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Meaningful Inertia Too

Should meaningful use objectives serve as the basal behavior for digital health information or serve as minimal criteria for governmental payments?

AMA Comments on Meaningful Use Stage 2 EHR Proposal (PDF):

The AMA is supportive of widespread adoption and meaningful use of EHRs by physicians, but the cumbersome proposed criteria will make successful physician participation extremely difficult…[d]ue to physicians' limited ability to exchange data with other health care partners[.] [M]any of the proposed Stage 2 measures will require extensive manual data entry…not an efficient way of practicing medicine or improving quality care outcomes for patients.

Physicians should not have to meet all 20 measures plus clinical quality measure reporting to prove that they are a meaningful user of a certified EHR. Allowing physicians to opt-out of a certain number of measures (e.g., three or more) is the type of flexibility needed in the meaningful use program that would encourage more physician participation and increase participation

[C]linical summaries [for patients] should [be] three business days and the threshold requirement should be 20 (not 50) percent. The measure should also be based on unique patients seen during the EHR reporting period, and not based on every office visit to minimize reporting burdens. In addition, a physician should have the flexibility to include only the information that the physician believes to be relevant for the summary.

Principles of patient access in Directed Exchange:

Paraphrasing

In the digital world, 36 hours is unreasonable. It means that humans continue to be involved in tasks that can be perfectly-performed by computers without errors. Thirty-six hours means that doctors, nurses and hospital administrators think in paper, view the patient as an unequal data partner, and leaves the patient blind to the data at the only time it really matters—now. Thirty-six hours old data can only be analyzed as a post-mortem and is a short-term solution while rethinking information flow and the notions of "inside"and "outside" the hospital.

Most Physicians Were Eligible For Federal Incentives In 2011, But Few Had EHR Systems That Met Meaningful-Use Criteria:

[A] 2011 nationally representative survey of office-based physicians [] found that 91 percent of physicians were eligible for Medicare or Medicaid meaningful-use incentives. About half of all physicians intended to apply[—]only 11 percent both intended to apply for the incentives and had electronic health record systems with the capabilities to support even two-thirds of the stage 1 core objectives required for meaningful use. [W]idespread gaps in readiness throughout the states illustrate the challenges physicians face in meeting the federal schedule for the incentive programs.

Physicians Ready for Stage 1 Objectives 2011

Modified from Health Affairs^†

Physicians Intending to Apply for Meaningful Use Incentives 2011

Modified from Health Affairs^†

Physicians Exchanging Electronic Clinical Summaries 2011

Modified from Health Affairs^†

• AMA
• Health Affairs
• AHIMA (PDF)
• O'Reilly's Radar: Trotter

• ^† Most Physicians Were Eligible For Federal Incentives In 2011, But Few Had EHR Systems That Met Meaningful-Use Criteria

Professional/Ethical Parity

Nutshell: common sense, social media = public media, and you are always a licensed professional. A "license" means a voltional act and a public duty.

FSMB Press Release:

[P]hysicians [] need to be aware of how to maintain the same professional and ethical standards in their online activity as they do in the rest of their practice. Failing to do so can hurt patients and physicians’ careers.

Violations of online professionalism are prevalent among physicians…92 percent of state medical boards in the United States have received reports of violations of online professionalism.

FSMB Policy:

Physicians should not use their professional position, whether online or in person, to develop personal relationships with patients. The appearance of unprofessionalism may lead patients to question a physician’s competency. Physicians should refrain from portraying any unprofessional depictions of themselves on social media and social networking websites.

Candor

Physicians have an obligation to disclose clearly any information (e.g., financial, professional or personal) that could influence patients’ understanding or use of the information, products or services offered on any website offering health care services or information.

Privacy

Physicians have an obligation to prevent unauthorized access to, or use of, patient and personal data and to assure that “de-identified” data cannot be linked back to the user or patient.

Integrity

Information contained on websites should be truthful and not misleading or deceptive. It should be accurate and concise, up-to-date, and easy for patients to understand. Physicians using medical websites should strive to ensure that information provided is, whenever possible, supported by current medical peer-reviewed literature, emanates from a recognized body of scientific and clinical knowledge and conforms to minimal standards of care. It should clearly indicate whether it is based upon scientific studies, expert consensus, professional experience or personal opinion.

• New FSMB Policy Addresses Appropriate Use of Social Media by Physicians: Press Release (PDF)
• Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice (PDF)
• Help! My Shrink Tried To Friend Me
• Online Posting of Unprofessional Content by Medical Students

Meaningful Inertia

Corpus omne perseverare in statu suo quiescendi vel movendi uniformiter in directum,
nisi quatenus a viribus impressis cogitur statum illum mutare.¹

Trotter posits a principle zero:

[S]ome clinicians [and hospitals] will do anything they can to make patient access to their health records impossible or cumbersome.

True in action, but not intent. What's at play here is inertia (Newton's Frist Law)—the installed practices, investments, expenditures, expectations, beliefs, etc. are sufficient to create a true adverse physical inertia. Inertia is not geared to patient access, but to minimally impact the status quo.

Oram commenting on inertia:

[T]he AHA offers no hint that the hospitals spent all this money to put in place new workflows that could improve care. All the money went to EHRs and the minimal training and installation they require. What will it take for hospitals to make the culture changes that reap the potential benefits of EHRs and data transfers? The public needs to start asking tough questions, and the Stage 2 requirements should be robust enough to give these questions a basis.

