HealthBlawg

A Declaration of Health Data Rights: Can't argue with it, but it's only a first step

I'm joining the party a day or two late, and am supporting:

A Declaration of Health Data Rights

In an era when technology allows personal health information to be more easily stored, updated, accessed and exchanged, the following rights should be self-evident and inalienable. We the people:

• Have the right to our own health data
• Have the right to know the source of each health data element
• Have the right to take possession of a complete copy of our individual health data, without delay, at minimal or no cost; if data exist in computable form, they must be made available in that form
• Have the right to share our health data with others as we see fit

These principles express basic human rights as well as essential elements of health care that is participatory, appropriate and in the interests of each patient. No law or policy should abridge these rights.

So, my first reaction: This is obvious stuff, right?  Say what you will about The People's Republic of Massachusetts, local law requires prompt provision of medical records to patients at nominal cost, and in the vast majority of cases, the rules are followed and everyone's happy.  In my own little world here in Boston, MA, The Hub of the Universe, I've never had a problem getting health data -- or pathology slides, or anything else -- released to me or shared with other clinicians when needed.  But, then, I suppose I'm an outlier: my physician is part of a totally wired multispecialty group practice, which has been wired for years and years; and I'm both an industry guy and a lawyer, so I know how to speak up when I need something, and perhaps folks are more apt to listen.  (Reminds me of the semi-apocryphal story of a classmate of mine who saw the "law student" stamp across the top of his medical chart at Mass. General years ago.)

Upon reflection, I realized that not everyone -- whether in Massachusetts or elsewhere -- has the same ease of access, and while the declaration is sort of a no-brainer, it is important to put it out there, and I'm happy to join the folks who got this thing going, including Adam Bosworth, David Kibbe, Jamie Heywood and Gilles Frydman (forgive me for leaving other names off this short list).  I discussed the Declaration with Gilles Frydman, who agreed that it is just a first step, but a critically important one to take while the national dialogue is focused on electronic health records.

Additional steps down the path will have to include other common-sense guarantees that are already enacted into law here and there, including guarantees concerning the rights of patients to obtain test results through their physicians or otherwise, the ability of patients to correct errors in their records (so we don't have easily-accessible garbage), as well as easy access to interoperable electronic health records and non-tethered personal health records.

There are good reasons why some physician notes in some patient records should not be shared with patients or family members (a subject for another day), but this Declaration is focused on data -- not free-text notes -- so those notes would not be covered.

What other rights along these lines would you like to see guaranteed?

Update 6/27/09:  Many supporters have signed onto the Declaration.  One notable exception: Jen McCabe, who was in on some early drafts, but feels strongly that the darn thing doesn't go far enough.  Jen has blogged about her thoughts on the subject and has laid out her own more comprehensive patients' healthcare information rights manifesto.

I agree with Jen's sense that the Declaration is a first step, a baby step, and that there's a lot farther to go.  However, I see this first step less as a near-futile gesture, and more a real first step, a way to to get the conversation moving at a time when it can converge meaningfully with parallel conversations about implementation of ARRA / HITECH Act / Son of HIPAA provisions.  As the old saying goes: A journey of 1,000 miles begins with one step.

Here's what I would like to see providers who are prepared to sign onto the Declaration do as a next step: Without waiting for government action, initiate a campaign to amend their HIPAA Notice of Privacy Practices (NPP) (perhaps now, perhaps as part of the NPP amendment that will have to be rolled out once the Son of HIPAA regs are finalized by next February) to incorporate into a standard form contract that binds the providers the next steps that Jen calls for now and that most, if not all endorsers of the Declaration would also agree are necessary and important.  This simple, yet far-reaching step, would have a greater impact than an endorsement by a provider organization.  These should include guarantees of the "common sense" rights articulated above as well as the following patient rights:

• The right to correct erroneous data -- and a mechanism for noting disagreements with clinicians
• The right to control access to data -- access for all purposes: care, payment, secondary use (including clinical research and marketing)

In the past, non-standard NPPs were drafted and distributed by patient advocacy groups for patients to use and add to their providers' NPP forms.  However, patient-specific NPPs are unadministrable.  In order for this to work, there needs to be adoption form the provider side, either as a result of new regulation, or as the result of a populist follow-on to the Declaration.

As I wrote above: Please join in; what other rights would you like to see guaranteed as part of the Declaration?  What are your thoughts on this approach?

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Health Care Reform: Two out of Three Ain't Bad?

Folksy ads for a local furniture store chain 'round these parts proclaim "quality, comfort and price; that's nice."  In the continuing saga of slouching towards health care reform, we need to deal with quality, access and cost.  The problem is, we can't really do everything at once. 

