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33 posts categorized "Podcast"

January 23, 2013

HIPAA Omnibus Rule - Google+ Hangout

For a first look at the HIPAA omnibus rule, I had a Google+ Hangout on Air with Brian Ahier and Deven McGraw this afternoon. We talked through the changes made to the privacy and security rules, the breach notification rule, the enforcement rule, and the harmonization of HIPAA and GINA. The video runs about an hour, and we got some pretty good reviews live and in the hours since this ran. Check out the HIPAA discussion on Google+ concurrent with and immediately after the hangout, too.

HIPAA Omnibus Rule Hangout

 

One viewer, Ben Watts, posted his notes almost immediately after we were through, on his blog EMRSoap. (Thank you, Ben!) Here's an excerpt from his post:

EMRSoap Write-up of the HIPAA Hangout by Industry Leaders

Below are our notes from the discussion – they’re not specifically tied to the individual speaker.

  • Most of the final rule was the same.  Except for the Marketing provision – that was quite a bit different than the proposed rule.
  • We’re still not done. Even though this is the ‘Omnibus rule’, there’s still 2 new rules that need to come out.
  • Bus related puns abound.
  • What do providers need to watch out for?  One thing: Primary liability of BA’s and subcontractors.  You really can’t sub out responsibility entirely.
  • There’s a community of small providers and Business Assocaites who aren’t aware of the reality of HIPAA and haven’t completed Risk Assessments (and more).  They’re just not familiar enough with their obligations and the HIPAA environment.  They’ll have till September 23rd to comply with this rule.
  • Date by which new BAA and NPP need to be entered into is a year after that September 23rd.  The agency will be issuing further guidelines throughout this timeline.
  • The government is committed to more audits and fines.  The fines they collect will fund the audit process.  We’re going to have audits of Business Associates and their subcontractors, not just Covered Entities.
  • Enforcement is moving to Penalty base, and away from voluntary compliance.
  • But not entirely, says Devin.  Rule was pretty clear – informal resolution and voluntary compliance would still play a factor in enforcement.  HHS will have discretion.
  • HHS has been going after the smaller groups as well, even without the Omnibus rule.
  • Environment of ‘Hands off’ has led to people being careless.  Behavior has been beyond what’s acceptable for building up trust in EMRs.
  • Why should patients be excited?  People most bugged by marketing – that’ll be limited by HIPAA Omnibus rule.  Also, breach notification provision much more clear means that institution are going to pay a lot more attention to encryption.
  • Discussion on the ‘conduit’ exemption – very narrow exemption.  Really only works for courier-like firms (ISP and postal services, for example).  Only making sense in cases of random or intermittent access to ePHI.  As opposed to entities that store data – would be a BA, even if the intention is to not to look at it.
  • Failing to sign a BAA doesn’t exempt you from BA status.
  • Researchers are now permitted to give people conditional treatment if they agree to research.
  • Now allowed to have authorizes for future research as long as the description is rich enough to give patient a general idea of the types of research that’ll be enacted.  No need for individual study approval.  Requirement is somewhere in between ‘all research’ and ‘one study’.
  • Patients can request records in forms that makes sense for them.  If you can’t technically do it in the form (5.5 in floppy, for example?) then the provider will have to reach an agreement with the patient.
  • Is it possible to segment your record, and keep some info off of your Health record?  Yes.  It’ll probably be hard for a fair amount of providers.  If a patients says ‘don’t send this to my payer’, you can’t do it.
  • Patient right to get data trumps security requirement.  If the patient is notified of risks of transmitting ePHI over email, then the ePHI can be transmitted to the patient.  Requirement of alerting patients is fairly low.  Bi-lateral communication is a different realm, however.
  • Changes to enforcement rule – bottom line is there’s a max of 1.5 million per violation.  Likelihood of greater fines in the future?  Maybe.  Largest fine to date was against a bankrupt company.
  • There’s more breaches reported…not necessarily more breaches in total.  Now, with our digital health system, we know who’s seen what.  We’ll see more breaches in total, but that’s not necessarily a bad thing.
  • BA’s right to use data is explicitly limited.  BA’s are directly liability, but they’re still subordinate to Covered Entities.
  • Breach Notification – we’ve moved away from the ‘harm standard’ – moved away from the subjective value of the underlying data.  We’ve moved to an examination of ‘what happened in this instance?’  Presumption being if we don’t know what happened, then there was  a breach.  Notion of ‘if it’s info about your big toe then it’s not harmful’ is gone, as is underlying subjective value judgment of data.  Faxing info to Doctor X instead of Doctor Y, maybe less of a big deal.  As long as that mistake is handled appropriately, it’s not that big of a deal.  If there’s greater than a low probability that the ePHI was breached, then there needs to be a notification.  There’s a 4 pronged set of standards that need to be examined in that investigation to determine if there was a breach.   But if you know that there was a breach, you don’t need to do an investigation.
  • Everybody: gotta revise your Notice of Privacy Practices.  Remember that you have until September.

We enjoyed using the Google+ Hangout on Air platform, though it was a little bumpy as it was our first time. We are considering putting together future hangouts on the HIPAA omnibus rule, and would welcome your input regarding which issues warrant a closer look.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

 

December 05, 2011

Deja Vu All Over Again: David Harlow speaks with Gene Lindsey, MD, President and CEO of Atrius Health and Harvard Vanguard Medical Associates

LindseyJr_H.Eugene

Recently, I had the opportunity to speak with Gene Lindsey, President and CEO of Atrius Health and Harvard Vanguard Medical Associates. Atrius is a 1000-physician allliance of six medical groups in eastern and central Massachusetts; Harvard Vanguard is the largest of those groups.  We discussed some current developments in the health care regulatory landscape and marketplace, and Atrius' approach to positioning itself for success -- as well as its definition of success -- in the current environment, in domains ranging from improvinmg medical education to achieving the Triple Aim. 

Gene is a student of the history of his organizations (he's been a part of their operations, and those of their predecessor, Harvard Community Health Plan, since the 1970s), and he traces current discussions about health care quality and cost back to the thinking and writing of HCHP's founder, Dr. Richard Ebert. He described delving into Ebert's papers in "the bowels" of Countway Library at Harvard Medical School (Ebert was Dean there when he founded HCHP) and is clearly committed to the framework of collaborative, physician-led efforts to manage health care and control costs. He's taking his organization through a Lean process of cost-cutting, and is working to further Atrius's early successes under the proto-ACO Blue Cross Blue Shield of Massachsuetts Alternative Quality Contract (AQC).  Atrius Health's first year's results under the AQC look promising, though researchers writing in the New England Journal of Medicine concluded that further study is needed.  Gene says he has another two years' data, and the results continue to look good.

The audio file of my interview with Gene Lindsey is available for download/podcast.  It runs about 25 minutes. A full transcript is at the end of this post (and in the linked Gene Lindsey, CEO, Atrius Health, interview transcript).

In thinking about how to create a high-performing health care system, Gene observed: "as Atul Gawande says, the issue is that we’re not without knowledge, we’re just inept in applying that knowledge."  He predicts that the next several decades will be devoted to figuring out how to apply the knowledge we already have.  

He wrapped up our coversation by tying his work at Atrius to the IOM's six domains of quality, making a strong statement about his organization's commitment to patient-centeredness:

We have constructed our organizational activities around what the IOM called the six domains of quality, the most important of which is patient-centricity.  We need to design the system to be a benefit to the people who come to us for care - they are our reason for existence. That’s not been true in the past. In the past we’ve designed it for a lot of other reasons, but not always and specifically to benefit the care of people.  Sometimes it’s for the convenience of physicians, sometimes it’s for the perpetuation of august institutions - whatever it’s been, but it’s not always been that the patient’s been at the center of it.  Lucian Leape, whose name you introduced earlier, focused us on safety. The other issues . . . care needs to be timely if it’s going to be safe and patient-centered, it needs to be efficient and effective if we’re going to have a society that continues to exist, and the last and most important of the domains is it’s got to be equitably delivered -- and probably that has been the biggest conundrum for our country.  How do we get the last 15% of our citizens covered in a fashion that doesn’t destroy the economics for the rest of us? [T]hat in and of itself is the most compelling reason to look hard at why and how we waste resources.  

During our conversation, Gene jokingly called me an anarchist, due to my hyperbolic characterization of the Lucian Leape Institute's recommendations about re-inventing medical education in the US. The truth is, we need to put a little bit of the anarchist in each of us to work if we want to achieve meaningful change to our broken health care system.

Keep an eye on the man with the bowtie.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

 

HealthBlawg :: David Harlow’s Health Care Law Blog

Interview of Dr. Gene Lindsey, President and CEO of Atrius Health 

 and Harvard Vanguard Medical Associates

November 30, 2011

David Harlow:  Hello, this is David Harlow on HealthBlawg and I have with me today Dr. Gene Lindsey, President and CEO of Atrius Health, an alliance of 6 medical group practices in Eastern and Central Massachusetts with over 1000 physicians at 50 locations.  Dr. Lindsey also serves as President and CEO of Harvard Vanguard Medical Associates, the largest of the groups.  He started practicing at Harvard Vanguard’s predecessor, Harvard Community Health Plan, over 35 years ago and has held a variety of leadership positions in these and related entities through the years.  Gene, thank you for joining us today.

Gene Lindsey:  I’m glad to be here David, thank you very much for inviting me.

David Harlow:  My pleasure.  So you’ve had some firsthand experience practicing in the early days at one of the country’s leading HMOs - in fact, working with our soon-to-be-former CMS administrator Don Berwick. How are those days and that experience similar to the current environment where so many folks are focused on accountable care organizations and new payment systems?  Many have said these look a lot like capitation - though we’re not allowed to say capitation these days, and of course we have some new bells and whistles.  I wonder if you could speak to some of the similarities and differences and, since we didn’t fix the healthcare system for good back in the ’70s, what’s different this time around?

Gene Lindsey:  Well, that’s one of my favorite questions, David.  It is déjà vu all over again for me in many ways, in that there is certainly a sort of a pioneer spirit that’s associated with our organization now that feels very reminiscent of the spirit that existed when I joined the organization in 1975.  In fact, the term “capitation” was not a term that we used back then. Dr. Robert Ebert, who was the dean of the Harvard Medical School and through whose vision Harvard Community Health Plan evolved, used the phrase “prepayment” and it was his concept which we still share today: that fee-for-service medicine led to a fragmentation of care that was deleterious to the concept of wellness and to the preservation of health.  And so some of the terms that were popular at that time really focused more on health maintenance and so we call them HMOs, Health Maintenance Organizations - it’s too bad that these three-letter acronyms became four-letter words.  But I think that that was because of the fact that the larger market that wasn’t driven by Dr. Ebert’s vision of wellness but was more economically focused on institutional bottom lines sort of took the spirit of the process and diverted it in a different direction; but the early days of Harvard Community Health Plan included not only Don Berwick, but other people who have gone on and made huge contributions like Glenn Steele who was a surgeon here - he is now the CEO of Geisinger.  Glenn was a surgeon at Harvard Community Health Plan from the mid 70s through the late 80s.  There was Glenn Hackbarth, who is the current chair of MedPAC, who was one of my predecessors as the CEO of Harvard Vanguard.  So our organization has always been focused on the future and always been focused on what we can do in the moment to improve the health of the individuals who come to us for care.

David Harlow:  So you said the word “pioneer,” so I wanted to ask you about what you’re doing in the pioneer arena as we’re moving towards ACO development, and my understanding is that you’re moving in that direction on behalf of the organization.  I’d like to get your thoughts on the Pioneer ACO structure and how that relates to your present activities, or activities over the past year or so under the alternative quality contract with Blue Cross Blue Shield of Massachusetts.

Gene Lindsey:  Well I certainly am in support of the Affordable Care Act, in particular the part of the Affordable Care Act that’s looking at the development of new practice models through CMMI, and on various occasions we have had conversations with people at CMMI and CMS -  they’ve asked us for our input in how to create programs that will be potentially successful.  Their goal is obviously to simultaneously reduce the healthcare spend while improving the quality of the care that’s provided, and our organization literally has adopted as a major portion of its reason for existence the success of what the IHI has called the triple aim: better care for individuals and better care for communities at an affordable cost. 

The ACO movement, I believe, is the national extension of Dr. Ebert’s ideals.  We’ve been looking for an economic model that actually supports the fact that care that’s going to be most effective will probably be care that’s delivered in a variety of environments that are difficult to harness in a fee-for-service way.  I think that we have sort of gotten as far as we can get in terms of health improvement and efficiency paying for care only in a hospital or in an office, and the advantage that Dr. Ebert saw 42 years ago was prepayment, was that many programs that utilize time and energy of clinicians outside the office and hospital environment were going to be the fulcrum of what we could accomplish with patients.  Now in this moment that means trying to take care out of the office into the space where the patient lives, and our organization does that through things like a patient portal on our website that allows them to have direct communication with their physician or with other caregivers in our system. We’d like to have programs of wellness, behavior modification, things of that sort, that go beyond the scope of the 15-minute appointment, and actually often take our clinicians into the home for the homebound elderly in ways that are very difficult to support – again, if there’s a turnstile in front of the office that a patient has to walk through to economically support the system. 

So those ideas all feel to me like they’re exploratory and in that regard the concept of it being a pioneer effort seems very appropriate.  I think in the commercial area - you referred to the AQC, I believe - we’ve learned a lot over the last 3 years because what the AQC contract had as a very laudable direction was moving from volume-based reimbursement to value-based reimbursement.  And when it started for us we didn’t know for sure how to begin that journey but what we did quickly learn was – and I know that you have a prior relationship with Marc Bard – Marc preaches that the whole success will be on the basis of moving from a concept of individual effort to group effort.  He talks about moving from I to WE and that’s exactly what was necessary to be successful within the AQC - to begin to assemble groups of clinicians and healthcare professionals to look at rosters of patients, to look at results in a collective fashion, to put together programs that would allow outreach to people whose health needed particular attention in one area or another - congestive heart failure and diabetes have been certainly big areas of focus, we’re beginning to try to put together programs that help with mental health issues and also with the new epidemic of obesity.  So all of these programmatic approaches to problems that are shared by patients is what we refer to as population medicine and you can do more, and do more effectively, if you approach it in terms of programs - and those are all not possible to support very effectively in a fee-for-service system.  But if you can group the budgets from many patients together as a resource then in fact you can very efficiently fund programs that do promote wellness which, over a series of years, will reduce the total spend on healthcare because it’ll be avoiding a lot of long term complicated problems that are otherwise going to be an individual drain on the collective healthcare spend.  So we’re learning a lot - it’s a fun time - my only regret in this is that I’m old as I am and I don’t have that many more years left to go because I think the next 20 years of healthcare is going to be a really fantastic place to be.

David Harlow:  Yes, we are certainly in interesting times.  You said a couple of things I wanted to follow up on.  One is on the question of seeing results and system savings from the approach that you describe.  There was a recent piece in The New England Journal of Medicine looking at initial experience under the AQC which basically said, if I remember correctly, looks good, looks like we’re moving in the right direction, but further study is needed.  Is there any information that you could bring to bear on that observation from prior experience with Atrius, with Harvard Vanguard, with Harvard Community Health Plan, that would tend to support the idea that this is actually going to work?

Gene Lindsey:  Yes, in fact that article was based on just the very earliest results from the first year and I’m aware of the results of the next year already and almost two years’ more data, and the data has continued to improve.  We’ve learned a lot, our initial efforts for instance in the quality areas led to what I would say is the reproduction of a typical dose-response curve.  You had a sharp improvement that then began to plateau off, and that’s not a surprise because I think that each time you do something new it has an effect, and the effect will carry you so far towards the goal, but then you have to come up with what’s next that’ll get you a little further so it’s a very interesting concept of continuous improvement.  And in fact much of the results that we’ve achieved have been through the adoption of continuous improvement in the form of Lean process management so that the results that we’ve achieved so far are the results of a very fledgling organization with Lean and I’m very excited that as our process improvement skills increase, our ability to yield results within the AQC-type payment mechanisms will improve as well. 

What we’re really driving for is improved health. We talk about outcomes, and ultimately, to get the sort of outcomes we need and want, we have to go through a process of creating professionals who know how to affect behavior.  And then we have to have those skills connect with patients in such a fashion that the patients begin to be involved in improving their health.  And that is a series of adaptive changes that takes time and so I think that it’s a long climb, but we’re well on our way, and it is a good example of the phrase that you sometimes hear, which is “act your way into learning.” We really, every time we do something, whether it works or not, it clarifies to us what will lead to more success - and that’s really the adventure of it.  I think physicians by nature are heuristic, they like to solve problems, the people who work with us - our other healthcare professionals - have found that this adds a new meaning to their work; they all went into healthcare because they have strong empathetic tendencies, they want to see improvement, it’s been frustrating for them to be embedded in systems that don’t deliver results,  and the hope of being involved in something that actually approaches what they dreamed of when they went into healthcare - I think it’s been a personally regenerative sort of process for a lot of folks.  It’s sort of exciting to be around. 

