Untangled Health

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Tag: Untangled Healthcare

Open-Access Guidelines for Patient-Centered Care (The tools we need are here!)

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How do I find the best treatment for me? Is it my doctors choice? Do I have anything to say about it? Is it possible that my doctor is unaware of best treatments?

Taken from the British Medical Journal. Click link to view the Aortic Valve Replacement Guideline.“The BMJ launched an innovative strategy to promote patient partnership in 2014. It took this step because it sees partnering with patients, their families, careers and support communities, and the public as an ethical imperative, which is essential to improving the quality, safety, value, and sustainability of health systems.”

 

My suggestions:

Make sure you read the educational material your clinic gives you at the end of the visit then compare it with what you are able to find independently. This is most important when you are diagnosed with a new condition or your doctor recommends a diagnostic or surgical or therapeutic procedure. By the way, new medicines are therapeutic procedures.

Since errors happen…what I choose to call Therapeutic Misadventures I like to check out the current best practices and research outcomes published in Europe, Japan and the USA.

Cool Tools are here!  Everyone knows that I am a big promoter of physician-patient partnership when it comes to researching treatment methodologies and selecting interventions for our personal care-plans. I received notice today on the MAGIC projects publication of guidelines in the British Medical Journal. This particular guideline is for Aortic Valve Replacement. BMJ provides an online experience for doctors and patients called Partnering with Patients. The  content provided on the site includes best practice guidelines for many medical procedures. One source of the guidelines is MAGIC project.

This is an international group, originating in Oslo, Norway operating as the MAGIC project. Magic is an acronym for “MAking GRADE the Irresistible Choice,” where GRADE is a system to develop high-quality guidelines that consider the whole body of evidence on a certain therapy in an objective way, and incorporate patient values and preferences, as well as other considerations.

For the consumer this implies the MAGIC team applies a scientific rigor to weighting the evidence supporting the effectiveness of medical and surgical interventions. The real bonus is that they also employ the patient’s perception of effectiveness which can often be missing in research studies. A common example I like to use is change in mortality rate. Example: If I have emphysema and experience failure of my respiratory system I will die. However, there is a variety of life sustaining interventions available to me in the USA. These include: Supplemental Oxygen, inhaled and oral medications and mechanical ventilation. Virtually all people with severe emphysema are faced with making a decision as to the technologies they will use to extend their life. Many choose all three: Then again, I have had many patients in the past elect to not receive mechanical ventilation as the notion of being connected to a ventilator for the remainder of their life is not acceptable.

When any of us with chronic illness take advantage of a therapy I would hazard a guess that we should always take the pre and post treatment morbidity and functional status into account. Questions we need to ask must include the published guidelines reported changes in health related quality of life after treatment.

I hope these projects become the foundation for a curated library of best practice and treatment outcomes in the near future. Of course my preference would be to make them free for patients which might level the playing-field for those with low incomes in societies with huge disparities in care and health between the wealthy and impoverished. That said, as I learn more about the availability of the guidelines and find those that are free and unbiased by funding resource or error in design I will publish them here.

Have fun and educate yourself prior to making any decisions on how to manage your health.

Warmth to all of my friends along the way.

Jeffrey 

Here are link to Magic

 

The Onslow Magic Project for clinical guidelines

 

 

SalesForce as a Patient-Centered Longitudinal Care Platform | I am one happy Diabetic!

The technology facilitating Patient Centered Care arrived over ten years ago. It was all a matter of configuration!

The technology facilitating Patient Centered Care arrived over ten years ago. It was all a matter of configuration!