Now that Obama has weighed in again on the subject -- the weekend radio and internet address, following on the heels of his letter to a couple dozen senators on health reform priorities -- Paul Levy has quite the discussion going at his blog, Running a Hospital, after suggesting that not all of the President's goals can be achieved at once.  We're in agreement that the health care reform effort is balanced on a three-legged stool, and I would concur that the current discussion in Washington is tending more towards the let's-fix-everything-all-at-once end of the spectrum, which is untenable.  I've said it before and I'll say it again: what we need is incrementalism, baby.

Here in the People's Republic of Massachusetts, we started with coverage, which is as good a place as any.  I would observe, though, that the starting point (along with a variety of other characteristics of the Massachusetts approach) are idiosyncratic and a product of the political wrangling/horsetrading that went on in order to get all stakeholders into the big tent.  (We're experimenting in just one of 50 laboratories here.)  Another (larger) playing field, and different (more) players are likely to yield a different set of compromises.  And that's OK, as long as the ball gets moved a bit further down the field (to mix a few metaphors).  I thought Obama's earlier approach, circa White House Health Care Summit ("you know what I'm looking for, guys; send me a bill I can sign") was politically brilliant; getting down and dirty on the details should be left to the operatives, so that Chuck Grassley doesn't get to score points by tweeting about Obama sightseeing in Europe over the weekend (though, gee, did he forget it was D-Day?).  I thought Obama better appreciated the need for results in this arena vs. taking the opportunity to do a little grandstanding.

So, I'd like to see Obama back off: more looking Presidential; less arm-twisting.  Staking out the range of options to be considered is a good thing, and hanging back a bit until there's a solid bill on his desk -- understanding that the White House is certainly involved in the private discussions leading up to such a bill being finalized -- would be even better.  Seems to me that's the clearest way forward for now.  While there is the potential for taking some giant steps this year, I'm OK even if the end result is less ambitious than is now hoped for.  Why?  Because I believe incrementalism is the way to go here, and it will end up being the first step of a long journey.

If you're interested in discussion of the leading health care reform policy and payment options on the table, please join Gregg Masters and me on Blog Talk Radio this Thursday, June 11, 12:00 Noon Pacific, 3 PM Eastern, and follow the continuing conversation here, there and on twitter.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Grand Rounds Vol. 5, No. 37: The June Is Bustin' Out All Over Edition

June is bustin' out all over . . . .  Lord knows my nose knows it, thanks to all the pollen in the air these days.  Check out the classic movie rendition of this set piece (well worth the eight-minute investment), let your coffee and/or antihistamines kick in, and then let's dive into the past week's medblogging, loosely categorized into insights of patient bloggers, provider bloggers, bloggers I've met in real life (the number keeps growing), bloggers following the money trail through the health care thicket, and bloggers who are or should be dancing and/or shirtless (watch the whole movie clip . . . on second thought, let's leave it at dancing).

  

Last time I hosted Grand Rounds, we delved into the origins of Valentine's Day, so even though we're a couple weeks shy of the vernal equinox, since June is bustin' out all over, the historian in me feels the need to touch on an ur-Spring nugget or two before we get going.  Where do these celebrations of Spring come from?

Attis was a Phrygian god, whose annual death and resurrection were mourned and celebrated at a Spring festival.  (On the other hand, the death and rebirth of the Sumerian Tammuz was a summer solstice thing rather than a vernal equinox thing.)  James Fraser, in The Golden Bough, wrote:

The annual death and revival of vegetation is a conception which readily presents itself to men in every stage of savagery and civilisation: and the vastness of the scale on which this ever-recurring decay and regeneration takes place, together with man's most intimate dependence on it for subsistence, combine to render it the most impressive annual occurrence in nature, at least within the temperate zones. It is no wonder that a phenomenon so important, so striking, and so universal should, by suggesting similar ideas, have given rise to similar rites in many lands.

What I best remember from The Golden Bough, though, is the tale of the king-for-a-year, who ascends the throne as a result of a cultic regicide, and ends his term the same way.  Great stuff.

For further reading linking The Golden Bough, The Holy Grail, Wagner's Parsifal, and T.S. Eliot's The Waste Land, check out Derrick Everett's article on The Waste Land.

I'm not certain that Rogers and Hammerstein had these themes in mind when writing Carousel.  Heck, who knows what they had in mind; they threw in a happy ending that wasn't in their source material (but hey, that's show business).  You, dear reader, certainly didn't have these themes in mind when you tuned in to today's edition of Grand Rounds.  Nevertheless, on with today's show.