David Harlow:  It sounds like it. I’m wondering as you’re talking a lot about retraining and redirecting and refocusing folks who have been practicing clinicians for a while, and earlier this year or last year the Lucian Leape Institute issued a recommendation to blow up medical education and start again, basically saying – look, we haven’t really addressed the issues of medical errors and cost and to do so we really need to reinvent medical education.  Do you see that as a reasonable approach? An organization like yours is of a size that can afford, in the scheme of things, to engage in this sort of reinvention, but most medicine is still practiced in smaller settings and folks can’t really do that.

Gene Lindsey:  I think you’ve thrown me enough to talk about for maybe 3 hours right there, in that last little soliloquy. Let me just begin with a first thought.  The core of the reason for the formation of Harvard Community Health Plan was to do just that - to change medical education.  Dr. Ebert envisioned it as a teaching practice. I’m a student of history, in a way, and I’ve gone to the Countway library archives, with permission of his wife, and gone down into the bowels of the building where all of his papers are stored and actually read what he wrote back in the ‘60s.  And he imagined then that much of the problem lay in medical education, in the fragmentation of the education that residents and interns and medical students received, where they learned about the kidney and then they learned about the heart and then they learned about the lungs, but they never learned about the whole person.  And he didn’t believe it that was possible in a hospital environment, which is very artificial in a way and he felt that the education needed to move into the ambulatory environment where people could actually see their patients closer to where they lived and closer to where the behaviors that created disease actually occurred.  So that’s not a new thought, and I think it is true that we need to be continuously redesigning medical education - in fact I read recently that some of our medical schools across the country, the one that I remember reading about, Jefferson Medical School for instance in Philadelphia, I think, has a program where they actually admit medical students to the hospital overnight so they can have the experience of being in the hospital to understand what it’s like from the point of view of the patient.  And I think that there’s been a lot of activity towards trying to introduce into the lives of medical students how to assess readiness for behavioral change and things of that sort.  So the progress is slow but it’s not non-existent - I do believe that it needs to continue.  I can tell you that every medical student who graduates from Harvard Medical School now has some sort of experience within Harvard Vanguard.  So it’s not as if we’re at zero; we may not be up to full speed but there is progress towards the issue of retraining, and revamping medical education, and I think Dr. Leape’s Institute is correct that process needs to - I assume that they’re using a lot of hyperbole in their statement and trying to --.

David Harlow:  I don’t think they said they’re going to blow it up - that was me -

Gene Lindsey:  That was you, okay -

David Harlow:  That was me -

Gene Lindsey:  Okay, so you’re the anarchist, okay - but it does need to continuously improve, that’s for sure, in this direction.  So I think that’s also a part of what’s encouraging in the moment.  The term that I’ve really come back to again and again and again are the issues of adaptive change both for patients and also for healthcare professionals. The ways in which we have worked have created a lot of understanding scientifically and yet, as Atul Gawande says, the issue is that we’re not without knowledge, we’re just inept in applying that knowledge. So I see this period of time, over the next 20 years, as the way in which we develop the systems that actually bring the fruits of the bench science and the medical technology that’s developed over the last 30 years to the benefit of more and more people in a more and more efficient fashion.  And that’s about organization and that’s about teamwork and that’s about redeployment.  It’s certainly true that as in many other industries we’re still shackled by the fixed investments that we have and so it’s about a process of, as a society, moving away from nonperforming assets and all of that is difficult because there is a sense of loss that’s associated with it, and that’s got to be balanced by a continuous reminder to ourselves of what it is we’re trying to achieve because that’s the only way that you can find the emotional energy to do the hard things that are necessary to get to a better level.  I don’t believe you can do it for money; I think you have to do it because you believe that it will be better for the community - for the same reasons that you plant flowers around your home: because you want it to look better and to be aesthetically something that provides you a gratification that just a focus on finance can’t ever bring.

David Harlow:  Well, hopefully, it has some of these desired results because otherwise we’re going to bankrupt ourselves.  I heard an interesting figure last month, or earlier this month, where somebody said that in order to support our expanding healthcare spend at the federal level, by 2050 our marginal tax rate will have to be 93%.

Gene Lindsey:  Absolutely.

David Harlow:  So we do have to focus on costs.

Gene Lindsey:  I was in a conversation recently with Jay Gonzales who is the Secretary of Administration and Finance for our State, Massachusetts. Right now we’re spending 41 cents of every dollar that the state collects as taxes on healthcare. You don’t have to be an economist to know that that’s probably not a good idea; it doesn’t leave us much left over for roads, for public safety, for schools, for the cultural things that add meaning to our lives.  It pretty much just makes it about supporting a hospital-based system and that’s really -- I don’t think, I can’t think of anyone who would prefer to go to the hospital versus the symphony.  It’s just not right – now, so let me clarify something: all of the stuff that I’m talking about is not in my mind a sense of adding more dollars to the system, I think that I’m a total proponent of the concept that we have allocated enough of our economy to healthcare we’re just not spending it effectively and efficiently.  If there is any phrase that reverberates through my mind on a daily basis it’s efficient, effective, and that’s the thing that’s appealing to me and if you remember those are two of the six domains of quality.  We have constructed our organizational activities around what the IOM called the six domains of quality, the most important of which is patient-centricity.  We need to design the system to be a benefit to the people who come to us for care - they are our reason for existence. That’s not been true in the past. In the past we’ve designed it for a lot of other reasons, but not always and specifically to benefit the care of people.  Sometimes it’s for the convenience of physicians, sometimes it’s for the perpetuation of august institutions - whatever it’s been, but it’s not always been that the patient’s been at the center of it.  Lucian Leape, whose name you introduced earlier, focused us on safety. The other issues - just quickly -  care needs to be timely if it’s going to be safe and patient-centered, it needs to be efficient and effective if we’re going to have a society that continues to exist, and the last and most important of the domains is it’s got to be equitably delivered -- and probably that has been the biggest conundrum for our country.  How do we get the last 15% of our citizens covered in a fashion that doesn’t destroy the economics for the rest of us and that in and of itself is the most compelling reason to look hard at why and how we waste resources. 

David Harlow:  Well thank you Gene.  I think I’d like to end it there wrap it up there and you’ve given us a lot to think about today and again I thank you for joining me on HealthBlawg. 

Gene Lindsey:  Thank you David.  I really appreciate this opportunity.

David Harlow:  I’ve been speaking with Dr. Gene Lindsey, CEO and President of Atrius Health and Harvard Vanguard Medical Associates.  Thanks again, Gene.

Gene Lindsey:  Thank you David.

July 07, 2011

Regina Herzlinger speaks with David Harlow about health care reform and other health care innovations

I spoke with Harvard Business School professor Regina Herzlinger this week about health reform – the good, the bad and the ugly – touching on ACOs and demonstration projects under the Affordable Care Act; innovations coming down the pike in the private sector either because of the law or because of market forces; social media in health care; and two key fixes to the ACA that she believes are absolutely necessary in order to make it work, or work as best it can.

First of all, she expressed her delight at the passage of a federal law nudging us ever closer to universal coverage, combined with dismay at its failure to address rising costs (noting that we're looking at policies yielding an accumulated Medicare deficit of $90 trillion, as compared to an annual GDP of $12-14 trillion) and at the paltry fines to be leveled at noncompliant employers that do not offer health insurance as required. As rational actors, she expects that more and more employers will simply opt out of the health care insurance market one way or another: gaming the system to avoid coverage requirements, paying fines that are less costly than insurance, and/or handing employees cash to put towards their own health insurance rather than arranging for a group plan, leaving the range of future health plans to be hammered out by insurers, state health insurance exchanges, and individuals. This outcome will be to the detriment of the insurers, who will be selling policies to individuals rather than groups (and, I must point out, whose underwriting practices will be constrained in the face of community rating mandates in the ACA); some of these individuals will be given the cash needed for insurance premiums by their employers. Herzlinger cited a recent McKinsey survey of employers (though its methodology and conclusions have been roundly criticized by some), endorsing its prediction of a widespread flight by employers from the field of employment-based health insurance.  Some see health insurance exchanges as a market opportunity; consider Bloom Health, which has launched what it calls the nation's first private health insurance exchange.

Herzlinger said that she sees the Medicare shared savings program (aka the ACO program) as a wholesale failure, unworkable because of the assumption build into the model that a single organization can effectively and efficiently manage all care for a population of patients. Her preferred approach (as outlined in her 2007 book, Who Killed Health Care?) is the development of specialty care organizations ("focused factories," anyone? She came up with the term a while back) focusing, say, on CHF – including all key CHF comorbidities. I am not convinced that this is a complete solution, since patients arrive as bundles of symptoms, not labeled with diagnoses, so there is a significant role to be played by primary care providers and others who do not necessarily fit into the focused factory model. However, there is merit to the notion that a system of providers and payments may be cobbled together in a manner different from the approach laid out in the proposed shared savings program regulations. (See my earlier post on Jeff Goldsmith's critique of the ACO concept, in which I suggest that his ideas should be welcome in the world of commercial ACOs; in addition, given the tremendous felxibility shown by CMS in promulgating the proposed ACO regulations -- for example, downside risk added to the mix despite being left out of the statute -- perhaps there will be a place for Goldsmith's proposed differential payment schemes for PCPs, EDs and focused factories.)  Despite the narrowing of patient choice due to the development of commercial proto-ACOs and other payor-provider alliances, Herzlinger has yet to throw in the towel on her vision of consumer-driven healthcare. She is focused on the notion that, as employers move in the direction of providing additional cash compensation to employees in lieu of group insurance plans, consumer-driven healthcare will thrive, since consumers – not employers – will be the purchasers of services, and providers, despite being squeezed by payors, will need to be more responsive to consumer demands.  Wearing my Society for Participatory Medicine hat, and as a patient myself from time to time, I like this line of thinking.

I also tended to agree with Herzlinger's take on health care social media as a critical tool in the armamentarium, to be used by providers and patients in order to improve health care for all.  (If interested in further reading I commend to you a recent piece of mine on issues surrounding the use of social media by health care providers.)

Finally, in response to my inquiry about what aspects of the ACA she expects to see amended in the near future, Herzlinger shied away from some of the issues being debated today (e.g., significant changes to the Medicaid program in order to forestall budgetary disaster at the state level, or waivers of the federales' state-level health insurance exchange structure, otherwise not obtainable for the first three years under the law, to assist early adopters like Massachusetts) and focused on two specific issues:

(1) The need for an amendment to the tax code so that cash payments by employers to employees, intended to be spent on health insurance premiums, will not be taxable as income to the employee (in order to mirror the economic effect of the tax treatment of health care benefits); and

(2) The need for better transparency in health care, so that patients/consumers can have as much information available to them as they would when it comes to making a purchasing decision about any big-ticket consumer item (car, refrigerator, etc.), including, for example, outcomes quality data.  We closed by agreeing that Todd Park has been doing a bang-up job in granting access to the tremendous store of data held by HHS, and hoping that his office would continue to expand its offerings.

Please have a listen to part of our conversation -- after extending a health insurance supermarket analogy just a little too far, technology struck back and deep-sixed part of the recording.

The audio file of my interview with Regina Herzlinger is available for download/podcast (the first 10 minutes or so, anyway; the rest was eaten by gremlins).

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

January 16, 2011

David Harlow is Guest on Lawyer2Lawyer Podcast on Massachusetts Health Reform Issue

LTN_RSS_2009_144x144 I am a guest on the latest edition of Lawyer2Lawyer, a podcast talk show on the Legal Talk Network hosted by fellow Bay State blawger Bob Ambrogi and Golden State lawyer Craig Williams, discussing aspects of the Massachusetts health reform plan, national health reform, and the lawsuit brought by their other guest, Michael Merlina, who is representing himself in seeking to overturn the denial of his application for a hardship exception from the individual mandate portion of the Massachusetts law.  He and his wife are being fined a little under $2000 because he says they can't afford a policy that would cost them a little over $5000.  Thus far, he reports that the state agency that denied his application has been ordered to review it again and provide a detailed response.  To listen to the show or download the podcast, go here.

Interestingly, Merlina is not challenging the individual mandate, just the application of the hardship exception rules to his situation.  As I have noted in the past, the Massachusetts law is theoretically open to challenge as being pre-empted by ERISA, but the realpolitik behind the coalition that ensured the law's passage has eliminated the risk of that sort of broad-based challenge -- at least it has to date.

Even more interesting, if you think about it, is the fact that the principal argument against health reform at the national level -- i.e., the individual mandate violates the Commerce Clause because stuff like this is supposed to be left to the states -- runs smack up against the principal argument against state and local health insurance mandates -- i.e., the mandate is pre-empted by ERISA because the federal government has claimed the entire field as it relates to health insurance.  (And, um, let's not forget that the federales get to have laws like ERISA in the first place because of ... the Commerce Clause!)  Thus, carried to their logical conclusion, these arguments mean that neither state nor federal government may impose an individual mandate.  If that's the case, then, to quote the Immortal Bard, Something is rotten in the State of Denmark (and Massachusetts, and Maryland, and California . . .).

Meanwhile, back in D.C., the Supremes recently let stand (by a 7-2 vote) a lower court ruling permitting intrastate regulation in the face of a Commerce Clause challenge (state law banning body armor possession by convicted felon survives challenge asserting in-state possession of body armor has nothing to do with interstate commerce).  The readers of entrails out there seem to think this bodes well for the health reform law (except for those who don't) when the challenges to the individual mandate come before the Supremes, probably in a year or so.

Bob posed the question that should be on everyone's minds as we get deeper and deeper into the Massachusetts model on a national scale: How could we structure this all differently so that everyone gets health insurance and there aren't so many rules, categories, exceptions, and cracks to slip through?  Well ... a single payor system would do that, and would save a bundle on administrative expenses, to boot.  Will that ever happen in this country?  Not any time soon.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

October 13, 2010

Massachusetts State Rep. Ruth Balser speaks with David Harlow about health reform, the Massachusetts experience, and potential implications for the federal effort

The Massachusetts health reform experience is often cited as a model for key aspects of the federal health reform law - the Affordable Care Act.  To gain some insight into the origins of the Massachusetts health reform law, and to explore current experience with implementation, I spoke with Rep. Ruth Balser, a legislative leader and supporter of the health reform laws in Massachusetts.  

The audio file of my interview with Rep. Ruth Balser (about 25 minutes long) is available for listening or download

A full transcript is at the end of this post (and in the linked Massachusetts State Rep. Ruth Balser interview transcript).

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


HealthBlawg :: David Harlow’s Health Care Law Blog

Interview of Massachusetts State Representative Ruth Balser

October, 2010

David Harlow:  This is David Harlow on HealthBlawg, and I have with me today Representative Ruth Balser, a state legislator in Massachusetts.  Representative Balser is a clinical psychologist by profession.  She’s a former Alderman in the City of Newton, Massachusetts and a leader in Massachusetts when it comes to health reform.

She’s a state house veteran.  She’s been on Beacon Hill for over ten years and has held leadership positions in the state legislature in various key committees and has been a prime mover behind Massachusetts health reform legislation.

Representative Balser, thank you very much for joining us today on HealthBlawg.

Rep. Balser:  Well thank you.  I’m happy to be here.  Thank for that nice introduction.  I think it’s more fair to say that I was one of a number of people who supported health care reform efforts.  The leaders at the time of course were the Speaker of the House at the time and the Senate President and the Governor, but I was a committee chair on the Joint Committee on Mental Health and Substance Abuse at the time.  I did pay particular attention in fact to protecting mental health and substance abuse within the health care reform efforts.

David Harlow:  Yes.  So that’s often an area that is ignored or left behind or gets short shrift in the discussion.

Rep. Balser:  Right.

David Harlow:  I wanted to start off with a question about how the legislation in Massachusetts came to be.  How it came to focus on access.  There are really three key issues that people keep talking about, the three-legged stool of health reform:  access, cost, and quality.

A decision was made early on in Massachusetts to address access first.  I’m wondering why did we start there?  How are we doing in terms of addressing access and also the other areas of cost and quality?

Rep. Balser:  The fact that we focused on access had to do with reapplying for a Medicaid waiver to the federal government.  We actually had to address access in reapplying for the Medicaid waiver, in my memory, so that became the initial, really financial reason for addressing the access issue.