I am pumped!
Years ago…1997 I believe; I had a job working for DocSite: the company founded by Physiatrist John Haughton MD that became one of the premier Registry products used as the EMR community was attempting to define itself. In the DocSite product we collected measures or “clinical indicators” that were compiled around the patient and associated with an infinity of conditions. Essentially the data design allowed physicians and grant recipients to have a single patient record yet extract, analyze and report on any constellation of outcome measures without having to spend money on redundant disease registry products. Example: Blood pressure is an important measurement for diabetes and heart failure. In diabetes the measure importance is 1) how often it is done and 2) the blood pressure value. In Heart failure the same measures of process (measurement frequency) and outcome (BP value) are required but they might be different depending on the cardiovascular guideline and contrasting diabetes guideline. In the DocSite system the blood pressure recording was simply a vital sign. The rules defining threshold for compliance with guideline were defined separately and associated with multiple conditions. When the doctor generated the data for PQRI and the Cardiovascular Excellence programs a single patient outcomes dataset was generated based on the programs associated with the patient. When the patient returned to any clinician using the Docsite system the Visit Encounter Sheet displayed the current measures due, the last values and trends for each measure and gave the physician or extender a place to generate an education note. Inexpensive, simple, multi-user, modifiable for EBG and data submission automated through clerical “generate and send PQRI data”. Now, I owned some stock in the company so I am biased but quite frankly I thought the system was elegant once it received data feeds from pharma and labs!

All of us at DocSite used a Client Relationship Management cloud application in our client services department. After using it for three years or so those of us that had worked in a previous company “the forerunner of DocSite” called Cognimed all thought that Sales Force had the proper design to create a community wide care coordination and patient centered care planning tool We had built one in the 1990s and sold it and moved on with our lives.
Today I see SalesForce has entered the arena. Knowing what I know about its capabilities I hope they capture the market by landslide. Please if you thinking about building a new care management platform…dont. As a patient, I would love to see this thing as an App. in all of my clinicians hands and on my IPhone please. Check out their demo. I am sure it all does not work as advertised but I can attest to the fact that they had the correct data model ten years ago!

Reconciling data in my six health portals

Reconciling data in my six health portals

An advocate gets busy while every politician and “talking head” takes credit for healthcare model ideas published long ago.

Reconciling data in my six health portals

Reconciling data in my six health portals

I watched Barbara Starfield again last night. She passed away in 2011 but it seamed as though she was sitting in my living room telling me everything will be alright but many of us will never get our way. Barbara spent several decades studying the characteristics of health systems all over the world. Her final conclusions were simple and easy to implement as long as social agreements were made between consumers of healthcare services and their providers. The contract (sort of) is that my primary care doctor will be available when needed if I promise to contact his or her office before going to the ER for an earache or other non-emergent condition; my doctor also agrees to follow my care as I transition through life stages and address all mental and physical health conditions as they arise by assuring I connect with the correct specialist if required. The specialists in return are in constant contact with my primary care doctor so the primary care clinic is coordinating continuous and comprehensive care and reviewing all interactions between myself and other medical environments. Like I said earlier this week. Someone to watch over me. I first learned of Dr. Starfield in 2001 and followed her publications. Funny, she was never accepted to sit on any best-practice boards but the scientific community considered her work to be spectacular in terms of statistical approach and quality. In other words, she looked for the null hypothesis also.

Again…concerns over repeal and replace.

Some more diatribe with hope at sarcastic humor is written for you below. Please follow through to the end as I pasted a really cool graphic pointing you to a new society of consumers and professionals that might fix the system over the long run.

The conversation doesn’t stop at my dinner table, on my phone, through IM or Facebook. It seems as though my popularity index took a healthy bump after November 8th, 2016. I wish I could be happy about the reasons for the traffic.
“Jeff, you are on Medicare are you concerned?”

