This Is Some Interesting Research On The Impact Of Health IT In The US. A Useful Report Indeed.

The following appeared a little while ago:

Federal study shows IT improves outcomes

Posted on Aug 15, 2013

By Diana Manos, Senior Editor

A new report issued Thursday by the Agency for Healthcare Research and Quality has found that certain health IT products, including those that provide decision support, clinical workflow support and care coordination can lead to better healthcare outcomes. 

"Findings and Lessons from the Improving Quality Through Clinician Use of Health IT Grant Initiative" documents the findings of more than 20 research projects that investigated how health IT applications can assist providers in providing evidence-based care. Multiple studies showed positive impacts on process and intermediate outcomes.

The report highlights key findings and lessons from the experiences of 24 projects awarded in 2007 under AHRQ. According to AHRQ officials, the initiative was designed to investigate approaches for using health IT to support clinicians in making patient care decisions and coordinating care with a focus on effectively incorporating evidence-based information at the point of care. It's part of AHRQ’s Ambulatory Safety and Quality program, which was designed to improve the safety and quality of ambulatory healthcare in the U.S.

The report summarizes the extent to which the federal projects addressed the areas of interest of the IQHIT initiative and identifies practical insights regarding the use of health IT to improve clinical decision-making and care coordination in the ambulatory setting, according to AHRQ officials.

More here:

http://www.healthcareitnews.com/news/federal-study-shows-it-improves-outcomes

There is also coverage here:

AHRQ Projects Show Positive Impact of HIT on Care Quality

Written by Sabrina Rodak | August 15, 2013

The Agency for Healthcare Research and Quality has released a report summarizing the results of the grant initiative, Improving Quality Through Clinician Use of Health IT.

The grant initiative is one of five initiatives under AHRQ's Ambulatory Safety and Quality program, which focuses on the role of health IT in ambulatory healthcare quality and patient safety. The report, "Findings and Lessons From the Improving Quality Through Clinician Use of Health IT Grant Initiative," describes the 24 projects that examined one of four main areas:

1. Providing patient-specific information, clinical knowledge and decision support
2. Supporting clinical workflow
3. Coordinating care
4. Understanding the impact on outcomes

More here:

http://www.beckershospitalreview.com/quality/ahrq-projects-show-positive-impact-of-hit-on-care-quality.html

The conclusions of these studies say it all.

Conclusion.

The IQHIT projects demonstrated significant progress toward addressing AHRQ goals of advancing  understanding of how clinicians can use health IT  to improve the quality of health care. They developed and tested a range of approaches for enhancing  CDS, providing clinical information at the point of  care, and improving care coordination, while also  studying how to integrate health IT systems into  clinical workflows. Several projects showed a positive  impact on process outcomes related to the delivery  of evidence-based preventive and chronic care, or the  use of health IT by clinicians. In addition, several  projects showed a positive impact on intermediate  outcomes such as chronic disease control, clinician  perceptions of health IT usefulness, and clinician  satisfaction. Other projects demonstrated improvements in health outcomes such as adverse drug events  and functional status. Their findings and insights can provide the foundation for advances in several of  the priority areas in the National Quality Strategy,  especially making care safer, coordinating care, and  promoting the use of effective care (HHS, 2012), as  the IQHIT researchers showed how clinician use of  health IT can improve outcomes in all of these areas.  The IQHIT projects continue to build the evidence  base for clinician use of health IT as they are consistent with the findings of a recent systematic review of  earlier research on the effects of clinician use of CDS  systems (Bright et al., 2012, Lobach et al., 2012).

The findings and lessons from the IQHIT initiative  can inform researchers and implementers interested  in using health IT to help clinicians improve the  quality of health care. The continued rapid pace of  technological change and the continued interest in  the use of health IT to improve health and health  care delivery make the results of this body of research  timely and relevant to ongoing efforts to expand the  use of health IT to improve the quality of health care

The full report is here:

http://healthit.ahrq.gov/sites/default/files/docs/page/findings-and-lessons-from-the-improving-quality-through-clinician-use-of-health-it.pdf

Well worth a download and read.