But once the state embraced that, it really did embrace it.  There was a shared goal on the part of the legislature and the governor to try to get as close to 100% health insurance coverage as possible.

We’ve been really successful.  We have 97% of the people of Massachusetts who have health insurance plans.  I believe we lead the nation.  I believe that’s the best rate across the country.  So from that point of view, our efforts were tremendously successful.

David Harlow:  So that was based on the legislation in 2006 that’s led to that rate of coverage which I very believe that is the highest rate nationally.  And then there was another bill two years later that was intended to address cost and quality issues as well.  How has that bill been implemented?  Or what can you say about that?

Rep. Balser:  Well, first of all, there were some quality issues which we addressed in 2006 as well.  We can get back to that a little later in the conversation if you’d like.  And the more recent legislation on cost which we actually also just did this session.

In 2010, we just did some cost measures but I think it’s agreed that it’s only the beginning.  I think there’s a pretty universal agreement that the rising cost of health care is the biggest challenge that we face.  There’s a lot of discussion about trying to grapple with that going into next session.

There were some market reforms this past session.  For instance, allowing small groups, small businesses to associate in groups which might help bring down the cost.  The governor actually did some capping of rates.  But I think it has been agreed in Massachusetts that we’ve been much more successful on the access side so far than on the cost side.

David Harlow:  Yes.  So in the small group reform legislation, there were some provisions that also address moving in the direction of bundled payment rates.  It’s really sort of, from my perspective, it looks like baby steps in that direction.

Following up on some of the agency and legislative hearings and reports that were issued over the past year, how do you think that will be going?  Do you see that as a direction that we need to move in - the bundled payments?

Rep. Balser:  Well, I guess to be frank, I haven’t weighed in on a particular strategy yet.  I think first of all, your reference to baby steps would be agreed.  I think people at the legislature know that they’ve only just begun to tackle this.  I know if you listen closely to the gubernatorial race that’s going on, there’s debate going on about payment reform which I think will be the hot topic next session.

One of the reasons why our health reform of 2006 was as successful as it was and why passage was so much easier here in Massachusetts than what happened nationally, was because all the stakeholders were brought to the table.  The insurers, the providers, consumers, and legislators all came together and developed a plan which eventually they could all buy into.

I think what’s going to happen - that has not yet happened on the payment issue.  I think that’s what’s going to have to happen next.  There’s going to have to be some real leadership in pulling together the stakeholders.

Right now, you have a blame game going on with the insurers blaming the medical community, and the medical community blaming the insurers.  I think we are going to need to see some kind of process similar to what happened a few years ago when everyone came to the table and reached a plan that they could all buy into.

David Harlow:  Is there a need, do you think, for an external crisis?  You mentioned in ’06, the issue was a deadline for getting a Medicaid waiver from federal government.  Is there some external crisis or are we in the presence of one already given the cost?

Rep. Balser:  I’m not aware of something analogous to the Medicaid waiver but yes, I think everyone agrees we’re in the middle of a crisis.  I think the cost of healthcare is unsustainable.  It’s breaking government.  I mean at the municipal level, you hear about it.  At the state level, you hear about it.  Small businesses complain that it’s breaking them.  It has a huge impact on the economy.  So I think there is definitely a sense of crisis.  Although there isn’t a deadline they way there was and I guess that was helpful.  It’s always helpful to have a deadline.

David Harlow:  Sure.  So one deadline that recently came and went was the end of the federal and hospital fiscal year and that seems to have brought the dispute between Boston Medical Center and the state forward, and resulted in some resolution.  I don’t know if that’s going to be a final resolution or how it affects other hospitals and their debates with Medicaid.  But there’s some additional federal Medicaid money now available for Boston Medical Center, Cambridge Health Alliance.

It seems to me that’s not a sustainable way of addressing these issues with stop-gap additional funds.  Do you have any sense about that being a step in the right direction?  Impetus for more structural change?  Or what can we take away for other providers from this experience with Boston Medical Center?

Rep. Balser:  You know, I’m not such an expert on that, but I think what everyone’s talking about is payment reform.  That’s the news: changing from fee-for-service to global payments.  That’s one thing.  Well actually that’s one thing Governor Patrick is talking about.

Then you hear candidate Charlie Baker talking about transparency.  He’s talking about just revealing the different payments that insurers and different provider groups are negotiating.  He’s saying that if you just laid all that out on the table, that would lead to some change.  Part of it is what’s going to make a difference is who’s elected governor which we’re in the middle of the campaign about.

David Harlow:  Now Charlie Baker, a couple of decades ago, was involved in working to dismantle the rate setting structure in Massachusetts.

Rep. Balser:  That’s right.

David Harlow:  Do you see his current stance as being consistent with that?  Is transparency going to be there just for the goal of developing more of a market for health care?

Rep. Balser:  Well, I’m certainly a supporter of the governor, so I don’t know if I’ll give a fair- but I think you’re right.  He was part of breaking that down and that certainly has contributed to the problems that we’re facing.

David Harlow:  So I take it you see this is not necessarily something that could be solved by throwing it to the free market?

Rep. Balser:  Oh, no, absolutely not.  The government is going to have to play an active role in negotiating some changed relationships between the payers and the providers.  That’s going to have to change.

David Harlow:  Do you see that role and that relationship leading to any resolution in the cost inflation side?  We talked a little bit about different types of approaches to payment.  Is that something that you see as being developed by regulation?  Will there be a menu of approaches to payment that could be offered by the state government to the provider?

Rep. Balser:  Perhaps.  You know it’s interesting when, you know, this is clearly a tougher problem to solve than the access problem.  In 2006, there was actually explicit conversation about how we were not going to tackle the cost problem yet.  It’s interesting and at that time, what we were debating, I mean it’s funny because the model we set up obviously had implications for cost.

There were a few different models one could choose from to set up a healthcare -- we might talk about the old Dukakis model.  Maybe we should walk through the steps of the model so that we can, to get to the cost question because what had been tried in years past was this Dukakis model which was an employer mandate, requiring employers to pay.  And that never got implemented.  The business community rejected responsibility.

Then there were many years where there were, at least on the liberal side of the political spectrum, people advocating for a single payer system.  In other words, government taking the responsibility for who would pay because the debate was always who would pay, not how much we would pay.

David Harlow:  Yes.

Rep. Balser:  So first, it was going to be the employers.  Then there were some folks who try to argue that the government should pay.  And there were hopes that at least maybe on the national level, we could expand Medicare.  That issue got revisited with the public option debate.

Even here in Massachusetts, people were saying perhaps we needed to do a single payer first at the state level.  What we did in 2006, was decide to develop a hybrid system that would have three payers.  One would be employers, another would be government, but the third and this was really the Republican contribution which the Democrats embraced, was the individual mandate.

So when we talked about who was going to pay, the model that we developed was that again, a three-legged stool, which is often the image.  It was going to be employers, government, and the individual.  That was the breakthrough was that we broke out of this argument, would it be employers or would it be government or would it be a combination?  But the final breakthrough was actually to add the individual mandate as part of that.  And that’s the Massachusetts model that then got embraced nationally.

I should just mention for those who don’t remember, this was debated when Hilary Clinton and Barack Obama were competing for the Democratic nomination.  It was actually Senator Clinton who was pushing for the Massachusetts model and the individual mandate.  Senator Obama at the time rejected it.  Although later when he became president, he embraced and supported that.  So now we have that at the national level.

But fast forward now, I think this is what makes the cost argument so complicated because the cost on individuals has gone up.  The cost on businesses…I mean businesses got off easy in our Massachusetts health plan.  We in the House had wanted a larger employer contribution.  The Senate and the governor, the former governor actually didn’t want employers to have to make a contribution at all.  We settled on a compromise where the employers pay a much smaller contribution than we in the House would have liked.

But I think someone will have to -- maybe you’ll help me figure this out.  But I think that model that we set up, made it all the more complicated to now tackle the problem of cost.

David Harlow:  Because of the shared responsibility for coverage?

Rep. Balser:  Yeah, well and then each sort of resisting taking the full responsibility.  Yeah, you’d think maybe it would make it easier because you had different people contributing or different forces contributing.  But you know, let’s say the government was responsible like with Medicare or whatever, well, then you would just tackle it as a federal budget problem.  The businesses certainly feel they can’t in this economy afford to manage to this rising cost and individuals certainly feel they can’t.

David Harlow:  The Massachusetts experience has been both praised and vilified nationally as the national debate continues.  I guess I’m wondering whether there are particular areas of the Massachusetts experience that you would highlight as being praiseworthy.  We spoke briefly about the fact that we’ve achieved near-universal coverage…

Rep. Balser:  Right.

David Harlow:  …and an uninsurance rate on the order of two or three percent of the population which is a vast improvement.  One of the criticisms of the plan early on was that we had not anticipated how many people would sign up for the various types of programs and that the cost was too great for the state to bear.

Rep. Balser:  But the state has maintained its commitment and has covered the cost.  Well, there were a few problems from my point of view.  We always knew once we embraced this model of the individual mandate, we always knew that would only work so long as there were sufficient resources and commitment to subsidizing those individuals who couldn’t afford the mandate.

So one reason for the individual mandate was because a significant portion of the uninsured were healthy - one group amongst the uninsured for instance were healthy young adults, people who could afford it actually.  Forget the percentage but significant numbers of relatively young adults who are healthy and who had good jobs and were making good money but just didn’t choose to buy health insurance because they [overlap]

David Harlow:  Right, our young invincibles.

Rep. Balser:  Yeah, that’s right.  So that was the model for why it would make sense to have an individual mandate.  Someone’s making a young, single adult who’s making $60-70,000 or something about like that.  They can afford to pay for some health insurance.  Plus, it helps the risk pool if you have more healthy people in it.  And that the idea was that it would also bring down the cost for everyone.

But it was also clear there would be people whose employers did not provide health insurance for them and had made more money than allowed them to be eligible for Medicaid, but who would not be able to pay the full amount of a private health plan.  So the idea was that the state, the public sector would subsidize part of the cost of their health plan.

We always knew the success or failure of the program would sort of rise or fall with whether we could appropriately subsidize those folks because otherwise, the individual mandate becomes really unfair.  You force someone to pay for something they can’t afford.

So what happened was the numbers the first year or so really didn’t work totally and so the state ended up exempting a bunch of people from the mandate which of course defeated the point of universal coverage but we knew it wouldn’t be fair to require them to pay what they couldn’t pay.

But there’s still the devil in the details.  The premium’s cost has gone up and there are a lot of folks, the working poor who are out there working two full-time jobs and raising kids and who can’t afford.  So that’s a problem.

I do remember during the presidential debate when Senator Clinton defended basing the national model on the state.  She pointed out that the federal government would have more resources available and probably could do the right thing as far as subsidizing people who couldn’t fully afford it.  We’ll see how that ends up playing out with what the Congress did. 

You were asking how has it worked out.  So that’s still a problem is that the resources aren’t there to really get the right amount of subsidy for people who are struggling to pay, the individual.

The other problem was that to keep plans affordable, we ended up supporting and by we, I’m being generous because I actually opposed this.  But we ended up allowing high deductibles.  I actually had filed some amendments during the debate to limit the increase in the deductibles and those failed because that seemed like a way to bring down the cost of the plans.  But when you have very high deductibles, people end up not really getting services because they can’t afford  the outpatient care to get up to the level of the deductible.  So that’s been another problem.

David Harlow:  Right.  There’s some research that has shown that people who could use the combination of high-deductible health plans and health savings accounts the most are the people who don’t use them.  They aren’t able to put the money away or are unwilling to pay those first dollar expenses for services that would be helpful, maybe preventive services.  So that does seem to be a problem.

Rep. Balser:  Right.  But I will tell a story if you’re interesting in a role I played that I’m actually particularly proud of which is when the process first began, and we were talking about how to get to universal coverage, of course different people had different ideas.  Just like now we’re going to have different ideas about how to manage the cost.  Then we had different ideas about how to provide access.

Governor Romney at the time, released his bill first.  One of the sentences in his bill was that all new health plans created under his plan would be exempt from all the current state mandates.  And so in other words, he wanted to insure people by creating what I would call cheaper and less adequate health plans because they would be exempt from the mandates.

I was particularly concerned about the mental health and substance abuse mandates but there was a whole list -- I think there’s more than 20 mandates that over time have passed.  You know, that the legislature at one point or another felt it was important that all health plans be required to cover these different aspects of healthcare.  So there was this little sentence in his bill that would have set all these new plans could be created that would really result in people being under-insured.

So I was watching for this and the Senate then came out with their plan and it had the same language in it.  And then the House and it goes to the House and the House came out with a plan that initially had that same sentence in it which I was watching for.  I was chairing the mental health and substance abuse committee at the time and I was watching for this issue because I wanted to make sure that the insurance would be comprehensive and include good mental health and substance abuse coverage.

So when I saw that same language was being mirrored, I filed an amendment in the House to remove it and to say that any new plan created under health reform would have to live up to the same mandates that all our previous plans had.  And that was quickly supported in the House.  The chairperson of the health care finance committee who was mainly overseeing this supported me in that.  Speaker DiMasi also very quickly supported it.  So the House went on record saying that if were going have universal health care, we wanted to make sure that health care would be comprehensive.

So in terms of your original point about the three-legged access, cost and quality, we were trying to deal with both access and quality.  And the House led the way on that saying if we’re going to cover everyone, it’s got to be comprehensive, quality insurance.  And the Senate then embraced it and Governor Romney did sign it that way.

David Harlow:  And now we’re facing a similar issue in the national front as some large employers and others are trying to find exceptions to allow for these mini-plans to be seen as adequate under the national rules.  So the conversation continues.

Rep. Balser:  Right.  You know it’s tough.  It’s always tempting I guess for people to cut cost by reducing quality.  What we were trying to say around that issue was we got to try to cut the cost through perhaps market reforms or changes in the way you know, payment reform but not in terms of reducing quality.

David Harlow:  As you said, that remains front and center and that’s the next set of issues to be addressed here.

Rep. Balser:  Right.

David Harlow:  Well thank you very much.  I’ve been speaking with Representative Ruth Balser, state legislator in Massachusetts on the question of health reform and the Massachusetts experience and what we can hope to see in the future in Massachusetts and on the national stage.  Thank you again Representative Balser.

Rep. Balser:  Thank you.  Bye now.

June 20, 2010

Healthymagination VP Mike Barber speaks with David Harlow about GE's investment in health care and health care improvement

What if you could improve health care across the three intransigent parameters of cost, access and quality by 15%?  That's the challenge GE has set out for itself in the form of its current five-year Healthymagination campaign, and it's investing $6 billion in the effort.  I caught up with GE's VP for Healthymagination, Mike Barber, recently, and I invite you to listen in on our conversation about GE's efforts in the US and globally, within GE's health care business unit and beyond, to roll out this major investment -- which, obviously, GE expects to yield a return in the future.

The audio file of my interview with Mike Barber (about 20 minutes long) is available for listening or download

A full transcript is at the end of this post (and in the linked Mike Barber, VP, Healthymagination, GE, HealthBlawg interview transcript).

One year into this five-year campaign, GE has issued its first Healthymagination annual report.  Check it out; I invite your comments and observations.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


HealthBlawg :: David Harlow’s Health Care Law Blog

Interview of Mike Barber, VP, Healthymagination, GE


June 10, 2010

David Harlow:  This is David Harlow on HealthBlawg and I have with me today Mike Barber, who is the VP for Healthymagination at GE.  Hello Mike, and welcome to HealthBlawg.  

Mike Barber:  Hi David.  Thanks for having me.

David Harlow:  Mike, I’ve read the Annual Report that was put out recently for Healthymagination at the end of first full year of the operation.  But let me ask you if you could provide some highlights for our listeners and readers.  First up, what is Healthymagination and what are the accomplishments in the past year that you see as having the greatest promise either on their own account or sort of as first or baby steps towards some greater future promise?

Mike Barber:  Sure.  A year ago, GE launched Healthymagination.  We view it as a strategy and we’re pledging to deliver better health for more people.  We want to do that through lowering cost through technology and innovation, improving access and improving quality.  So, it’s a long-term commitment.  Right now, we’re looking at some goals that we’ve put together between now and 2015, in terms of what we’re going to do.  That includes investing about $3 billion in product development targeted at products which improve cost, quality and access; $2 billion of financing looking at health care technologies, financing solutions in underserved markets; and $1 billion in technology and content which would be related to reaching consumers in new and different ways, whether it be NBC Universal content or through water technologies and other properties that are part of the GE portfolio.  We want to improve each of those by at least 15% and as you said, we’ve just completed our first annual report and we’ve made some key progress. We’re very excited about the progress that we’ve made, that investment -- it’s been about $700 million in R&D towards those health innovations, then we’ve validated 24 products, and when I say validated, we have an outside firm which comes in and takes third-party, peer-reviewed information to see in fact, did this product meet the claims in terms of improving cost, quality or access by at least 15%.

