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20 posts from July 2007

July 31, 2007

First statewide EHR system announced -- in Rhode Island

Of course, the plan for RI's statewide EHR system was announced within a day of the merger announcement from Lifespan and Care New England, which together represent about 75% of the state's hospital capacity (and affiliated physicians).

It's a small state, and it will have effectively one major provider by the time the EHR system is rolled out (unless the deal tanks, which it did the last time they tried this, eight or so years ago).  Nevertheless, I suppose this is some sort of milestone.

There are both the good and the bad secondary uses of PHI to be considered as this system is built.

-- David Harlow 

July 26, 2007

We have met the enemy and it is us

The Massachusetts universal coverage plan and the next-stage efforts at health care cost containment get somewhat cynical, yet sobering, coverage at CommonWealth magazine.  The article in the current issue is titled Cost Unconscious.  MassINC, which publishes the magazine says:

The Summer 2007 issue of CommonWealth magazine examines the factors underlying the ever increasing costs of health care. Though the state is drawing national headlines for its strides in expanding coverage to nearly all residents, “I don’t see a parallel sense of urgency in figuring out what we’re going to do about what, to me, is pretty close to a cost-control emergency,” says John McDonough of the advocacy group Health Care for All.  Other healthcare leaders and experts lend their insights and perspectives to the question.

John also blogged on this issue today at WBUR's CommonHealth(He gets credit for the Pogo quote, too.)  As usual, he has some concrete suggestions, and Health Care For All's legislative package includes some proposed fixes.

This is a longstanding, intractable problem, and seems unlikely to succumb to a comprehensive fix on the heels of Chapter 58.

-- David Harlow

July 25, 2007

Health Wonk Review is up at Health Care Policy and Marketplace Review

Bob Laszewski collects the best of what all the usual suspects wrote on our summer vacations in the current edition of the Health Wonk ReviewAs usual, the breadth of subject matter and diversity of perspective makes for a good read.

-- David Harlow

July 23, 2007

The latest on Minute Clinics in Massachusetts

I'm just catching up with last week's Minute Clinic news here in Massachusetts. (TOH to A Healthy Blog; I can't be expected to read the paper all summer long, can I?)  For background, see earlier HealthBlawg posts on Minute Clinics generally and Minute Clinics' entry into Massachusetts.

The Boston Globe reports that the Department of Public Health will issue draft regulations for licensure of a new category of clinic represented by retail clinics rather than grant a whole raft of waivers from the existing clinic regulations as requested by CVS. 

To echo John McDonough's approval over at A Healthy Blog, John Auerbach, as DPH Commissioner, accomplishes a number of things by taking this approach: DPH (1) controls the agenda; (2) levels the playing field for community-based providers that may wish to test the waters of new models for health care delivery; (3) raises the big tent to let everyone have their say through the rulemaking's public hearing process; (4) eliminates a scattershot approach of a waiver here and a waiver there, or trying to fit a square peg into a round hole, in favor of a new creature of regulation that may have a positive impact on the local landscape; and (5) potentially improves access to limited health care services for certain vulnerable populations.

-- David Harlow

July 22, 2007

Charity care at tax-exempt hospitals: how much is enough? for the IRS? for Sen. Grassley?

The IRS's interim report on hospitals and community benefits was released last week, one day after the latest missive from Sen. Chuck Grassley.

One interesting point of comparison: Grassley would condition hospitals' tax-exempt status on spending 5% of annual patient revenues or operating expenses (whichever is greater) on charity care.  The survey shows that a quarter of all hospitals provide only 1% and over half of hospitals provide only 3%; only about 20% of hospitals provide more than 10%.

The WSJ Health Blog asks whether the IRS should be in the business of setting a 5% charity care threshhold.  Some say yes; some say no. 

Truth is, the IRS has been wrestling with this for a long time and has not come up with a bright-line test; it seems that instituting one will create at least as many problems as the current more diffuse test has engendered.