Well yes; you see, as we become older the likelihood of needing assistance from case managers, specialists, short stays in skilled nursing or rehabilitation facilities increases. Same with home health services which is always the preferred place to recover from the self-inflicted fractured hip that occurred while my masculine ego informed me of my capacity to clean out my gutters.
One of the most important changes to the clinical language coming from Obamacare is the right for all patients cared for by primary care doctors with Medicare contracts to receive “Coordinated, Comprehensive Care”. Lately you might have heard the terms: “Patient Centered Care” or “Medical Home”. You probably heard President Elect Trump mention “Patient Centered” or a new commercial by Humana presented by a handsome young doctor stating that Humana’s system of Patient Centered Care is superior because of their capacity to coordinate your care within their “medical community”. Then you will watch a local conservative pundit state: “those stupid narrow networks tried through Obamacare didn’t work: here is a toast to repeal and replace.
This stuff cracks me up for the same proponents of patient centered care realize that closely collaborating narrow networks can provide you with clinical personnel that understand your needs better than anyone else! In fact, they have the same attributes of a Patient Centered Care Team using a single medical record and plan of care to increase safety and minimize mistakes. Yet you will hear no one (perhaps save me and a few of us that are tired of scraping the poop off our boots) tell you that the words Patient Centered, Narrow Network, Accountable Outcomes, Value Added Payment, Medical Homes, and all other terms implying a tightly coordinated, error free clinical team surrounding all patients are not original concepts. In fact, they are in place in many of our successful neighbor nations who provide universal enrollment and have always demonstrated lower reliance on emergency room services for basic medicine, better health outcomes and no difference in treatment effectiveness for cancer, diabetes, cardiovascular disease and other leading causes of premature mortality. Our own CMS (The Centers for Medicare and Medicaid Services) have published the policy here July 2016:
So all of a sudden the administration of 2017 will be using terminology invented by others to describe care models that work after years of academic surveillance by healthcare policy analysists and already written into The Patient Protection Affordable Care Act or what the opponents call “Obama-Care”.
My prediction is we will keep the new payment systems for coordinated care and chronic disease care management. However, the credit for the success will fall under a new Trump label. My fears is that the same three insurance companies comprising the oligopoly of payers for American Healthcare will recoup their lost profits of mandated care without premium inflation for the chronically ill by shifting the premiums higher for those with pre-existing conditions. So here is another question from the week:
“Jeff, what will I do now I couldn’t get covered because of my history of cancer before the ACA?” “What if “Trump-care” requires coverage for pre-existing illnesses but allows insurance companies to include the illness in the premium pricing model? “ My response to this question was “not sure, my cost in the NC High Risk Insurance Pool for my diabetes prior to Obamacare was $1200.00 per month not including co-pays. Today it is $350.00.
More on Patient Centered Care AKA Medical Homes AKA Integrated Care AKA Chronic Illness Care.
I discussed the integrated care model and its payment adjustments to my Men’s group on Thursday night as they requested a primer on planning for their last ten years of life. Their hope was that our system of care had evolved and they would not have to lose their homes to cover the long-term care charges. Many of the guys in my group neglected to buy long term care insurance when they were young and healthy, had since suffered a chronic disease diagnosis and episode of treatment and no longer qualified for long term care insurance. They could however place $10 K per month into an account to pre-pay up to one year of long term care. This is what my father did: In 2006 he entered into a contract with a transitional care organization. He paid them $350,000 for full access to assisted living and long term care until his death. They also allowed him to live in the attached apartment complex for independent seniors for an additional rent of $3200 per month including one meal per day. Not a bad deal eh? Oh yeah…one more oversight: My friends ; all retired upper middle class professionals had no idea that Medicare didn’t pay for long term custodial care either in home or inpatient facility.
Now, like I said the other day, I am a bit tired of shouting the truth to those who were unfortunate enough to buy into the following promise: “Oh we will have the most wonderful healthcare system in the world” and “We promise to repeal the expensive policies and replace with something better.
We were on our way folks: The biggest mistake, President Obama’s team was denied the necessary Medicaid expansion for ALL not SOME States by our supreme courts. If you don’t understand the math I will be pleased to describe it in another column. Basically when the folks that would have had access to Medicaid don’t receive the insurance they still consume services. The loss of revenue winds up on the balance sheets of hospitals and providers and they respond by increasing their cost per service. The insurance companies pay more and your premiums increase. So… my neighbors policy (55 year old male) in NC costs $11,000 per year. The very same policy in New Hampshire where they expanded Medicaid costs $5,500 per year. As Mr. Obama leaves keep in mind that the rate of increase in health costs since the inception of Obama Care is the lowest it has been in 40 years.
Somehow, someway; we need to cover everybody. If we do not we cannot cover the losses incurred in the private sector without the Magical Thinking that has been sold you for so many decade. Hide the losses, get others to pay for the losses through modest increases in cost of living and blame the doctors, and hospitals who give away more free care than you could ever imagine.
What would happen if our incredible consumer driven internet harnessed the decision support technology that we use daily on Amazon and instantly brings the right service to you when needed should you or a loved one become ill? What if we harnessed IBM Watson to make the diagnosis thereby reducing error rates and reducing unnecessary utilization of expensive diagnostic procedures?
What if we didn’t need insurance companies any more to assess population risk and perform preauthorization services while we waited for our new medication?
Since we have all of the data connecting lifestyle, culture, nutrition, infection and the human genome can anyone appreciate where we are headed with our capacity to discover the cause of disease and effect of treatment? This is not decades from now my friends; it is within the reach of our children’s lifetime. I have wonderful friends with incredible scientific minds that are creating open source technologies to accomplish human collaboration like humankind has never witnessed. The only barrier to their success is a loss of priority to cure disease, increase well-being and expand the functional-years of human life.
Or…we can keep these technologies secret, forget those we have developed through the natural sequestration of competing private enterprise and traditional silo thinking. If this is where we are headed then the best investment to assure a painless end of life if you are not surrounded by humanitarian friends is my undying support for the second amendment. If you catch my drift.