David.

This Seems To Be A Trend That Is Worth Watching The Private Sector Stepping Up In E-Health.

This appeared last week.

At your fingertips

19 August, 2013 John Kron

A growing number of practices are offering online services that benefit their patients and their business.

General practices used to only interact with patients in person or over the phone. Now they’re starting to offer online services through their websites, including booking appointments and receiving test results, referral letters and repeat scripts.

Bondi Junction Medical Centre in Sydney began offering online services in March and the experience has been highly satisfying, says practice manager Rakesh Vyasabhattu.

The benefits reaped by the GPs are primarily time saved and extra income. For example, the GP and patient agree beforehand that test results will be available online for the set fee of $20.

The GP then simply ticks a box in the medical record and the patient, who registers on the practice website with a user name and password, accesses the results when they’re ready, without having to ring the GP, says Mr Vyasabhattu.

Referral letters and repeat scripts are also available for a fee of $20, while booking appointments is free at the centre. The convenience is what appeals to many patients, Mr Vyasabhattu says.

“They don’t have to ring and be put on hold; they can access us and do these things 24/7,” he says.

“For our receptionists, the main benefit is less time taking phone calls, which makes them more available to speak to patients at the reception desk and also respond to the needs of the doctors.”

Online service providers
Online services made available through practice websites are in the early days of uptake. Heather Grain, director of course development at eHealth Education and council member at the Australasian College of Health Informatics, estimates that fewer than 10% of practices in Australia are currently offering these services through their website.

“The level is much higher in countries like the UK where the government strategy has been driving the uptake, whereas in Australia, the government focus has been on IT communications related to clinical care,” she says.

“As a result, private companies, as well as GP enthusiasts, are driving the uptake of online services through practice websites.”

These companies provide online services either embedded into a practice’s existing website or include them as part of a package of setting up a new practice website. These companies also can provide e-consultation capability, practice newsletters and patient health information for the website.

Practices that don’t have a website can use providers for online booking appointments such as 1stAvailable and Health Engine.

Lots more here:

http://www.australiandoctor.com.au/in-depth/work-wise/at-your-fingertips

What needs to be noticed here is the services that are being offered are the services patients want and that are not deliverable via the PCEHR. They are also being provided by private and not government entities.

To be able to make appointments, provide script repeats, provide referrals and access to test results you need to be to interact with a live local clinical system and not an delayed secondary and possibly incomplete system.

Combine this structural problem with the user unfriendliness of the current implementation and it is clear the PCEHR is a major failed design in terms of really delivering what patients actually want and would value.

Practitioners may also find the level of engagement with their patients and the additional income that is possible rather a win-win.

As the title says, well worth watching how this plays out in the future.

David.

Setback for Sutter after $1B EHR crashes (in followup to post "RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals")

At my July 12, 2013 post "RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals" (http://hcrenewal.blogspot.com/2013/07/rns-say-sutters-new-electronic-system.html) I reproduced a California Nurses Association warning about rollout of an EHR at Sutter:

RNs Say Sutter’s New Electronic System Causing Serious Disruptions to Safe Patient Care at East Bay Hospitals

Introduction of a new electronic medical records system at Sutter corporation East Bay hospitals has produced multiple problems with safe care delivery that has put patients at risk, charged the California Nurses Association today.

Problems with technology are not unique to health care ...  [What is unique to healthcare IT is the complete lack of regulation - ed.]

In over 100 reports submitted by RNs at Alta Bates Summit Medical Center facilities in Berkeley and Oakland, nurses cited a variety of serious problems with the new system, known as Epic. The reports are in union forms RNs submit to management documenting assignments they believe to be unsafe.

Patient care concerns included computerized delays in timely administration of medications and contact with physicians, ability to properly monitor patients, and other delays in treatment.  Many noted that the excessive amount of time required to interact with the computer system, inputting and accessing data, sharply cuts down on time they can spend with patients with frequent complaints from patients about not seeing their RN.  [Note: patients are not given the opportunity for informed consent about the risks, nor opt-out of EHR use in their care - ed.]

In related posts I'd observed such concerns being ignored by hospital management.  See header of the aforementioned post.

Now we have this:  a major system crash.

Healthcare IT News
Setback for Sutter after $1B EHR crashes

'No access to medication orders, patient allergies and other information puts patients at serious risk'

SACRAMENTO, CA | August 28, 2013

The nearly $1 billion electronic health record system at Sutter Health in Northern California crashed early this week, leaving nurses and clinical staff unable to access any patient information for a full day.
he Epic EHR was down Aug. 23 due to a planned upgrade for eight hours during which nurses and other clinical users could read medication orders and patient histories but had to record new data on paper to then be re-entered into the system later, according to reports from the California Nurses Association, part of National Nurses United, the largest nurses union in the U.S.

Then, on the morning of Aug. 26 at approximately 8 a.m., the system crashed completely, at which time nurses, physicians and hospital staff had no access to patient information, including what medications patients were taking or required to take and all vital patient history data. 
 
The Epic EHR went dark at several Sutter Health locations, including Alta Bates Summit Medical Center, Eden Medical Center, Mills-Peninsula Hospital, Sutter Delta, Sutter Tracy, Sutter Modesto and numerous affiliated clinics.

"This incident is especially worrisome," said Bonnie Castilla, RN, CNA legislative director, in a news release. "No access to medication orders, patient allergies and other information puts patients at serious risk.  These systems should never be relied upon for protecting patients or assuring the delivery of the safest care."  [This is no exaggeration.  My mother was nearly killed by such a problem when caused by an EHR defect (link) that I averted at the last minute by happenstance of showing up at the right time, while she recuperating from another EHR-related disaster - ed.]   

Some RNs also reported that Sutter failed to provide adequate support during the blackout and didn't implement adequate backup planning.
 
"All information such as medication administration records and patient histories was outdated by two to three days," said Mike Hill, Alta Bates Summit RN, in a news release. "There were no orders that could be seen of any kind through the day so nurses called for what they needed."

Kevin Sweat, an emergency room RN at Eden Medical Center, a Sutter affiliate, also weighed in on the blackout, saying that in his 12 years as an RN he has never seen a system crash like this. 
  

Worse, clinicians must now serve their Cybernetic Master to perfection, or be whipped (apparently to improve morale):

... "We have been on Epic for 5 months now, and we can no longer have incorrect orders, missing information or incorrect or missing charges. Starting on September 1st, errors made in any of the above will result in progressive discipline," according to another hospital memo sent to staff.

In the setting of dire warnings by the nurses of EHR dangers several months back that were likely largely ignored, if any patient was harmed or killed as a result of this latest fiasco, the corporate leadership has literally begged to be sued for negligence, in my view.

However I'm sure a press release soon will claim that "patient care has not been compromised."

Of course this includes now and moving forward, even with informational gaps all over the place.

-- SS

Aug. 29, 2013 additional thought:

The punishment for not being a 'perfect' user of this EHR is the ultimate "blame the user" (blame the victim?) game, considering the pressures of patient care in hospitals in lean times - partly due to EHR expense! - and EHRs that have not been formally studied for usability and are poorly designed causing "use error" (that is, a poor user experience promotes even careful users to make errors).  Cf. definition of bad health IT:

Bad Health IT ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.

The study of usability is getting underway only now via NIST but will likely be done in an industry-friendly way due to health IT politics.

-- SS

Aug. 29, 2013 addendum

There have been numerous comments over at HisTalk (at http://histalk2.com/2013/08/27/news-82813/) defending the outage as not EPIC's fault.   From the point of view of clinicians - and more importantly, patients - it doesn't matter what component of the hospital's entire "EHR" (an anachronistic term used for what is now a complex enterprise clinical resource and clinician command-and-control system) went down. 

Aside from all the EPIC issues the nurses have been complaining about (see earlier July 12, 2013 post linked above), the larger problem is that IT malpractice occurred.  The term "malpractice" is used in medical mishaps; I see no reason why it does not apply to major outages of mission critical healthcare information technology systems.

IT malpractice in healthcare kills.

These are the types of nurses I'd want caring for me and mine.  Letting this kind of snafu go "anechoic" does not promote proper management remedial education on Safety 101 and on health IT risk, two areas of education that management appears to desperately need in hospitals.

-- SS

Calling Dr. Moe, Dr. Larry and Dr. Curly: Advocate Medical Breach of Four Million Patient Records, and No Encryption

At my Oct. 2011 post "Still More Electronic Medical Data Chaos, Pandemonium, Bedlam, Tumult and Maelstrom: But Don't Worry, Your Data is Secure" (http://hcrenewal.blogspot.com/2011/10/still-more-ehr-chaos-pandemonium-bedlam.html) I thought I'd seen the worst.

Yet another post to add to the category of medical record privacy/confidentiality/security (http://hcrenewal.blogspot.com/search/label/medical%20record%20privacy), however:

Advocate Medical Breach: No Encryption?
Computer Theft Raises Questions About Unencrypted Devices
By Marianne Kolbasuk McGee, August 27, 2013.

The recent theft of four unencrypted desktop computers from a Chicago area physician group practice may result in the second biggest healthcare breach ever reported to federal regulators. But the bigger issue is: Why do breaches involving unencrypted computer devices still occur?

According to the Department of Health and Human Services' "wall of shame" website listing 646 breaches impacting 500 or more individuals since September 2009, more than half of the incidents involved lost or stolen unencrypted devices. Incidents involving data secured by encryption do not have to be reported to HHS.

... The four unencrypted but password-protected computers [passwords on PC's are bypassable by smart teenagers - ed.] stolen during a burglary in July from an office of Advocate Medical Group in Illinois may have exposed information of about 4 million patients, according to an Advocate spokesman.

4 million is about 1.3 percent of the entire U.S. population (about 313.9 million in 2012) ... on just four desktop computers.

Try that with paper ...

As to the subtitle of the article, "Computer Theft Raises Questions About Unencrypted Devices", I've written on that issue before.  I'd noted questions like that are remarkable considering both MacOS and Windows have built-in, readily available encryption, the latter for a few extra $ for the "deluxe version" (see  http://en.wikipedia.org/wiki/FileVault and http://en.wikipedia.org/wiki/Bitlocker).  

Perhaps the best explanation in 2013 for unencrypted desktop PC's containing millions of confidential medical records is this picture, symbolic of the apparent attitudes of corporate and IT management on health IT security:

Encryption?  We don't need no encryption.  We got triple protection already!

-- SS

It’s Wonderful To See Some Real Evidence Of E-Health In Australia Making A Difference - Again In The Private Sector.

This abstract appeared in the Medical Journal Of Australia last week.

https://www.mja.com.au/journal/2013/199/4/impact-diabetes-management-general-practice-management-plans-team-care

Impact on diabetes management of General Practice Management Plans, Team Care Arrangements and reviews

Leelani K Wickramasinghe, Peter Schattner, Marienne E Hibbert, Joanne C Enticott, Michael P Georgeff and Grant M Russell

Med J Aust 2013; 199 (4): 261-265.

doi: 10.5694/mja13.10161

Abstract

Objectives: To investigate whether General Practice Management Plans (GPMPs), Team Care Arrangements (TCAs) and reviews of these improve the management and outcomes of patients with diabetes when supported by cdmNet, a web-based chronic disease management system; and to investigate adherence to the annual cycle of care (ACOC), as recommended in diabetes guidelines.

Design, participants and setting: A before-and-after study to analyse prospectively collected data on 577 patients with type 1 or 2 diabetes mellitus who were managed with a GPMP created using cdmNet between June 2008 and November 2012.

Main outcome measures: Completion of the clinical tests in the ACOC (process outcome) and values of six of these clinical measurements (clinical outcomes).

Results: Significant improvements were seen after creation of a GPMP in the proportion of ACOC clinical tests completed (57.9% v 74.8%, P < 0.001), total cholesterol level (P < 0.01), low-density lipoprotein (LDL) cholesterol level (P < 0.001) and body mass index (BMI) (P < 0.01). Patients using GPMPs and TCAs also improved their glycated haemoglobin (HbA1c) level (P < 0.05). Patients followed up with irregular reviews had significant improvements in the proportion of ACOC clinical tests completed (59.2% v 77.6%, P < 0.001), total cholesterol level (P < 0.05), and BMI (P < 0.01), but patients with regular reviews had greater improvements in the proportion of ACOC clinical tests completed (58.9% v 85.0%, P < 0.001), HbA1c level (57.7 v 53.0 mmol/mol, P < 0.05), total cholesterol level (4.8 v 4.5 mmol/L, P < 0.05), LDL cholesterol level (2.8 v 2.4 mmol/L, P < 0.01) and diastolic blood pressure (76.0 v 74.0 mmHg, P < 0.05).

Conclusion: There were significant improvements in process and clinical outcomes for patients on a GPMP or a GPMP and TCA, particularly when these were followed up by regular reviews. Patients using cdmNet were four times more likely to have their GPMP or TCA followed up through regular reviews than the national average.

The article is here (full access freely accessible):

https://www.mja.com.au/journal/2013/199/4/impact-diabetes-management-general-practice-management-plans-team-care

I was also sent a press release with some commentary:

Melbourne 19 August 2013

MEDIA RELEASE
INTERNET TECHNOLOGIES MAY BE KEY TO TREATING ‘FASTEST GROWING EPIDEMIC IN HUMAN HISTORY’ STUDY SUGGESTS

As diabetes looms as a runaway epidemic in Australia, a Monash University study suggests that Internet technologies may be key to overcoming this challenge to our healthcare system.  

The study monitored 577 diabetes patients over 14 months. It showed significant improvements in quality of care and clinical outcomes for patients whose care was supported by an internet-based care management service called cdmNet. The study is published in the Medical Journal of Australia issue of 19 August.

cdmNet assists General Practitioners (GPs) and patients to manage chronic diseases and other illnesses.  Using cdmNet, any member of the patient’s care team can access the patient’s health record and care plan, including the GP, specialists, allied health, pharmacists, and the patient themselves. They can do this from anywhere, anytime, while maintaining data privacy and security. Everyone on the team knows what everyone else is doing, all the time.

The results of the study show that 80% of patients on a care plan created and managed using cdmNet were regularly reviewed and followed up compared with national figures indicating fewer than 20% follow up of (non-cdmNet) patients. 

Furthermore, of those patients who received regular reviews, 85% adhered to best practice care compared with 59% otherwise.

Comparing patients before and after the use of cdmNet, significant improvements were observed in

·         HbA1c*, the surrogate measure of blood glucose levels, fell from a mean of 8.4% to 7.4% for patients with an initially high HbA1c

·         Lower total cholesterol (4.6 to 4.3 mmol/L); and

·         Lower LDL (bad) cholesterol (2.6 to 2.3 mmol/L)

The greatest improvements were in patients who had regular reviews of their care plan.

Professor Michael Georgeff, CEO of Precedence Health Care, the company that developed cdmNet, said the study suggests that improvement in clinical outcomes is related to the level of coordination among the care team and with the patient. It also indicates that patients are more likely to adhere to their plan when it is regularly reviewed and followed up by the GP and the care team.

“How to put this into practice is the challenge. GPs’ waiting rooms are full of people with a chronic illness. Trying to keep track of what everyone is doing or not doing places a huge burden on GPs and practices, especially when communications among the team are limited to fax, telephone tag and hand delivery of patient information.