Provider Bloggers

At Musings of a Distractible Mind, Dr. Rob discusses Atul Gawande's recent New Yorker piece on health care cost variations across the country (a good read, well worth the time), which focuses on McAllen, TX, a small border town that consumes far more than the average annual per capita amount of health care services.  Gawande loops in the Dartmouth Health Atlas folks, asks the hard questions about physician-owned facilities and financial incentives, and concludes that outfits like Geisinger, Intermountain, Kaiser Permanente and Mayo -- not-for-profit integrated delivery systems with salaried docs -- have the model we should strive to emulate systemwide.  Dr. Rob recounts his own experience with physician-owned facilities.  His conclusion is a folksy twist on Gawande's:

How do we fix it?  There are lots of good answers, and lots of dumb ones as well.  The bottom line is the bottom line, though.  How you pay docs will determine what happens.  It’s America, after all.  It’s what makes us great.  Right?

Right.  The thing is, guys, we've known this for at least forty years.

ACP Hospitalist reports on Sid Wolfe's new Public Citizen campaign to get hospitals to step up reporting of physician wrongdoing.  Bob Wachter, at Wachter's World, delves deeper into the problem, and says:

I’m proud to say that over the past five years, my hospital (UCSF Medical Center) has taken Leape’s challenge to heart, withdrawing clinical privileges (and filing accompanying NPDB reports) in several cases for behavior that, I’m quite confident, would have been tolerated a decade ago. This is progress. As Kissinger once said, “weakness is provocative.” As more hospitals take this tougher stance, I think we’ll see the boundaries of acceptable behavior shift everywhere. And patients will be safer for it.

Bongi, at other things amanzi, recalls a suboptimal experience in his training, when the "see one, do one, teach one" approach was reduced to "read an article about one, do one immediately afterwards."

At Providentia, Romeo Vitelli looks at the historical precursors to Jenny McCarthy and the current crop of anti-vaccinationists. 

Ken Cohn, a physician and consultant (who I know in real life [IRL]), recounts a (positive) experience in asking health care administrators to consider ethics in physician-hospital relationships.

I take a baby aspirin a day, and Doc Gurley says I should keep on doing so, because I'm better off puking up blood than having a heart attack.

Seizures and how they have been misunderstood (epilepsy vs. demonic possession) is the subject of this week's selection from Mind, Soul and Body.

Suddenly becoming a first responder at 35,000 feet? On Your Meds' Barbara Olson takes you there.  (The blog is part of Medscape, so free registration is required).

NurseAusmed recounts difficulties in handling patient communications and managing patient expectations at Nursing Handover.

How to Cope With Pain takes a page from a book offering guidance to those who have lost their spiritual way and turns the advice to use for those facing physical, rather than spiritual, pain.

Web 2.0 meets the health care establishment, and KevinMD [IRL] observes that since health care is largely a business, this should not be surprising.  For a window into social media use by health care provider organizations, check out healthsocmed.

The anonymous author of Notes of an Anesthesoboist says it's hard for women doctors to make friends . . . perhaps they should introduce themselves as drug pushers instead?

John Crippen wants to, but the NHS Blog Doctor just can't look away from the kids pushed onto TV talent shows by 21st century stage mothers.

Paul Levy [IRL] goes another round with SEIU Local 1199 at Running a Hospital.

At UDM Solutions, David Siwicki provides a clinical perspective on deciding whether to prescribe opioids for chronic pain patients who use marijuana.

Nancy Brown offers sound advice on talking to teens about alcohol at Healthline's Teen Health 411.

Follow the Money

DrRich, at the Covert Rationing Blog, always follows the money, and this week the trail leads to the following unlikely destination: the American College of Surgeons encouraging malpractice suits -- against overseas surgeons offering services to medical tourists.

Big Pharma also always follows the money, and David Williams, at the Health Business Blog, remains perplexed over Pharma's failure to engage with the public via twitter.  (GSK has already responded to David's post, but in a way that doesn't exactly undercut his point.)  For a window into Pharma's engagement with social media, look no further than Shwen Gwee, who organized the Social Pharmer unconference in conjunction with the HealthCamp Boston unconference I co-organized in late April.  Speaking of social media, feel free to follow me on twitter: @healthblawg.  

Last week, I took a look at the proposed Medicare Inpatient Prospective Payment System (IPPS) updates for FFY 2010.  Among other things in the rule (including payments cut to the bone), I was surprised to see tucked away in there a tacit acknowledgement that the whole "no pay for never events" thing isn't really saving anybody that much money.