Check out Right Care Folks!

Right Care Now

Right Care Now

Doctor Price? Should we run for the hills?

A serene day in St. Croix

 

His history might clue you in.

Tom Price on healthcare: What should we expect?

What happens when you strip coordinated care incentives through repeal of the PPACA. One outcome is certain: orthopedic surgeons like Dr. Price perform more amputations for which they receive several thousand dollars for a fifteen minute procedure.

What happens when you strip coordinated care incentives through repeal of the PPACA.
One outcome is certain: orthopedic surgeons like Dr. Price perform more amputations for which they receive several thousand dollars for a fifteen minute procedure.

Click link above to access Dr. Price’s priorities. First please read my fears, doubts and insecurities below?

 

 

 

Pres. Elect Trump hired Rep. Tom Price as the new Director of US HHS today.
Mr. Price is a vocal supporter of Mr. Trump when other republicans were not. It appears Mr. Trump continues to hire loyalists.
Dr. Price is a successful physician having authored numerous bills to replace PPACA. When hired he stated his objective is to repeal and replace.
The bills authored by Price do have language that sounds attractive e.g. Patient Empowerment but when read…show a clear intent to remove the most important economic controls on health cost escalation in the PPACA. These include: DME competitive bidding for items such as prosthetics, motorized wheelchairs etc. Competitive bidding on drugs purchased by Medicaid and Medicare, Removal of our veto on using genetic data to derive insurance premiums for individuals and many more.

I have long thought that it is weird that Americans who place so much emphasis on pure free market tactics in all industries vote for politicians that author bills to veto competitive pricing virtually eliminating 100 million people from hiring a government payer to reduce the cost of medicine.

Now, I always suggest we follow the money.
Dr. Price’s three leading PACs and individual campaign contributors fall within these industry’s.
Physician Membership Organizations
Hospital Systems including HCA ( brought to testify on anti trust and fraud several times in front of congressional committees)
Pharmaceutical Industry
Insurance Industry

Where I have worked for HCA, consulted to the American Academy of Family Practice, Anthem Blue Cross, NY BC, and State Government I am confident in my conclusions about their business objectives. If you trust me and want more info please feel free to call on me.

I highly suggest that everyone who voted for PETUS look at who has been appointed to lead US agencies and fill important cabinet posts. My prediction and I hope to eat my words is that the middle class is about to be dealt a final death-blow that will eliminate any hope of having enough left over at our death to pass on to future generations.
I am suggesting people like myself: aging with chronic illness describe what they hope for quality of life in their final years and make preparations. The only way to do this is to understand how necessities are priced and determine individual bargains strength.
We had Price transparency tools created through the PPACA. My guess is they will disappear in short order .

My colleagues who believe in universal enrollment for defined evidence based public health and personal health interventions will be fighting any changes that do not provide consumer-facing competitive shopping tools that dispense with confusing terminology commonly used by healthcare institutions and insurance organizations. I also look to the millennial to jump in since they have a future at stake.
Tony Antony Williams may be right in his suggestion that PETUS is a liar.

Doing my best to stay healthy enough to escalate beyond the occasional battle into a Full Blown War against Wall Street.

The War in DC is for campaign reform and term limits.

“Oh what a drag it is getting old”

Wait, Wait, Don’t Kill Me; I have my data and you don’t! A Chronic Disease Patients Point of View Part 1

 

A 33 year veteran worker from the US HealthCare Industry who was diagnosed with type 1 diabetes in 1966 describes his  realization that health care efficiency solutions must first address social and business barriers prior to implementing technology and hope for the future.

