Open Personalized Health Informatics

[Jose's Notes]

This article points to a significant opportunity to leverage tele-health technologies to help manage patients with chronic diseases.

Along those lines, the Chronic Care Model (“CCM”) is a robust, proven mechanism to improve outcomes for patients with chronic care illnesses.

I’ve developed a proposal for a technology-rich platform to enhance and extend the CCM through the use of patient-controlled mobile phones. We call this “mCCM”. mCCM is envisioned as a platform to facilitate patient self-management when dealing with chronic conditions.

Tele-health systems are sometimes designed from a technological perspective. OpenPHI proposes to use an existing care model (CCM) as the core and then to wrap the most effective mobile technology elements around the patient’s point of view.

See http://www.openphi.com/files/OpenPHI_Mobile_Chronic_Care_Model.pdf for the full proposal.

Comments welcome.

[/]

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http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2009.0474

Health Affairs, doi: 10.1377/hlthaff.2009.0474
(Published online February 18, 2010)
(c) 2010 by Project HOPE

Chronic Conditions Account For Rise In Medicare Spending From 1987 To 2006

Kenneth E. Thorpe1,*, Lydia L. Ogden2 and Katya Galactionova3

1 Kenneth E. Thorpe (kthorpe{at}sph.emory.edu) is the Robert W. Woodruff Professor and Chair of the Department of Health Policy and Management, Rollins School of Public Health, Emory University, in Atlanta, Georgia.
2 Lydia L. Ogden is on assignment from the Centers for Disease Control and Prevention and is currently chief of staff for the Center for Entitlement Reform and a doctoral candidate in health services research and health policy at the Rollins School of Public Health.
3 Katya Galactionova is a research analyst at the Department of Health Policy and Management, Rollins School of Public Health.

*Corresponding author

Medicare beneficiaries’ medical needs, and where beneficiaries undergo treatment, have changed dramatically over the past two decades. Twenty years ago, most spending growth was linked to intensive inpatient (hospital) services, chiefly for heart disease. Recently, much of the growth has been attributable to chronic conditions such as diabetes, arthritis, hypertension, and kidney disease. These conditions are chiefly treated not in hospitals but in outpatient settings and by patients at home with prescription drugs. Health reform must address changed health needs through evidence-based community prevention, care coordination, and support for patient self-management.

Key Words: Medicare – Health Spending – Chronic Care – Health Reform

Full text freely available at http://content.healthaffairs.org/cgi/content/full/hlthaff.2009.0474v1

Slowing the rise in health spending is among the nation’s top health policy priorities. Absent policy change, the Congressional Budget Office (CBO) estimates that Medicare spending will grow at an average of 7 percent each year from 2010 to 2018, rising to $879 billion annually and 4 percent of gross domestic product (GDP). The rate of growth of Medicare spending over the long term is predicted to exceed the rate of growth in federal revenues and the overall economy. As a result, much academic and political attention has focused on reforming Medicare as imperative for restraining spending increases.

Many Medicare reform proposals designed to slow the growth in spending would redirect costs from the government to others, such as enrollees and participating providers. The slowdown would be accomplished by reducing provider payments, increasing the age of Medicare eligibility, implementing means testing for Medicare, restricting coverage as with the Part D “doughnut hole,” and increasing copayments and deductibles. These approaches are unlikely to produce long-term reductions because they fail to address the key factors driving the rise in health care spending overall and in Medicare spending, particularly for chronic diseases. Understanding these facts is essential to reaching the right policy solutions.

Common approaches to tracking trends in health spending analyze changes in use (who is seeking care and for what), payment source (who pays), and provider (who gets paid). Analyses also examine trends in the inputs used to treat patients, such as rising rates of diagnostic imaging and treatment duration and intensity, as well as changes in the definition of treatable disease and targeted patient populations for medication therapy.

But cost-trend analysis by itself provides little insight into the ultimate causes of spending increases or the clinical characteristics of patients driving the rise in spending. And factors underlying the rise in treatment duration and intensity are not well understood across disease states.

We examined the changing clinical characteristics of Medicare patients that account for the rise in spending over the past twenty years, analyzing changes in the prevalence of treated disease, condition-specific spending, and sources of treatment in 1987, 1997, and 2006.