So, we have 24 of those products that have been reviewed, so we’re well on our way to target of up to 100 innovations by 2015.  And then we have financing, a stimulus simplicity program to help hospitals, doctors who want to start down the IT journey earlier; as you know with the stimulus package, there’s been incentives that have been identified, some of those incentives start in late 2010, 2011 in terms of doing that.  We want people to start taking and getting their value out of IT immediately.  So, we’ve come out with a program to provide them bridge loans until those incentives become available, to be able to start using IT systems right now, we guarantee that we’ll meet any meaningful use criteria that comes through the regulations.  Also, we have a $250 million fund, equity fund that we’ve launched, the Healthymagination Fund, where we’re looking to invest and co-invest in different start-up companies that are in relevant spaces strategically for GE Healthcare, as well as good value for the investment dollars.

David Harlow:  I’ve read about an initial investment through that fund. Could you tell us a little bit about that company?

Mike Barber:  That’s right.  Cardio DX is a company that we’ve invested in and it is one that is in the area that we call high-value diagnostics, areas where there’s in-vivo tests that can help stratify patients in terms of what follow-up diagnostic treatment is most appropriate and so in the area of cardiology is where the Cardio DX team is focused on initially, and they have some unique algorithms and biomarker tests in the area of cardiology that we feel are very exciting and then can marry and provide better overall outcomes and cost, if you look at what again follow-up tests and vivo tests that might be necessary through imaging and then into treatments for patients.  So, combining the strengths of in-vivo and in-vitro diagnostics is something we’re very excited about.

David Harlow:  Now you mentioned earlier that you’re looking for an improvement in cost, quality and access by 15% and you mentioned some third party verification, so you’re looking at improvements on a particular product, on a particular service?  How are you measuring this 15%?  What’s the idea there?

Mike Barber:  The way that we looked at this, really through the eyes, the external eyes.  So, it’s not about just what we do from a product perspective, but how does our product enable the ability to improve the cost of a overall procedure or the continuum of care a patient might have by 15%.  So, if you’re talking about having a better diagnostic or a diagnostic which can lead to a more targeted therapy, where you can differentiate and understand that if a person has cancer, what stage their cancer is at.  Therefore, being more pinpoint, more targeted at what their therapies are, as you know, there’s many cancer treatments that are coming out that are very expensive and they don’t work on everyone in the population.  So, being able to identify those patients or those conditions where this procedure would work versus ones that wouldn’t are ways that you can reduce the overall system cost and that’s what we’re looking at when we talk about cost reduction.  

David Harlow:  You mentioned there a couple dozen innovations that have been certified in this first year.  I wonder if you could give a couple of examples.

Mike Barber:  We have an example of a health care IT product which helps with decision support or looking at the appropriateness of imaging procedures, so a hospital administrator can use it to see based on the issues, the symptoms that a patient has, are the appropriate kinds of tests being run from an imaging perspective?  There’s another one looking at asset management and if you think about a hospital and all the different infusion pumps and other kinds of devices they have that are necessary and we have RFID tracking along with software to help manage and so we’ve had customers’ CFOs show this outside firm their operating statements that show that net of purchasing this software they’re able to save on their operating expenses by 15% in the area of procurement as well as maintenance for really understanding where those assets exist and how they can be best leveraged.  Products like our Discovery CT750 has been launched looking at reducing the dose in a CT scan by over 50%, across body and heart procedures where we’ve had clinical studies done to show that the diagnostic confidence and the speed of diagnosis that the radiologists use, the clinicians use, stays the same the same, but in fact being able to have 50% less dose to the patient; and then for access products like a handheld, portable EKG machine which can travel to the patient, so it’s leveraged in many developing countries where you know if somebody traveling and they need an EKG, they might have to, you know, travel several hundred kilometers to a hospital kind of setting, but being able to have this in a battery-powered, portable, very rugged package, it’s something that can exist in rural villages and a clinician can carry it out with them as they go see the patients.  So, bringing healthcare technology which is important such that somebody in a rural village has the right symptoms, sometimes they get the EKG and then back and should travel for a follow-up care.  They travel 50 or 100 kilometers as necessary but those that don’t need or can be treated locally don’t have to do that.  So, those kinds of products have been shown to increase access to health care technology.  

David Harlow:  Great.  Let’s talk a little bit more, if we could, about the diagnostic imaging innovations, similar to what you just described, that are detailed in the annual report, focused on India and China in particular. Do those in-country efforts hold promise for lower-cost innovations in the US?

Mike Barber:  Potentially, it’s clear at this point we’re focused on what are the needs of those markets like you talked about, India and China, where access to health care professionals might not be the same as it is in a developed market, looking at what is again the essential elements which are needed and it’s focused around that, but clearly, we can see a day where you can leverage some of those technologies and innovations and put it into a package that could be appropriate in the US or other parts of the world, something that might be able to be in a physician’s office versus being in a hospital setting that can provide targeted kind of diagnostics, that could be appropriate.   I talked about that EKG machine, there is a version of that, that is under development, that could be in a physician’s office or be in a rural clinic in the US, where it could be appropriate.  So, even in places in the US and Europe and developed markets you find that urban settings versus rural settings there are different needs that can be there and so these products that are developed primarily for India and China, we do believe could have a place in the US in certain segments of the health care system.

David Harlow:  Could you explore further the degree of coordination or integration across business units in implementing Healthymagination.  It sounds like it’s not simply an effort of GE Healthcare; you mentioned GE Water and other business units as well.

Mike Barber:  That’s correct.  It’s really looking at the health sector as a mega market and how can we leverage the various assets of the General Electric Company in that market, for instance.  So, one of the biggest that we’ve looked at it is, how do we reach consumers in new and different ways and clearly the NBC Universal team has a lot of expertise and ability to do that.  So, we’ve leveraged that platform and we’ll continue to leverage that platform to understand that.  They’re launching a campaign on nutritional literacy, something that’s important for all of us to understand and so will be leveraging them in that area.  As you mentioned GE Water, you think about the foundation of health – it’s clean water and so wastewater reuse technology, as well as, you know water filtration are things that we’re looking at with that business.  Our research labs are looking at new and innovative ways to, again, in the diagnostics space and life sciences space, as to what’s possible how do, you know, leverage our various technologies which can be in a developing market to provide better access to care again to people that are in those markets.  And then, GE Capital.  GE Capital, we financed MR and CT machines for many years but can we leverage the capital business to look at, you know, financing of IT systems, something that we’ve started to do, as well as look at new markets like community health clinics and other places which have a different profile than some of our standard customers, but again, could be a way to leverage the capital infrastructure to provide better access to care for technologies and products that can serve patients and consumers.

David Harlow:  Right.  And you mentioned earlier that there is a $2 billion commitment to serve as bridge financing for HIT systems.

Mike Barber:  That 2 billion is not all for HIT.

David Harlow:  Oh okay.  What other sorts of technology would be financed through that fund and do you see that as a revolving fund or sort of short term bridge loan as you mentioned ?

Mike Barber:  No, there are various aspects. The $2 billion commitment is in total from what we call our GE Capital portfolio.  Of that, there is a $250 million fund which was started and that fund will look at technologies which are in the life sciences space, health care IT space or the diagnostic imaging space.  So, the bulk, the rest of that, other things that we’re looking at is the bridge loans that we talked about is something that we launched last year and again, it will have a limited life because the incentives will then be available directly from the government, but we looked at that and then we’re looking at expanding the portfolio of financing that we do to community health centers, we’re looking at more financing on the international side of the business, potentially looking, you know, at markets which are growing and doing local currency financing as appropriate in some of those markets.  So, given this is a long term commitment and journey between now and 2015, everything is not defined today, but as we learn, as we really get into these markets and understand what’s the need, what the needs are and what are the key issues we have to solve, we’ll adopt and adapt but the commitment at the top levels is one that we’re going to reach.  

David Harlow:  So, you’ve set yourself quite an ambitious goal for a 5 year, 6 year time horizon.  Particularly, I’m just thinking about the commitment to improve along the parameters of cost, quality and access which is something that payers, providers and governments have been struggling with for decades and I’m wondering what, I guess to put it bluntly, what gives you the confidence that you can be successful in this arena where success has eluded so many people for so long.

Mike Barber:  Well, there’s confidence and this isn’t GE standing alone doing all this, we’re working in partnerships with many of the stakeholder groups which you’ve talked about, but it is going to take people coming together and fundamentally we have a strong belief and confidence that investments in the right technologies and the right solutions can provide that kind of improvement and so it’s really leveraging and focusing our own investments in areas that are well focused around cost, quality and access.  We’re working with those stakeholders groups which you talked about to understand what are the real needs and issues, how can we leverage, there’s been you know, lots of discussion around Health Care IT and how IT can help us solve this problem, putting in decision support, making sure through e-health collaboration can happen between clinicians to make things more efficient so you hear about duplicate tests being run on patients that potentially aren’t necessary.  You think about looking at payers and governments and we’ve worked with them in many parts of our market, we’re a global company, so we sell products today and to marketplaces which are, you know fully public, some fully private, mixture of both and some of it’s, we feel it’s our ability to interact with those stakeholders, leverage our deep understanding of the technology and of the innovations that are necessary and work with those stakeholders, use the complete power of the General Electric Company to get those stakeholders together that gives us the confidence that we can do this and we’ve proven that in the area of Ecomagination in environment, we’ve been able to do this in another mega market in a large societal issue and so, health is the next one that’s key for our businesses, we want to be in the health, we plan to be in health business for many decades in the future and so we want to be a key part of making it better.

David Harlow:  Great.  I was about to ask about Ecomagination and just sort of wondering whether this effort is modeled on the Ecomagination effort, are there similarities beyond the name and if you could speak to that a little bit more.

Mike Barber:  Well clearly, Ecomagination was a similar commitment from, that was in 2004, 2005 time frame, where GE as a large industrial company, but in many businesses, which touches the environment and looking at, you know, renewable energies and power generation and carbon emissions and again wanting to be in those marketplaces for decades into the future just like we’ve been for decades into our past, we know that there’s needs, determined there were needs that were needed to be viewed and looked at in new and different ways and commitments that we could make.  So, commitments were made to increase our funding for products which improve the environment, green products, looked at increasing our revenues and growing our business in those products with our customers, looked at our own greenhouse gas emissions and commitments in reducing those and then being open and transparent in working with partners on that, so if you, if that at top level, the same kind of words, yes can be applied to Healthymagination in terms of partnership, in terms of commitment for investment in R&D in particular area and for commitments for ourselves, we have a program with our employees that we call Health Ahead and to look at from our own employee health, how we get the maximum, maximize the value that our employees get, as well as reduce the cost that we have as a company, as a self-insured company, so there’s been several parallels between Ecomagination and Healthymagination.

David Harlow:  Very good.  Well, I thank you very much for your time today.  I’ve been speaking with Mike Barber, VP for Healthymagination at GE.  Thanks again, Mike.

Mike Barber:  Thanks David.  Have a great day.

May 02, 2010

Healthcare Performance Management Institute's Executive Director, George Pantos, speaks with David Harlow about tools and strategies for employers to manage health care services and expenses

Health care costs are a perennial issue for employers and employees.  There are a variety of approaches out there designed to improve health status and health outcomes and reduce costs at the same time.  Proponents of a variety of approaches have been featured here on HealthBlawg in the past.  I recently had the opportunity to speak with George Pantos, of the Healthcare Performance Management Institute, a brand-new organization on the scene, founded by a group of folks who have developed tools for managing these costs.

The audio file of my interview with George Pantos (about 20 minutes long) is available for download/podcast.  A full transcript is at the end of this post (and in the linked George Pantos, Executive Director, Healthcare Performance Management Institute, HealthBlawg Interview transcript).

Pantos enthusiastically describes Healthcare Performance Management as a new management discipline, based on analyzing health care data for a given employee population and comparing it against a large data set - in this case, 3 million health records collected, with data sliced and diced by the good people at Johns Hopkins.  He raises the interesting point that health insurance companies regard this sort of data about members, or subscribers, as their property, rather than the property of the plan members or the plan sponsor -- i.e., the employer that is paying the bulk of the costs, and has an interest in managing those costs, and in helping employees manage their health.

Other tools Pantos mentioned include a Facebook-like community where employees can log on and interact with their health care providers and receive tailored messages to help them manage their own health care. 

The Institute's tools may be used by employers down to around 250 employees in size (mostly self-insured) to begin to manage health care in the same sorts of ways that only very large employers have been doing to date.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


HealthBlawg :: David Harlow’s Health Care Law Blog

Interview of George Pantos, Executive Director, Healthcare Performance Management Institute
April 21, 2010

David Harlow: This is David Harlow on HealthBlawg, and I have with me today, George Pantos, who is the Executive Director of the Healthcare Performance Management Institute, a new organization on the scene that is expressing a point of view on healthcare, healthcare reform and the management of healthcare costs and quality. Hello George, thank you for being with us.

George Pantos: Hello, good morning, David.

David Harlow: George, I wonder if you could give us a thumbnail sketch of the organization and its mission, for starters?

George Pantos: Sure. The Health Performance Management Institute is a think tank established by some business executives to deal with the issue of ever increasing healthcare costs. It’s primarily a research and analysis and education organization and the main thrust is to promote the use of successful business technology and management principles, and apply them to the management and more cost effective delivery of benefits for health plans, for employers who cover their employees. The mission of the institute is, really, to introduce and disseminate a new corporate discipline which is not currently in use on a widespread basis, called Healthcare Performance Management (HPM). It’s a business strategy to look at the challenges of controlling healthcare cost and quality in much the same way that enterprises have applied such disciplines to optimize customer relations, such things as supply chain management and enterprise resource management. But now, we are saying why not apply the same successful principles to health plan?

David Harlow: Right, okay; sounds like that makes sense. Now earlier in your career you had a leadership role with a group representing self-insured companies, is that correct?

George Pantos: Yes, I, for about fifteen years, was General Counsel of the Self Insurance Institute of America; it’s a trade association that advances the notion of self-insurance for health benefits among employers, third party administrators, stop-loss carriers, managing general underwriters and a host of others. You may know, David, we have an employment-based system today that covers some 160 million people and this system primarily provides benefits to those under 65, private system, employment based, and of that group, approximately half are insured by carriers, traditional insurance carriers, and the other half are self-insured employers who pay the benefits of health employees out of their own pocket.

David Harlow: So in your experience in that world did you see a sort of lack of understanding or management of these costs? Is that part of the impetus to developing the current HPM approach?

George Pantos: Well, the facts are pretty clear that health costs have been rising significantly over the past decade. The average family health cost is now at about $13,000 according to the Kaiser Family Foundation, and the Business Roundtable, which is an association of major US CEOs, is projecting tripling of that to nearly [$39,000] over the next decade. So as we experience these increases in costs, I think the corporations, the employers who pay those benefits in the private system are increasingly concerned about the impact of that on the bottom line. And so this is an attempt to focus on how an employer who pays these benefits can begin to apply certain principles of management to bring that health plan under a greater control and produce healthier outcomes among employees, as well as reducing costs.

David Harlow: Okay, now your organization issued a white paper in the last few days on healthcare performance management, which seems to lay out the issue as you have described now, that essentially, we can’t manage what we do not measure. So as you have mentioned, some large employers have been self-insured for a while, and just as an example, IBM leaps to mind, as an example. There are plenty of others who are self-insured and have also taken the lead in establishing cost and quality control initiatives. So my question is, what is HPM, exactly? Because what I read thus far on your website really describes the problem more than describes the solution.

George Pantos: Okay.

David Harlow: And how is that different from what folks like IBM have been doing to date?

George Pantos: Well, IBM is a member of the HPM Institute’s Advisory Board because they embrace the same concept in their approach toward what they refer to as a “smarter planet.” We have brought into the institute thought leaders like IBM, as well as Lockheed Martin, Wells Fargo, Cantor Fitzgerald, which is a major investment bank in New York, and others who are bringing their stories and successes and principles into the institute to be able to aggregate these thoughts and disseminate them on a more widespread basis. You say that we do identify the problem, well the problem is pretty clear; it is a non-partisan issue of cost control. Everybody agrees that health plan costs are too high and they should be lowered. The question is how do you do that? There are a lot of suggestions that are out there and many of them are working. What we have tried to do is to introduce a new concept to the discussion on health cost control with Health Performance Management which, to simplify the process of what it is and how it works, Health Performance Management is grounded on the availability of data. Data is the key. You have to have plan data in order to analyze what’s going on in the plan, what are the loss ratio trends, what are the major drivers of cost in the plan? You can’t do that without the data. So the first step is to get the data from the plan, claims data, essentially, both clinical and prescription drug data, and to put it through a data warehouse; we use the Johns Hopkins University database, it has been put together at the School of Public Health at Johns Hopkins, the Bloomberg School, and essentially, this is a database of some three million cases which have been benchmarked, and it allows us to take a look at a particular company’s claims data and benchmark it against a broader database like the one at Johns Hopkins and come up with a profile of the workforce as to the employees in that workforce that are at high risk for possible catastrophic conditions.