Lots of hospitals are touting new private rooms these days.  Seems to help patient care (lower infection rates, better sleep, more privacy), but despite the benefits, Jeffrey Seguritan at nuts for healthcare observes that the private room is being pushed by the AIA, and wonders whether health care dollars really ought to be spent these days on capital projects such as these.  (My brief response: these days, they really aren't, given the tight financial markets).

In a medblogosphere first, The Happy Hospitalist has publicly described an entry in the $10 million X Prize competition:

How do you [reduce health care costs dramatically]?  Here's my theory.  You can do more to affect health care costs by getting 10,000 people to change their lifestyle habits than you can by getting a few hundred docs to change how they document and collect data and prescribe some pills.

So here's what you do.  You bribe the public.  People are inherently lazy, but they respond well to piles of money.

For a fuller introduction to the X Prize competition: Scott Shreve [IRL] posted his twitterview on the X Prize with Bertalan Mesko (@berci) at Crossover Health.  Learn more about it there.

The big HITECH Act pot of money that everyone in health IT is itching to get their hands on is going to have some strings attached: chief among them are going to be definitions of "meaningful use" and "certified EHR."  Them that are likely to be certifying -- CCHIT -- have been the target of some possibly well-deserved pot-shots, and the gloves have come off.  See Gilles Frydman's [almost met IRL at the Health 2.0 conference in Boston a month or so ago] framing of the debate at e-patients.net and John Moore's [IRL] take at Chilmark Research.  

Health technology research and development yielded two bits of news this week: FDA approval of a handheld ultrasound unit, via Vijay Sadasivam's scan man's notes, and Ves Dimov's post at Clinical Cases and Images on the Rovio - a WiFi-enabled mobile webcam, which may be more attractive to medical users given the recent study that found patient satisfaction, physician satisfaction and diagnostic agreement (measured both between face-to-face and virtual vists, and between two face-to-face visits) to be similar for face-to-face and virtual visits.  (Yesterday's Boston Globe took a closer look at this study, virtual visits in general, and American Well in particular.)    

The health IT crowd is working on interoperability and portability of health information.  Google Health is one of the platforms that may enable folks to reach this holy grail.  Brian Dolan at mobihealthnews says that Google Wave, an open-source tool for communication and collaboration, looks like a killer tool for enabling Google Health to do more in terms of provider-provider and patient-provider collaboration.

Evan Falchuk's observation at See First on prevention: it ain't cheap; treatment of preventable disease is more expensive than the savings from avoided disease and complications, so we need to be talking about more than cost-effectiveness.  [Supposed to meet IRL soon.]

Patient Bloggers

For some reason, diabetics are very well-represented among Grand Rounds' usual suspects.  This week, they're turning into media critics as well, following President Obama's nomination of Sonia Sotomayor to the Supremes.  Amy Tenderich [who I also almost met IRL at Health 2.0] touched on the media frenzy regarding the nominee's Type 1 diabetes at The Diabetes Mine, as did Six Until Me's Kerri Morrone Sparling.  Not to leave Type 2 diabetes unattended, Rachel Baumgartel offers tips for the newly diagnosed Type 2 diabetic at Diabetes Daily.  (For those who care to immerse themselves in The Politics of the Sotomayor Nomination, the good folks at SCOTUSblog say come on in, the water is fine.)  For a taste of the difficulties faced by some diabetics traveling through airports with needles and curious liquids, head on over to Tim Brown's post at Shoot Up or Put Up. 

At Getting Closer to Myself, Leslie offers her reflections as a twentysomething with auto-immune disease, specifically a feeling of how she can't go home again to an idealized summer retreat.

Barbara Kivowitz describes a good day at In Sickness and In Health, and invites all of us to do the same.

Bloggers Who Are or Should Be Dancing

Val Jones [IRL] is pretty pleased with her high-deductible health plan (HDHP) - cash-only PCP combo.  I hope her husband is dancing after the office procedure scheduled on a dime last weekend . . . and I hope Dr. Val has all the releases for those photos stashed away somewhere.  It's a good solution for those with no chronic conditions, young kids, or other sources of regular interactions with the medical-industrial complex.  And no less a luminary than Clay Christensen says we're 5-6 years away from the tipping point (to mix metaphors) on HSA/HDHP combos, at which time we're likely to see a significant change in the economics of healthcare (with or without significant movement in DC).  For one example of where this may play out, see my recent post on retail health clinics.

No dancing for you if you're susceptible to one of the side effects of Cipro and its relatives (fluoroquinolones): tendon rupture.  There's a black-box warning regarding this, but many clinicians and patients are unaware, says Paul Auerbach at Healthline's Medicine for the Outdoors.