Much of the recent growth in spending among Medicare beneficiaries is attributable to rising spending on chronic conditions -specifically, diabetes and hypertension, both of which rose considerably in treated prevalence over the past two decades. Channels of spending for the most prevalent conditions have changed, too, with more spending for care provided in outpatient settings and for prescription drug therapy and less for inpatient care.

Our analysis did not disaggregate the component increases in spending that result from factors such as expanded treatment guidelines or innovative medical technology and therapies. Instead, we focused on changes in disease prevalence, changes in spending by disease, and changes in treatment locations as three important aspects of overall health outlays. Understanding these disease and care trends is critical to ensuring that health reform policy levers address the real drivers of current and anticipated health spending.

[Jose's Notes]

The use of Health IT systems, by the very nature of their intended use, has life-and-death implications. And healthcare-related information has a lifespan of dozens of years: you may not need to open that business-related spreadsheet again in the next 40 days, but as a 40-plus adult I still need access to my childhood vaccination records.

We should all be concerned if massive amounts of our tax dollars are wasted in proprietary software packages that are unsupported a few years from now (due to mergers, acquisitions, bankruptcy, etc.). It’s also worrisome if large numbers of patients’ medical information is locked in proprietary formats that become unreadable in 10 years.

It’s bad enough when the vendors of proprietary business software change their file format solely to force you to upgrade because they need a new revenue stream. But do we rally want these obnoxious business practices to control our future access to our family’s health information?

Therefore, buyers of health IT should demand that vendors:
* provide the source code of their software packages
* disclose their proprietary data formats
* provide tools to export data from the vendors’ system to industry-standard formats

[/]

http://huffpostfund.org/stories/2010/01/shopping-health-software-some-doctors-get-buyer%E2%80%99s-remorse

Shopping for Health Software, Some Doctors Get Buyer’s Remorse
By Emma Schwartz

Huffington Post Investigative Fund
Created 2010-01-29 16:55

Volatile Industry Prompts Calls for Oversight of Firms’ Financial Strength

Robert Cameron wasn’t much of a technology buff, but the orthopedic surgeon knew he wanted to get rid of all the paper in his nine-physician practice in Pensacola, Fla. So he bought an electronic medical records system from a California-based company called Acermed.

Cameron’s group spent more than $400,000 on the software, but the system still never fully worked and even confused patients’ scheduled visits, according to a lawsuit the doctors filed against the technology company in 2006. Acermed filed for bankruptcy in September 2007, complicating the doctors’ attempts to recover their expenses.

The effort to go digital “was a disaster,” Cameron says now.

Computerizing American medical records within five years is a key goal of federal health policymakers, who have committed to dispense billions of dollars in stimulus money to doctors and hospitals that make the transition in the coming years. Although the dispute between the Florida doctors and Acermed is an extreme example of what can go wrong during a move to digital systems, it highlights some of the challenges for individual medical practices making the conversion.

“This is a very volatile industry,” said Steven Lazarus, president of consulting company Boundary Information Group. “Any product doctors buy could be bought or changed within two years.”

Federal officials hope that electronic medical records will help lower costs and improve health care quality. And while they acknowledge that the effort will be difficult, they say that any hurdles along the way will pay off through savings to the health care system and improved quality of care.

But there’s also concern that the government may not be doing enough to ensure that taxpayer money isn’t wasted on faulty systems.

What’s more, doctors often have little expertise in buying electronic health records, commonly called EHRs, and do not always know what questions to ask or what protections they should push for in their contracts, several industry consultants said in interviews.

“I’ve seen physicians buy EHRs where they’ve spent less time buying them than their house and car,” said Margret Amatayakul, a prominent health care information technology consultant, who has studied the market for more than 10 years.

In a marketplace full of eager sellers of technology -and some with limited track records- “there’s a lot of risk,” she said.

Hundreds of companies -big and small, new and old- sell health information technology but industry analysts expect a wave of consolidation in the market, creating uncertainty that certain products will stay in the marketplace or even if some vendors will survive. Amatayakul said she found that up to 70 percent of vendors moved in and out of the market in some years, through mergers, acquisitions or on occasion, bankruptcy.

