The height of health IT

Even health insurance giant WellPoint—with more than 35 million members and arguably enough reach to change the system with sheer volume alone—is taking few chances on the future of healthcare delivery. Like most plans, it’s testing new programs with cautious optimism, while aiming for large-scale implementation.

Charles Kennedy, MD, WellPoint’s vice president for health information technology, has a vital role in the plan’s innovation because few initiatives these days can be accomplished without the backbone of health IT.

Specifically, WellPoint’s emerging Individual Health Record—a simultaneously patient-facing and physician-facing electronic record—is “almost an air traffic control system to manage disease,” according to Dr. Kennedy. It’s probably one of the most promising efforts to control costs among members with chronic conditions. Pulling claims and clinical data through complex algorithms to arrive at a functional health summary differentiates the Individual Health Record from the typical EMR system.

“If you’re a hospital or institution, you have a variety of clinical data sources that have information on the patients that you see,” he says. “If you haven’t deployed an interface engine or some way of pulling those various clinical data sources together, you’re late to the party, and you need to do that ASAP.”

With more than 20 years of experience comprised of clinical practice and health IT implementation, Dr. Kennedy began his career in internal medicine. When he was a resident at Highland General Hospital in Oakland, Calif., he noticed how the patients’ needs far outstripped the hospital’s resources, and that experience solidified his vision of where medical care and information should meet.

“We tried to treat each patient regardless of who they were or their ability to pay,” he says. “It had the unfortunate side effect that we never thought about cost. We only thought about what was right for a patient. But that created a system where people are actually being hurt because they can’t afford care. I began to realize that the very laudable and applaudable approach of not caring about cost—only the patient—is right, but that doesn’t mean you can become cost unconscious. Cost unconsciousness has its own set of bad outcomes. That’s what’s led me into thinking we need to be more efficient. We need health IT.”

Earlier this year, Dr. Kennedy was named by the Government Accountability Office as a member of the new Health Information Policy Committee, which was established by the American Recovery and Reinvestment Act. Serving a three-year term, he and other committee members are creating policy framework for the development and adoption of a nationwide health IT infrastructure, including standards for the exchange of patient information. The committee will also make recommendations for handing out the $38 billion in health IT funding earmarked in the reinvestment act.

WHAT ARE SOME OF THE HEALTH INFORMATION POLICY COMMITTEE’S GOALS?

A:We’re trying to make sure the Obama health reform strategy becomes real. What people don’t realize is the number of things the industry and the government agree on. For instance, the government invested $1.1 billion in comparative effectiveness research.

The stimulus bill has $38 billion in it for health IT, and we’re trying to help the government develop policies to spend that money wisely. Our function is to say, ‘How do we take this incredible resource that Congress and the President have given us, and how do we turn it into an investment that creates healthcare value for the whole country?’ It’s a massive undertaking.

Our first objective was to ensure that the money from the stimulus package paid out over five years created value. We asked ourselves where we wanted to be five years from now, and then we worked backwards from there.

Deploying computers is not the goal. Having physicians and patients use computers to create better care at a lower cost is the goal. To do that, we have to set the bar high for the care system. Not only must you use the computer, you must use it in a meaningful way for better care. These are the ‘meaningful use’ criteria that we’ve published.

If we distribute a substantial number of computers, and physicians don’t use them, we won’t be successful. We didn’t want to focus on technical measures. We created the meaningful use criteria, and every single one is clinical.

We want physicians to achieve a clinical result, and we want information technology and the money in the stimulus package to be a contributor to that improved clinical result. For instance, one of the criteria is to avoid 1 million heart attacks and strokes by 2015. Another is to make cardiac disease no longer the leading cause of death in the United States. Those are stretch goals. That is not something simple and trivial.

It would have been much easier to say, ‘Our goal is to make sure 90% of physicians have computers.’ But we consciously didn’t do that because we recognize that health IT is a tool and that other changes need to happen.

HOW WILL THE INDUSTRY ACTUALLY ACHIEVE MEANINGFUL USE AND OTHER MILESTONES?

A:The law is actually quite specific in defining what a qualified system is, and we have a subcommittee that’s identifying the actual entity—such as the Certification Commission for Healthcare Information Technology (CCHIT)—that will assess systems as to whether they qualify or not. The bigger challenge is data integration.

Everyone recognizes that healthcare is horribly fragmented, that there are silos of care. We know that there’s massive inefficiencies, and there are significant quality concerns because information is not shared as people move across silos.