InsureBlog's Bob Vineyard shares good news for Cuba's pre-op transsexual population: coverage is here.  Surely cause for someone (patients, if not bloggers) to dance.

Well, that's the last dance . . . for this week.  See you around the medblogosphere, and next week at the next edition of Grand Rounds. 

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Retail Health Clinic Summit: Can we get there from here?

At one of the pre-summit workshops yesterday, Tom Charland (ex-MinuteClinic exec and now consultant) channeled Clay Christensen (Mr. Disruptive Innovation) for a while and laid it on the line: unless retail clinics find a way to beef up off-season volume for at least 5-6 years, they may be dead in the water.  In that time, if Christiansen is right, HSA/HDHPs will become much more prevalent than they are today -- prevalent enough so that retail clinics could safely opt out of health insurance plan provider networks and have a sufficient patient base to draw from.

In the interim, Tom and I agree that retail health clinics need to break out of current operating modes, particularly into chronic care / disease management.  In fact, I was quoted on this point towards the end of a thoughtful piece on retail health clinics in BNA's Health Care Policy Report last month.  Retail clinic providers (including one from Spain), other consultants, payor representatives, drug and device reps, urgent care center operators, and even the US Armed Forces (planning a pilot project foray into retail health clinics) all showed up for the Summit, which provided a mix of perspectives on challenges and opportunities facing this nascent industry.

Slides from my talk at the summit on the Massachusetts experience, and lessons for the future  -- especially the need to move into chronic care and to partner more effectively with health care systems -- are provided here for your viewing pleasure.  My work with all components of health care systems -- including physicians -- makes clear that these combinations have the potential to be very powerful, and makes equally clear that the groundwork must be laid carefully with physician partners and champions in order to ensure the success of such an undertaking.

Retail Health Clinic Summit 2009 - The Massachusetts Experience and Lessons Learned

View more OpenOffice presentations from DavidHarlow.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Dr. Ben Kruskal, Director of Infection Control at Harvard Medical Associates: Conversation with David Harlow about Swine Flu / H1N1

My conversation with Ben Kruskal, MD, PhD, HVMA Director of Infection Control, about swine flu / H1N1 continues. 

In today's installment we discussed incidence of new cases, their concentration among children, chances for emergence of a more virulent strain of flu, and closer coordination between large ambulatory practices such as Harvard Vanguard Medical Associates (which has 400,000 patients) and the state Department of Public Health. 

The audio file of our conversation runs about 10 minutes and is available for download/podcast.

Update 5/15/09: Read the linked transcript or the copy below. 

Our earlier conversation is available here.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Interview of Ben Kruskal, MD, PhD, Director of Infection Control,
Harvard Vanguard Medical Associates, May 14, 2009

David Harlow:  Hi, this is David Harlow on HealthBlawg and I have with me today Dr. Ben Kruskal from Harvard Vanguard Medical Associates where he is Director of Infection Control.  We spoke a week or so ago about swine flu or the H1N1 virus, and I am eager to learn whether this week you see any change in the progression of this pandemic or epidemic and what sort of changes you see in its progression?  I looked at the numbers today, here in Massachusetts we’re up to about 133 confirmed cases as of this morning.  So, I'm curious to see if you see a progression or a trend in the past week or so?

Dr. Ben Kruskal:  Well it's pretty clear that the virus has, as predicted, started to spread pretty widely in the community and the number of confirmed cases being reported is clearly a pretty big underrepresentation of the real number of cases because we're not even attempting to test all cases.

David Harlow:  Okay, so these are just lab confirmed cases, is what you're saying?

Dr. Ben Kruskal:  Exactly.

David Harlow:  Okay and what was interesting to me in looking at the Department of Public Health's figures is that the majority of these cases are among school-aged children, and CDC said last week that it felt it was no longer necessary to close schools in the event of children being sick.  I am wondering if these numbers might cause us to reconsider that approach.

Dr. Ben Kruskal:  Well, I think what CDC said was not to not close the school at all, but rather not to close the school for a single case which is what the original advice was.  What they are now saying is that the school should only be closed if there is a significant cluster within the school, so I think they're still acting responsibly in the sense that if the school is clearly a focus of spread, that is the time to close things down.  If there are one or two cases that are well-contained, then the inconvenience to the large number of people would occur from closing the school isn’t worth it.

David Harlow:  Okay, fair enough.  And so I think it was in New York today or yesterday where a number of schools were closed.  There is a cluster of 50 cases in one of the schools, so that's consistent with what you are saying, and the CDC policy.