Once that has been identified it’s possible to adopt actionable strategies -- interventions with those individuals on a HIPAA-compliant basis -- which allows the lifestyle, behavior of those people at risk to be influenced by strategies that bring those people into a better lifestyle. This is done with health coaches and wellness programs and disease management programs and a series of other strategies. So that’s one part of it. It’s the technology of analytics, metrics, predictive modeling, and the second part is to combine those features with a member engagement software tool which, I guess, to make it easier to understand, it’s sort of, a Facebook-like social networking approach towards health which allows the plan participant to engage directly, online, with their health community, including providers, caregivers, pharmacies, lab technicians, others who have something to do with that individual’s health profile, and to engage in interactive exchanges that allow actions to be taken, and to coordinate more closely and more effectively. So it’s a whole big technical approach to dealing with healthcare costs rather than having them hit the plan and then have to respond.

David Harlow: Okay, well that certainly puts more meat on the bone.

George Pantos: Hope I made that one clear.

David Harlow: A clearer picture of what the intent is. A couple of questions related to what you just said: First, the sharing of this information with employers raises at least a red flag about privacy and potential inappropriate uses of individual healthcare data in the workplace setting. It’s not unheard of, in the past, to hear stories of folks who have been terminated, perhaps, because of their long term healthcare conditions.

George Pantos: Well, as you know, David, the HIPAA privacy laws include many provisions for waivers of consent in connection with plan administration. So in the area of plan administration, outside parties, third party administrators will become what they call business associates and are allowed to access that information. It is not shared with the employer, however; it’s agnostic when it comes to the employer. It’s an approach that allows the employer to do the analytics and then have an outside third party, which is a business associated under HIPAA, do the follow up. So it is HIPAA-compliant.

David Harlow: Okay, so it’s outsourced, it doesn’t sit with the employer. The other question that I had is about what sort of size employer are you targeting with this? As we were discussing a moment ago, some of the large employers have been doing this for a while and are actually on the advisory board of your organization. I imagine that the appeal of this would be to target smaller employers in order that they may take advantage of the same tools that are currently available only to the very large employers. Is it for a particular size, or is there a lower limit on the size of employer that you think this approach would work for?

George Pantos: Well, let me answer that this way. The key to be able to get a handle on the trends in the plan, what’s happening in the plan, where is the risk exposure, is having the data. And if the data is available then the first step is reached. Generally, self-insured employers are the ones who have greater access to the data rather than the employers who are insured, because the insurance carriers take the position that the data is proprietary to them and they are reluctant to share it. But in the self-insured case, employers are able to request the data through the third party administrators and there aren’t any obstacles or blocks. Generally, self-insured employers can insure, depending on their financial situation and whether they are capable of paying the benefits out of pocket. And the data is that most self-insured employers are in the category of anywhere from 250 employees and on up. We have some early pilots here that we’ve looked at that deal with employers in a range of about 500 employees, who have embraced the HPM concept and have saved quite a bit of money. As a matter of fact, one employer down in South Carolina who started this program about a year ago has already saved about $1.4 million in the first year based on a shift that was identified in the technology approach from brand name drugs to generic drugs. So that’s one example of where a self-insured employer with 500 employees has saved significant amounts of money. But I would say that it’s not something that would be immediately attractive to an employer of 25 or 30 or 40 or 50 employees, but probably upward of 250.

David Harlow: I see. And would smaller employers be able to access through you this John Hopkins database to at least do some…

George Pantos: Oh, yes. We have a license from John Hopkins to utilize it; we have enhanced it and it’s a very powerful tool to be able to determine how your workforce stacks up in terms of its risk exposure, yeah.

David Harlow: Yes, and the online community tools that you described, those are also licensable from you?

George Pantos: Yes, we have, within our organization, two of the founders of the Health Performance Management Institute; one is Healthcare Interactive, the President of which is Henry Cha. He is the architect of this concept, and Keith Lemer, who is the President of WellNet Healthcare. These two companies have pioneered in applying this program to a number of employers and have been able to come up with some early results. So, yes, it is possible to access the technology through third party service providers such as Healthcare Interactive and WellNet Healthcare, and also within our advisory board, we have some of the larger companies like the thought leaders in this area, who are available to interact and answer questions.

David Harlow: Very good; so in your view, is there one particular locus in the equation for the potential savings in the system or current waste, if you will? I mean, it’s a three or four way equation involving employers, employees, insurers and/or third party administrators and healthcare providers.

George Pantos: Yeah.

David Harlow: Where, in that system, do you see the greatest potential for savings, or put another way, who is going to squawk the loudest if this is implemented in a big way by employers?

George Pantos: Who is going to benefit the most, you mean?

David Harlow: I mean who is going to be hurt the most?

George Pantos: Hurt? In what sense?

David Harlow: Well, we are talking about cost savings; a cost savings, on one side of the equation, is a reduction in payment on some other side of the equation.

George Pantos: Well, the objective of this is as follows; we know, just basically, on generally accepted data out there, that 80% of the costs of healthcare come from about 20% of plan participants, and that 20% is generally, the group that has catastrophic conditions of strokes and diabetes and things like that, that cost a lot of money. The purpose of the Health Performance Management concept is to identify those people before they reach those catastrophic conditions and intervene, so that that can be alleviated. It’s a way of helping employees to have healthier outcomes, as well as helping employers to reduce costs. So it has a double benefit. It seems to me like a no-brainer, in the sense that the whole concept of performance management, leave the word health aside for a moment, but the whole concept of the performance management has been embraced by enterprises around the world as a business strategy, science, technique, whatever you want to call it, in helping to more efficiently manage the enterprise. So the issue was, here, why not apply the same principles to health plans? Generally, employers do not take control of their health plan; they leave it in the hands of the third party administrators or in the case of an insured plan, leave it in the hands of the carrier. This principle is aimed at the top side of a corporation, of having the CEO, the CFO, the CIO take control and use analytics, desktop dashboards, to identify these trends and to make sure that actions are taken before these costs are incurred. It’s a very common-sense approach to cost control. Hope I’ve answered that?

David Harlow: Yes, thank you. Well, thank you very much, George. I appreciate you taking the time today.

George Pantos: Sure; but let me also say, before I close here, that anyone who is interested in getting more information can log on to our website, which is http://www.hpminstitute.org and there, the first white paper is available and we’ll have another one next week on the use of prescription drug data in doing the analytics, and then we’ll have another one on how the process works. So anyone interested in latching on to more information, this is the way to go.

David Harlow: Great; tools you can use. Well, this is David Harlow on HealthBlawg and I have been speaking with George Pantos, Executive Director at the Healthcare Performance Management Institute. Thanks again, George.

George Pantos: Okay. Thank you, David.


April 06, 2010

GE Healthcare IT's SVP and General Manager of eHealth Earl Jones speaks with David Harlow about the connected health care ecosystem

GE Healthcare IT has been working in the years leading up to the HITECH Act on a number of initiatives to enable meaningful use of health care IT -- or as Senior VP and General Manager of eHealth Earl Jones puts it, building the "connected health care ecosystem."

In what may be seen as either a pragmatic move or a revolutionary one, GE is developing tools that allow for communication across health care IT systems -- not just connecting one GE Centricity installation with another -- but acting as a technology-agnostic bridge for information across health care IT systems and across health systems.  While Jones notes that we're in the early stages of linking isolated lily pads across the surface of a pond, GE is developing tools that not only facilitate interoperability, but also facilitate the dissemination of medical knowledghe and the use of clinical decision rules developed locally or by pacesetting health systems (e.g., Mayo, Intermountain -- see the discussion of Qualibria below).

The audio file of my interview with Earl Jones (about 35 minutes long) is available for download/podcast.  A full transcript is at the end of this post (and in the linked Earl Jones, SVP and GM, eHealth, GE Healthcare IT, HealthBlawg interview transcript).

While he is necessarily politic about the role of regulators in the development of health care IT, Jones is clearly excited about the breadth and depth of GE Healthcare IT's reach, the way in which its priorities dovetail with change management initiatives in US government, and the ways in which it can enable clinical care and population health improvements.  Please join us for a wide-ranging discussion of these issues.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


HealthBlawg :: David Harlow’s Health Care Law Blog

Interview of Earl Jones, SVP and GM, eHealth, GE Healthcare IT

April 1, 2010


David Harlow: This is David Harlow at Health Blawg and I have with me today Earl Jones, who is the Senior Vice President and General Manager for eHealth at GE Healthcare IT. Hello Earl, how are you today?

Earl Jones: I am doing just great, thank you.

David Harlow: Well thank you for being with us Earl. I have to ask you, first question as we start off today is - I’d like to ask you to define eHealth. That is the definition of your bailiwick.

Earl Jones: Sure. So eHealth speaks to this concept of the connected health care ecosystem. So I think all of us as professionals in the health care industry, but also as patients in the health care industry deal with really frustrating issues associated with moving clinical information from provider to provider. The classic use cases that we talk about are: mom goes to the hospital with her kids would really love to have medical information from their primary care physician. That information isn’t available to the hospitalist at the time of care treatment. Trying to get information from the hospital back to your primary care physician, those are challenging. That ability to move clinical information around the health care community is -- causes problems at that care level, also causes some, or it precludes us from getting at some real opportunities to improve the health care system like making cross-enterprise workflows faster, easier, cheaper; allowing us to do new care models like managing chronic diseases better, like bringing things like clinical decision support and population health to bear.

So eHealth speaks to this concept of the things that we can do in the connected health care ecosystem. We define eHealth more structurally as, at its core, health information exchange, the ability to take health information exchange and to do things with it. So collaborative workflows and then trying to bring performance application like quality reporting and clinical decision support and make those things available across the enterprise. So that’s what we think about when we think about eHealth.

David Harlow: Okay, great. This division or business unit within GE Healthcare has been formalized within the past 6 to 12 months I believe, maybe slightly more recently.

Earl Jones: Yeah.

David Harlow: Is that a structural change is that a new focus for GE Healthcare or is it a new name for what you’ve been doing previously?

Earl Jones: So I think it might be helpful to put GE Healthcare IT into context. So GE Healthcare as you know we are a big global health care technology provider. GE Healthcare is about an $18 billion business and it does three things primarily. GE Healthcare does diagnostic technology, MRI, CT, PET ultrasound, really focused on core health care technology. GE Healthcare does life sciences, so protein synthesis for example, bio-markers, the whole area of life sciences. And then the third part of GE Healthcare is GE Healthcare IT. And so we’re a multi-billion dollar global healthcare IT provider. And GE Healthcare IT has traditionally done three things; imaging systems, that’s radiological information systems, picture archiving; software for hospitals; and then software for physician practices. This concept of eHealth -- we started it as a new product line last year. But it was really born out of work that we started about 5 years ago, long before health information exchange or eHealth were topical issues like they are today.

We started this issue with a handful of our customers a few years ago who just had this problem of, wow, I wish we could share clinical information within our community and we started working with them around terminology, around hosting services, around translation, de-duplication services, really putting that core infrastructure in place that allows clinical information sharing. So it’s something we’ve been doing for several years. But last year we elected to break this out into its own business unit for a couple of reasons; one is certainly with the stimulus that’s happening here nationally and there is a lot of stimulus and attention on eHealth infrastructure globally. We thought it would be a little easier to talk about ourselves and what we are doing for our customers with our technology.

The second is, and I think it’s an important issue – it’s important to keep in mind, if you really want to enable cross-community clinical information sharing you have to be able to do it in a technology-agnostic way, this can’t be about sharing information amongst GE systems from hospitals to doctors office to specialty facility. It’s got to be able to share – we’ve got to be able to share clinical information in the environment that our customers live in and that environment is heterogeneous software applications, a disconnected variety of terminologies, the continuum along adoption of standards varies dramatically, I mean that’s the technical and systems complexity that our customers live in. And so it’s important for us to break this out into its own product line, really send the message that this isn’t about GE Centricity connectivity; it’s about enabling clinical information sharing in the environment that our customers live in without having to rip or replace any software.

David Harlow: Well that sort information sharing really sounds like the holy grail of Health IT and I am wondering how successful you’ve been or where you see yourself on the trajectory of really implementing that kind of connectivity?

Earl Jones: We feel like this has a transformative potential, this whole movement of connected care has a transformative potential in healthcare. Now let me characterize this by an example; I spent a lot of my early career in supply chain, and I was there when the factory couldn’t talk to the warehouse and you literally would have to write down material pulls on a piece of paper and send a runner off to get material. And in the span of a relatively short amount of time, 15 years, we went from that to a globally connected supply chain. And every metric that you can think of in supply chain got better, profitability, performance, service level, velocity. New business models were created; it was transformative when we connected trading partners in supply chain. And I think that kind of analogy, kind of parallel is exactly -- we’re on the precipice or the beginning phases of seeing that happened in healthcare. And we’ve been working with customers that are doing some very interesting things. One of our customers is The Boston Medical Center and The Boston Medical Center -- it’s an inner-city hospital here in Boston – it’s connected with 13 unaffiliated clinics. So clinics that have a different governance structure from Boston Medical Center.

And they came together and they said wouldn’t it be great if we could share clinical information in our community? And they did that using our health information exchange technology, and they’re doing some really fun things with it, right? They are able to do things like health emergency room doctors make better care decisions. So it’s tough being an ER doc. An ER doc gets the patient, may have no medical history of the patient and often times they are dealing with some pretty acute issues. Now at The Boston Medical Center if a patient comes in, if they are part of the community and belong to one of the community clinics, if there is no medical record at the ER at the Boston Medical Center for the patient, the ER doc can look into the local clinics and via the health information exchange and get information about the patient. And these can be life-saving kinds of information, thing like allergies, medications that the patients are on. Being able to get that kind of clinical information to an ER doc is important.

They are also using the health information exchange to enable a better way of doing referrals management which in healthcare is an awkward and expensive process that often ends with a lot of patient and doctor frustration because it’s not well managed from an information perspective. They are doing population health, right? They’re able to, now, because of sharing clinical information in their community, they’re able to understand the overall impact of some of their patient outreach programs because they can actually see it in the data whether they are making a difference. So, here we are in Boston, small hospital, a relatively small community, doing some really important things in their community because they’re able to share clinical information. That’s kind of exciting.

David Harlow: It is -- and I guess the next step is to see whether this can be bridged beyond a local system where it’s a dozen or so community health centers that are affiliated with Boston Medical Center and take that beyond. So someone who is away from home, out of town, goes into an emergency room can those records be pulled up remotely or is that something that you see us heading toward?

Earl Jones: I think we are squarely in the early adoption phase of this whole eHealth program. I mean we’re in the first steps of the first mile of a marathon. But looking at parallels in other industries, if we stay committed, if we continue to focus on value, in the span of what could also be a relatively short amount of time, it’s not inconceivable that we’ll have the way to share the information nationally for the betterment of care providers and patients. So we’re not there yet, I mean you can think of where we’re heading as lily pads on a pond that we’re going to see a lot of community health exchanges like Boston Medical Center pop up and start filling the pond and the good news is that organizations like IHE have been thinking about how do we make these lily pads, how do we make these community health information exchanges, work together and so there are good protocols and methodologies for cross-community access of information that over time we’ll see get built out.

David Harlow: Are you optimistic about some of the Federal initiatives building on the ARRA and HITECH Act initiatives on local medical records systems, to build out the NHIN Connector or other sorts of interchange infrastructures, through Beacon Communities or other programs?

Earl Jones: I give ONC a lot of credit. This is a thorny problem, a lot of stakeholders, a lot of different ways to come at this, and what they have done is they said look here are some functional requirement of things that we want to try to get accomplished because they are going to make the health care system better. Here’s $42 billion to help get you going, and if you aren’t adopting the technology for the betterment of our national health care system, in a handful of years we’re are going to move from carrot to stick, it’s just conceptually, what they are trying to do from an overall change management perspective makes a ton of sense and it really by any measure what the ONC has done has really crystallized this concept of connected care in our industry.

NHIN is interesting, I think NHIN is evolving; I am not sure what NHIN will look like whether it will be servers moving data or it will be just a concept that we are building toward. I don’t know what it is going to look like in future I am not sure ONC does I think that’s something that’s evolving and I think that’s okay. This concept of Beacon Communities which you brought up I think is brilliant. You know in any large organization change management -- and by any definition trying to change US health care system is a large organization change management problem -- one of the best ways to drive momentum behind the change program is to create showcases. You know, let’s go create some examples of where people are out ahead of the curve in technology options, out ahead of the curve in thinking through new process and ways of using data and bringing communities together. In using those showcases sort of as beacons to bring the rest of the organization along and in context, I thought the Beacon Communities program is brilliant and you know let’s hope that monies that gets flown down to Beacon Communities when the final grants are announced, let’s hope that folks put that money to good use and really create some spectacular showcases that prove the case for why connected health care is so important.

David Harlow: Now we might say that the government gives with one hand and maybe takes away with the other. In concert with the grantmaking and incentive producing rules and regulations that have been coming out, there is also now a discussion about regulation of health care IT as a device by authority of the Food and Drug Administration. I guess some would say that you can’t really serve two masters, and that the Federal government should come up with some sort of integrated approach on eHealth and EHRs and other related systems and programs. The FDA is working with ONC on trying to develop a way to work together, I suppose. I am wondering if you could speak to through your experience with these organizations, these agencies, and where do you see this heading? Where would you expect this to end up? Or where would you like this to end up?

Earl Jones: The FDA often gets tough rap because their job is tough one. They really perform an important public service which is ensuring that things like health care are out there for the betterment of the citizens of the nation and aren’t doing negative things around helping improve people’s health and welfare, so you know they have a tough job, I have tremendous respect for professionals that work in FDA and you know I think they wake up every day really thinking about how they do their job as best as they can do it to protect the citizens in the US. As far as my experience has been they have been very, very reasonable in their approaches. I think they could take some very draconian regulatory positions if all they want to do is think about their job only as regulator. But I have always found them to be very open in thinking about how to work through a problem in a balanced way and as far as I can tell when it comes to health records they are doing that very thing. They haven’t just launched in, saying look, we’re going to go regulate it, they haven’t said that this is off the table either, because they recognize the importance of IT in the overall health care continuum.

So, from my observation is they are taking a very measured approach. All I can say however it comes out you know GE is no stranger to regulated environments we are ready for it; if it doesn’t get regulated, that’s fine to. The only thing that I think we would encourage is -- let’s not slow the progress down that ONC is driving; I think we really do have some great momentum, if it ends up regulated let’s come at it in a way that doesn’t slow the market down. I think that calls for good balance, good collaboration and my sense is that FDA has got that top of mind.

David Harlow: So I think that the FDA may be working together with ONC so that some of these regulations may end up folded into the meaningful use certification process. So to the extent that all can be harmonized, it’ll certainly be better than having to deal with two separate organizations.

You spoke earlier about respecting the patient-centered aspect of health care IT and I am wondering whether you see this sort of regulation as a challenge to that? And also whether -- how you would characterize some of the work that your organization has being doing, in meeting the needs of patients in a patient-centered sort of way.

Earl Jones: Yeah. It’s a great question. I think there is a lot of discussion around moving from a payor/provider-centric to let’s go put the patients in the middle because that’s really at the end of the day what’s this is all about – care, treatment, for the patient. And I think it’s a very healthy dialog. The whole concept of electronic health records, and again let me just be clear electronic medical record -- think of it as sitting on a computer in a doctor’s office, literally or virtually. Electronic health record is a sum aggregation of the health information of the patient that lives within a healthcare community. And this concept of electronic health record, one patient, one record available to the primary and specialty care providers that are treating a patient, that’s a very patient-centric concept which is absolutely what we’re trying to enable with eHealth. Things like privacy and security -- those things we take very seriously and are very integral parts of our health information exchange infrastructure. And -- so I think this whole focus of how do we empower patients more, with better information, better tools and do it in a safe, secure private way is exactly what we are trying to do with our solutions.

David Harlow: Great. Now one of the solutions or products that you’re rolling out is Qualibria, which was previewed or announced at the HIMSS conference a month or so ago. I am wondering if you could explain a little bit what that system is, what it’s built on, and how you see it rolling out?

Earl Jones: Sure. We are exceptionally excited about Qualibria. Qualibria is a clinical knowledge platform. So what does that mean? Let me characterize this by the problem that we were trying to solve with this technology. Dartmouth did a study and said if everybody in the nation was as good at care treatment as the Mayo clinic, they said $40 billion would have come off that number [cost of care] and if everybody was as good as Intermountain something like $119 billion would come off the number. I am probably misquoting the numbers. But the concept is it turns out Mayo and Intermountain are really good at what they do and if we could just harmonize and reduce the variation in care treatment across the country, we could take a substantial chunk of the cost out of the system by just providing better care.  There are couple of other alarming stats that go along with this; one is that the medical body of knowledge is doubling every 8 years, or more quickly. And I think we can go: Wow, when all this genomic stuff starts hitting, we start getting really targeted around that kind of care treatment based on genomic data you can see the medical body of knowledge exploding even at a more accelerated rate. Tie that in with the fact that it may take as much as 17 years for a best practice to propagate out throughout the medical community, you quickly get this vision of, wow, there’s a lot of variation in the quality of care delivered and as it turns out, we patients only get the best practice treatment -- for whatever the disease state or illness or injury that we’re dealing with -- we only get the best practice care treatment a little over half the time, like 55% of the time.

So the problem Qualibria was trying to solve was, wow, can IT do something to make that better? And it turns out it’s really hard. The things that Mayo and Intermountain are doing – they’re instantiated their own systems but they are pretty complicated sort of flow chart processes for treating something like acute respiratory disorder. I mean it can be as detailed as: at this time turn the respirator to this value, give the medication certain minutes after this care treatment.

Trying to take that and do it in a system like Intermountain’s hard. Trying to translate that across systems, turns out you had to rethink the architecture. And that’s what we did with Qualibria. So with this partnership with Intermountain and Mayo we launched into a total rethink of a technology architecture which includes a pretty advanced clinical element model and something like several tens of thousands of rules that are then built on top of the clinical element model that allow you to take complex terminologies, draw insights and attributes from that and use that clinical element model to create decision support tools. And Qualibria is our first product that’s going to roll out from the partnership with Intermountain and it’s designed to do that very thing, which is take disparate information, aggregate it, be able to put single patient, multi-patient views with clear alerts and processes and tracking that can immediately become useful -- I don’t have to rip anything and replace it -- drop it in and immediately become useful in a hospital clinical setting in driving better coordinated care. So it’s very exciting.

David Harlow: You sound excited; sounds like a very exciting project and product. So do you see this rolling out beyond Intermountain and Mayo in the near future?

Earl Jones: Yeah absolutely. I think our product plan is to – so it’s up and running now -- and to roll it out to a couple more controlled sites the balance of this year, before a more broad national rollout in 2011 and will quickly be followed by international rollouts as well. So it’s something that we put a lot of research and development money into, we’ve got great partners that are helping us and I think it’s important to point out that we love Mayo, we love Intermountain -- I mean their bona fides are tremendous. But there are a number of healthcare institutions that are doing some really wonderful things in advancing the medical body of knowledge on specific care protocol treatments. And this technology can allow them to better and more quickly roll out the things that they learn as well. You can build your rules right into the tool. So we’ll have care bundles that are mapped after what Intermountain and Mayo do; it’s also going to be a wonderful environment to quickly take things that hospital systems are doing in an excellent fashion themselves and instantiating that in a tool that can be rolled out across their enterprise.

David Harlow: Now with this new kind of tool, do you have a concern about new kinds of liabilities, legal liabilities, as you are essentially rolling out as you said bundles of decisions support rules -- does that not come along with additional liabilities, whether it’s the content or the application of the rules or even perhaps a different kind of liability interms of encountering corrupted data or other sorts of problems rather than the decisionsupport rules themselves.

Earl Jones: Well I am not the best person to answer that question. Certainly we take all these things tremendously seriously and it’s been very well thought through. None of this replaces the need to have experienced care professionals orchestrating the care delivery, right? This isn’t -- lets get rid of docs and nurses. This is about how do we help docs and nurses deal with the tremendous complexity and a tremendous body of knowledge and time variant change of body of knowledge. It’s about giving them some tools that can help them do their jobs better. So I think that’s a very important distinction that -- I think there is a statement that says something to the effect that the complexity of modern health care surpasses the human mind sort of gets your mind around it. It’s too big for anybody so we think that what we are trying to do is not replace docs and nurses -- quite the opposite – it’s to give them some important tools to help them do their jobs better.

David Harlow: So are these tools part of what the company has been referring to as healthymagination and a large investment and innovation and health care?

Earl Jones: That’s certainly part of healthymagination so let’s talk about healthy. And first I’m going to talk about something different -- I am going to talk about ecomagination. So we launched this program about five years ago called ecomagination and at the time one of the real pressing global issues is the environment; it still is. It’s a huge, huge problem, and Jeff Immelt, to his great credit, stood back and said, you know, as the General Electric Company we can be doing more to help this important issue of environmental sustainability. He said let’s do it like an operating company, like GE ought to do it, which is let’s set ourselves some clear goals, clear metrics and really rally behind it not just as a fad initiative but as something that becomes part of our culture and DNA and we called it ecomagination. We said that we are going to invest more in environmentally-friendly technologies, we are going to do our job to try to inform the public on issues related to the environment, and then we are going to try to walk the talk and reduce our own greenhouse gas emissions as an enterprise and that was launched a handful of years ago and it was just a smashing success -- great for our employees, great for our customers, and really it was a revitalization of our culture around environmental sustainability.

A couple of years ago Jeff sort of took a step back and said health care is going to be -- it is, and will continue to be -- a pressing global problem of tremendous importance and magnitude and not only are we a big health care technology company but GE pays a tremendous amount of money, several billions of dollars in health care costs each year. He said we can be doing more as the General Electric Company to lead in the evolution of health care. So in a parallel construct we launched this initiative called healthymagination. Yet again, as a good operating company, what are we trying to do? It’s really focused around bringing innovative technologies -- this doesn’t mean high technologies it means innovative technologies. Some may be high technology some may be low technology but innovative technologies to help improve quality of care delivered, reduce the cost of care delivered and improve access, and we are going to put about six billion dollars of investment into technologies globally aimed at these three metrics. We’re doing our job to inform the public about issues related to health care. We launched the largest advertising campaign in the General Electric Company’s history, I believe, earlier in the year concurrent with the Olympics with some really lovely -- some times funny, sometimes poignant -- commercials around health care, I think they were very well received. And so healthymagination is more than an initiative -- it’s a major focus for the company, again trying to get at culture, DNA, around thinking about health care differently and making sure that we as the General Electric Company are doing our part trying to help the world improve on cost, quality, and access to health care.

David Harlow: OK, well thank you. So any last words on what you are doing now and how you see your division moving forward under the HITECH Act and now under the new health reform law?

Earl Jones: Well certainly we’re very happy about the HITECH Act -- that’s been great for the industry. I don’t know there is a whole lot of – well, some money has been flowing down, so it’s been great, but more than anything else it really has gotten people galvanized and motivated and gained some momentum around changing the landscape of health care IT, which is great. But, by the way, this is happening on a global basis, so sometimes we like to think about the world as being the 50 states here, but there are some folks in China, in Singapore, in India, in the Middle East, in Saudi Arabia, in Europe, in Brazil, I mean folks are really doing some innovative things with health care IT globally and so eHealth is absolutely playing in that arena. We are very focused on delivering value for our customers here domestically, but frankly just very focused and very passionate about the opportunities to help health systems and countries on a global basis as well. With reform, with health care, HITECH Act, with all that, the challenge that we have, and I think other people may have it as well, is not to get carried away – we’ve got to stay good at what we do, which is sort of sticking to our knitting, if you will, which is working with hospitals, working with IDNs, working with health information organizations, but working with folks around delivering real, concrete, measurable value. And I think as long as we do that and stay focused on solving the problems and pain and enabling new care delivery models, enabling new transparency and performance reporting -- as long as we stay focused on what we do well, I think we feel very good about the future. We love all the reform, we love the HITECH Act, but I don’t want to get carried away and focus on chasing that money. I think we’re just going to stay focused on trying to solve hard problems for our customers.

David Harlow: Sounds like a plan. Thank you very much. I have been speaking to Earl Jones Senior Vice president and General Manager for eHealth at GE Healthcare IT and this again is David Harlow on HealthBlawg, thank you once more.

March 19, 2010

Peter Neumann, Director, Tufts Center for the Evaluation of Value and Risk in Health, speaks with David Harlow about the role of cost-effectiveness research in health care policy

The national debate on health care reform is currently focused on health insurance reform -- coverage, one of the proverbial three legs of the health care reform stool: coverage, cost and quality. 

In order to bend the cost curve -- no matter what the approach to health care reform: be it federal legislation, state initiatives, federal pilots and demonstration projects, and/or private sector initiatives -- most would agree that we need a rational approach to cost-effectiveness research, or comparative effectiveness research that we can all rely upon.  Anyone who embarks on a search for such an approach will soon find Peter Neumann's Center for the Evaluation of Value and Risk in Health at the Tufts University Medical Center and the CEVR's Cost-Effectiveness Analysis Registry

I spoke with Peter this week about the use of "quality-adjusted life years," or QALYs, as a tool in standardizing the measurement of benefit derived from different interventions (be they medical, surgical, pharmaceutical), so that results of cost-effectiveness research used in the health care policymaking sphere can be compared, apples-to-apples, when we need to make tough decisions about paying for certain interventions and not for others.  The Registry may aid in making such choices, since its purpose is to provide standardized summaries of all studies using QALYs to quantify benefits of interventions, allowing for easier comparisons to be made across interventions and across conditions.         

The audio file of my interview with Peter Neumann (about 25 minutes long) is available for download/podcast.  A full transcript is at the end of this post (and in the linked Peter Neumann, Tufts CEVR Director, HealthBlawg Interview transcript).

We also touched on the ways in which cost-effectiveness research may be used by clinicians and policymakers in their decisionmaking as one of an array of factors; American exceptionalism; communications failures (as in the case of the mammography guidelines released a few months ago); and the prospects for cost-effectiveness research to inform development of clinical practice guidelines in the future.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


HealthBlawg :: David Harlow’s Health Care Law Blog

Interview of Dr. Peter Neumann
Director, Center for the Evaluation of Value and Risk in Health
Tufts University Medical Center

March 16, 2010

David Harlow:  This is David Harlow at HealthBlawg, and I have with me today Dr. Peter Neumann, who is the Director of the Center for the Evaluation of Value and Risk in Health at Tufts University Medical Center here in Boston.  He is also a Professor of Medicine at the Tufts University School of Medicine.  Hello, Peter, and thank you for joining us.

Peter Neumann:  Thank you, David.

David Harlow:  So I would like to ask if you could, just for starters, introduce us a little bit to the work of the Center for the Evaluation of Value and Risk in Health.

Peter Neumann:  Sure, well thanks for inviting me; I’m pleased to be here.  Our Center focuses on a variety of health economics issues and essentially we are a group of economists and other researchers who are trying to understand how we can better spend our health care dollars, and we do that by measuring the cost-effectiveness of the value of different health care interventions.  So we’re looking at pharmaceuticals, devices, procedures, public health programs - a variety of different strategies in health and medicine and trying to understand, in a sense, the health gains for the dollars that we spend in different areas, and how we can deliver health care and to improve health most efficiently.

David Harlow:  Yes, so you work with private industry as well as with governments, I understand, and I’m wondering whether you see an openness to this sort of approach in the midst of the national debate on health care reform here in the United States; or whether there’s a different sort of openness or resistance to the quantification of these matters in the public debate here versus elsewhere in the world or in other circumstances.

Peter Neumann:  Right, we do work with diverse groups; so we work on government grants, we work with foundation grants and we do work with private industry as well.  So I think everyone recognizes we need to deliver care more efficiently and everyone recognizes that we have a cost problem and that formal analysis likely will help us understand what we are getting from what we are spending.  That said there is a lot of sensitivity around using cost-effectiveness analysis openly.  People are worried that it will result in rationing of care to people who need care, will result in denying care in ways that are unfair and so forth.  So even while we recognize our cost problems, there is great concern that these techniques would be used inappropriately. 

I think there’s more openness to using these techniques, broadly speaking, outside the US than inside the US.  No one even overseas likes to deny care or ration or use cost- effectiveness analysis explicitly, perhaps.  But I think there’s a greater willingness in many countries - certainly in many western European countries, in Canada, Australia,  even countries in Asia – to set limits using cost-effectiveness information to inform health care choices, and that hasn’t been the case in the US to a large extent.

