joelhaugen

What needs to be tackled in 2011?

JHaugen — Tue, 11 Jan 2011 14:19:24 +0000

As we within the Healthcare IT industry drive what needs to be tackled in 2011, there are numerous articles, reports and discussions around the top items to focus on in the coming year. I found one succinct article that does a nice job of articulating the top 6 items.

PwC lays out what their top six issues are:

#1: Booming business in health information technology
#2: Gearing up to redefine health insurance: From MLRs to insurance exchanges
#3: ACOs: Is this the next big thing or not?
#4: Nowhere else to cost shift: Consumers could continue to reduce utilization
#5: M&A: Deals will bond the familiar and unfamiliar as organizations look to fill strategic gaps
#6: Follow-me healthcare: Patients look to health organizations that are always on

While I commend PwC for truly tackling the major items, I do think there is one underlying item that was missed. Truth in transparency. While healthcare consumers are dealing with the cost shift and while payers are working to establish the strongest network with the highest quality of physicians, much of this is down behind the scenes with little shared. Consumers need to be equipped with transparency in pricing. How quality is measured needs to be transparent and shared with the consumers. This will lead to a more educated consumer in how and where their dollars are spent in 2011.

Any that you think should be added?

Client Feedback

JHaugen — Thu, 21 Oct 2010 04:59:00 +0000

I have the opportunity this week to join one my client’s at their user conference. It is amazing to hear direct feedback from the ultimate recipients of the work you have completed. It is equally interested in hearing where you may have missed the mark, where you hit the nail on the head and what their thoughts are on your next steps.

All too often organizations assume they know what members/clients/users want. Sometimes they are right and they are ahead of the curve. These visionaries are unique in the industry and differentiate themselves (Facebook’s News Feed, Google’s Instant Search, etc.). Others see where these stakeholders need and eventually will go but they are not quite ready to get there (Google Wave or Google Health among others).

The question becomes where is the sweet spot and how do we get there? This is a question many healthcare solution providers are pondering. My recommendation is you start not just by listening to your membership but witnessing their experience, documenting their struggles and seeing first hand what isn’t working for them. Start there and you’ll be headed in the right direction.

What are our Internet rights?

JHaugen — Thu, 09 Sep 2010 16:17:29 +0000

There was an interesting article written several months ago by Jeff Jarvis. Jeff is a commentator on a new podcast I began to follow called This Week In Google (TWIG). With the recent discussions around Net Neutrality, I worked back through some of his blog and found his proposed “Bill of Rights in Cyberspace.” Here is his description of what his attempt was:

This Bill of Rights attempts to establish the fundamental freedoms of our internet that must be protected against abridgment by governments, companies, institutions, criminals, subverters, or mobs. I suggest in my column that in its confrontation with China, Google is acting as the ambassador for the internet to the old world under its own (rediscovered) principles. So we would be wise to establish our principles. I ask the column’s readers to come to this post to suggest and discuss articles.

One of the most interesting points he raises is around who controls/owns your data. His assumption is it should be you but it raises questions around around access, copyright and portability. Interesting read.

Take a look: “A Bill of Rights in Cyberspace” by Jeff Jarvis.

Defensive medicine costs less money than physicians think

JHaugen — Tue, 07 Sep 2010 13:27:12 +0000

This was originally posted on KevinMD.com by JHaugen. Please Click Here for original post.

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Very interesting article and commentary. While I have been of the thought that tort reform would save significant dollars in the healthcare debate, its impact may not be as profound.

by Kevin Pho, MD

Nothing polarizes the heath care debate more than defensive medicine. A recent study from Health Affairs will only add more fuel to the fire.

Here’s what I wrote a couple of years ago in USA Today: “When you consider that rampant testing is a major driver of escalating health care dollars, addressing defensive medicine should be a primary goal of cost containment.”

Is that still true?

Well, yes and no.

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No comment | Tags: Malpractice | Category: Malpractice

HSA-compatible high deductible health plan advantages

JHaugen — Wed, 02 Jun 2010 19:10:02 +0000

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I count myself as one of the people who struggled to get my head around an HSA. The industry still struggles with the transparency necessary to make it completely successful but its getting there.

by Ray Carlson

With so many health insurance consumers familiar with standard “PPO” or Preferred Provider Organization health plans that feature lower annual deductibles, the HSA-compatible health plan might be getting overlooked.

These same consumers who – because of the downturn in the economy and subsequent job loss – are now shopping for, or considering shopping for, a new individual or family health plan might gravitate towards a PPO that features the lower deductibles they are both familiar and comfortable with from past experience as a member of a group health plan.