Dr. Ben Kruskal:  It is also very interesting to see that cases do seem to be concentrated among younger people and the explanation for that isn't clear.  I think the predominant speculation is that older people may have encountered strains that were related enough to afford them some immunity, whereas younger people have never seen a strain like this before.

David Harlow:  Interesting.  So you're referring to the swine flu that we had in the mid-70s?

Dr. Ben Kruskal:  Not necessarily that strain, but some other related strain at some point far enough back -- at least 20 years back -- so the young people who are the predominant population affected so far wouldn’t have had any exposure.

David Harlow:  And are those numbers in terms of age distribution consistent across other areas as far as you know, beyond Massachusetts?

Dr. Ben Kruskal:  It's a little hard to make good sense out of the numbers and areas that don’t have a lot of cases because the people who are being tested are very a skewed population, and probably not representative of all cases.  I think in the areas where many fewer cases are reported the predominance of adults is largely because they're looking at people with travel histories.

David Harlow:  Okay.  So how do you see this playing out over the next weeks and months as we get into the warmer weather, and how do you see this playing out next fall or next winter?

Dr. Ben Kruskal:  Well it's still very much up in the air.  The fact that there is as much transmission as there is, even in the relatively warm weather that we've been having in the last couple of weeks, is a little bit of a concerning sign to me that transmission may continue at a really, really high rate even through the summer.  So in terms of spread, it’s surprising that it’s still going on at the rate its going.  There is a concern based on some previous examples of novel strains that as the virus is transmitted from person to person, there may be selection for more virulent sub-strains and that the severity of disease may increase over time.  In some prior outbreaks, the virus has gone underground for the warm season and then re-emerged in a more virulent form in the fall, but I am somewhat concerned, seeing the level of the transmission we’re still sustaining now, that we may be possibly headed for more severe cases even sooner than the fall.

David Harlow:  So it likely will continue even through the warmer weather which will be unusual as I understand it.

Dr. Ben Kruskal:  Absolutely, but again the degree of spread that we're seeing now is pretty unusual as well.

David Harlow:  But thus far at least, it doesn't seem to be that virulent an illness?

Dr. Ben Kruskal:  No, thank goodness, it has been quite mild in the vast majority of cases.

David Harlow:  So, I’m interested to hear how you are dealing with this on behalf of your medical group in dealing with the large population [of 400,000 patients] that you are responsible for?  What are you and your team doing on a daily or weekly basis in order to help manage this?

Dr. Ben Kruskal:  Well, we started from the very beginning and we're fortunate enough to have a plan in place which we were able to adapt quickly to the current situation.  We focus on providing information for our patients that’s been crafted centrally but we’re not relying every on every individual doctor and nurse to create the message themselves.  We had the help of specialists in communications and we have also been working hard to get timely, consistent and accurate information out to our staff in order to equip them to deal with patients’ questions and concerns.  The patient anxiety clearly has been much, much bigger than the actual number of cases, so I think done a reasonably good job of giving people these tools and giving our patients information directly as well.  In addition, we focus very heavily on protecting our staff, knowing that it's hard to come to work if you think you’re going to be infected with something nasty and we’re taking precautions that may be excessive given the relatively mild nature of the illness, but again being conservative and making sure that our staff feel safe coming to work.

David Harlow:  I also understand there's has been a national stockpile of antiviral medication being distributed, has that been distributed to your group as well or is that going just to pharmacies?

Dr. Ben Kruskal:  It actually was initially meant to be distributed only to hospitals and we were active in lobbying the Department of Public Health to include the ambulatory health care organizations as well and succeeded in getting a significant chunk of the distribution for large practices such as Harvard Vanguard.

David Harlow:  So have you been coordinating with the State Department of Public Health along other lines as well?

Dr. Ben Kruskal:  Yes.  We’ve been talking to them for quite some time about the role of ambulatory care providers in provision of care in pandemics and other disasters and I think we’ve really pushed their attention in the direction of what ambulatory care can provide in a disaster like that, and we have extensive discussions which I think have helped to inform the way they are working with other ambulatory groups as well.

David Harlow:  That's encouraging and it makes a lot of sense, since so much care that was in the hospitals traditionally has really been pushed to the ambulatory setting.

Dr. Ben Kruskal:  Right, and enabling the primary care providers to continue to function during an outbreak has several advantages.  One is that by virtue of the existing relationship that we have with our patients we may be able to convince them of things that they might otherwise feel too nervous to hear from a provider they never met before,  so we can help them comply with public health directives in a way that's much harder for an unknown person to do.  In addition, we can take the load of the worried well and the mildly ill off of the hospital, so they can focus their attention on the things that only they can do, which is caring for the most severely ill.