Reconciling data in my six health portals

Reconciling data in my six health portals

Keeping our eye on the ball: Let us not forget why we showed up over these last few years and started shouting out!

A small sample of issues that we learned about in the last fifteen years:

  • Disproportionate Growth in Healthcare Costs (greater than GDP and growing as a multiple of consumer price index) with poorer health outcomes
  • Disparities in care and care outcomes directly related to personal income. (as family income falls so does family health)
  • Lack 0f availability of critical, decision influencing data when and where we are treated (The Patient Information Gap) arising from lack of governance of data exchange between industry segments, physicians and payers at local, State and Federal levels, (often hidden behind well intentioned efforts to secure the privacy of patients).
  • Reliance on antique point of care exam model: Patient and family as historian.
  • Poor price transparency due to confusing and always changing industry syntax such as: Facility charge, Allowed amount, Deductible, Co-Pay, Co-insurance, Patients responsibility, Cost Sharing, Plan Type, Episode of care; Discharging to next lower level of care;  Medical Savings Account appeared to us as a shell game where we would always find our total cost out of pocket living under a different shell!
  • Certification processes: JCAHO Ambulatory, JCAHO Hospital, NCQA, URAC, CARF, Insurance Company’s Center of Excellence! What does it all mean! 
  • Questionable ethics of pharmaceutical industry: Tiers level 1,2,3,4. When our doctors told us they prefered a brand drug because of evidence that the drug was more effective but the insurance company required we pay 4X cost of their PBMs generic who do we trust! Will I die because I spent $200 less per month on my medication than my Dr.Recommended?
  • Numerous Business to Business relationships that supposedly have value for payers but only decrease the size of the consumers wallet. What is a PBM anyway? A Pharmacy Benefits Manager! You mean my medical insurance company needs another company to manage the medications!!!!
  • Disease Management Companies: Nurse calls me monthly who works for Depression Institute LLC who evidently subcontracts (like the pharmacy benefit manager) to my insurance company or my employer. She asks me if I am” downhearted and blue.” I say “yes” and she sends me some uplifting books and websites to look into. Meanwhile I would like to see a therapist because I am loosing function at work due to diabetes and am very sad and can not concentrate. My primary care provider sees 10 patients per hour and is empathetic but can only refer me to a psychiatrist associated with his institution. The institution psychiatrist places me on multiple medications to address my depression and the nurse from the DM company calls me monthly. I feel no better. Months later I begin having heart palpitations which turn out to be a side effect of the antidepressants. I am now afraid to work out.

Then we approved the HITECH ACT, ARRA and ACA all of which contain system enhancing improvements that are to address our concerns and help us feel safer, have better health outcomes and have better consumer capacity to analyze the state of our own health, determine our care needs. plan for our care needs and finance our care. Because as we all know: We are all temporarily able-bodied individuals; that is unless we are delusional.

My mission with these next series of posts, articles and perhaps a self-care book is to frame America’s Healthcare System as it evolves in front of you. How is it that I can do this when others can not? Well many, more qualified people can. Most will not due to the shackles of our industry and survival instinct. Ezekiel Emanuel will lay it all out for you if you listening to a compassionate physician who gets the big picture. For now: I am no longer dependent on this industry to support me. I have no fear of exposing the truth including those elements of my past that cause me to carry shame, anger, fear and a substantial amount of JOY. The truth is; all of the commentary I have heard at cocktail parties attended by physicians, employers, patient rights groups, hospital administrators, nurses, mixtures of all levels of worker-bees is beautiful material and quite humorous. If you are a healthcare worker and are reading this than you know this material is true. If you are recently graduated from your professional training venue whether it be nursing. medical school or other and you find my words a bit offensive then please forgive me and disengage 

So for now: Let’s get started, I welcome all feedback as this material comes belching forth from my repressed memory and will try to frame my words with ego disengaged.