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8 comments | Tags: Health reform, Patient | Category: Health policy and politics

Primary care doctors are saying farewell

JHaugen — Wed, 14 Apr 2010 20:01:25 +0000

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Interesting impact on the Consumer-Driven Health Care. What this makes clear is every solution has ramifications to patients, doctors and payers.

by Aldebra Schroll, MD

It has been three months since I closed the door on my primary care office for the last time. It was with a heavy heart that I said goodbye to the many patients I cared for over the last six years. I am the fourth physician to leave the practice in as many years.

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No comment | Tags: Primary care | Category: Primary care

Customer Disservice: Health Care #FAILs again and again

JHaugen — Wed, 07 Apr 2010 14:04:15 +0000

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One of the areas we hear over and over again in trying to solve our health care situation is transparency of cost for our consumers. This is a great illustration of the challenge.

Disservice (dĭs-sûr’vĭs)

A harmful action; an injury
An act that is not just

Our health care system is completely devoid of customer service. It is pathetic.

I took my son to have a simple tympanostomy (ear tubes) procedure this morning. I show up, sign in and take my seat amidsts the throngs of people in the surgical center waiting room. I brought my laptop and some reading materials to bunker down for the long wait ahead.

20 minutes later I get called up front to sign some additional paperwork. Instead of being greeted, 15 documents each complete with a full page of legalese is shoved my way regarding various aspects of responsibility, payment, agreement, arbitration, and host of other information. The grumpy lady has clearly done this a thousand times and she has absolutely no tolerance for any of my questions. She paries my first few skillfully, but I don’t let her blunt my questions regarding the finances.

She shows me that the facility is charging me $5,600 but that fee has been reduced by the insurance to $1,799. This is an all in fee for the facility only (includes staff, equipment, monitoring, etc) and does not include fees charged by the physician and the anesthesiologist. I ask what those charges will be (I already knew ahead of time), but she says she is not responsible for their charges and that I would have to speak with those providers about that. I start asking her why they don’t bundle everything into one price so I can compare across various combinations of facilities and providers. She has no idea what I am talking about and ends the conversation by giving me their phone numbers. Take your seat Mister, how dare you ask a question about pricing comes across clearly as she stares me down to my seat.

I immediately pick up the phone and talk to the physician office. After about 10 minutes, I finally get the billing person who is able to provide me the CPT code (69436) and Zip Code (92691) as well as what they charge for procedure ($345). I tell here I am not interested in her price because it is irrelevant and that Blue Cross has already dictated the price that you are going to get. A little defensive, she then relays to me the the administratively set Blue Cross reimbursement that has been dictated to this particular physician ($208.08). I then ask her about bundling of services and created an Ear Tube product that would include all the components so that I can compare across facilities and providers. She has no idea what I am talking about. I give her the hamburger example (I don’t get separate receipts for tomoatoes, buns, and burger – I get a single price for the thing I want – the complete hamburger). I refer her to Carol.com as an example and she thinks this sounds like a good idea. When I ask why they don’t do it now that she understands, she says that she doesn’t think the physicians would ever agree to work in that way. She tells me she will pass this along to the physicians, and with a laugh that indicates that will never happen, we end the call.

Next, I call the anesthesiologist group. First the lady attempts to tell me she can’t give the pricing because it is a HIPAA violation. I quickly disabuse her of her ignorance and get her manager on the phone. Anesthesia is unique in all of medicine because anesthesiologist charge for their time in increments called units (typically 15 minutes). So they get a “set up” fee and a “time-based” fee for their services, both in terms of units. So I ask them what their per unit charge is and the manager tells me that it is proprietary information. I call him out on it and say that pricing information is not proprietary, perhaps his costs structure is, but he has a duty to tell me the cost of the service I am about to engage him in. I am pretty frothy at this point and really lay into this guy. He still refuses to tell me his proprietary, negotiated per unit rate with Blue Cross but relents on giving me the overall price. He then passes me along to someone else who looks up in their database and tells me the cost will be either $300 or $360 for the procedure for either a 15 minute or 30 minute anesthesia time. So, knowing they go in 15 minute unit increments, I can tell that there is either 5 or 6 units involved, and therefore a $60 / unit price. So, full pricing is 4 units “setup” and either 1 or 2 units for their time. So much for your proprietary formula and negotiated pricing. $60 bucks every 15 minutes or $240/hour for anesthesiologist time. Thats mid-tier lawyer rates for South Orange County but interesting in how at least this type of physician’s time might be valued by insurance companies.