David Harlow:  That makes a lot of sense.  Thank you for your time.  This is David Harlow on HealthBlawg.  I’ve been speaking with Dr. Ben Kruskal, the Director of Infection Control of Harvard Vanguard Medical Associates here in Boston, Massachusetts.  Thank you again.

Dr. Ben Kruskal:  Thanks David.

David Harlow speaks about swine flu with Harvard Vanguard Medical Associates Director of Infection Control Dr. Ben Kruskal

I've been following a lot of updates on swine flu (or, as we're now supposed to call it, H1N1), found everywhere from The Daily Kos to the swine flu feeds "blokcast" set up by Tom Stitt.

Update 5/4/09: There is also an excellent overview of pandemic preparedness and thoughts about the future on Health Affairs' blog. 

To get a handle on the situation, I spoke with Ben Kruskal, MD, PhD, Director of Infection Control for Harvard Vanguard Medical Associates, a Boston-area medical group with about 400,000 patients.  The audio file of our conversation runs about 6 minutes and is available for download/podcast.  I plan to check in with him periodically as this situation unfolds. 

Update 5/5/09: Read the linked transcript or the copy below.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Interview of Ben Kruskal, MD, PhD, Director of Infection Control, Harvard Vanguard Medical Associates, May 3, 2009

David Harlow:  This is David Harlow on HealthBlawg and I have with me today Dr. Ben Kruskal who is the Director of Infection Control for Harvard Vanguard Medical Associates -- that’s a large group practice in the Boston area with about 400,000 patients.  Thank you for being with us today.

Dr. Ben Kruskal:  It’s my pleasure, David.

David Harlow:  I am interested in your perspective on the H1N1 flu pandemic, and how that is affecting your patients, the patients of your group and the public at large.  What should we be concerned about at this stage?

Dr. Ben Kruskal:  Well, the good news is that the severity of illness seems to be very much on the low end of the spectrum as of now.  Unfortunately, I don’t think we can be entirely complacent because there certainly is potential, based on history, for things to become more severe over time.

David Harlow:  Is there some point in time where you think we’ll have a good sense whether this is a pandemic that’s going to blow over with a less severe illness or whether we’ll start to see a more severe illness?  Is there a point in time where that will be apparent?

Dr. Ben Kruskal:  I don’t think we’ll be able to say with great confidence until quite a while from now.  Again, by analogy with the previous outbreaks, sometimes a novel strain will appear very mild, will go underground for a period of some time, often months, and then reemerge in a more virulent form.

David Harlow:  Right.  Now, I’ve seen some graphs and depictions of the course of pandemic in the 1918 Spanish flu epidemic and the question that’s raised there is whether some stricter controls including, for example, closing schools might be beneficial.  I'm thinking in particular of a graph comparing the number of cases say in Philadelphia versus St. Louis where Philadelphia didn’t close any schools or other public areas and St. Louis didn’t, their experience was overall better.  Do you see a need at this point in time for sort of stricter approaches to closures of places like schools?

Dr. Ben Kruskal:  Well, no question that with a virulent strain and a strain with a very high attack rate, school closures and others so-called “social distancing measures” can be very helpful.  It’s not clear to me at this point how necessary, how stringent we need to be in terms of school closings.  Right now the CDC has taken a fairly conservative view and is recommending that schools consider closing with even one confirmed or likely case. Given how mild this disease is and the fact that spread doesn’t seem extremely high at this point that may not be quite necessary, but again, it’s early to say for sure.

David Harlow:  Okay.  So the way things look now, it doesn’t seem that that’s entirely necessary.  We’re talking about the CDC and some recommendations coming from there, and I understand that the Federal government had put a pandemic plan in place over the past year or so and that that’s being activated or put into play.  There’s a lot of discussion in recent weeks about the fact that a lot of top appointed positions in the administration have remained unfilled.  Do you see that that has been a problem in addressing the pandemic as it unfolds?

Dr. Ben Kruskal:  I don’t think so.  I think, again, fortunately, things have been relatively mild so far and the CDC’s response seems as if it’s been pretty well coordinated, no major issues or problems.

David Harlow:  There are these plans that are in place -- whether it’s the Federal level or say the local levels -- and I wonder if, as you’ve been saying, this seems so far to be a relatively mild pandemic or relatively mild strain of flu, is it entirely necessary to be activating these plans?

Dr. Ben Kruskal:  Well, I think everyone has been reasonably measured in the response so far, really with a strain as novel as this one.  The potential for rapid spread and for severe disease is there and I think both at the state and the Federal level it has been appropriately conservative initially and is being tempered over time based on what’s occurring, so I think things had been quite proportional.