-- David Harlow 

July 19, 2007

Sen. Chuck Grassley has another go at 501(c)(3) hospitals

Sen. Chuck Grassley: there he goes again.  (Check out some of his other recent activities regarding tax-exempt hospitals.)  As Finance committee chairman, he's put out a press release and discussion draft of potential non-profit hospital reforms.  The draft tees up the proposal thus:

The staff proposal recommends setting specific standards for hospitals that seek exemption under § 501(c)(3), including: (i) establishing a charity care policy and wide publication of that policy; (ii) quantitative standards for charity care; (iii) requirements for joint ventures between nonprofit hospitals and for-profit entities; (iv) board composition and other governance requirements and executive compensation; (v) limiting charges billed to the uninsured; (vi) placing restrictions on conversions; (vii) curtailing unfair billing and collection practices; (viii) transparency and accountability requirements; and, (ix) sanctions for failure to comply with applicable requirements for a 501(c)(3) or 501(c)(4) hospital.

The draft gets into some detail on each of these proposals.  Comments are invited over the next month.

Question to consider:  Should tax-exempt payors be subject to the same sort of scrutiny?

-- David Harlow

Is the AMA crossing the line in disclosing physician data?

The AMA licenses the use of its "master file" physician data, compiled over the past 100 years or so on AMA members and nonmembers, to commercial interests (presumably for a tidy sum).  Virtually all, if not all, the data is publicly-available directory-type information about physicians.  Some vendors combine physician data with composite data on the physicians' prescribing habits, and resell that data to Big Pharma for detailing.  Rob Restuccia at Community Catalyst, among others, doesn't think this should continue to happen.

Medscape is running a story on this allegedly improper use of data on physicians and their prescribing patterns for pecuniary gain.  (Free registration may be required.)  The objection seems focused on the licensing of the directory information, so I found it pretty amusing that the ad served up opposite this story as I was reading it was for a physician directory marketed by WebMD, which owns Medscape.

I'm less concerned with the AMA's licensing of physician info (they're on the receiving end of other info-sharing deals, e.g., Sermo) than with the availability of patient data, prescription and otherwise, and the so-called secondary use of this health data -- which really ought to be better-protected than it is.

-- David Harlow

July 18, 2007

Wisconsin Supreme Court upholds jailing of uncooperative tuberculosis patient

A woman who refused treatment for TB was properly confined to jail for treatment, according to the Wisconsin Supreme Court.  Check out the AP story and the court ruling.

Interesting tidbits: under Wisconsin law, the patient did not have to be confined to the least restrictive setting, and it was OK to consider cost (i.e., jail is cheaper than bringing in guards 24/7 to a hospital for one individual). 

Quite the coda to the tale of the tubercular honeymooning lawyer.

-- David Harlow

July 17, 2007

The social uses of data stored in EHRs and the privacy protections needed

EHRs either make sense clinically or economically on an individual patient or practice basis, or they don't, depending on which study you read

Let's assume that implementation does not make economic sense, or that implementation is cost-neutral, at the individual practice level.  Should the EHR implementation agenda be advanced nevertheless?

The argument goes like this: aggregate data will point to new findings regarding safety, efficacy and efficiency of different treatment modalities for patients with the same or similar diagnoses.  Providers can then be incentivized (through P4P, or its subset, value-based purchasing) to follow the preferred approach. 

This has the potential to help all of us, but of course there is also the potential for inappropriate sharing of personal health information.  HIPAA doesn't quite help in these circumstances (there are some aspects of EDI, RHIOs, etc. not contemplated when the HIPAA rules were being written, not all that long ago) though some fixes may be in the works.  See news regarding NCVHS letter to HHS promoting expansion of HIPAA (and a copy of the NCVHS letter, too), though it's worth noting that's been in the works for about a year).

"Secondary" use of health data -- i.e., use of data "for non-direct care, including analysis, quality, research, payment, provider certification, marketing and commercial activities" -- is the subject of ongoing review and consideration by an AHIC workgroup and by AHRQ.

Update 7/20/07:  The Washington Post reports on concerns about holes in HIPAA and proposed legislation to tighten it up; Jeff Drummond, at the HIPAA Blog is dismissive of what he sees as folks getting all hot and bothered about not all that much.

Here's hoping that the potential for using all this data we're collecting for the collective good isn't mucked up by the federales and -- dare I say it -- the lawyers.

-- David Harlow

New study: EHRs really do save money over time

OK, so there's a study to back up any statement you may want to make about EHRs. 

Last week, it was: EHRs don't improve outcomes.  This week, it's: EHRs save money over time.  This week's study was based on a much smaller sample size, and the major cost savings was on staff time spent pulling charts.  Both studies were limited to ambulatory care settings.

-- David Harlow