So finally, after about 45 minutes of phone time, by someone who knows the ins and outs, all the secret handshakes and covert codes, and most aspects of healthcare financing, I am able to arrive at an all in price for a very simple surgical procedures:

Tympanostomy
CPT Code: 69436
Zip Code: 92691
Facility Fee: $1,699.00
Surgeon Fee: $208.08
Anesethsiologist Fee: $360.00
TOTAL: $2,267.08

This is great to know the price information for my selected combination of facility and physicians. However, I have no information on outcomes achieved, safety rates, customer satisfaction, or other metrics to determine if I would not be better off with a different combination of facilities and physicians. What do you think the response was when I attempted to ask about health outcomes for my physician?

Pin drop, anyone?

This is not just another rant, but meant to highlight that the very basic, fundamental courtesies expected during a consumer transaction are all but non-existent in health care. Simple things like getting pricing information, like getting helpful customer service, like understanding what you are buying, and the quality features that attract you to purchase something in the first place. Health care should be one area where customer service is impeccable. I believe you begin to see “brands” emerge that get this, invest in it, and deliver it consistently over time. Looking forward to the ongoing retailization of health care – it truly needs it.

Rethinking Clinical Documentation

JHaugen — Tue, 06 Apr 2010 17:15:27 +0000

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Want to know how to radically change the health care industry? This guy gets it.

Over the past 5 years, I worked with HITSP and the HIT Standards Committee to select standards for exchanging clinical summaries. But what exactly is a clinical summary?

There is common agreement about the need to exchange codified, structured data for problem lists, medications, allergies, and labs.

However, what is the role of unstructured clinical documentation text?

Some have suggested that unstructured text is hard to navigate, at times repetitious, and challenging for computers to interpret.

I believe the exchange of free text notes such as operative reports, history&physicals, ED charts, consult notes, and discharge summaries is very important.

Consider this example.

A 40 year male with no family history of heart disease presents to the ED at 3am with a chief complaint of chest pain and left arm numbness. The EKG is normal, a stress test is normal, labs are normal, and a cardiology consult is completed. The patient is discharged on H2 blockers with a diagnosis of gastritis.

A summary which only includes a problem and med list may state a Problem List of Gastritis and a Medication List of Prilosec OTC.

When the patient next visits an Emergency Department, no one will know about the cardiology consult, the differential diagnosis considered, and the thought process that led to the diagnosis of gastritis to explain the chest pain.

An entire workup will be started from scratch.

There is a great article in the March 25, 2010 of the New England Journal of Medicine “Can Electronic Clinical Documentation Help Prevent Diagnostic Errors?” by Gordon D. Schiff, M.D., and David W. Bates, M.D. in which the authors note:

“Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient’s history and making assessments, and notes should be designed to include discussion of uncertainties.”

I agree.

Notes should be included as part of clinical summaries.

However, we should do all we can to improve the quality of notes.

Over the next year, we hope to try a radically different approach to clinical documentation at BIDMC which we think will leverage all the strengths of the full text note as described by Drs. Schiff and Bates without the repetition and navigation issues.

Today’s inpatient charges are a collection of SOAP notes written by the medical student, intern, resident, fellow, attending, and consultants largely for billing and medico-legal purposes.

What if the chart was recast as a communication vehicle for the entire team that summarized the day’s events and collective wisdom on next steps?

Our answer – a daily Wiki entry for each patient authored by the entire team and signed/locked by the attending at the end of each day.

How will this work?

Think of it as a private wikipedia build inside our clinical systems and hosted in our data center.

Each member of the care team will use our Team Census application to view the list of patients for whom the team is responsible.

Clicking on any patient name will bring up the daily Wiki. Each member can add documentation, revise existing text, and leverage the work of others on the team until the attending makes the final edits and signs/locks the day’s documentation. Just like a wiki, a complete journal shows all all edits/changes/deletes, so no information is lost. Importantly the day’s wiki entry has one physical exam, one assessment, and one plan – not 17 repetitive entries saying the same thing that often appears in today’s paper charts.

The idea of a daily wiki entry for each patient creates highly readable succinct documentation authored by the entire team with a medical legal record of the process that was used to generate it. It’s a perfect single document to share with the referring clinician and the patient/patient’s family.

After our initial pilot work, I’m guessing we’ll also engage the patient and families to add to the Wiki, reflecting the shared decision making between the team, the patient, and the patient’s family.

We’re in the design stage now, but I’ll report back on how it goes.

A daily patient Wiki as unified clinical documentation, exchanged with the team, other providers, and the patient. I bet even the free-text naysayers will agree that this should be part of the clinical summary!

The iPad goes live at BIDMC

JHaugen — Tue, 06 Apr 2010 17:15:19 +0000

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Some were wondering on ways to leverage the iPad beyond the super consumer. Here is an example of use at Providers.

The following is a guest post from Dr. Larry Nathanson MD, who leads BIDMC’s Emergency Medicine Informatics efforts. (Note that the photo contains only fictitious patient names):

I had been anxiously awaiting the arrival of my iPad –This is the form factor I have been asking (begging) of all the vendors for years. I’m very happy to say that it appears to be living up to my high expectations.

The screen is gorgeous. It’s very clear and bright, I had no trouble seeing the screen in bright outdoor light. The machine seems extremely responsive — it reacts immediately to user input and the browser renders pages as fast as my laptop. In landscape mode, its surprisingly easy to type on the on screen keyboard. I wouldn’t call it “touch typing” but the autocorrection fixes almost all of the typos that are introduced when I just let my fingers fly. It turns out to be much easier to enter data than I expected, and in fact this entire review was typed completely on my iPad.

I tested it today during my shift in the ER. Initial tests with our clinical applications went amazingly well. The ED dashboard, WebOMR and Provider Order Entry all appear to function well without modification. The popup blocker does try to get in the way of new windows, but it’s a only a minor annoyance. The EKGs look better onscreen than on paper. It was great having all of the clinical information right at the bedside to discuss with the patient. The only problem was that the increase in efficiency was offset by the patients and family who wanted to gawk at it.

The battery life is one of the most astounding features. I don’t know how they did it but the claimed 10 hour run time might actually be more accurate than the usual inflated claims that I’m used to for mobile devices. The device arrived at full charge and after testing all day and leaving it playing several full length movies the battery still had 40% left. This could easily make it through an entire ER shift on one charge, eliminating the need for hot swappable batteries.

I am a little concerned about how well it will hold up in a clinical environment, particularly the abuse it will get in the ER. The case is very smooth and the rounded bottom makes it easy for it to slide out of a hand or off a table. I don’t get the feeling it will be as forgiving of drops as some better padded (albeit heavier) devices. I’m hoping someone will create a case that has a hand strap on the back (like the Panasonic MCA has).

One problem that plagues all tablets that I’ve used clinically is the difficulty entering strong passwords. The onscreen keyboards of mobile devices makes it much harder to quickly enter numbers, symbols and mixed case and is, in my opinion, one of the biggest barriers to medical tablet adoption. A biometric, or other creative way of addressing this will likely be needed.

From a consumer electronics point of view I’m also impressed. When just web surfing or watching video I do like that I can just lean back and hold the iPad as I would a book or magazine. My wife found that she preferred the iPad Kindle program to the actual Kindle device. (That bodes poorly for my plans to develop software on it!)

In summary, I’m very excited — the form factor is close to perfect and it’s robust enough to keep up with a busy ER. I think this is one of the most promising developments in medical mobile computing in a long time.

There is one major drawback however: Now my iPhone seems slow and inadequate!

Sent from my iPad

The future of Joel

JHaugen — Tue, 06 Apr 2010 15:02:53 +0000

As Google Buzz rolled out and I made the switch to an Android phone (Motorola Droid), I struggled with where to invest my time and social media. I went through a previous effort to determine where to update virtually. Here is what it has come down to for me personally.

1. LinkedIn: This is purely my professional space. I do not plan on updating status or other personal information on the site. This is publicly searchable and I engage here with other professionals in the health care and consulting industries.

2. Twitter: While I still am not enamored with Twitter I see that it has become a viable social networking solution. My only plan here is to update specific Buzz posts as well as any posts on this blog here. It will hopefully drive traffic to this site versus the other way around.

3. Facebook: This is my purely personal space. While I have connected with a select few business professionals here, I may scale back. Here I update with family pictures, notes on events, connect with formal classmates. Folks..pretty sure Facebook is here to stay.

4. Buzz: This will be a mix between personal and professional. The beauty of Google is its ease of sorting between showing personal information to friends and professional information to the public. I plan to update some buzz posts on to twitter but this is still a wait-and-see product for me.

5. Ning: I have a variety of Ning Networks (Church, Blazeman Warrior, I Am Tri) that I engage for social networking with specific groups. Its group functions are currently superior to what is offered on Facebook but maybe that will be taken over some day?

5. Abandoned Services: Here are the list I have almost completely abandoned for one reason or another:
- MySpace
- Orkut
- Message Boards
- Chat Rooms

6. Services I have no desire to use:
- Foursquare
- Windows Live Spaces
- MyLife
-Friendster

Thoughts from the readers here? Which services to you use and which ones do you find most useful (both personally and professionally).