Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!
By Dan Field, MD
- Tort reform. Cap every state as has been done in California and Texas.
- Medical justice panels. A jury by our peers. Medically trained arbitration panels to hear cases.
- Eliminate doctors’ malpractice costs for patients who demand free care. If the government insists that ED docs see every patient (through EMTALA), they are de facto government employees for those patients and should receive government indemnification.
- Limit advertising again. It was a bad move when they opened it up.
- Research, publicize and reward best practices. The worst hospital at Kaiser today has a better record of sepsis prevention than the best Kaiser hospital two years ago. Some have had ZERO sepsis in two years. Sepsis costs $40,000 to $100,000 per patient and frequently adds to the nation’s iatrogenic death load. Replicate this through the major diseases and some of the $500 billion of savings we need to achieve becomes realizable.
- Divest physicians of the benefit of profiting from ordering tests. A study shows a doctor who owns a scanner is seven times more likely to refer a patient for a scan.
- Generics drugs for everybody, name brands for those who want to pay out of pocket (or from the HSAs).
- Revamp medical reimbursement
- Create a two-tiered medical system where everyone has catastrophic coverage and HSAs. Allow the rich and others to opt out for value-added service. This might be just enough incentive to keep some innovation moving forward. I seriously doubt most medication advances are necessary — seems to me they just add a molecule so they can extend the patent without any new, real benefit. First tier accepts all, including, pre-existing illness, with no rescission. Everyone pays same rate for basic tier, everyone gets a tax credit. Not sure how to deal with those that don’t work. Incentivize healthy behaviors — non-smokers with low cholesterol and great genetics are an attractive subgroup. Second tier insurance companies will compete for these stars with lower premiums. Veal calves with remotes and cancer sticks will be avoided like the plague and end up in the first tier or paying more.
- Accept that disparities will continue but that they will be better and more morally acceptable disparities than before.
- Allow true portability.
- Give needles to addicts, along with access to treatment.
- Strongly consider legalizing and decriminalizing drugs.
- Realize that screening doesn’t save money for society.
- People should have a right to unlimited end of life care … as long as they can pay for it.
- All government officials must utilize the system they insist we follow, especially “the public option”.
Dan Field is a physician with The Permanente Medical Group.
CPOE – One Size Fits All?
By Mark Moffitt
The goal behind Computerized Physician Order Entry (CPOE) is worthy — replace handwritten physician orders using information technology to minimize translation errors and provide conflict checking at the point of entry. There’s only one problem: many physicians are not satisfied with CPOE. The reason I hear often by non-physicians is this: “Older physicians reject technology. The newer generation of physicians is more accepting.”
I admit I have voiced this sentiment in the past. But after working with physicians and having seen them embrace technology that makes them more productive, I’ve changed my view. My view now is that physicians accept technology if it helps them be more productive and they reject technology that makes them less productive — regardless of age. However, I have observed that physicians over 50 are less tolerant and more vocal than physicians under 40 when their workflow is slowed. Maybe because they have more work to do in less amount of time?
Most all in the industry know the issue. CPOE shifts work done by low-cost clerical staff on a hospital payroll to the highest-paid people working in a hospital. Compounding the problem, physicians are not always employed by a hospital. So the work is shifted from a hospital payroll to an individual physician. And time spent in front of a computer is time not spent with patients. And seeing patients equals making money.
Let me qualify my statements above with this: This discussion is restricted to CPOE in an acute care setting and does not apply to all physicians. Some physicians love the current model for CPOE. It works for them. It makes them more productive.
National adoption of CPOE is low. The 2008 KLAS CPOE Digest reports that less than 10 percent of hospitals are “doing some level of CPOE.” In only six percent of hospitals nationwide, physicians enter more than 50 percent of orders directly using the system.
CPOE adoption is affected by many factors. One factor is availability of CPOE. Another factor is ease of entering orders. Another is physician workflow.
Physician workflow is influenced by factors including specialty, size of hospital, employment model, practice size, etc. There is no one model for how physicians do their work. There are many models.
It’s possible that CPOE, once widely available, will be embraced by physicians and the nationwide adoption rate will rise quickly to near 100%. The other possibility is that the current CPOE model does not work for all physicians and CPOE adoption rate climbs slow and stalls at some level, say 50%. What outcome do you think most likely?
Given the money involved, I wonder why more research isn’t being done to find other models that provide the benefits of CPOE that doesn’t require a physician to sit at a computer and enter orders? Why, when many physicians have expressed dissatisfaction with the current model? Why, when the industry is spending BILLIONS, partially underwritten by the federal government, to implement CPOE and other technology in healthcare?
For what it’s worth I’m doing my part by researching a new model for CPOE. I call it CPOE without the “POE.” Not a replacement for CPOE, but an alternative to physicians entering orders on a keyboard. Same benefits, only a different model. I’ll write about this topic in a future article.
Mark Moffitt is CIO at Good Shepherd Medical Center in Longview, TX.
Those Who Believe in The Network Will Go Far
By Carl Byers
As one of Mr. H’s and Inga’s biggest fans, I am lucky to have had the chance to meet them in my travels as CFO of athenahealth. It is therefore an honor to submit this post.
I soon will be far from the world of HCIT. As announced in June, in early 2010 I will step down from the job I have treasured for more than twelve years to live abroad with my family. My wife and I have dreamed of immersing ourselves in another culture before our kids (ages 11, 7 and 3) are too cool to hang out with Mom and Dad. We will be in Chile for 18 months, and we look forward to returning with new energy and a fresh perspective on the world and on our role in it.
As a finance guy, I am not a technology innovator or a clinical subject matter expert, so I can’t address the future of technology or patient care. What I can address is a question that I am often asked gingerly and respectfully: “How is athena able to achieve such a high value?” Last week, on a panel discussion in Boston, an audience member’s way of asking was far less discreet: “Everyone thinks you are overvalued. Why is that?”
There are all sorts of fancy answers from capital markets people to explain prices based on total addressable market, long term margin profiles, and Price-to-Growth ratios (in fact, a fellow panelist from Goldman Sachs gave this type of answer to the questioner). I won’t attempt to do that sort of analysis justice here. And, I certainly can’t tell you why stock prices jump around as much as they do, but I do have a clear point of view on athena.
Simply put, I think our company trades where it does because of the scope of our vision and the confidence people have in us actually accomplishing it. It was Warren Buffett who said that, in the short run, the market is a “voting machine” and in the long run it is a “weighing machine.” I have no idea what the votes will say from day to day or even year to year, but I know that the weight of our business will be extremely hefty over time.
How can I be so sure? The reason athena has done well as a public company is the same reason athena has done well in the marketplace — because we offer a better way to solve our industry’s most complex problems and the market is responding. athena is one of very few companies in our sector that is not hopelessly stuck in a software mentality, and the market understands that the days of software as we know it are limited.
From complex reimbursement processes, to clinical coordination, to patient communications, to research, the future of health care (just like the future of the rest of the world!), is not software; it is “The Network.” In 1992, I worked on the Clinton campaign staff in Little Rock. If James Carville were in HCIT, he’d put an even sharper point on it — “It’s the Network, stupid!”
The market understands this because outside of HCIT, The Network has already taken over. This shouldn’t be news. How long has it been since salesforce.com put that big “no smoking” sign on the word “SOFTWARE”? For how many years has Sun Microsystems declared, “The Network is the Computer”? My boss and friend Jonathan Bush said it even more clearly a couple of years ago: “Software is dead… Dead. Dead. Dead.”
And yet everyone — from pundits in Washington to some of our industry’s best technologists — remains fixated on terms like “versioning,” “implementation,” and “interoperability.” Not only is client-server software fundamentally unable to succeed in this new reality (whether installed locally or hosted from a giant data center), it drives business models with much lower visibility, much weaker alignment of incentives with practitioners, much lower sustainable margins, and much lower lifetime value of a customer than does a software-enabled-service like athenahealth.
What the software mentality misses is that at its core, the problem with health care is one of supply chain coordination. Isolated practitioners typically know next to nothing about what care has occurred in a patient’s life outside of his or her own four walls. Creating software that asks practitioners to type into templates in isolated local databases will not accomplish much of anything given the broader coordination challenge. This is why EMR adoption is so incredibly low today. Only through the emergence of copious networks of information and related process-oriented services will the silos break down and will the coordination (and quality) actually improve.
In every industry (including health care), the only way such networks come about is when there are financial incentives to exchange information. PBMs, pharmacies, and manufacturers of pharmaceuticals seem to have figured out how to build networks, and they didn’t need federal interoperability standards to do it! All they needed was a strong financial incentive to get aligned and remove wasted effort from the supply chain so patients could get their meds without huge inventory write-downs or large commissions for middlemen.
Similarly, athena is focused on building real networks so that the supply chains that extend into and out of the physician office can improve — not just for the coordination of payment information with payers, but also for the coordination of physician order information with labs and pharmacies. athena is also building a network for coordinating schedule, payment, and results communications with patients and referring providers. And to do this, we don’t need to wait for federal transaction and software standards — we just need an opportunity to earn financial rent for having made it happen (and in the process having made physicians, their trading partners, and the industry better). Networks cannot be only about information, they have to relate to real work — and it is through accomplishing the work that revenue, profits, and value flow.
So, as I start a new personal chapter in the New Year, my answer to that persistent question and my message to our industry is this: those who believe in software alone will fall away; those who believe in The Network will go far. Companies that embrace this distinction and produce tangible improvements in the delivery of care as a result will help to bring about the health care vision we all seek.
Thank you for the opportunity to comment here on this very unique network of your own.
Carl Byers is senior vice president and chief financial officer of athenahealth of Watertown, MA.