Meaningful use financial inducements are not about making fundamental changes affecting the state of health information's inertia, but rather all about using (channeling) existing inertia to collect today's carrots and to ward off tomorrow's sticks.

A very long gentle sloop…

Modified from AHA²

Acute Care Non–Federal Hospitals with at least a "Basic" EHR

The stage 2 meaningful use objectives³:

1. Clinical Decision Support
2. Drug Formulary Checks
3. Patient Education
4. Patient Lists
5. Advance Directive
6. Comprehensive List of Allergies
7. PACS for Imaging Results
8. Demographics
9. Vital Signs
10. Structured Labs
11. Smoking Status
12. Bar Coding
13. Patient Medication Lists
14. Immunizations
15. Reportable Labs
16. Syndromic Surveillance
17. Patient Problem Lists
18. Automatically Generated Quality Measures
19. Care Record Summary
20. CPOE for Medications
21. Information Exchange
22. Patient Portal

The majority of hospitals, as assessed in the fall of 2011, do not meet the stage 2 objectives in whole or part.

Modified from AHA²

Distribution of Hospitals Meeting Stage 2 Objectives in Fall 2011

Modified from AHA²

Share of Hospitals Meeting Stage 2 by Objectives

Larger

The overarching principle with respect to patient access to electronic health record data…should be[] nothing about me without me[;] but the overarching reality is all about me with nothing to see.

• Radar: Trotter's Principles of patient access in Directed Exchange
• Radar: Oram's The state of health IT according to the American Hospital Association
• Nothing about me without me
• CHIME stands with AHA, comments to CMS (PDF) and ONC (PDF)

1. Newton's First Law of Motion (Inertia): Every body persists in its state of being at rest or of moving uniformly straight forward, except insofar as it is compelled to change its state by force impressed. The velocity (inertia, momentum) of a body remains constant unless the body is acted upon by an external force.
2. AHA Comments on Meaningful Use Proposed Rule (PDF)
3. Medicare and Medicaid Programs: Electronic Health Record Incentive Program–Stage 2

Sheer Typelessness

11,515 tweets ≈ 6 tweets/day

• 5 years
• 60 months
• 1,827 days
• 43,846 hours
• 2,630,760 minutes
• 1.578456×10⁸ seconds
• 2 much

Nothing about me without me

SPM’s responses to the proposed rules for Meaningful Use Stage 2:

• We favor improving the likelihood that patients will access their data by allowing for some automation of the process of accessing and downloading patient data, using existing technologies that protect patient privacy and security.
• We also favor immediate patient access to information in the patient’s electronic health record—unless the patient has elected otherwise.

The overarching principle with respect to patient access to electronic health record data running through the entire meaningful use regulation and the health IT standards regulation should be:

“Nothing about me without me.”

• Society for Participatory Medicine
• Meaningful Use Stage 2
• SPM’s open letter to CMS (PDF), to ONC (PDF)

Accreting Scrutiny

Debt Panels

Accretive Health Annual Report 2010:

The Accretive Health Revenue Cycle Process Structure and Metrics

Payer Relationship Management: People & Technology

1. The Medical Quack
2. Colbert Nation
3. Accretive Health's response, Annual Report 2010 (PDF), Annual Report 2011 (PDF)
4. Minnesota Attorney General's filing (PDF )
5. Accretive LLC's portfolio

Beyond "R" is "F"

Beyond rationing and the duty to avoid waste lies the fiduciary duties—control cost and provide care.

From an Ethics of Rationing to an Ethics of Waste Avoidance

Bioethics has long approached cost containment under the heading of “allocation of scarce resources.” Having thus named the nail, bioethics has whacked away at it with the theoretical hammer of distributive justice. But in the United States, ethical debate is now shifting from rationing to the avoidance of waste.

…

The main ethical objection to rationing is that physicians owe an absolute duty of fidelity to each individual patient, regardless of cost. This objection fails, however, because when resources are exhausted, the patients who are deprived of care are real people and not statistics. Physicians collectively owe loyalty to those patients too.

…

The two principal ethical arguments for waste avoidance are first, that we should not deprive any patient of useful medical services, even if they're expensive, so long as money is being wasted on useless interventions, and second, that useless tests and treatments cause harm. Treatments that won't help patients can cause complications. Diagnostic tests that won’t help patients produce false positive results that in turn lead to more tests and complications. Primum non nocere becomes the strongest argument for eliminating nonbeneficial medicine.

Beyond the “R Word”? Medicine’s New Frugality

Quietly, Washington policymakers have begun to concede the need to weigh health care’s benefits against its costs if our country is to avert fiscal ruin. That costs must be counted against benefits is common sense in other domains—and among health policy professionals. But it’s anathema in public discussion of medical care. To silence talk of tradeoffs, politicians invoke the “R word”—rationing.

…

Even if we could eventually eliminate that waste, we would merely postpone the reckoning…unless we start saying no to some beneficial care. Eliminating only ineffective care would shift the cost curve down but wouldn't change its slope.

Sharp Dull

sharp (ὀξύς, oxus) + dull (μωρός, mōros) = oxymoron = trust + advertising

We trust individual(s) and institution(s) based upon a positive history, or a belief in those that have had a positive history. Trust is an historical or surrogate value assessment. Advertising is the inference of value without an historical or surrogate relationship. Brand is about the creation (earning) of trust—surprise, ads in whatever venue won’t fare well.

To what extent do you trust the following forms of advertising?

Modified from Nielsen Global Trust is Advertising Survey, Q3 2011

Global trust-in-advertising-2012

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