No Ma’am, We’re Statisticians

Yes, it’s true. I wanted to build the Illinois Health Care Report Card just so I could finally write a blog post laden with Blues Brother quotes. You could say I was on a mission from God. Our Lady of Blessed Web Site Acceleration don’t fail us now. Continue reading

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$1300 Nose Bleed

I received the following E-mail this morning on another blog:

“Where is Wyoming on your list. It is a state in the USA. Our local
hospital, Wyoming Medical Center here in Casper Wyoming, is so greedy
about their charges and will not tell you what they charg before
you have your visit. Emergency care for a simple nose bleed wes $1,300.00
Why are they allowed to get away with this.
How do you make the greedy companies tell you what their charges are
BEFORE you agree to have care when it is not a life or death situation. If
I had been informed how much it was going to cost I would have refused the service.
HELP”

The sender did not leave an E-mail address to reply, so I thought I’d reply here.

First things first: $1300 for a “simple nosebleed” is outrageous.

Second things first: going to the emergency room for “a simple nose bleed” is outrageous.

What to do? Call the billing department, make them an offer. But bear in mind you elected to use highly specialised services of a very expensive health care facility.

I had a lot of nose bleeds as a kid. Spontaneous ones, they would just start happening. The remedy cost less than a cent and involved tearing one tissue into two, plugging my nostrils and tilting my head back. Occasionally, I would pinch the bridge of my nose (as instructed) but it didn’t really seem to do anything.

When did it become acceptable to go to the ER for a nose bleed? This is half the problem, this is what drives costs up. I don’t have nearly enough information to figure out how serious the author thought the situation was, maybe it was the first time it had ever happened and he or she thought their brains were going to fall out, but I’m going to go out on a limb and say no, it was a simple nose bleed.

I feel really bad for the author that they are now stuck with a ridiculous bill. I would absolutely call the hospital and offer them $500 and a payment plan. I agree wholeheartedly that pricing needs to be more upfront. In the absence of hospitals doing this, we’re working as hard as we can to publicise as many prices as we can. You can browse pricing at OutOfPocket.com where you’ll notice I have a similarly-priced ER visit, for which the insurance paid less than $500.

But I would also counsel that next time you have a nosebleed, tilt your head back lean your head forward (1970s Welsh national health advice aside, apparently the thing to do is lean *forward*, thanks Kenneth!). Visiting the ER for a nosebleed is like going to the car dealer for a flat tire. They’ll do pretty much the same thing as the guy on the corner, but charge you ten times as much.

As long as this country refuses to have a public option, you are consuming health care in a free market economy, with all the trappings that come with that. The ER is not your local clinic. But as long as you treat it like one, they will be happy to bill you.

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Is it a Bird? A Plane? No, it’s Electronic Clinical Data!

Faster than a speeding bullet, the clinical data portal we launched in June has scored it’s first physician! It’s pretty exciting to have built it, even more so to actually see a physician using it.

The portal allows a physician – or a group of physicians – to upload clinical data relevant to a given condition, in this case Diabetes. We ask for a set of specific, discrete data, not the entire record, such as blood sugar levels, blood pressure, eye exams and the like, and then using the data from the record we score the physician(s) against an evidence-based measure set that scores the doctor on his or her performance for that condition.

So, in this case, the doctor voluntarily submits to being scored for his performance treating and managing his diabetic patients. Any eligible physician who scores well on the measure will start receiving incentive payments from participating payors and purchasers, as well as be recognised in HealthGrades.com

Pretty cool, huh?

In addition, using the same engine we also scored two batches of physicians who are using the NextGen EHR package, thereby scoring their performance directly from the data.

As EHR adoption in the United States grows I anticipate more and more data being available to more and more performance assessors like ourselves, and I look forward to the next five years. Next step? Live report cards that tell you not how a hospital did last year, but how they did YESTERDAY.

Can’t wait.

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Netflix Winner Announced

Health transparency wise we have three great new projects each due to go live in the next 60 days or so, hence the lack of posts, just too much going on. However, I do like to talk about technology that isn’t health care-related once in a while. Netflix started an open contest three years ago offering a million dollars to anyone who could improve their movie recommendation engine. The contest is finally over, whittled down from over 50,000 contestants to two teams who came in at the last minute just a few minutes apart. The full story is at Wired, go to http://www.wired.com/epicenter/2009/09/bellkors-pragmatic-chaos-wins-1-million-netflix-prize/ and enjoy the read.

I think it’s a great example of both using the collective consciousness and open software principles.

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Worldwide Flandemic

Once in a while, I post a funny. This is one of those times.

For those of you who clicked through, here’s a bonus extra.

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Physician Performance Assessment


A bit of a departure from my usual transparency efforts, but this week we launched our Clinical Data Portal, a Web-based portal that allows physicians to upload clinical data directly from the chart or from an electronic medical record software and be assessed instantly on their clinical performance. Physicians who score high enough automatically start receiving bonus checks from the Bridges to Excellence program. Pretty neat stuff.