David Harlow:  Okay.  Well, thank you very much.  Any thing else that you would like to add?

Dr. Ben Kruskal:  I'm not sure I would call this a pandemic at this point, pandemic generally refers to a large segment of the population being infected and we’re certainly not there yet.  I think there is still quite a lot of potential for spread although again I hope the severity of the illness will remain as mild as it is now.

David Harlow:  Okay.  Well, I certainly hope so too.  Thank you very much.  I’ve been speaking with Dr. Ben Kruskal, Director of Infection Control at Harvard Vanguard Medical Associates in the Boston, Massachusetts area.  This is David Harlow in HealthBlawg.  Thanks once again for speaking with me and I hope we’ll have a chance to follow up on the swine flu situation again in the future.  Thank you.

Dr. Ben Kruskal:  Thank you David.

David Harlow quoted in Boston Business Journal column on lawyers and twitter

I spoke last week with Lisa van der Pool at the Boston Business Journal about twitter, now the hot trend in social media for lawyers.  See her Legal Briefs column in the current issue.  I know newspaper websites have policies on links, but it drives me nuts when online editions don't have links to resources they reference.  So ... please check out my twitterfeed and the feeds of the other attorneys featured in the column: @healthblawg (David Harlow), @attyimmigration (Joshua Goldstein), @jayshep (Jay Shepherd) (employment), @dfrederico (Donald Frederico) (litigation).

The Legal Brief piece puts the fact of twitter use by lawyers out there for those not already following Massachusetts' "legal birds" or healthcare "legal birds" -- if you're one of those, I encourage you to experience the twitterstream for yourself.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

MGH pediatric heart surgery: Volume, volume, volume, or, How low can you go?

Today's Boston Globe reports that Massachusetts General Hospital has voluntarily suspended operation of its pediatric cardiac surgery program, following two significant negative outcomes.  MGH is conducting an internal investigation, much as UMass Memorial suspended its heart surgery program while investigating higher-than-average CABG mortality rates a while back (see HealthBlawg interview with UMMMC general counsel Doug Brown on its cardiac surgery program).  David Torchiana and MGH will certainly be able to identify opportunities for improvement, as did UMMMC, by going through this exercise.  UMass Memorial restarted its program after implementing quality improvements it identified through the review process.  The question on many minds today is whether it makes sense for MGH to continue to run such a program, with the relatively low volume that it has, given the resources and existing programs of Boston's nearby Children's Hospital.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Blog Rally to Help the Boston Globe

We have all read recently about the threat of possible closure faced by the Boston Globe.  A number of Boston-based bloggers who care about the continued existence of the Globe have banded together in conducting a blog rally.  We are simultaneously posting this paragraph to solicit your ideas of steps the Globe could take to improve its financial picture.

We view the Globe as an important community resource, and we think that lots of people in the region agree and might have creative ideas that might help in this situation.  So, here's your chance.  Please don't write with nasty comments and sarcasm:  Use this forum for thoughtful and interesting steps you would recommend to the management that would improve readership, enhance the Globe's community presence, and make money.  Who knows, someone here might come up with an idea that will work, or at least help.

Thank you.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

Health insurance mandates: Geez, good thing Obama isn't pushing them, 'cause he'd get tied up in litigation for forever

San Francisco's municipal health insurance mandate is in the news again this week.  The 9th Circuit Court of Appeals upheld the mandate in September (after sturm und drang and litigation over the San Francisco health insurance mandate going back almost two years now), and the local restaurant association has taken the fight to the Supremes.  The association suffered a setback this week, as the high court refused to enjoin enforcement of the law pending appeal.  We'll see this fall whether the Supremes will hear the case.  The program has extended health benefits to tens of thousands of folks, and is set to underwrite some new clinics as well. 

The challenge comes out of the arcane left field that is ERISA pre-emption jurisprudence.  The Circuit Court's response last fall, per the local paper:  "San Francisco was exercising its legal authority to protect its residents' welfare and was not regulating employee benefit plans, because employers have a choice of insuring their own workers or paying a fee to the city."

As I've observed before, the fact that an ERISA challenge has not been brought in Massachusetts is a testament to the coalition-building that went on across all sorts of lines before the Massachusetts plan was enacted.  For all its faults, the Massachusetts experience -- like the San Francisco experience -- serves as a laboratory environment in which experimentation is taking place.  Here's hoping that a workable national health care reform plan -- backed by a solid coalition -- comes out of all these experiments and the continuing national discourse on the subject.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting