Princess Health and Pollyanna Rhetoric, Proximate Futures and Realist's Primer on Health IT Realities in 2015. Princessiccia

Princess Health and Pollyanna Rhetoric, Proximate Futures and Realist's Primer on Health IT Realities in 2015. Princessiccia

Charlie Jarvis David Blumenthal Edward Ehlinger healthcare IT difficulties healthcare IT myths healthcare IT pollyanna Mark Leavitt proximate future subjunctivisation bias Trisha Greenhalgh

Gusty 09:33 Add Comment

Pollyanna statements about healthcare IT such as the following are still appearing, and are growing increasingly tiresome.  They are, at best, demonstrations of people with a fiduciary duty to have known better making fools of themselves.

Pollyanna: someone who thinks good things will always happen and finds something good in everything (Merriam-Webster, http://www.merriam-webster.com/dictionary/pollyanna)

Examples:

... Before ARRA, most surveys concluded that cost was the No. 1 barrier to EHR adoption. But as soon as it appeared that the cost barrier might finally be overcome, individuals with a deeper-seated "anti-EHR" bent emerged. Their numbers are small, but their shocking claims -- that EHRs kill people, that massive privacy violations are taking place, that shady conspiracies are operating -- make stimulating copy for the media. Those experienced with EHRs might laugh these stories off, but risk-averse newcomers to health IT, both health care providers and policymakers are easily affected by fear mongering.  (Mark Leavitt, former head CCHIT, http://www.ihealthbeat.org/perspectives/2009/health-it-under-arra-its-not-the-money-its-the-message.aspx)

and:

"The [ONC] committee [investigating FDA reports of HIT endangement] said that nothing it had found would give them any pause that a policy of introducing EMR's [rapidly and on a national scale - ed.] could impede patient safety."  (David Blumenthal, former head of ONC at HHS, http://www.massdevice.com/news/blumenthal-evidence-adverse-events-with-emrs-anecdotal-and-fragmented)

and:

"We don't think there's a great deal of data to substantiate that there are major safety problems with the majority of electronic health records systems in use today," said Charlie Jarvis, executive committee vice chair of the EHR Assn., a trade group that represents 46 organizations that supply most of the EMR systems implemented in medical practices. "These products are safe, dependable, time-tested and display a lot of the safety features we think are necessary to prevent problems going forward." (Charles Jarvis, erstwhile NextGen VP and holder of prestigious (and mysterious) "American Medical Informatics Certification for Health Information Technology", http://hcrenewal.blogspot.com/2011/11/two-opposing-views-of-ehr-1.html)

The most recent example highlighted on this blog is:

As Minnesota�s health commissioner, I work to improve the health of all Minnesotans. As a physician, I�m dedicated to providing the best care possible to patients. Secure electronic health records help achieve both goals by enhancing the safety, effectiveness, and efficiency of our health care system. With that in mind, I have been concerned to see some recent pushback on Minnesota�s requirement that all health care providers use electronic health records (EHR) by 2015 ... All Minnesota patients, whether they visit a small clinic, need mental health treatment, or receive care from multiple providers, stand to benefit from EHRs and the improved care coordination they make possible. (Minnesota's Heath Commissioner Dr. Edward Ehlinger, http://www.minnpost.com/community-voices/2015/04/electronic-health-records-advance-quality-care-all-minnesotans.)

Here is the tragic reality.

Recommended for reading, and for feeding to the press and to our elected officials:

Primer on health IT realities in 2015:

-------------------------------------------------

(1)  "Five biases of new technologies", Trisha Greenhalgh.  Br J Gen Pract. 2013 Aug; 63(613): 425
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722815/

The most dangerous of these biases is the "subjunctivisation bias".  It results in clinical disruption, mishaps, injury and death:

Subjunctivisation bias: Much of the policy rhetoric on new technologies rests not on what they have been shown to achieve in practice but on optimistic guesses about what they would, could, or may achieve if their ongoing development goes as planned; if the technologies are implemented as intended; and in the absence of technical, regulatory or operational barriers.⁴ This is what Dourish and Bell call the �proximate future�: a time, just around the corner, of �calm computing� when all technologies will be plug-and-play and glitch-free.

(I point out a related bias - that of the hyper-enthusiastic technophile who either deliberately ignores or is blinded to technology's downsides, ethical issues, and repeated local and mass failures.  See http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html.)

(2)  ECRI Institute Deep Dive Study on Health IT risks (2012)
http://www.healthit.gov/facas/sites/faca/files/STF_Deep_Dive_Health_Information_Technology_2014-06-13.pdf

171 IT mishaps sufficient to cause harm reported voluntarily by 36 hospitals in 9 weeks; 8 injuries; mishaps likely contributed to 3 deaths as well.  Projected to a nationwide annual figure, the result is likely many thousands of times greater (see http://hcrenewal.blogspot.com/2013/02/peering-underneath-icebergs-water-level.html).

(3)  Letter to ONC from 37 Medical Societies (January 2015)      
http://mb.cision.com/Public/373/9710840/9053557230dbb768.pdf

This letter speaks for itself on exceptionally well-justified clinician dissatisfaction and alarm at the risks and disruptions posed by this technology in its current form and with present roles (e.g., the experimental use of clinicians as cheap data entry clerks).

   
(4)  Joint Commission Sentinel Events Alert on Health IT (March 2015)   
http://www.jointcommission.org/assets/1/18/SEA_54.pdf

Late, but better than never.  Most of what's in this alert has appeared on this blog since 2004.   Footnote 1 (ECRI Institute PSO Deep Dive, the report linked above) is somewhat bizarrely used as a justification of the statement "EHRs have demonstrated the ability to reduce adverse events."  I do also note at the linked http://www.jointcommission.org/safe_health_it.aspx these statements:

• Poorly designed or implemented health IT can contribute to patient harm
• Health IT-related patient safety events can go undetected
• As health IT adoption becomes more widespread, the potential for health IT-related patient harm may increase

These could have come directly from my writings dating back over a decade here.  (Perhaps they did.)

(5)  Accenture - Fewer U.S. Doctors Believe It Improves Health Outcomes (April 2015)                    
http://www.businesswire.com/news/home/20150413005148/en/Increased-Electronic-Medical-Records-U.S.-Doctors-Improves#.VT5bmpOTqUk

This survey also speaks for itself.  A less formal nurses' survey is here:  http://hcrenewal.blogspot.com/2013/07/candid-nurse-opinions-on-ehrs-at.html

(6)  U.S. Centers for Medicare & Medicaid Services (CMS)
https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjc5Sf4nMN_8ru94JGGWglCefBw1O1K2WcOwRR8UMpvbpaOuWRm3-NVWGs6wnLuCiqyNgzZNNwjHW6lFNSziG_uAA36U2yJ1K3e8HfOMzFNxpgdRdSxtbG9It7_nbDMAXh3d5xHzZWD-OB9/s1600/CMS_Letter.jpg

FOIA response:  "We do not have any information that supports or refutes claims that a broader adoption of EHRs can save lives."  (But let us spend hundreds of billions of dollars and put patients at risk to find out...)

CMS: "we do not have any information that supports or refutes claims that a broader adoption of EHRs can save lives.  [Click to enlarge.]

In conclusion:

Next time you encounter pollyanna/head-in-the-sand statements about health IT that ignore the risks, throw this primer the way of the authors and audience of such statements.

-- SS

Princess Health andFederal agency offers a consumer-friendly website that ranks patients' experiences in your local hospitals .Princessiccia

Princess Health andFederal agency offers a consumer-friendly website that ranks patients' experiences in your local hospitals .Princessiccia

hospitals Medicare Patient Protection and Affordable Care Act poll rankings

Gusty 17:14 Add Comment

Consumers now have access to a website that ranks 3,500 hospitals around the country on patients' experiences to help them choose a hospital and better understand the quality of care participating hospitals offer, according to a Centers for Medicare and Medicaid Services press release.

The 12 star ratings on Hospital Compare are based on 11 of the publicly reported measures from the Hospital Consumer Assessment of Healthcare Providers and Systems Survey, and a summary rating for the survey. The survey asks patients questions about nine topics:communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, quietness of the hospital environment, and transition of care. This survey information is self-reported by patients and will be updated quarterly.

�The patient experience star ratings will make it easier for consumers to use the information on the Hospital Compare website and spotlight excellence in health care quality,� Dr. Patrick Conway, acting principal deputy administrator for the CMS, said in the release.

Consumers already have access to Medicare star systems to rate nursing homes, dialysis centers, private Medicare Advantage insurance plans and certain situations for physicians and group practices, but are they using it?

Not much, according to a recent Kaiser Family Foundation poll. It found that only 31 percent of those polled had seen any information comparing doctors, hospitals, and health insurance plans in the past 12 months. When asked specifically if they had seen information comparing prices or quality across plans and providers, fewer than 1 in 5 people said they had seen such information, and fewer than one in 10 reported using such information.

CMS said the website helps meet goals of the Patient Protection and Affordable Care Act, which calls for transparent, easily understood and widely available public reporting. The agency also reminds consumers that the site is just one tool to help them make a decision abut which hospital to use, and encourages them to talk to their health-care providers about hospital quality, and to use "multiple factors" when deciding about a hospital, such as clinical outcomes and other publicly reported data that is on the website.

To see the rankings:

• Go to the Hospital Compare website
• Type in your ZIP code, or the name of a particular hospital
• Click on "Search"
• Choose three hospitals, by clicking on the "Add to Compare" button
• Click on "Compare Now," located at the top of the screen
• Click on "Survey of Patients' Experiences"
• Scroll down and view star ranking and additional information results

This is a screen shot of the final screen, with a bar of options to click on.

Princess Health andStudy shows that removing a clot that causes a stroke leaves victims with higher functional independence.Princessiccia

Princess Health andStudy shows that removing a clot that causes a stroke leaves victims with higher functional independence.Princessiccia

blood pressure research stroke

Gusty 16:11 Add Comment

In Kentucky, strokes cause about 5 percent of deaths, and the state had the 11th highest stroke mortality rate in 2009, according to data from the Kentucky Cabinet for Health and Family Services. Fewer than 40 percent of severe stroke victims regain functional independence if they get only the standard drug intervention, but a study has found that also removing the clot both helps restore blood flow to the brain and can lead to more favorable long term outcomes.

"The outcomes are the difference between patients being able to care for themselves after stroke and being dependent," said Demetrius Lopes, surgical director of the comprehensive stroke center at Rush University Medical Center.

The traditional treatment for ischemic stroke�a stroke that involves clots in vessels bringing blood to the brain�is intravenous tissue plasminogen activator (tPA), a medication to dissolve the clot. However, doctors can also perform thrombectomy, a minimally invasive procedure to remove the clot that is allowed only in clinical trials.

In the study, patients with severe ischemic strokes were split into two groups. One group received only tPA, while the other group received tPA as well as thrombectomy. After 90 days, those who received both treatments had less disability and had a functional independence rate of 60 percent, compared to 35.5 percent of those who received only tPA. Also, patients who received thrombectomy had better blood flow rates in the brain.

"Ethically, we can't deny patients a treatment when we have such strong evidence it's better for them," Lopes said. Now thrombectomy is a standard treatment for severe strokes at Rush and some other locations. The study is published in the online edition of the New England Journal of Medicine.

Princess Health andENDURrace 8K.Princessiccia

Princess Health andENDURrace 8K.Princessiccia

Gusty 09:15 Add Comment

After a great experience at the ENDURrace 5K, we were back a week later to enjoy the second race in this 2-race series.  Here's how we did at the ENDURrace 8K:

Full Results
Team Rankings

At the front of the race, Dave and Aaron had an outstanding battle for 3rd place.  Dave ended up taking it, just seconds off his PB, running 29:46.  This was good enough for 3rd OA and 1st in his AG.

Aaron was very close behind with a PB (and all-time fastest race) of 29:53.  This brought him in 4th OA and 1st in his AG.

Holger came in next for the team.  Less than one week removed from Boston, he still managed a new 8K PB of 32:12, good enough to crack the top 10 and place 2nd in his AG.

Derek Hergott was in next with an outstanding 36:14, placing just inside the top 25, and 4th in his AG.

Paul showed that his fitness continues to improve.  Coming off a great TYS10K, he ran an excellent 36:53.

Kyle MacKenzie, the youngest H+P-er out there, was in next for the team with an outstanding result of 38:47.  He won his AG, and he also won the parent/child division with his dad!

Jessica came in next with an outstanding time of 41:13.


Cari Rastas Howard was in next for the team with an outstanding 42:10 personal best.

Tracey had a very strong 4th place AG finish with a time of 42:45.

Thanks again for another great event RunWaterloo!  And thanks to Julie for all the great photography.

#cantwontstop

Princess Health and2015 Boston Marathon.Princessiccia

Princess Health and2015 Boston Marathon.Princessiccia

Gusty 08:52 Add Comment

H+P had a very solid, 8-athlete contingent that raced Boston this year.  Conditions were tough, but our runners persevered!  Here are the results.

Team Rankings

Holger came in first for the team with a very solid 3:09:09.  He later celebrated by putting on his medal, letting loose and partying, as shown below:

Jordan was in next for the team with a time of 3:09:49.  An ultimate frisbee injury severely reduced his mileage during the key training blocks leading into this race, but he still was able to cross train his way to a very respectable time.  Congrats!

Jess was in next with a PB of 3:15:48!

Right after Jess was our masters female All-Star, Val Hobson.  She had a very strong finish of 3:16:49, good enough for 25th place in her AG that included just under 1900 women who qualified! 

Andrea was in next for the team.  Battling through some injury adversity in the final weeks leading up to the race, she still ran an outstanding time of 3:19:17.

Our Manulife Crew (Jeff Collins, Erica Hall and Laura Hewitson) all had strong races and great finishes in their first marathons.  Jeff ran a very solid 4:16, Erica came in at 4:25 and Laura finished in 4:47.

Way to make our team proud in Bawstin!  

#cantwontstop

Princess Health and More Barbarians at the Gates: Private Equity Puts Primary Care in Play. Princessiccia

Princess Health and More Barbarians at the Gates: Private Equity Puts Primary Care in Play. Princessiccia

corporate physician primary care private equity You heard it here first

Gusty 07:24 Add Comment

There are still some idealistic physicians who enter primary care practice as a calling.

The usual informal definition of primary care is care which is continuous, coordinated, comprehensive and compassionate.  The official definition used by the American Academy of Family Physicians (AAFP) is:

Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the 'undifferentiated' patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis.

Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care is performed and managed by a personal physician often collaborating with other health professionals, and utilizing consultation or referral as appropriate.Primary care provides patient advocacy in the health care system to accomplish cost-effective care by coordination of health care services. Primary care promotes effective communication with patients and encourages the role of the patient as a partner in health care.

Private Equity Firms are Buying Out Primary Care Practices

However, an article this week in Modern Healthcare described how primary care in the US is getting a rude surprise.  Apparently, primary care practices are now "in play," (using the terminology for the classic 1987 movie Wall Street, in which Gordon Gekko declared that greed is good).



The argument was that there is

a small but growing number of investments that private-equity firms are making in primary-care physician practices that are ahead of the curve in offering new care delivery and payment models. Investors see an opportunity in being early participants in value-based care, even as the business case is still unclear given mixed results in Medicare's payment and delivery reform demonstrations so far.

But the niche is well-suited for private-equity firms, which feed on uncertainty, said Todd Spaanstra, a partner at Crowe Horwath, an accounting and consulting firm. 

This is not about quality of care, it is about the idea that business people think that "value-based care" and "risk-based contracting" are the current rages, and so there is money to be made investing in entities that seem to fit in with these fashions.

said Slava Girzhel, managing director at KeyBanc Capital Markets. 'There's a lot of discussion about private-equity investing in risk-based models, and I do think we'll see more of that.'

Continuous, coordinated, comprehensive and compassionate care may suffer when the time horizons are not that long, and the owners of the practice are ultimately looking to sell it. 

The long-term opportunity for private-equity firms is the ability to sell these managed-care-savvy medical groups to insurers or health systems, which may pay a premium for the care-coordination expertise and data analytics these practices offer.

Also,

The typical private-equity investment timetable is short�about five years. At that point, the firm would probably look to sell the practice, ideally to an insurance company or a health system, said Dan Hosler, a principal at private-equity firm Sterling Partners.

Furthermore, why private equity may be interested in primary care now, continuing interest will depend on the numbers, not on the benefits to patients

'This is an area where there are winners and losers,' said Dr. Andrei Gonzales, director for value-based reimbursement initiatives at McKesson Health Solutions. 'It's everyone trying to get a slice of the pie that's getting smaller.'

What Happens When the Barbarians are at the Gate

Conspicuously absent from this article was discussion of aspects of the private equity modus operandi which are even more at odds with primary care values than the short time horizon noted above.  We previously warned about the perils of private equity employing physicians (look here.)  The main points were:

-  Private equity is just the new name for leveraged buyout firms (the type of firm described the book, Barbarians at the Gate.)

-  Therefore, when they buy out firms (e.g., the primary care practices discussed above), they use borrowed money.

-  But they leverage in two senses.  Once firms are bought, the private equity owners makes the firms take out further loans, and the money from them may go back to the owners, usually in the form of a special dividend, to pay down the debt originally incurred by the private equity owners.  This leaves the bought out firms heavily in debt, but frees the private equity firm from its original debt.  If the firm is eventually sold, the new buyers take over the debt.  In a worst case scenario, however, the bought out firm goes bankrupt, the private equity's firm stock in it becomes worthless, but the private equity firm need not be responsible for its financial obligations.

-  If the private equity firm desires more money while it still owns the acquired firm, it may sell parts of it off.

-  To make the finances of the acquired firm look more attractive to the next buyer, the private equity firms often undertakes short term cost cutting measures that may involve layoffs, increased workload on remaining workers, etc.

Other dark aspects of private equity are discussed on the Naked Capitalism blog here.

Summary

Primary care physicians thinking about selling their practices to private equity ought to think at least twice before doing so, assuming the physicians are serious about upholding the values of primary care.  Private equity firms are in it for the money, and in the relatively short term.  Private equity firms are unlikely to care about the mission of primary distinct from the ability of primary care practices to make the firms richer.  Therefore, practices owned by private equity may well not provide the best possible care for their patients.  In any case, the physicians working for such practices may be answering to owners who are very explicitly only in it for the money.  They will have become corporate physicians, possibly in the most pessimistic sense of the term.

In general, Dr Arnold Relman reminded us that physicians used to shun the commercial practice of medicine (look here).  Physicians and other health professionals who sign on as full-time employees of large corporate entities have to realize that they are now beholden to managers and executives who may be hostile to their professional values, and who are subject to perverse incentives that support such hostility, including the potential for huge executive compensation.  It is not clear why physicians seem to be willing to sign contracts that underline their new subservience to their corporate overlords, and likely trap them within confidentiality clauses that make blowing the whistle likely to lead to extreme unpleasantness.

Things are likely to be even worse for corporate physicians who are employed by firms owned by private equity. Because of the way private equity operates, primary care practices owned by such firms are liable to be very unstable.  At best, they are liable to be sold to totally new owners in a relatively short time frame, and those owners are likely to be those who will pay the highest price, not necessarily those who will provide the best stewardship for the practices.

Furthermore, primary care practices owned by private equity are likely to end up heavily indebted and subject to strict cost cutting measures that may decrease care quality, decrease access, increase patients' out of pocket costs, and demoralize providers.  Practices acquired by private equity may be broken up and sold as separate pieces.  Should the debt be too high, and the cost cutting not be sufficient, such practices could end up bankrupt and possible completely defunct. 

Do not say I did not warn you.

Physicians need to realize that to fulfill their oaths to put patients first, they have to reduce the influence of rich and powerful organizations with other agendas, like health care corporations, and especially corporations owned by private equity.  The metastasis of private equity into primary care should make us all rethink the notion that direct health care should ever be provided, or that medicine ought to be practiced by for-profit corporations. I submit that we will not be able to have good quality, accessible health care at an affordable price until we restore physicians as independent, ethical health care professionals, and until we restore small, independent, community responsible, non-profit hospitals as the locus for inpatient care.

ADDENDUM (28 April, 2015) - This post was re-published on the Naked Capitalism blog.  

Princess Health andElementary-school students prompt Middlesboro smoking ban.Princessiccia

Princess Health andElementary-school students prompt Middlesboro smoking ban.Princessiccia

electronic cigarettes smoking smoking ban smoking bans smoking ordinances tobacco tobacco prevention youth

Gusty 08:21 Add Comment

UPDATE, May 20: The council passed the ban with one member opposing it. Gary Mills said, �I don�t think it�s the government�s right to intrude on businesses owned by individuals. If the public doesn�t like it, they won�t come. . . . This is too intrusive by the government.� Two non-smoking business owners expressed similar sentiments.

The Middlesboro City Council has approved on first reading an ordinance that would ban smoking in public, enclosed spaces. "It remains unclear if the ban would apply to the use of e-cigarettes and vaping products," William Tribell reports for the Middlesboro Daily News.

The ordinance was prompted in part by a March presentation and petition from a group of Middlesboro Elementary School students involved in Destination Imagination, "a volunteer-led, educational nonprofit organization whose purpose is to inspire and equip students to become the next generation of leaders," Tribell writes. "The team was awarded the DaVinci Award for Outstanding Creativity for their efforts and will now compete at the world competition May 20 in Knoxville."

The students drafted the ordinance after researching those in other cities, Tribell reports: "In their presentation to the city council, the team said that 33 percent of Bell County�s population smoke, and they discussed the health effects it has on the community at large."

"The council voted unanimously in favor of the ban ordinance, and it will go up for a second-reading vote at their meeting on May 19," Tribell reports.