The challenge with data integration is that we really haven’t figured out how to do it correctly. If you’re an integrated delivery system and you buy one EMR, that’s fine, and that works. But 70% of physicians practice in a community setting, solo and small group practice. You have this tremendous problem that all of these systems are different. They call things by different names, and they even capture different sets of data.

WELLPOINT HAS CREATED THE INDIVIDUAL HEALTH RECORD SYSTEM THAT USES ALGORITHMS. HOW WILL THAT MAKE A DIFFERENCE?

A:Algorithms, also known as decision support, are going to be the key to getting value out of these systems. Let’s say the federal government funds a comparative-effectiveness study that identifies a new drug is great for certain people. In today’s world, we know it can take up to 17 years for that to be commonly found in a physician’s paper record. With this approach, you can create an algorithm as soon as physicians or specialty societies have decided on certain best practices. Now you’ve created an infrastructure to get that message to every doctor, but only when there’s an appropriate situation for that rule to be applied. That will take that 17 years down to 17 days. That’s a huge advance.

Let’s say we have noticed that there’s a lot of inappropriate use of PET scans. In today’s world, a doctor would have to call us for preauthorization every single time he orders a PET scan. In the future, the algorithms will be running, and they will only alert the doctor if there’s an issue with a PET scan. Today, they call 100% of the time, and we generally approve the scan more than 90% of the time. Algorithms will take hassles, administrative costs and bureaucratic burdens out of the system.

The right kind of health IT allows us to use new knowledge from our outcomes research subsidiary [HealthCore] and any gaps in a member’s care identified by our informatics company [Resolution Health] in much more effective ways. The right kind of health IT allows these advances to be applied real time at the point of care while the doctor is treating the patient or helping the patient at home.

IS WELLPOINT’S INDIVIDUAL HEALTH RECORD WORKING? HOW IS IT ANY BETTER THAN OTHER EMRS OR PHRS?

A:We’ve run a pilot in Dayton, Ohio. The idea was not just to create interoperability—don’t just allow System A to talk to System B. When you connect systems together, what you create is just a data dumpster. It’s like putting a jigsaw puzzle on a physician’s desk.

That information has to be organized to just the summarized information that the doctor needs…You don’t take all of the information out of these various systems, you only take the information necessary for the ongoing management of the patient.

Many EMR implementations have failed to show value. About 30% of the time, physicians will actually turn them off because they are incredibly time-intensive and will reduce a physician’s productivity. That will hit them in the pocketbook. We’ve looked for solutions that wouldn’t be so intensive from a physician’s data-entry perspective and would do more sorting of information and presentation of information.

Physicians are not data generators. They’re data consumers. Their orders create significant amounts of data, but the physicians themselves usually just scribble a relatively brief note. The problem with many EMRs is they will require physicians to become data-entry clerks.

In Dayton, Ohio, we have a very significant market share. We’re Anthem Blue Cross Blue Shield of Ohio, and we also have a strong partnership with Kettering Hospital Network.

Kettering had already installed an application integration solution, so even though they had 120 different clinical sources, many of those clinical sources could be accessed through infrastructure they had already built. That made it easy for us to collect all of the clinical data out of their systems. We built feeds to the application from Anthem’s claims systems. We were able to get this application up and running in a little over three months, which is incredibly rapid. We made it available to the patient in the form of a PHR and to the doctor in the form of a CCHIT-certified EMR with e-prescribing.

When we looked at who was using the tool, we found that patients who had a higher illness burden actually made preferential use of the tool. For many of the tools we’ve deployed, the ‘worried well’ have been the type of people who used it, not the people with the chronic disease that we really need to reach.

We noticed the people who used the tool and had the higher illness burden, their cost increase year over year was actually less than the people who didn’t use the tool, even though those people who didn’t use the tool were healthier.

We built algorithms in the system that exactly correlated with various HEDIS measures and every time the doctor or the patient logged on, they could see their exact compliance. By giving the patients and the doctor the same information in a simple red light, yellow light, green light format with algorithms enabled us to see quality improvement scores of anywhere from 10% to almost 40%.

WHAT’S THE BUSINESS CASE FOR A HEALTH PLAN TO CREATE A SYSTEM LIKE THAT?

A: Our strategy is maximizing healthcare value, and healthcare information technology is really a tool to get you there. But it has to be the right kind of health information technology. It has to influence doctor’s decisions, and you have to present sufficient clinical data—not mountains of data but the key things the doctor needs to know so that you can influence his decision to do something that’s consistent with the evidence base, or to prescribe a drug that will cost the patient less but has the same likelihood of creating a good patient outcome.

If you look at why healthcare spending is out of control, it’s chronic disease, not health plan profits and not health plan administrative costs. We are seeing an explosion of chronic disease in this country, and chronic disease is managed largely by the patient at home. They’re managing their diabetes 99% of the time at their home, not in the physician’s office. If you don’t make your health IT solutions patient-centric and if they don’t address chronic disease, I don’t think that you’re going to get the kind of value that you want.

HOW ARE THE PHYSICIANS EMBRACING THE INDIVIDUAL HEALTH RECORD?

A:We have 300 physicians using the system now. We’re planning for a broader rollout to the greater Dayton area in 2010 to virtually all primary care physicians.

What we’re focusing on is chronic disease management, and there’s not huge debate about many of the things that need to be done to take care of these patients. That’s not the problem. The problem is actually getting it done. The physicians in general have been positive and are beginning to see how their lives could be easier.

We also added all of our pay-for-performance rules. We pay physicians more if they practice medicine consistent with the evidence base, and we took the existing measures and turned them into algorithms in the system. As long as the physician follows all the alerts, he can be sure that he’s going to maximize his pay for performance incentive. That’s convenient for the doctors because what they usually have to do is identify the patients who haven’t had certain interventions and then reach out and call them.

We’re just starting to incorporate our utilization management rules. If we can begin to move those algorithms to the point of care, then physicians might not have to call except for when there’s a real reason to discuss something, which might be 5% of the time.

DETERMINING THE EFFECTIVENESS OF TREATMENTS IN ORDER TO BUILD THE ALGORITHMS IS AN EXPENSIVE PROCESS. HOW CAN IT BE DONE?

A:This is the beauty of health information technology…if you bring it together in a repository that’s reflective of the patient’s clinical condition and how they’re being managed, you can begin to do database-driven studies rather than very expensive prospective clinical trials where you’re enrolling patients and following them over time. You can begin to do database driven studies that are a fraction of the cost. No, they’re not the gold standard, which will always be a randomized perspective-controlled clinical trial, but there’s a lot of information we’re going to be able to glean out of database-driven studies that are more observational and more retrospective.

BE A VISIONARY. WHAT DO YOU SEE AS THE POTENTIAL FOR HEALTH IT?

A: I hope that every time a patient needs information when they’re home or need to take care of their chronic disease or want to stay well, that they have that information at their fingertips, it’s actionable, and they don’t even have to think about it. If we can make it that easy—and there is a path to get there—we could actually fix the healthcare system.

Charles Kennedy, MD, has held strategic health IT positions with a variety of organizations. He also served as the medical director of a California health center in addition to other clinical service. He earned an MBA from Stanford University, an MD from the University of California at Los Angeles, and a bachelor’s degree in genetics from the University of California at Berkeley.
” Physicians are not data generators. They’re data consumers.”

One case is one too many

I have been attending the annual meetings of the American Society of Anesthesiologists since 2004.  These are huge meetings with hundreds of individual sessions, necessitating some hard choices about which sessions to attend out of so many choices.

I was lucky to be accompanied by long-time friend and fellow choir singer, Anne Black.  She was invaluable in helping me get around, figure where to go, and graciously serve as constant companion.  So many people help me accomplish the work of this Campaign!

This year I was privileged and humbled to be a Refresher Course lecturer.  I spoke for 24 minutes of a 2-hour panel on Sunday afternoon, October 18.  The panel was titled Best Practices:  It’s Not Just Science, and my speech was titled Be Aware:  The

Role of Patient Advocates. The session was opened and moderated by Dr. Dan Cole; and other speakers included Dr. Jeffrey Apfelbaum (past president of the ASA) and Dr. Karen Domino (head of all of ASA’s registries, including the awareness registry).  The session, held in a double room, was very well attended. Both the moderator and Dr. Apfelbaum said they had searched the records of ASA meetings, and this was the first time “a patient has addressed the Society.”  Being unable to see any of the audience, I had no visual feedback as I spoke, and while being repositioned after my speech, was unaware of what I am told was sincere and sustained applause.  The panel did not have time to accept the hoped-for 30 minutes of Q&A.

We had some terrific meals with various friends and organizations.

Relationships were renewed, established, and strengthened during these evenings.  It seems to be assumed that there is much free time at ASA meetings, but in reality, I had exactly 2 hours of “tourist” time before we caught our plane home after 6 very busy days!  The convention hall was just short of a mile (according to hall officials) and many were the times we had one meeting at one end (which Anne named Florida) and the next at the other end (a.k.a. Texas!).

I spoke at a book signing of a friend, Dr. Fred Ernst, on Tuesday night.

A special experience was being the “subject” of two Problem-Based Learning Discussions moderated  by Dr. Don Mathews.  These are small groups (about 12) where the discussion is interactive.  At one of the sessions there was another awareness victim/anesthesiologist and also an anesthesiologist who had had a known awareness victim (both international attendees); at the other there were two anesthesiologists with known awareness victims, besides myself.

There was a tremendous number of sessions having something to do with awareness or consciousness in some form or other.

Thinking back to 2004, when a guard tried to deny me admission to a meeting, and most meeting moderators reminded their audience that there were “non-anesthesiologists in the audience,” this year’s meeting showed amazing progress.  In those early meetings, my website was often projected on the lecture screens with disdain and ridicule; this year the Campaign was on many screens as a significant force in a positive manner.

The last 11-1/2 years have not been easy for me or for the ASA to accept.  The last 3 years have been ones of great progress, trust, and collaboration.  The 2009 meeting was historic and humbling.  Those who heard me speak listened politely and intently, and in my opinion, many of them “got it!”

I’m happy that I see my work as a God-given mission.  It certainly hasn’t been easy, and my heart breaks each time a new victim calls.  I’m not at my goal yet:  that of being obsolete.  We’re not at the goal of “One case is one too many.”  We all are certainly moving toward home base.  Never, ever give up!

Response on Preventing Intraoperative Awareness

In response to the June 3, 2009, article Preventing Intraoperative Awareness,  I am disappointed with this article because I see it as one-sided.  The clause but caution must be used when discussing this controversial trend makes no sense to me.  Anesthesia awareness is not a “trend”: it is real; it is devastating; it causes tremendous emotional sequelae, it is often denied; and it needs to be prevented by any means possible.  The only caution I see in discussing anesthesia awareness is in NOT discussing it – before or after surgery or an actual occurrence of awareness.

Dr. Johnstone’s statistic of .1-.9% incidence of unintended intraoperative awareness shows a significant increase from previous statistics of .1-.2% of awareness during general anesthesia surgeries (quoted later in the same article).  These new statistics increase the real numbers to 100-900 reported cases per day in the US alone.

For over 11 years, the Anesthesia Awareness Campaign has advocated for victims of awareness and worked in every way possible to increase awareness of awareness and acknowledgment of awareness by the anesthesia profession.

The fact that the use of brain activity monitors was only fleetingly referred to in your article is disappointing.  While not universally accepted as the answer to the prevention of over- or under-dosing of anesthetics, brain activity monitoring may well be the best currently available non-invasive tool to significantly decrease anesthesia awareness, and it is becoming more and more widely used.

Indeed, while the ASA has funded an awareness registry and does provide literature on awareness, there is still much to be done.  In the last year, the ASA, AANA, and this Campaign have been working together on the problem — one would never know it from this article.  I appreciate the opportunity for The Anesthesia Awareness Campaign to present another side of the story.

The Joint Commission (JCAHO at the time) Sentinel Event Alert #32 of October 2004, states, as cited in your article, Factors contributing to the risk of anesthesia awareness include the increasing use of intravenous (IV) delivery of anesthesia, as opposed to inhalation, and the premature lightening of anesthesia at the end of procedures to facilitate operating room (OR) turnover. The Anesthesia Awareness Campaign agrees with these statements.

Consistent use of brain activity monitors, with alarms left on, during all general anesthesia procedures is, at present, the best way to monitor level of consciousness in intravenous anesthesia. The most disturbing, but true, part of the statement is the premature lightening of anesthesia at the end of procedures to facilitate operating room (OR) turnover. How can anyone justify risking something as serious as anesthesia awareness in order to facilitate OR turnover?  Every patient should be given the dignity and patient safety of remaining anesthetized until the procedure is completed.

As Dr. Moore correctly said, Stop Anesthesia Awareness.  One case is 1 too many. Why is every possible step not being taken to avoid this trend?  Awareness continues to happen every day.

Many prominent anesthesia providers have told me that up to 95% of non high-risk cases of awareness are due to human error. Patients can’t know which providers will fail to check their equipment, administer drugs in the wrong amount or frequency or order, or allow other lapses of care.  Patients place their trust in providers, but patients are vulnerable.

I have spoken with anesthesia providers from all surgical situations who tell me, I’ve done xx,000 anesthesias’s and never had a case of awareness.  The statistics suggest that these providers just don’t know who or how many have experienced anesthesia awareness.  First-time victims of awareness don’t wear signs saying, it’s going to be me.