“Without the use of advanced Internet and mobile technologies, one simply cannot achieve the level of coordination and follow up needed for these patients.

“More than seven million Australians have a chronic disease, costing the health care system more than $70 billion per year. The losses to the economy through reduced workforce participation rates and productivity are more than $8 billion per year. Diabetes alone accounts for nearly a quarter of avoidable hospitalisations and 9% of deaths.

“It will be impossible to maintain a sustainable health care system without the use of these technologies,” Professor Georgeff said.

For GPs on the front line who have adopted cdmNet as a patient management tool, the results speak for themselves. Dr Tim Denton, GP in Anglesea, Victoria and chair of the Barwon Medicare Local, said: "Since using cdmNet for ensuring quality of care, we have not had any amputations, strokes or progressive retinopathy in our patients with diabetes. People have fewer complications, are living better lives and living longer."  

Professor Paul Zimmet, AO, Director Emeritus at the Baker IDI Heart and Diabetes Institute and Adjunct Professor at Monash doesn’t hold back on the level of concern he holds for the “rise and rise” of diabetes in Australia.

“Diabetes in the 21st century is the equivalent of cholera in the 19th century and HIV/AIDS in the 20th century. During this millennium, diabetes is well on the way to cementing its place as the fastest growing epidemic in human history. And the situation in Australia is daunting both from the personal cost to individuals for medical and support care and the economic cost to the nation due to reduced national productivity as type 2 diabetes is now affecting the workforce age group and even children and adolescents.

“In Australia, there are at least 1.5 million known cases of diabetes and a similar number with pre-diabetes. Moreover, for every diagnosed person with diabetes, there is likely to be one undiagnosed case. So, we are looking at potentially more than 4 million people, either with diabetes or who are at risk. It is possible therefore that some 20% of the Australian population is affected by diabetes in some way.

“The medium to long-term answer, of course, is prevention. But, in the meantime, to reduce the burden of this epidemic, people with diabetes require comprehensive support and care from a whole range of allied health professionals along with GPs and specialists. It is a unique healthcare challenge and its treatment is best administered through a management plan involving a complete care team.

“Web-based tools appear to enable this kind of care more easily and, as the Monash study indicates, clinical outcomes are worthwhile and likely to reduce the burden of the sometimes devastating complications of diabetes.

“Diabetes is potentially the greatest epidemic in the history of world. By 2020, the condition will bankrupt the economies of many nations unless urgent action is taken,” Professor Zimmet added.

For further information

Professor Michael Georgeff
CEO Precedence Health Care

Mobile + 61 411 193 247

Office +61 3 9023 0800 during business hours

The release is here:

http://www.itwire.com/science-news/health/61192-internet-technologies-%E2%80%98key%E2%80%99-to-treating-diabetes

I think this is really very encouraging and shows how sensible planned progress can make a difference as compared with expensive overly complex and ambitious national programs.

Well worth reading the full paper.

David.

What Sorts of People are "Most Influential in Healthcare?"

Modern Healthcare just put out their list of the "100 Most Influential People in Healthcare" for 2013.  A look at what sorts of people are on this list says a lot about who runs US health care, and raises questions about who should.

Some Health Care Professionals, Lots of Hired Managers

I did some quick descriptive categorizations. (Counts were double checked but I am not guaranteeing accuracy.  Categorizations were sometimes difficult for highly diversified organizations.)

First, less than one third of list members are physicians (31% by my count).  I did not see any other health professionals on it (although I confess I did not look up the biographies of all 100).

Of these physicians, most are now functioning as hired managers, usually at the CEO level, of big health organizations.  I found only a few who could be characterized as somewhat academic: Dr Atul Gawande, professor at Harvard Medical School, Dr Eric Topol, chief academic officer at Scripps Health, Dr Harvey Fineberg, President, Institute of Medicine, Dr Brent James, chief quality officer and executive director, Institute for Health Care Delivery Research, Intermountain Healthcare,  and probably Dr Jeffrey Drazen, editor-in-chief of the New England Journal of Medicine. 