Congress did not address the possibility that federal incentives could be spent on products from companies with shaky finances when it wrote the stimulus law setting aside billions of dollars for electronic health records.

But as government officials write the rules for distributing the stimulus money, there have been renewed calls for oversight. During testimony before a congressionally mandated advisory committee last summer, Sheldon Razin, chairman of Quality Systems, a large electronic medical record vendor, urged officials to “consider a review of company financials to include long-term viability,” according to his presentation document.

“We just think it’s an important issue that the government needs to consider,” said Steven Plochocki, who works with Razin as chief executive of Quality Systems. “Government can’t guarantee people will stay in business, but we think it’s an important element.”

The federal committee did not suggest any consideration of financial viability in their recommendations to David Blumenthal, national coordinator for health information technology. Paul Egerman, who chaired the group that heard Razin’s comments, acknowledged that financial viability was a concern, but said that the group was swayed by the recent experience of the financial industry.

“We had a fear that there’s a greater risk to hospitals and doctors from organizations that are too big than ones that are too small,” Egerman said. “We wanted to make it possible for innovation.” He said the committee believed that the centers the government plans to set up around the country to aid doctors in their purchases would include help on how to better evaluate companies’ financials.

Officials from another advisory group, the National Committee on Vital and Health Statistics, disagreed in a May report to Blumenthal.

“We’re starting a very exciting process that could change the landscape of health care, but the thing that will stop it quickly is if the doctors feel that they don’t have some good direction,” said Harry Reynolds, chair of the committee and a vice president with Blue Shield Blue Cross of North Carolina. “You’ve got to make sure that there’s a clear definition of viability.”

Although Blumenthal’s unit has no plans to review company financials at this time, it “will continue to examine the issue”, said Nicholas Papas, a spokesman for the Department of Health and Human Services.  “This is a complex matter,” he said.

Bankrupt Vendors

The Bush administration first set the goal of putting most Americans’ medical records online by 2015. By 2006, the industry had begun to receive some oversight through the Certification Commission for Healthcare Information Technology (CCHIT), a nonprofit organization contracted by the government to certify electronic health records.

The commission reviews whether companies’ products meet the operating standards they promise. It does not evaluate the firms’ financial viability, although since 2008 it has asked companies to voluntarily disclose their number of customers and how long they have been in business.

Mark Leavitt, chair of the certification commission, said evaluating the financial stability of a company poses many challenges. For example, he noted, even a big, financially successful company could decide to discontinue a software system that didn’t pan out. And merely certifying the firm’s financial strength could give doctors “a very misleading sense of security” about the future of the product they bought, he said.

Still, some doctors have complained that their practices have been hurt after purchasing certified software from a vendor that later went bankrupt.

Canada-based MedcomSoft, which received certification in 2006, declared bankruptcy two and a half years later. The year before, MedcomSoft began installing its software for some members of the 1,200-doctor Independent Physicians Network in Wisconsin. The company also agreed to build a database of the network’s patients and provide maintenance, but failed to do so, according to a 2008 lawsuit filed by the physicians’ group. That forced the doctors to pay outsiders to keep their system going, they alleged in court documents.

Four months after the doctors filed suit in November 2008, MedcomSoft’s attorney filed a motion to withdraw representation, stating that it appeared “neither Medcomsoft nor its parent corporation has any employees, officers, or directors.”

Not every client fared as the Wisconsin group did. Megan Peterson, a manager with medical billing company PBF Online, the Johnstown, Pa., company that bought Medcomsoft out of bankruptcy, said the successor firm had retained 85 percent of the original customers. “We’re a strong stable company and will continue to be that for our clients,” she said.

Nevertheless, the executive director of the Wisconsin physician network, Michael Repka, said: “It’s going to be considerable time and labor for [medical] practices that are going to switch to a new system.”

In another case, a Florida-based company, Dr. Notes, went bankrupt in 2007 after 57 liens were filed against the company, according to a tally by the South Florida Business Journal. Some doctors alleged they were locked out of their medical records or left saddled with hundreds of thousands of dollars in loan payments on hardware despite being promised by the company they would recoup the costs.

