addition, this study may warn us that complicated systems lead to complicated problems; when it comes to EHRs, the truth may be that less (like computerized physician order entry or medications, lab review) is more. EHRs may eventually improve caregivers' decisions and patients' outcomes, but this study shows patients have yet to consistently experience the benefits of this technology for heart attack, heart failure and pneumonia. The truth is that there are hundreds of thousands of physicians have not seen these benefits in their clinical practice.

Dr. Blumenthal may wish to reconsult with his crystal ball.

The Spin in HHS Secretary Sebelius' Year In Review Video

In her end-of-year-in-review video below, Secretary Sebelius extols the many accomplishments of HHS. As the Disease Management Care Blog has come to expect of our national leadership, this latest Affordable Care Act (ACA) commentary is laced with spin. Just repeatedly SAYING stuff about the ACA's impact on small businesses, health information technology, community health centers and anti-fraud efforts doesn't necessarily mean that its true, or that our Republic is getting our money's worth in government or leadership.

Some of the counter-arguments below are just partisan, but there is enough truth in all of them to make the DMCB hope that Ms. Sebelius' 2011 end-of-the-year review has more ballast and less bombast.

To wit:

Tax credits to help small businesses buying health insurance. "The value of the benefit declines quickly, so many business owners in high-cost states get no tax break, and those elsewhere often say the credit is too small to make much of a difference."

National standards for health information technology. "Among themes of cost savings, workflow efficiency, and quality, the only benefits to be reliably documented were those regarding efficiency, including improved access to test results and other data from outside the practice and decreased staff time for handling referrals and claims processing. Barriers included cost, privacy and liability concerns, organizational characteristics, and technical barriers. A positive return on investment has not been documented." (Assuming national standards are eventually shown to be effective, the ACA really sets up a process to define those standards which remain a controversial work in progress.)

Community Health Centers. "Although most people probably imagine that community health centers are an inexpensive way to provide health care to poor people, the Colorado experience suggests otherwise. Medicaid payments to the FQHCs are far above Medicaid rates for private physicians and clinics."

Tough Medicare anti-fraud efforts: "Congress has been increasing appropriations for the anti-fraud program that’s jointly run by Justice and HHS. Administration leaders promote the value of a special fraud prevention and enforcement task force known as HEAT. The health care law enacted this year dedicates even more federal dollars to these efforts. Yet, despite the record number of defendants, actual criminal convictions for health care fraud violations are flat resulting in a falling conviction rate" (After so many years or promises that we really REALLY mean it this time, can we prosecute our way out of the problem?)

To give credit where credit is due on the non ACA issues, the DMCB finds Ms. Sebelius was more truthful:

Dramatic changes in cigarette packaging. The link to the evidence says the FDA is getting this one right thanks to it's expanded powers under the recently passed Family Smoking Prevention and Tobacco Control Act. It remains to be seen if this will translate into the outcome that counts: declines in the national rate of tobacco use.

Childhood nutrition in public schools: The DMCB says Ms. Obama's Healthy, Hunger-Free Kids Act of 2010 is evidence-based, but let's see if it really makes any difference and leads to less childhood obesity: it was only just passed.

Emergency response efforts for the "Swine Flu" epidemic: The DMCB notes that CDC's expertise was outstanding but public support is not a given.

happy new year!

In 2010, I:

Made soup.

Started running again and kept at it (in fact, I did the Resolution Run 5K last night before breaking into the wine and fondue).

Started editing my novel. It doesn't really have an ending yet but I don't totally hate what I've written, so that's a start.

Found a writing buddy.

Knit a lot of dish cloths.

Played lots of Scrabble/Lexulous

Had my heartbroken when my dog died.

Went to Florida in the in the summer to get away from a heat wave.

Spent some quality time with girlfriends.

Organized a team for the Run for the Cure, called No Pink for Profit. By run day, we were more than 40 women and we raised more than $20,000.

Fell in love with Twitter.

Finally got a smart phone.

Learned that grief is not a linear process.

Spent a lot of time thinking about community, friends and family. I am very, very lucky.

For 2011, I wish us all love, peace, good health and many wonderful adventures.