David Harlow:  Yes, now one of the terms used in some of these analysis, including some of the analysis that you’ve written and participated in, is the term ‘the quality-adjusted life year’ which I think raises a lot of red flags for US-based listeners and readers; and I’m wondering whether you can help us understand how that term is used.  What does that measure mean and how is it used explicitly or implicitly in the sorts of analysis that you and others are doing in this field?

Peter Neumann:  Sure, so the quality-adjusted life year, or QALY, is a health metric, it’s a measure of health that combines morbidity and mortality into a single number.  We often think about life expectancy as a metric that sort of helps us think about gains in health and we talk about people’s life expectancy, we might even talk about life expectancy gains with a new cancer therapy - say a new cancer drug may come along, and on average it increases one’s life expectancy for those with cancer say by one year. 

All that a quality-adjusted life year is doing is adjusting that year of life gained with some information about the amount of impairment or disability lived in that life year.  So you could imagine someone might gain a life year with cancer but they live that life in very poor health, so we would weight that life year by some amount.  They would only get, say, a half of a quality-adjusted life year gained.  So the quality has been…

David Harlow:  Let me interrupt you for a moment; if I can like to interrupt you . . .  Well, many patients or families would say well, I am happy to make that sort of assessment on my own, let me be the judge…

Peter Neumann:  Sure.

David Harlow:  Of whether a year in pain is worth half a year. 

Peter Neumann:  Sure.

David Harlow:  Don’t let an economist make this decision for me.

Peter Neumann:  Sure, there’s a lot of pushback to economists or - even worse -  bureaucrats making these decisions that patients would like, and feel they should make on their own.  So a QALY is really a population-based metric, in a way, it’s an average of sorts, averaging across different people in the population and we do that in all sorts of ways in health care.  We average results from clinical trials into a single number, a new drug improves quality of life by so much and a new drug, a new program improves life expectancy by so much; and those are population-based metrics as well and they’re used as guides to clinical care, and maybe to policy. 

So a QALY is not doing anything really that different.  I think one of the red flags that your question suggests that is a little bit different as well: My being in pain is very different than my neighbor’s being in pain.  I maybe don’t tolerate pain as well, so I have a different number and while that’s probably true or at least true that people all have different preferences around health states – again, all the QALY is trying to do is give a guide to roughly amount of life lived and the quality of that life lived. 

And so the other thing I suppose I would add is, a physician treating a patient can look at a QALY and make his or her own informed decision along with the patient about whether it’s applicable for them in their particular circumstance. 

But I think as your question rightly highlights, it is with some controversy.  And people feel often that QALYs are not capturing what they care about, that’s another criticism of the QALY: that people may care deeply about aspects that are not captured by quality-adjusted life years gained.  For example, we might want to give priority to certain populations, whether or not it’s the QALY-maximizing thing to do, we might want to give priority to vulnerable populations or children or people with rare diseases or people with cancer and people with - and on and on.  Whether or not the QALY-maximizing strategy would lead us there and I think that’s a very real concern and again all the QALY is doing is giving a benchmark or a common metric to help us understand the gains for the spends.

David Harlow:  Yes.  So it’s a metric. And what you are saying is that a policymaker could add other adjusting factors when translating a result that’s in terms of QALYs into a policy decision.

Peter Neumann:  Exactly.  And the economist would say: well, resources are limited, whether we like that or not, we can’t do everything we want for everyone who is in need of care and we do make decisions and those decisions have implications.  The QALY is simply a guide to helping us make those decisions more fairly and consistently and perhaps rationally.

David Harlow:  You’ve written or spoken in the past about the notion of American exceptionalism and that’s a notion that a lot of folks have been speaking about in connection with the health care reform debate in recent months.  My question to you is whether there is anything we can learn from the ways in which other countries in the world have resolved or attempted to resolve these issues of allocation of scarce resources in health care?  What can we learn from the way this has been addressed elsewhere in the world?  Is there a particular country or two that you think has addressed this particularly well?

Peter Neumann:  Right, so there is this theme of American exceptionalism that is much broader than just in health care, but the basic idea, oversimplified somewhat, is that because of our unique history and culture, our strong inclinations towards personal economic freedom and the institutions we’ve set up that make it difficult to enact major change, and the culture’s sort of broad mistrust of government and big corporations that makes it very hard for us to enact policies, universal health care, it’s very hard for us to use cost-effectiveness analysis, and so forth.

So other countries also have their own unique history and systems and culture, and have addressed this in ways that I think offers some lessons to us.  They’ve created institutions in places - the UK is a good example, Canada is another - where they have policy experts,  often including stakeholders, citizens’ councils, physician groups and others, patient advocates perhaps, who are collectively trying to make these difficult decisions and using economic evaluation, cost-effectiveness analysis, to help make those decisions; and in many cases not covering new technologies that are very expensive but have small marginal gains.  So the UK maybe most famously has an institute called the National Institute of Health and Clinical Excellence that sifts through the data, looks at the economics of new treatments and then decides whether or not to cover.  And in some cases at least decides not to pay for new very expensive technologies that offer marginal benefits.

David Harlow:  Do you think that there would be a change in approach or a change in decisionmaking about what should be covered, what should not be covered, if there were a change in the basic approach to reimbursement for health care services in this country?  Would a change in those incentives drive a change in behavior of providers?

Peter Neumann:  Well I’m a strong believer that it would.  I think part of the issue that we’ve been talking about is the information itself and to what extent do we use that information in decisions.  Another issue we haven’t to this point talked about is the incentives in the system, and I think the information would have a much bigger impact in an environment with different incentives.  So if providers were under bundling arrangements where you have a global payment that follows a patient with a particular disease for example, particular diagnosis, I think the incentives change in ways that makes this information more relevant and more powerful.  And there are other ways to change incentives to also make this information more relevant - it could be salaried physicians, it could be changing incentives to do more and getting paid more, it could be incentives that are different for patients where they face more cost sharing. 

Now changing incentives in all those ways has some potential downsides too, of course, but I think in an environment where we really have a cost crisis, I think we are going to see changes in incentives and behavior will change accordingly.  And I think this information that we’ve been talking about, cost-effectiveness analysis, may have a more important role in ways it doesn’t have today.

David Harlow:  Speaking of incentives, on everybody’s mind these days are the incentives for the propagation of electronic health records systems in this country.  I’m wondering whether you see an opportunity there for gathering of more data in an effective way through the deployment of electronic health records systems that would help inform some of the decisions that we are talking about.

Peter Neumann:  Yeah, absolutely. I think giving people incentives is being widely discussed and maybe we are seeing some policies now to use electronic medical records should have an impact that in turn will generate lots of data with clinical detail we don’t have now; and that kind of information can feed into analyses that can help us better understand the impact of different treatment strategies - both safety and efficacy and cost- effectiveness.

So I think there is perhaps a data issue, data problem, infrastructure problem that exists today where I think we are not capturing the kind of information that would be possible if encounters led to more systematic data capture.  So I think that would be an important part of moving forward.

David Harlow:  Okay. Now one of the projects that I understand you’ve been working on - that your Center has been working on for a while - is a registry of cost-effectiveness studies, Cost-Effectiveness Analysis Registry and I wonder if you could speak a little about that, explain what that is, how you use it in your work.

Peter Neumann:  Sure, it’s the Tufts Medical Center Cost-Effectiveness Analysis Registry which we refer to as the CEA registry.  And it's essentially a database of published cost-effectiveness analyses, and these are studies that have appeared in the peer-reviewed Medline literature that my group, there is a formal protocol for the collection of data from each of these published studies.

We collect something like 35 or so variables on each cost-effectiveness analysis.  We have two readers independently reading each study and then coming and meeting in consensus; their consensus meeting to enter data into a database.  We enter data on the cost-effectiveness ratios that are produced by these studies as well as a lot of detail on how the studies were conducted.  So with an online searchable database, and I would invite all of your listeners and readers to go on the site if they are interested it's www.cearegistry.org and you can plug in a word or phrase or an author’s name and so forth or type of intervention.

So for example if you were interested in what is cost-effective in the area of multiple sclerosis you can look and plug that term into the database and you’ll find published studies on the cost-effectiveness of interventions for MS and similarly for any other disease that you’d like.

I should emphasize all of these studies are in the form of cost per QALY studies so that is the currency or benchmark that we use.  The great strength of that is that the results are comparable so you can compare a cost per QALY in a study on depression, to a study on cancer to a study on I don’t know some kind of new diagnostic technique to detect I don’t know, I’m making it up, heart disease.

So there’s lots more I can say about this database but we’ve always viewed it as a public resource and we plan to expand upon it in the future, and the goal of this exercise is really to try to understand society’s best opportunities for improving health efficiently.  So we’ll keep it going in the future and again I invite everyone in and we’d love feedback if anyone has any.

David Harlow:  Terrific.  What I’d like to ask a little bit more about there is - you’ve mentioned a moment ago about the notion of using QALYs as a standardized measure so you could look at issues across different diseases or treatments and I’m wondering, what would you be looking at exactly if you’re comparing effectiveness between a cardiac issue and a neuromuscular issue? What would be the outcome of that comparison?

Peter Neumann:  Right, so the idea is we have limited resources to spend on health and we need some common measure that would allow us to say, “well, the money we have to improve health is better spent over here in a certain area, than it would be spent in a different area” so the way we standardize everything is through these cost per QALY ratios.

So for example if you have some kind of surgery for cardiac care a study might - someone might do a study and say the net cost per QALY gained for that type of surgery is say $10,000 per QALY and the neuromuscular condition let’s say an expensive new drug and the cost per QALY ratio in the study someone has reported is $200,000 per QALY.  So the idea is if you’re trying to improve health it's much more efficient to spend that money on the cardiac care than it is on the neuromuscular drug in that case.

And while it's difficult to make direct comparisons across very diverse treatments this gives us a way of measuring value for different uses of resources to improve health.  And what some countries are doing is saying we are not going to pay for the very expensive strategies, the $200,000 example, and we will pay for the less expensive more efficient better value strategies, the $10,000 for example.

David Harlow:  If you had a crystal ball how would you predict this sort of information playing out into coverage decisions and policy decisions in this country?

Peter Neumann:  Well, I think there will continue to be a lot of concern and sensitivity around doing cost-effectiveness analyses openly.  I think it’s still fraught with a lot of political problems and mistrust and so forth.  However, I think that we will slowly but steadily begin to use more of this information and we are beginning to see it - even in Medicare we are beginning to see it on the prevention side.  So how frequently you screen for cancer is really an issue of the clinical and the cost-effectiveness information.

So you know at the extreme we could screen for cancer very frequently - every month - or we could screen much less frequently - every ten years - and what the right level of frequency is determined by the clinical outcomes of screening, it’s determined by false positive rates and by maybe some safety issue that would result from false positives.  But it's also a cost issue and I think we will have cost-effectiveness information  informing decisions like that; not only frequency of screening but we will have it likely for which subgroups get which types of prevention.  Perhaps immunization schedules in the future will be informed by this and maybe even in certain cases, and I think this will come, treatment guidelines; failing cheaper therapies first before you get to the expensive one. 

That’s a decision that can be informed by cost-effectiveness analysis.  Even if you take the more expensive ones first and it gives you a little bit more clinical benefit, guidelines increasingly will dictate that patients try the cheaper drugs first or the cheaper treatments first and then get to the more expensive ones only if they can’t tolerate or they fail the others.  And again I think cost-effectiveness analysis in the public sector and the private sector will inform those kinds of decisions.

David Harlow:  Yes, well it certainly seems to make a lot of sense.  The question is always how it is communicated.  We’ve seen some stellar communications failures in the context of the mammography guidelines in recent months and changes in the way that’s been explained following a public relations disaster…

Peter Neumann:  You’re right.

David Harlow:  And it remains to be seen how those will actually be implemented by payors.

Peter Neumann:  Yeah I think you’re absolutely right and the mammography episode shows how challenging this is going to be - but even there, there are limited resources, there are complex cost-risk-benefit trade-offs and we will see how it plays out.  But I would argue even there, cost-effectiveness analysis could help us think through those issues, but it certainly will not be easy.

David Harlow:  Yes, well, thank you very much.  I have been speaking with Dr. Peter Neumann, Director of the Center for the Evaluation of Value and Risk in Health, Tufts University Medical Center.  This is David Harlow on HealthBlawg, and thank you for listening.

March 09, 2010

John Glaser, CIO of Partners Health Care, speaks with David Harlow about health IT and meaningful use in a $7.9 billion health system

What does a large health system CIO worry about if his system is already fully up to speed in the day-to-day use of EHRs?  Using them in ways that improve communication of information across a diverse group of clinicians, and that enable the integration of additional interesting and useful data as time goes on -- such as the integration of genetic testing data into the diagnostic and treatment logic built into the EHR.

John Glaser explains how Partners uses its EHR system to leverage knowledge for the benefit of patients, and describes some of the ways in which decision support systems are being used today and may be used in the future.  

Tools in place at Partners now:

[T]here is for example a monthly report put out on dozens and dozens of quality measures and they are coded red, yellow, green depending where we are relative to the national benchmarks and that . . . allows us to focus on areas that do need some attention.  In addition to that you can use the systems like CPOE or the EHR to introduce logic at the time of care, so to make sure that an order is a safe order or that an overdue health maintenance activity has been noted and followup is occurring.

...

[L]argely at this point focused on cancer . . . we do have decision support that says before you order this chemotherapeutic agent you should run this genetic test because that will tell you whether the agent will or will not be successful.  We do have a piece of software called the patient genome explorer which sits right beside the results viewer for chemistry results, and this allows you to look up genetic test results and understand the ramifications for the patient you are treating.

Glaser acknowledges the difficulties that may be faced by smaller provider organizations in gearing up to meet the meaningful use criteria related to EHR implementation, but notes that for him, there is no separate ROI calculation for implementation of these tools, saying

I mean, what’s the ROI of email? Beats me but, nonetheless, few of us could get through a day without it.  At other times the ROI is quite tangible because you could say golly, we are cutting real costs here or making real revenue.  At times the outcome is tangible - it may not always be expressible in terms of dollars.  You can, but that’s not the point. . . .  So I think we will see a return broadly speaking . . . .  I think at the end of the day it is one of those things which you say listen, this is a given.  It is hard to imagine that we would sit here today and say if ten years from now we ran our health care system on paper that would be okay or a good thing.

The Partners team has the luxury of being able to spend significant time on R&D, and Glaser says that

we do have some people who are looking at different techniques to be applied to putting a layer of logic on top of complex and idiosyncratic data coming in, and teasing out that sort of data. So, for example, if you know that there are, let’s say, 200 notes [in a patient's EHR, entered by a variety of clinicians] and that the patient is being seen by a cardiologist, you just have the system be able to identify that subset of notes that appear to have a bearing on the consultation in question and being able to categorize those notes for the doctor, so that he or she can say jeez, of the 200, there are five that are related to prior cardiac events, there are four that are related to what appear to be cardiac procedures . . . to help to filter through and surface that subset of note, or other data, which appears to be the most salient.  So we are learning.  We are trying a bunch of different techniques to figure out how to do that.

And a final note on meaningful use: The transcription service I use (which is based in India) rendered "interoperability" as "entrapped ability" in the first draft of the transcript -- an unwitting bit of wry commentary on the need to unlock the potential of EHRs through the kind of broader thinking shared in today's interview.  I think you'll find it to be an interesting read or listen. 

The audio file of my interview with John Glaser (about 25 minutes long) is available for download/podcast.  A full transcript is at the end of this post (and in the linked John Glaser, CIO, Partners Health Care, HealthBlawg interview transcript).

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


HealthBlawg :: David Harlow’s Health Care Law Blog
Interview of John Glaser, CIO of Partners Health Care

March 3, 2010

David Harlow:  This is David Harlow at HealthBlawg, and I have with me today John Glaser, the CIO at Partners Health Care in Boston.  Hello John, thank you for joining us.

John Glaser:  It’s a pleasure, David.

David Harlow:  So Partners Health Care - for those of you who are not familiar with it - is an organization that includes ten hospitals, 7000 physicians, 45000 employees.  Have I got that right, John, more or less?

John Glaser:  Yes, you do.

David Harlow:  And John has been the CIO at Partners for quite some time.  He’s also been acting as an advisor to the ONC on implementation of the HITECH Act since last spring.  We’ll try to steer clear of government-related issues today and focus on issues at Partners.  So John, moving beyond the numbers, how would you describe Partners Health Care and what it means to be CIO of Partners?

