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13 posts from December 2008

December 05, 2008

Constabulary notes from all over

The ever-vigilant law enforcement community meets the health care system:

Item: Massachusetts state trooper pulls over woman in labor; asks "what's under your jacket?" while writing ticket for driving in breakdown lane en route to hospital.

Item: New Hampshire state trooper pulls over man after PET scan; asks for proof of medical procedure after radioactive isotope detected by anti-terrorist hardware.

Can't be too careful, eh?

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

December 03, 2008

Interoperable EHRs: elusive grail or within our grasp?

The indefatigable John Halamka makes a convincing case that "interoperability is implementable today with harmonized standards, appropriate security, and a service oriented architecture using the internet," and that the only thing barring the way to a fully interoperable national EHR system is resources, or incentives -- the technology is there.

(This conclusion begs the question: is GE's recently-announced foray into developing a new open standard for EHRs really necessary?  The $200 million committed seems to be a drop in the proverbial bucket; as a recovering public health official, I always tend to ask: How many childhood vaccines could you buy with that kind of money instead?)

So, what sort of incentives would move providers to climb on board the interoperable EHR express?  The federales have taken at least two approaches thus far:

First, the executive order giving hospitals a free pass for kicking in some dough when physicians in a position to refer business are buying EHR systems.  (Not exactly doing land-office business, even after the IRS cleared up a little issue -- the executive order created a Stark exception and fraud and abuse safe harbor but hadn't addressed issues raised by tax-exempt hospitals forking over big bucks for the benefit of for-profit medical groups.)

Second, a little MIPPA carrot-then-stick action on the electronic prescription front, with the potential promise of expanding the 2% incentives into other related arenas.

Will these incentives move a lot of docs online?  I'm not convinced.  Frankly, the hospital community is not exactly looking for ways to spend money these days.  I'd like to see the time limits on the executive order extended so that hospitals have a chance to rebound and fund some physician EHR infrastructure.  The MIPPA-type or RHQDAPU-type incentives will move docs, as other similar incentives have moved docs and hospitals to report on a million measures.

I'd like to see the federales make some bold moves -- which the Obama administration may be prepared to do -- and fund EHR infrastructure in the private sector.  Directly.  By writing some checks.  There's at least $700 million of public and private funds on the table, but more is needed. The benefits to be realized are great enough, both in terms of public health and in terms of cost savings to government and other payors (and by payors I mean ultimate payors -- those who pay health insurance premiums) that the short-term cost (which is not inconsequential) should be underwritten in the same sort of deficit spending kind of way that FDR used to fund the New Deal.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

December 01, 2008

Convergence of Health 2.0 and medical home?

Two items that entered my consciousness this morning: group medical appointments as a manifestation of the medical home and order-your-own labs as a manifestation of Health 2.0.

At 700-plus-doctor Atrius Health here in the Boston area, CEO Gene Lindsey still sees patients, but only in 90-minute group appointments.  Other large group practices across the country have already implemented this practice, and it's growing at Atrius (which includes Harvard Vanguard Medical Associates and a number of other groups).  Patients opt in and benefit from longer contact with the physician and discussion of issues that may be of general concern to all of them (Lindsey is a cardiologist; he can fit many more "canned" speeches to his patients into a 90-minute visit, and his patients seem to appreciate it).

This innovation addresses a couple of issues simultaneously: PCP shortage, under-reimbursement of cognitive services and patient dissatisfaction with too-short office visits.

Scott Shreve is not your typical patient, but as the linked post in his blog argues, patient-directed lab ordering makes better use of the office visit: you can discuss results with your doc, rather than discussing which tests to have ordered.  Scott further argues that consumer-directed health care, as exemplified by this service, is ineluctable, just as we cannot turn back the clock on consumer-directed financial services (e.g., on-line trades) which cut out the financial advisory intermediary.  Given the recent dip in our collective net worth, the unmediated access to stuff that matters (retirement funds, health care data) cannot yet be counted an unqualified success.  However, Scott's point that we can't fight it, and that it may offer some benefits, is well taken.

The order-your-own labs innovation, like the group physician visit innovation, is a neat solution to a bundle of problems.  These are the sorts of leaps that are necessary to get us out of the current downward spiral that will otherwise leave us all without adequate access to appropriate levels of medical care.

(Tip of the hat to Bob Coffield for the Scott Shreve post.  That's a link to Bob's twitter post, not blog post.  For those of you not yet following me on twitter, please do so right here: @HealthBlawg.)

David Harlow
The Harlow Group LLC
Health Care Law and Consulting