My counts of hired managers on the list included

CEOs of For-Profit Health Insurers - 5%

CEO of For-Profit Hospital Systems - 8%

CEOs of Non-Profit Hospital Systems - 21%

CEOs of Other For-Profit Care Delivery Corporations - 7%

CEOs of Drug/ Device/ Medical Supply Corporations - 2%

CEOs of Health Care Information Technology Corporations - 1%

CEOs of Non-Profit Trade Associations - 14%

CEOs and other Leaders of Professional or Medical Association - 5%

CEOs of Health Care Charities - 4%

CEOs of Other Non-Profit Organizations - 15%

Elected Government Leaders - 6%

Leaders of Government Agencies, Departments - 10%

Union Leaders - 2%

People Whose Organizations Have Issues

The list included quite a few people who lead organizations which have had issues of the sort we discuss on Health Care Renewal.  For example, the list included the following among its top 10 most influential, in order of listed influence -

4.  Stephen Hemsley, CEO of UnitedHealth Group - We have discussed concerns about his executive compensation and how it does not fit his organization's stated mission, or his organization's long list of ethical misadventures (most recently summarized here)

6. Mark Bertolini, CEO, Aetna - We most recently discussed how Aetna's leaders' pontifications on health policy seem mainly based on self-interest (here)  We also discussed various other management, ethical and legal issues.

7.  Richard Bracken, CEO, HCA - A long time ago, HCA was one of the first big health care corporations to have to make a billion dollar plus settlement for fraud, among other issues (look here).  The company has had legal, ethical, and management issues since.

8.  Joseph Swedish, CEO, WellPoint - He is new as CEO, but under previous leadership, the company amassed a record of misadventures while making its leadership very rich (summarized here, and look here for details.)

The list also included many other people whose organizations have been frequent fliers on Health Care Renewal.  For example, the CEOs of Epic Systems (ranked 13),  Tenet Healthcare (18), Cigna (20), McKesson Corp (24), Sutter Health (42), Johnson & Johnson (46), Pharmaceutical Research and Manufacturers of America (PhRMA) (48), HealthSouth (59),  UPMC (69), and  Steward Health Care System (86).

There are many other people on the list who lead organizations that have gotten unfavorable notice on this blog, and a few whose own extreme executive compensation garnered comment.  As my science professors used to say, I leave their identification as an exercise for those interested.

Who Is Not on the List

It is interesting who is not on the list.  There are no physicians in private practice.   I would argue there are no physicians who are "pure" academics at the moment.  There are no other health care research, health policy research, or public health academics.

I saw only one person on the list (Senator Charles Grassley - R, Iowa) who has been identified with the sorts of real health care reforms we discuss here.  (Senator Grassely has investigated many instances of alleged conflicts of interest and fraud, and sponsored the Sunshine Bill to disclose better physicians' conflicts of interest.)  I do not see anyone else who in my humble opinion is identified as a dissident within the current environment. 

Many of the media accounts we have noted include people identified as experts who decried such issues as excessive executive compensation, mission-hostile management, conflicts of interest, ethical issues leading to legal settlements, or crime and corruption in health care.  None of them save Senator Grassley  are on this list. 

Summary

The Modern Healthcare list of 100 most influential people in health care demonstrates the enormous influence of hired managers in modern health care.  The vast majority of list members were hired managers.  While the list did include some physicians, most of them were currently working as hired managers.