We have started with Diabetes and Cardiac Care, but we’ll be rapidly adding more topics for physicians to measure themselves with. Physicians are free to become recognised for any of the topics, but if they fall under a BTE program area, they are eligible for real reward dollars. Next up we’ll be processing batch files of data from EMR vendors. Exciting stuff.

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Why I’m Not Camping

Ahh, my poor blog languishes. As I have nothing interesting to say here’s a list of what I’m working on, which may explain why my blog is so sparse these days.

Pay for Performance: Physicians are eligible for many programs that will pay them bonuses for delivering care at defined levels. For example, there are strict measures of evidence-based care that should be delivered to a diabetic patient. Starting this month, physicians will be able to enter data into a new clinical data portal that will instantly or near enough instantly score their performance and – if the physician achieves the correct performance level – be identified to these programs. We’ll be kicking off with diabetes and cardiac care. Down the road,we’ll also process data directly from EHR systems. Go live mid June, 2009.

Transparency: Illinois has elected to use my team to produce their state’s hospital report card, we’ll be publishing everything you never wanted to know about Illinois’ hospitals. Go live Octoberish, 2009.

Transparency: This year’s Regional Health Care Report Card is underway, and will split HMOs from hospitals, making it easier to review one or the other. Additionally, this year’s hospital report will be the juiciest report card you’ve ever seen. Go live end August 2009.

Quality Improvement: Phase two of the WhyNotTheBest.org Web site is coalescing, more data, more benchmarks, more quality improvement resources. User interface is being reworked for a smoother, faster onramp to the content by a very cool team, and we’re following behind loading up the new data. Go live November 2009?

Transparency: Pellucid is my new project to collate every ounce of publicly reportable data that exists. As you can imagine, that one’s keeping me up nights. Go live of yesterday or never, depending on when you ask me.

All that, plus my youth rugby team made it to the semis in the Annual NYC Mayor’s Cup. Busy year…

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Uninsured and Charges

Two items caught my eye today that neatly juxtapose. One is from California, which discusses the publication of hospital charges (retail sticker price) for surgeries, and the hospital’s insistence that these prices are meaningless. The other is from a Families USA study counting how many people were without health insurance for some period in 2008.

“That database is meaningless,” said Jim Lott of the Hospital Association of Southern California. “There’s no relationship between the price on that list and what your insurance company has negotiated.”

OK, fair enough. So how many people *didn’t* have insurance, and thereby didn’t have the benefit of a negotiated rate?

Turns out in California, during 2007 and 2008, 37.4% of the population under 65 spent some time without health insurance. Of these, 76.9% were without health insurance for six months or more.

80.2% of all people who went without health insurance were members of working families, i.e., someone at the house has a job. i.e., employment does not mean health insurance.

Most interestingly, 26.2% of uninsured people have incomes at or above 200% of the federal poverty level. I would hazard a guess that these folks are not rushing to claim bankruptcy to avoid the bill.

And of course, *all* these people are subject to the meaningless numbers. They all are charged sticker price. Maybe they don’t pay them, but someone does, either through direct write-offs which impact us at the local tax level (we pay it for them) or indirectly through these folks becoming indigent.

Sticker prices hurt all of us. They are not meaningless. I myself have been charged them, even with my PPO in place.

I, like many other folk in public reporting, would prefer to report the cost of care – how much it costs a hospital to perform a given procedure – but this data is still hidden from us.

In the meantime, and even if I were to have cost data in hand, I would still publish charges, because charges most certainly do mean something, and they mean something to an ever-growing portion of the population.

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National Health Care Reform – and Its Potential Impacts in New York

Please join us for a major forum about:

* the urgent problems in health care (escalating costs, increasing numbers of people with no coverage, disparities in access, and unsafe care),
* the increasingly intense debate about options for national health care reform, and
* the potential impacts of national reform in New York

To address these issues, the non-partisan National Coalition on Health Care has invited an extraordinary panel of experts to share their insights about how national reform could affect patients, health care providers, employers, employees, and communities in New York.

Registration: http://www.nchc.org/registrations/?id=12E0D163-D762-488E-B0CD-D47B7599DB41

And we have invited a wide range of leaders and stakeholders – from many organizations and vantage points – to attend and participate.

The future of health care – in the United States and here in New York – could be changed fundamentally by decisions made in the next few months. The stakes – for the health and well-being of all of us, for the growth and competitiveness of our economy, and for our living standards – are enormous.

We hope that you will join us for an important, informative program — and a vigorous debate of these issues.