John Glaser:  Well, Partners Health Care has got a couple of attributes.  One is it’s large, so we’ve got another number to put in there, it’s about 7.9 billion in revenue and in addition to its hospitals and extensive array of outpatient clinics, physician practices and 90 key facilities, it’s a very large, very complex organization.  It’s also quite academic given its two founders [Massachusetts General Hospital and Brigham and Women’s Hospital, both of which are major teaching affiliates of Harvard Medical School].  So it has tremendous resources, tremendous talent, some world class organizations, and using those assets it can be a challenge at times to line everybody up and have the organization move in a concerted direction. I guess that’s true of all large organizations, although we certainly feel that at Partners. And while that can be difficult at times, the fact that there is such talent, and there is such a commitment to the mission of care, research and education makes it worthwhile and enables us to accomplish - from time to time - some very remarkable things.

David Harlow:  Would you say that things have gotten easier as the association has lasted longer, or more complex as it’s grown larger? You’ve been with the organization quite some time now and I was wondering how things have changed over the years.

John Glaser:  Well I have been for quite some time. I’ve been the CIO since 1995 and so that’s a little over 15 years.  And prior to that, CIO at the Brigham for another seven years, so 22 plus years in the family as a whole.

So I think it’s very clear that as the organization has matured and has begun to understand how to work together, that it is more effective at working together, bringing together very disparate organizations, large AMC’s, small community hospitals, for example, bringing together people who may or may not have a track record of working together.  So it is better at moving as an integrated system than it has been in years past.

On the other hand, the challenges it has to address have become more significant so there are greater cost pressures today than there were ten years ago and there are greater quality pressures than there were ten years ago.

The pace of medical innovation and events are more significant. As our community of clinicians and others have become more experienced with the technology, they also become more demanding and more sophisticated.  So the demands and the expectations are higher and have been paralleled by a growing ability to work together as a collective.

David Harlow:  So going back to a couple of things that you said specifically, I’m wondering if you could tell us, how does the health information technology function within Partners help to enable the organization to deal with some of these issues - whether it’s adherence to quality measures; whether it’s dealing with payment issues - and, how does your function, your part of the organization’s function integrate with the clinical function?

John Glaser:  Well, there are a number of ways in which we try – and, at times, succeed - in helping Partners address these challenges.  At times we take processes and make them more efficient and save money in addition to having those processes work faster, be less error-prone, etc.

By providing data that comes out of the EHR, the organization’s in a much better position to look at variations in care practices and identify those practices that are more efficient than others, that are of better quality than others.  I actually have the data to assess quality and to then deal with that variation in whatever manner it chooses to do so.  So the fact that you have clinical data, and data that also brings along the cost component of that clinical data, allows us to look at where we need to do some work, where we don’t.

So there is for example a monthly report put out on dozens and dozens of quality measures and they are coded red, yellow, green depending where we are relative to the national benchmarks and that again allows us to focus on areas that do need some attention.  In addition to that you can use the systems like CPOE or the EHR to introduce logic at the time of care, so to make sure that an order is a safe order or that an overdue health maintenance activity has been noted and followup is occurring.

So through the transactions systems one has the ability to carry out a lot of the guidance and recommended care that comes out of the data activities.  So there is a series of analysis capabilities and transaction capabilities that help address this complicated mixture of cost, quality and safety.  But also in addition to that is the ability to adapt.  So for example it’s fairly clear in the next several years - 3 to 5 for example - genetic testing will be increasingly a lager component of health care because of our greater understanding of your genetic makeup and how it guides treatment decisions, or what disease you really have.

And so the ability of systems to adapt and to capitalize on advances in medical care, to capitalize on advances in care models such as the medical home or accountable care organizations, and also capitalize on the gains that new technology can bring - that we are trying to make sure that our infrastructure and applications are able to move as the collective environment moves.

David Harlow:  Now I understand a few years back you established together, Partners established together with Harvard Medical School a center for genetics and genomics and is this what you are talking about, is this informing some of the care management, is there genetic testing data that’s included in patient profiles that can be used to guide clinical services?

John Glaser:  Yeah, we formed several years ago what is now called the Partners Center for Personalized Genetic Medicine, and it has two major roles.  One is to facilitate research into the genomic basis of disease or treatment variability.  So for example if you are clinically depressed and given an SSRI, it works well a third of the time, medium well a third of the time and not at all a third of the time, and so helping investigators determine whether there’s a genetic underpinning to that.

So we’ve learned a lot and this will help accelerate research into how genes contribute to our disease and our treatment success for example.  In addition to that, that is also not only because of the advances themselves but the knowledge of how do you store genetic test results and what does genetic decision support look like, how do you present genetic test results to the clinician.  It’s begun to make its way into the clinical systems, largely at this point focused on cancer, but we do have decision support that says before you order this chemotherapeutic agent you should run this genetic test because that will tell you whether the agent will or will not be successful.  We do have a piece of software called the patient genome explorer which sits right beside the results viewer for chemistry results, and this allows you to look up genetic test results and understand the ramifications for the patient you are treating.

David Harlow: Is there an overlay now with the GINA legislation on top of HIPAA in terms of privacy requirements and protection requirements, encryption, others, relating to genetic information that’s on the system or does HIPAA deal with that sufficiently?

John Glaser:  Well, there are clear genetic privacy ramifications for all of this and it gets complicated.  I will give you two examples.  If a genetic test were to say that you or I were at great risk of a debilitating form of dementia, one would say, well, I ought to keep that private, because of – for lots of different reasons.

On the other hand, a genetic test result that says you will be a slow metabolizer of sulfa drugs, you might say -- jeez, I’m less worried about loss of job or loss of insurance based on that. But I do want my doctor to know because I do want to make sure they don’t inadvertently overdose me on a particular drug.  So genetic test results actually span the gamut of those which are highly sensitive to those which I think most people regard as no more sensitive than a blood potassium reading.

And given that, nonetheless, what we have decided to do is to treat any genetic test result as being in the same category as the most sensitive data and so this is HIV data, this is mental health data - we treat that and provide both the policy procedure the consenting processes for example but also the IT controls over that type of data that we would - I think perhaps society may evolve to the point where it categorizes genetic data into different forms or buckets of sensitivity.  But until that’s the case, we will treat it as the most sensitive.

David Harlow:  So you’re not looking to get patient consent to disclose certain types of genetic information like for example the way you would…

John Glaser:  Yeah just as you would on any sort of highly sensitive set of data.

David Harlow:  Okay.  One area of interest at Partners is the electronic health record and the use of electronic health records over time, which, I understand, is a home grown system.  Is that right?

John Glaser:  Yes -  the bulk of our, we have approximately 4200 physician users of our outpatient EHR, 85% use the homegrown version and 15% use a mix of GE and a couple of other systems that have been in place for quite a while.

David Harlow:  And what would you recommend, having had the experience with both?  What words of wisdom would you have for other providers who are looking at implementing EHR systems in this era of HITECH incentives?

John Glaser:  Well I think these systems, whether you build them yourself or you buy them from the market - and most people buy them from the market, and most people should buy them from the market - these are a challenge to get in place.  They are very invasive to the workflow and so a physician, or a nurse practitioner or any other health care professional who now is documenting on them, writing orders on them, reviewing results, - it’s very invasive.  It’s not something that is kind of off to the side.

And as a result there is a great deal of demand for systems that have a lot of strong features, functions, but also are very usable and quick.  It requires that workflow be understood, changed if necessary and that includes where do you place printers and things like that. It requires a good deal of training and some strong support, and I think practices who undergo this should be prepared for several months - and it seems to vary at least in our practices, sometimes it’s as long as six months, sometimes it’s short as two months - where there is a form of disruption and people just getting their feet wet and getting oriented to this.  So there are a lot of demands on the systems, there are a lot of demands on the implementation process and the workflow change process and there are a lot of demands on support, and obviously there are a lot of demands on the practice who goes through this.  Nonetheless once you get through that we have never had any clinician of any form say I wish I could go back to paper.

They clearly see that the care is better, that there have been some efficiencies gained, there’s been some challenges.  Sometimes it takes longer to do certain tasks.  But nonetheless it is a journey that is - both from the care perspective and the cost of care overall but also the ability of the providers to say I’m practicing good medicine, must be able to say that.  So I think it is a hard journey but it is a worthwhile journey that the federal government incentives recognize the importance of us collectively moving in that direction.

David Harlow:  Part of the issue is the interoperability, the opportunity for free exhange of data from one provider’s electronic health record to another, to be able to follow a patient across care settings.  Given the size and the scope of the Partners network, I’m wondering how important the development of RHIOs and health information exchanges are to Partners? Are patients who are seen within the Partners’ network receiving all of their care within the network?

John Glaser:  No and I think that some networks are more closed than others; the VA, Kaiser, are more closed than others. For example, almost 50% of our referrals – remembering we’re academic at our core - come from physicians outside of Partners. So we have extensive movement of people in and out of Partners, some stay within the Partners community but a lot don’t.

So I think this notion of exchanging data is critical, and it runs a sort of a gamut, it runs a gamut of giving the referring physician access to the core institutional systems, to the gamut of the movement of a structured transaction - maybe it’s an operative note, maybe it’s a set of chemistry results - from one system to the other.  At times we have clinical affiliations which are very strong and we wind up with shared scheduling systems, shared email systems and much more extensive integration and interoperability.

So I think the basic rubric of putting out standards and encouraging the exchange is a very important set of activities.  It creates parallel issues, it creates issues of making sure that the privacy and the security steps necessary are put in place, because we now have different privacy and security challenges when this occurs.  It also places a challenge on the providers who now may be going into their EHR and seeing lots and lots of data from lots and lots of other providers and saying holy smokes, I have a brief period of time with this patient, but I have 200 notes and 180 of them are not mine.  How do I wade through these and determine which ones are the most important? So a knowledge management function, and a decision support function, and a set of guidance using all of the above, might help the physician zero in on the most clinically relevant - becomes a challenge.  So there is, there is great gain to be had. It does bring some parallel challenges that we still need to address.

David Harlow:  Have you seen some movement in the direction of being able to wade through those kinds of notes, the kind of volume of notes there might be from outside providers, any sort of knowledge management systems that you are using or that is on the market today?

John Glaser:  Well, I don’t know about on the market.  We are, as an IS group, unusually academic in our approach - about 15% of our staff are funded by federal grants or through industry partnerships to explore leading-edge topics in healthcare IT and they run the gamut from what is known as telemedicine, to genetic medicine, to knowledge management – things like that.

But we do have some people who are looking at different techniques to be applied to putting a layer of logic on top of complex and idiosyncratic data coming in, and teasing out that sort of data. So, for example, if you know that there are, let’s say, 200 notes and that the patient is being seen by a cardiologist, you just have the system be able to identify that subset of notes that appear to have a bearing on the consultation in question and being able to categorize those notes for the doctor, so that he or she can say jeez, of the 200, there are five that are related to prior cardiac events, there are four that are related to what appear to be cardiac procedures.  So anyway to help to filter through and surface that subset of note, or other data, which appears to be the most salient.  So we are learning.  We are trying a bunch of different techniques to figure out how to do that.

David Harlow:  On a related note, some of the tools and products that have been on display at HIMMS this week or announced at HIMMS this week down in Atlanta – I’m wondering whether there are categories or particular types of tools coming out of that conference and from the exhibitors there that are of particular interest to you, something that catches your interest?

John Glaser:  Well, I was at HIMSS for only a day and I was only briefly on the exhibit floor so I didn’t get a chance to see what was going on.  I think in general obviously the major topic is the federal stimulus funds and how to address those.  So I think tools that invariably help providers to meet those meaningful use requirements or the standards and particularly help the smaller physician practice, the smaller hospital, which have very low adoption rates and have in general, not entirely but in general, not been as well served by the market as the larger organizations as technologies that are directed there are of great interest.  Anyway I didn’t have a chance to personally see a whole lot of the exhibit floor.

David Harlow:  Fair enough. What would you identify now as areas of opportunities as well as areas of challenge in adopting not only EHRs but also other health information technology tools across the health care spectrum?  Maybe speaking from your experience within Partners but also as you mentioned looking at some of the smaller providers which is where I think collectively we’re hoping there will be greater adoption.

John Glaser:  Well I think broadly, and across the country, we still have the challenge of getting higher adoption rates and now meaningful use of those technologies so those of you folks listening to this know the rates as well as I – but they’re low.  So that challenge which has been with us for a while, it’s still with us, and perhaps we’ll have a series of factors that will cause us to pursue it more aggressively and I think in particular, as has been mentioned before, it’s the smaller provider organizations which need the most innovative approaches to the delivery of these systems in helping those patients, and remembering that two-thirds of all of outpatient visits occur in physician practices of three or fewer docs. That’s where the bulk of care occurs in the US. So there is - that challenge is going to be with us for quite some time - several years.  And all that implies - the difficult work of implementation and some of the comments mentioned earlier.  In addition to that it is also clear that there are some opportunities emerging or at least will be different as result of broad adoption of interoperable electronic health records. One is itself the management of interoperability at scale, protection of privacy, the assurance of standards, helping docs deal with large volumes of information. And so there will be a series of things we’ll have to do and understand this is when you have interoperability at scale, what gain really occurs but also what challenges are present or revealed that we still need to develop tactics and tools to deal with.

The other is that there is a clearly going to happen or beginning to happen now, large accumulations of data about patients which can be used for comparative effectiveness research, clinical research, post-market surveillance of medications and devices, public health surveillance, etc.  And I think we have a lot to learn about how to manage that data, not only the protection of privacy but also how to distill patterns out of data which is often conflicting, noisy or incomplete.

The third area - we still have a lot of ground to cover - is how best to engage patients; we use the technology to engage patients - personal health records, personally-controlled health records, a lot of targeted applications where you can measure your blood sugar or your blood oxygen saturation, or whatever it might happen to be - people with chronic disease; we have a lot to learn there.

So lots of promise there but still relatively small levels of adoption and very limited understanding of how much of a contribution this will make to the management, let’s say, of a chronic disease, or the gradual improvement of health.  So there are a couple of big areas.

I guess one other big area is - if we have large bases of knowledge or decision support across wide ranges of systems - is managing this knowledge base.  A knowledge base of rules or order sets or templates, it is now quite sizable, which changes from time to time.  And I think one of the factors of our growing knowledge of the relationship between the genome and our health is whatever volume of decision support rules you think there are now – it’s going to go off the charts as that becomes increasingly incorporated into medical practice, so how best to manage that knowledge base and to ensure that it’s effective remains a daunting challenge.

So, as we address the core one, getting these systems in place and used well, and broadly looking at a series of challenges coming up that will result from the broad use of interoperable electronic health records.

David Harlow:  Do you see a direct correlation between the advances in the systems and the return on investment, if you will, or is this just part of the infrastructure that has to be in place in the future? Is this just like you need to have a telephone, you need to have this…

John Glaser:  Well I think it’s a combination of things. One is technology at the end of the day is a tool and, per se, guarantees no ROI and you see that in some of the studies they’ve done or sometimes great gains in patient safety have occurred, sometimes they haven’t, and sometimes the organization runs more efficiently and sometimes it doesn’t.

So we have very variable outcomes and partly because it’s not the tool that delivers the outcome, it’s the way that it is implemented and how effective it is.  So we will continue to see that because again it is at the mercy of the skill of change management and leadership and a wide variety of other things so, given that, we also recognize that that the nature of the return is really diverse, at times it is very intangible - I mean, what’s the ROI of email? Beats me but, nonetheless, few of us could get through a day without it.  At other times the ROI is quite tangible because you could say golly, we are cutting real costs here or making real revenue.  At times the outcome is tangible - it may not always be expressible in terms of dollars.  You can, but that’s not the point.  So if you are, if you deliver safer care, you can certainly measure the dollars there but those aren’t really the measures that people are focused on - or improved service.

So I think we will see a return broadly speaking - realizing how tangible or intangible, how dollarizable or not dollarizable it is, to the sort of settings in which it’s delivered.  I think at the end of the day it is one of those things which you say listen, this is a given.  It is hard to imagine that we would sit here today and say if ten years from now we ran our health care system on paper that would be okay or a good thing.

I think there are very few people who would stand up and try to carry that argument forward - at a face validity level, and at an empirical level, it just doesn’t make sense.  So I think the basic idea that if we really want to make extraordinary gains in the care in this country you have to have this foundation in place.  The foundation doesn’t guarantee it but it’s hard to imagine that you would accomplish it without it.

David Harlow:  Well, thank you very much.

John Glaser:  My pleasure.  I hope this is interesting and informative, and I appreciate the time.

David Harlow:  It certainly is.  I’ve been speaking with John Glaser, Chief Information Officer at Partners Health Care in Boston on implementation of health information technology and the improvement of health care. Thanks again, John.

John Glaser:  All right. Thank you, David.