South Carolina-based First Choice Healthcare was one such company, which in 2005, won a $1.5-million judgment against Dr. Notes in state court. Since then, the health care provider has only collected $100,000, the company’s lawyer Andrew Schwartz.

“The doctors are left holding the bag,” Schwartz said.

A Fight Over Source Code

Cameron’s Florida doctors group, Gulf Coast Orthopaedic Specialists, looked at half a dozen companies before signing with Acermed in April 2005. After installing the first part of the system, they alleged in their lawsuit, the scheduling software “malfunctioned causing patient appointment[s] to disappear.” Also, the billing system was not feeding claims back to insurers, which over the next six months nearly ran the practice into bankruptcy itself, the complaint alleged.

Gulf Coast doctors continued to alert Acermed to the problems, but the company was unable to fix them, the lawsuit stated. They weren’t the only ones having trouble. Two other doctor groups-one in Florida, another in Tennessee-had also filed suit against Acermed, alleging similar problems. Gulf Coast filed its suit in October 2006.  Acermed stated in court documents that the doctors had no basis for their claim.

As it turned out, Acermed had been dealing with problems of its own. In July 2006, a federal judge ordered Acermed to pay more than $750,000 for using some of the source code from another vendor it had once worked with to develop its own electronic medical record software in 2004.

Gulf Coast’s lawsuit was still pending when, in September 2007, Acermed filed for bankruptcy. Company officials at the time said that the reason for their bankruptcy was the financial impact of legal bills, not problems with their software.

In January 2008, Ophthalmic Imaging Systems of Sacramento, Calif., bought Acermed and renamed it Abraxas Medical Solutions with Acermed’s former chief executive Michael Bina as president.

In an email, Bina said he does not “represent AcerMed any more and would not like to comment on its behalf.” He said that one of his conditions for joining Abraxas had been that it continued to service Acermed customers, and that “many clients” of AcerMed have stayed with the new company. One of those clients, Tony Cattone, general manager of a 70-doctor medical practice in New Jersey, said in an interview, “they have lived up to their commitments and it’s working fine.”

Several other doctors said they were left with loan payments for a system they never received.

And today, the Gulf Coast group still hasn’t entirely gotten rid of paper. In December 2008, the doctors settled their lawsuit with Acermed for an undisclosed amount. They invested in a different electronic system, but the doctors aren’t entirely happy with the new one either, said Alan Trest, the group’s technology manager. With the current system, doctors have to type rather than dictate notes. Some aren’t willing to make that transition because they say it takes them more time. So the group still pays for transcriptions.

“They haven’t really completely bought into the idea,” Trest said.

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[Jose's Note]

The idea of providing care at home has a lot of merit.

“The current system, focused on reactive and emergency treatment, mainly in hospitals, has changed little since the NHS was established in 1948, he said…” The same could be said for the US system.

[/]

http://www.guardian.co.uk/society/2010/feb/03/nhs-home-treatment-care

NHS ‘could save BP$15bn’ treating more patients at home.

CBI report fuels debate about what role hospitals would have if community services were significantly expanded

* Denis Campbell, health correspondent
* guardian.co.uk, Wednesday 3 February 2010 13.10 GMT

Is it time for the NHS to offer more treatment at home? Photograph: Ian Waldie/Getty Images

The NHS could save BP$15bn by treating far more patients at home and in new high street walk-in centres, according to a new report {http://www.cbi.org.uk/ndbs/Press.nsf/38e2a44440c22db6802567300067301b/f2aa76202344d1a880257650005a50e7/$FILE/CBI-Doing%20More%20With%20Less.pdf} from the CBI [Confederation of British Industry (CBI)].

Too much medical care is delivered in hospitals because there are not enough alternatives in the community, says the business group, which is urging a rapid expansion of “smarter care”.

Controversially, the report recommends that private companies should be allowed to provide the new services and that the NHS should not necessarily have a monopoly on delivering care in such ways.

It will also add to the growing pressure for the NHS to deliver much more care in patients’ homes – a demand backed by two other reports today – and will fuel the debate about what role hospitals would have if community services were significantly expanded.

“At present resources are skewed in favour of hospital care, but there is considerable scope for treating more people at home, near their workplace or the high street,” said John Cridland, the CBI’s deputy director-general.

“By re-engineering health services to give people more choice about how and where they are treated, we could diagnose problems earlier and reduce the number of costly hospital admissions.”

The NHS will have to rethink how it operates in order to cope with major problems – such as the ageing population, increasing medical problems associated with obesity and alcohol abuse, and the growing number of people with long-term conditions such as diabetes – at a time when its budget is being squeezed, added Cridland.

The current system, focused on reactive and emergency treatment, mainly in hospitals, has changed little since the NHS was established in 1948, he said. But its future will see it building on existing partnerships between the NHS and independent sectors in areas such as hip operations and the running of walk-in centres.

“If the examples of good practice contained in this report were applied more widely, we estimate that around BP$15bn could be saved by 2015,” said Cridland.

“But for that to happen the government must allow the best provider to deliver health services, irrespective of whether they are from the NHS, private or voluntary sectors.”

A separate report out today, by healthcare information analysts Dr Foster Intelligence and Healthcare at Home {http://www.drfosterintelligence.co.uk/index.asp}, estimates that the NHS could save up to BP$1.2bn a year by delivering in patients’ homes more chemotherapy, end-of-life care and treatment for long-term conditions.

In addition, a third paper, from the Expert Patient Programme Community Interest Company {http://www.expertpatients.co.uk/}, says that greater use of self-management techniques by the 15.4 million people with long-term conditions could save BP$1,800 on each patient each year in care costs.

The Department of Health said that NHS services were already being delivered in these ways. A spokeswoman said: “[There is] an impressive track record in the NHS for putting more services into communities, tailoring care to people’s individual needs and giving patients more choice.

“We have more early-intervention mental health teams operating in communities, there is increasing use of telecare for older people and we have invested in new GP services to improve access to primary care.”

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* Report errors or inaccuracies: userhelp@guardian.co.uk
* Letters for publication should be sent to: letters@guardian.co.uk

[Jose's comment]

I’m constantly amazed that anybody would be surprised that consumers are very concerned about the privacy of their health data.

Consumers already keep different accounts in different banks to spread both their risk and to try to hide the extent of their financial holdings from (ex)spouses / creditors / tax agencies. Why would consumers then want a single entity (government or for-profit) to hold all their health information in a single account?

If in the financial sector the working model is already consumer-centric, maybe this is model worth considering for health records as well.

[/]

http://ehr.healthcareitnews.com/blog/public-wary-about-data-privacy

Public worried about health data privacy
By Jeff Rowe, Editor

A recent poll suggests that as federal officials move forward on expanding the role of IT in the healthcare sector, they need to make sure that public is on board when it comes to who gets access to patient data.

The poll, conducted by the Michigan-based Ponemon Institute [http://www.ponemon.org/research-studies-white-papers], clearly indicates that, while the public is largely inclined to allow physicians to share patient data, they are much more wary when it comes to allowing federal officials or non-healthcare private companies the same access.

According to a recent article on the poll in Forbes magazine [http://www.forbes.com/2010/01/25/digital-privacy-ponemon-technology-cio-network-healthcare.html?boxes=financechannelforbes], “of the 868 Americans surveyed about their views on digitizing and storing health records, only 27% said they would trust a federal agency to store or access the data –the same percentage as those who would trust a technology firm like” Google, Microsoft, or General Electric.

The article rightly points out that federal data storage is not part of the Obama administration’s recent push for electronic health records, but the public’s wariness could certainly impact federal and state policy when it comes to the possibility of having companies such as Google managing web-based healthcare portals.

The survey also found that when “asked to rate the sensitivity of various types of personal information, users rated health records as far more sensitive than other information they typically share with Web companies. On a scale from one to seven, medical data received an average rating of 6.64, while credit card information received only a 4.27 and online search records just a 1.86.”

According to Larry Ponemon, the Institute’s director, “The takeaway message is that people still care about privacy.”

That fact, when combined with the recent rise in attempts by hackers [http://www.healthcareitnews.com/news/attempted-hacker-attacks-healthcare-rise] to access healthcare data, suggests that policymakers need to put security issues front and center in order to reassure the public about the safety of their personal information.