Speakers will include (in alphabetical order):

* Ana Abraido-Lanza, Ph.D., Associate Professor of Socio-medical Sciences, Mailman School of Public Health, Columbia University
* David Dobbins, Chief Operating Officer, American Legacy Foundation
* Ben Geyerhahn, New York Project Director, Small Business Majority
* Sherry Glied, Ph.D., Department Chair, Health Policy and Management, and Professor of Health Policy and Management, Mailman School of Public Health, Columbia University
* Mark Goldberg, Executive Vice President, National Coalition on Health Care
* Atul Grover, M.D., Ph.D., Chief Advocacy Officer, Association of American Medical Colleges
* Lori Heim, M.D., President-Elect, American Academy of Family Physicians
* Sue Klug, Assistant in Health Benefits, Program Services, New York State United Teachers
* Joann Lamphere, Dr.P.H., Director, State Government Relations, Health and Long Term Care, AARP
* Susan Lerner, Executive Director, Common Cause/ New York
* Joel E. Miller, Senior Vice President for Operations, National Coalition on Health Care
* Margaret K. Offermann, M.D., Ph.D., Deputy National Vice President for Research, American Cancer Society
* Vivian Riefberg, Principal, McKinsey & Co.
* Anthony Shih, M.D., M.P.H., Chief Quality Officer and Vice President of Strategic Planning, IPRO
* Hugh Waters, Ph.D., Associate Professor, Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University

The National Coalition on Health Care is the nation’s largest and most broadly representative alliance of organizations working for system-wide health care reform. Its 78 member organizations include major businesses and business associations, unions, medical societies, health and pension funds, insurers, faith organizations, patient advocacy and medical research groups, and higher education councils. Its honorary co-chairs are former Presidents George H.W. Bush and Jimmy Carter. Together, the organizations that belong to the Coalition represent – as employees, volunteers, members, and congregants – more than 150 million Americans.

The Coalition is grateful to the W.K. Kellogg Foundation for its financial support of this forum.

Registration: http://www.nchc.org/registrations/?id=12E0D163-D762-488E-B0CD-D47B7599DB41

If you have any questions about the forum, contact either Mark Goldberg (goldberg@nchc.org) or Joel Miller (jmiller@nchc.org) at the National Coalition on Health Care. We hope to see you on May 27.

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Guest Blog: Collective Clinical Wisdom by Heather Leslie

I’d like to invite and encourage all clinicians to register for the openEHR Foundation’s new Clinical Knowledge Manager (CKM) – found online at www.openehr.org/knowledge.

CKM is an international repository for openEHR archetypes and has two primary purposes – that of archetype publication and archetype governance. It is a real opportunity for clinicians to collaborate and agree on clinical content definitions for publication and use in our electronic health records.

openEHR archetypes are open source, computable specifications that define clinical information about a single and discrete clinical concept. For example there are separate archetypes defining a ‘symptom’, ‘diagnosis’, ‘blood pressure’, ‘medication order’, and ‘risk of disease based on family history’.

As structured and standardised definitions of clinical content, archetypes are increasingly being recognised as fundamental building blocks of electronic health records, especially when integrated with clinical terminologies such as SNOMED CT. If we all start to record information based on the same archetype, then we can meaningfully and unambiguously share health information between systems, and we start to query that information across systems.

A primary goal of CKM is to encourage a broad range of clinician input to make sure that the clinical content in each archetype is correct. Absolutely no openEHR experience is necessary to participate in CKM, although we anticipate you will learn about openEHR as part of the journey. All participation is purely on a volunteer basis, and you can opt out at any point.

Whilst CKM is still in its relatively early days, we are already seeing the benefits that contributions by grassroots clinicians are bringing to the archetypes currently undergoing team review. Technically oriented openEHR experts support the review process to provide guidance on design and implementation issues, so there are no unrealistic expectations of the clinicians. Contributions of clinical and technical nature are equally and gratefully received;-)
By design, each archetype contains all the relevant information about the specific clinical concept – a maximal dataset which can be used in all clinical scenarios. So, for each archetype we are seeking a range of views from a variety of:

- professions – including every type of clinicial expert;
- geographical locations – to make sure we can capture diverse clinical and cultural practice; and
- knowledge domains – from general healthcare to all specialist areas.

Please actively ‘adopt’ the archetypes that you would like to be involved in. This will ensure that you will be invited to participate in the review of archetypes that are of interest to you. At other times you may also be invited to participate in a review where we consider that your expertise might provide balance out the current team of reviewers.

While we will strive to achieve maximal datasets for each archetype, we are pragmatic and know that we won’t get it 100% right – certainly not at first try. However, I suggest that a small group of 3-4 clinicians with complementary skills and appropriate expertise can create and develop a draft archetype to approximately 80-85% complete. Further review within CKM by a team of clinicians from a range of professions, countries, institutions, research, and health domains will contribute and refine the archetype further – maybe this still will only get it to 90% complete; but maybe much more. Our experience to date shows that maximal datasets are much easier to agree on than minimal datasets!!

Over time it will be interesting to see how the models evolve – no doubt a good research topic!

Obtaining agreement on clinical content within archetypes in this manner is a significant achievement, even if in retrospect we find they are not 100% complete at the start. The flow-on benefits that come from sharing a standardised set of clinical specifications for EHRs can potentially transform some eHealth initiatives and is a necessary foundation for the truly sharable electronic health record.

So, all clinicians are welcome to get involved in CKM – we will certainly set you to work very quickly! We expect that by contributing domain expertise and insights, clinicians will also benefit personally by gradually developing openEHR understanding and expertise as part of the experience.

And then of course, there is also the contribution to the good of mankind… ;-)

[Instructions for registering can be found at: www.openehr.org/wiki/display/healthmod/Registration+in+CKM]

Posted in guest blog, health information exchange, standards | 2 Comments