What is your facility doing to prevent anesthesia awareness?

About the Author:

Carol Weihrer is the President & Founder of the Anesthesia Awareness Campaign, Inc… She can be reached atanesawareness@aol.com, or visit the website at www.anesthesiaawareness.com.

Medicare and Social Security at Risk and Other Health News

Recession Is Quickly Drying Up Funds for Medicare 

Rising healthcare costs and the down economy are draining the funding for Medicare, according to Reuters UK. The Social Security fund is taking a hit, too, from the recession and unemployment. A government report from Tuesday indicated that by 2017,Medicare’s trust money will be gone, and Social Security’s trust fund drought will follow in 2037; earlier predictions showed Medicare running out in 2019 and Social Security by 2041. President Obama is focusing on Medicare first with a system overhaul effort to lower healthcare costs for consumers, Reuters UK reports. Members of the House Ways and Mean Committee don’t want seniors to worry. After the government report’s release, two of the committee’s senior members issued the following statement: “Nothing in today’s report should give seniors a reason to be concerned that their benefits will not be paid in full.”

Learn about the recession’s impact on womens health, and here are10 secrets to finding happiness during the recession.

7 Signs You Could Be at Risk of a Stroke

Stroke is the third-leading cause of death and the leading cause of adult disability in the UnitedStates, but it trails other major diseases in awareness and recognition of symptoms. U.S. News’s Sarah Baldauf lists 7 factors that may be putting you at risk of having a stroke. Risk factors include uncontrolled high blood pressure, smoking, migraines, and high levels of the amino acid homocysteine in the blood. If you’re at risk, leading a healthful lifestyle—including getting exercise, eating a nutritious diet, and not smoking—may reduce your odds of ischemic stroke, the most common form of stroke. Women looking to prevent a stroke may need to stop taking hormone replacement therapy that contains estrogen since the treatment has been found to significantly increase risk.

Once a stroke hits, it’s critical to seek treatment immediately, doctors say, because one powerful drug is approved for use only in the first three hours after symptoms begin. Strokes come on suddenly and can cause a range of symptoms. Learn how to recognize these 5 symptoms of stroke.

Swine Flu‘s Fall Return: 3 Steps We Must Take Now

The H1N1 influenza virus known as swine flu first hit public consciousness just weeks ago, then quickly spread from Mexico to at least four other continents, 30 countries, and more than 5,000 people, reaching near-pandemic levels before subsiding. So far, the global outbreak has caused milder and less transmissible disease and far fewer deaths than feared. But experts are saying that the virus could pose a bigger threat when flu season begins in the fall. U.S. News’s Dr. Bernadine Healy proposes 3 major actions the government needs to take now that could shape what happens if and when the new strain of flu returns. Speeding up diagnosis would allow communities to figure out how to tailor vaccination programs more precisely and distribute antiviral medicine; both vaccines and drugs are apt to be in short supply if things turn bad next fall, Healy writes.

Learn how swine flu could become a pandemic, and explore whether alternative remedies can help ward off swine flu. Here are 14 things you should know about swine flu and 5 ways to prepare your family.

“Green” Medical Products: Is it Possible?

Is it possible to have eco friendly medical products?  The answer is a resounding “yes”.  As the push comes for all industries to be more environmentally conscious the medical industry is no exception.  One company that has always embraced the concept of environmental consciousness in conjunction with patient safety is B. Braun Medical Inc.  For 30 years, B. Braun has provided the broadest infusion therapy product line free of both PVC and DEHP in the industry.

B. Braun realized the benefits to not only the patients but also the environment when they chose to manufacture their infusion therapy products without using PVC or DEHP.  In terms of patient safety, the elimination of these two chemicals alleviates the possibility of sorption or leaching jeopardizing patient health.  Sorption occurs when medications do not stay suspended in the solution but actually adhere to the sides of the IV bag.  This results in patients not getting correct or even full dosage.  Leaching occurs when the DEHP or PVC gets released into the medications which have been shown to have toxic effects on certain groups of patients.  From the environmental aspect, removing PVC and DEHP results in fewer emissions of harmful toxins being released during incineration and reduces the weight of the waste that will be brought to the landfill (which actually reduces disposal costs as well).

B. Braun has embraced the commitment to environmental leadership and provides many resources on their website to explain their corporate policy, direct others to follow in their footsteps, and also has a calculation tool in which facilities can take a look at how the reduction of PVC & DEHP in the IV bags they use can result in direct landfill savings.  This company has shown that being “green” can not only benefit the environment but can directly make a positive impact on patient safety and also reduce waste costs as well.