It also demonstrates the influence of the for-profit, industrial part of health care.  It included 5 for-profit insurance CEOs, 8 for-profit hospital corporation CEOs, 7 for-profit health care delivery corporation CEOs, 2 for-profit drug/device company CEOs, and 1 for-profit health care IT CEO, a total of 23.  It also included CEOs of multiple trade associations, some of which represent the for-profit side of health care (e.g., PhRMA, America's Health Insurance Plans).  While it included leadership of many non-profit organizations as well, some of these organizations have clear financial links to the for-profit industrial side.  These ties may include significant financial support from industry, significant holdings of health care corporate stock, or managers or board members with their own relationships to industry.  (For example,  see this discussion of conflicts of interest affecting the Gates Foundation, whose co-chair is 76 on the Modern Healthcare list.)  Many of the large, non-profit hospital systems, 21 of whose CEOs are on the list, have major institutional conflicts of interest, and have many people with individual conflicts of interest among their leadership and on their boards of trustees.

As opposed to the influence of the for-profit industrial part of health care, the influence of government seems muted.  The list included only 6 politicians and 10 government managers.  Some of the politicians are notable proponents of smaller government, e.g. Senator Grassley, and specifically of a smaller role of government in health care, e.g., Governor Bobby Jindal, R, Louisiana.    Nor do unions have much influence.  Only two union leaders were on the list.  There was little counterweight provided to industrial influence from academia, and an almost complete absence of those who might question the current US status quo of dominance of health care by commercial interests. 

So here is the latest evidence that US health care is dominated by commercial interests (in an era of regulatory capture, revolving doors, and financialization) and professional, if often generic managers.  This suggests why our health care system seems more about revenue (and thus is very expensive), and less about improving patients' and the public's health.  True health care reform would require increasing the influence of people who have different priorities than the currently most influential. 

The Coalition Is Planning A PCEHR Review - What Should We See From The Review.

As I mentioned last week we found this late in the week from Coalition Policy.

In the full .pdf of the policy a review of the PCEHR is mentioned.

Page 15:

"Health professionals will be increasingly reliant on effective e-health tools to better
coordinate care, particularly for patients with complex health conditions.  Unfortunately, the Labor Government has failed to deliver on its Personally Controlled Electronic Health Record (PCEHR).

Despite the $1 billion price tag, only 4,000 records are reported to be in existence. In recent weeks, the clinical advisers for Labor's e-health record program have quit  en masse, leaving the Federal Government's flagship programme floundering with virtually no clinical oversight.

If elected, the Coalition will undertake a comprehensive assessment of the true status of the PCEHR implementation. In government, the Coalition implemented successful incentives to computerise general practice and will continue to provide strong in principle support for a shared electronic health record for patients. The Coalition will again work with health professions and industry to prioritise implementation following a full assessment of the current situation."

 Here is the link.

http://tonyabbott.com.au/LinkClick.aspx?fileticket=DRbioW4-J0w%3d&tabid=86

For me the review has to address the following.

First we need to know just where the implementation of the PCEHR is actually up to and just what levels of usage it is seeing - separate from the spin being put out by DoHA. We also need to understand where all the money has gone, who has profited and if there has been any issues like have been seen with the Qld Health payroll procurement and implementation.

Second we need a serious evidence based review of the options for having what has been built actually be used better and to have it actually achieve the desired health and clinical - and not technical outcomes. My feeling if this is done it will be concluded that the design of PCEHR is fatally flawed from both a clinical and patient utility point of view and needs a pretty large scale re-design. The opportunity cost of not correcting course and starting to invest in approaches that are more likely to work and deliver the Health Sector benefits we need is huge I believe.

Third - with a clear idea of what might work and where our gaps are - we need to plan how we migrate from where we are to where we need to be. The plan needs to be stakeholder and benefits focussed.

Lastly we really need to come up with an approach to the leadership and governance of the e-Health domain that much better manages the power of government, vendor needs for profit and opportunity, consumer requirements and the clinician’s need for quality and safe Health-IT. We need to properly balance all these interests while ensuring proper accountability on the part of each stakeholder.

A Clayton’s review is really not an option as all that will result in is good money being thrown after bad. Of course, the review needs to be made fully public

Remember e-Health is not intrinsically a good. To make a difference it has to be done well with co-operation and commitment from all.

David.