 

My first experience with accidental death bordering on murder:
In 1982 I experienced one of three medical errors in my career that culminated in a person’s death. I was 26 years old so I took it less seriously than I do now: but it was the start of a change in consciousness regarding my thoughts on communication breakdown within the care delivery system. Ultimately this one focus would become my life’s pursuit.
Setting: A beautiful, crisp fall day in New Hampshire, My duties that day were respiratory therapist ‘on call’ for code blue (resuscitation events): A man of about fifty walked into our emergency room noticeably distraught. “I can’t catch my breath he said, it feels like my heart is coming out of my chest”. We took him immediately to our trauma room where all of the equipment would be available should we need to perform complex procedures (temporary pacemakers etc). Laying him down on the gurney the EKG technician hooked him up to the monitor and I reached up to turn it on. My job was to assist the team if the patient arrested and then intubate and ventilate him upon order of the physician. What I saw on the EKG appeared to be a life threatening rhythm yet the physician ran into the room and announced the rhythm to be less threatening  which requires a completely different treatment approach: So I figured “well he is the doc and knows much more than little old me”. This was back in the days when a patient’s personal physician could deliver direct care in the ER as opposed to a board certified emergency room physician. This Navy Dr. was quite sure of himself and demanded respect. At the time the Dr’s diagnosis called for electrical cardioversion with a defibrillator to establish a normal rhythm so I began preparing the defibrillator. However, this was 1982 and we had a new cardiologist on staff so the Dr. in charge thought it best to ask the cardiologist if there was a less traumatic way to correct the patient’s rhythm. He yelled out Hey Dr. XXXX; what is the standard for cardioversion for intraventricular tachycardia? Now keep in mind that the nurse and I were concerned that this was a missed diagnosis and that the patient was in-fact having a heart attack.  We spoke up at this point but were dismissed due to our lower level of credentials RCP and RN vs. MD. The cardiologist said “there is a great new class of drugs that have been used for years in Europe they are Calcium Inlet Channel Blocking agents. Give your patient 4 mg of Verapamil! So our esteemed leader –without running the EKG to show it to the cardiologist pulled up 10 mg of verapamil –not 4 into a 3cc syringe and handed it to the nurse. “You will be okay in a minute Mr. Smith said his doctor, we will take your shortness of breath away shortly by giving you this drug”. The poor man was terrified and his horror made worse when my nurse friend refused to push the drugs into the patient’s IV. Dr. (Navy Save the Day) said “Fine I will do it”; injected the medicine, looked at the patient and then up at the EKG monitor. Mr. Smith sat straight up in bed, grabbed his chest and fell unconscious. As we looked at the monitor we could see that there was a clear EKG rhythm but the patient had no blood pressure nor could we feel a pulse. He had stopped breathing and his eyes were wide open with pupils dilatesd.We worked on the poor man for almost an hour. I intubated him and started ventilating while the nurse began chest compressions. The cardiologist had come into the room to take over the resuscitation effort. As soon as he looked at Mr. Smith’s first EKG he knew that he and the other doctor had made a terrible mistake. Had he looked at the EKG before recommending verapamil he would have labeled the rhythm as acute myocardial infarction with ventricular tachycardia and suggested defibrillation immediately.  What confused the patients doctor who had little clinical experience in cardiology was the fact that his patient was walking and talking.One is taught in school that a person usually loses consciousness when in “V-Tach” however, those of us who spent hours our lives reading 24 hour EKG recordings knew that many patients with good strong heart muscle can be in this rhythm while having coffee with a friend and simply complain of some shortness of breath. So this was an old-school clinical decision support error: the wrong diagnosis (bad data) given to the cardiologist (software decision support engine) caused the report (feedback loop) to the patient’s doctor to recommend the wrong therapy. Taking the advice the physician administered verapamil caused the patient’s cardiac muscle to stop contracting due to the lack of exchange of calcium across the cell membrane.

The patient’s wife arrived 30 minutes later to be informed that her partner had died from a heart attack. It’s hard to forget the screams of agony one hears throughout a career in the hospital ER. There was no incident report or mortality round on this case. The nurse and I were dumbfounded as the patient’s physician took off his gloves, through them on the patient’s chest and said “that’s the last time I ever take advice from a cardiologist”!

What I have just illustrated is a failure to communicate and validate; even in the presence of communication technology. Years later we would have computerized EKG interpretation algorithms that were often ignored due to as lack of trust in the computer. After a decade or so the interpretation algorithms became spot on and many stopped arguing with the machine.

I always wondered after this event “would this happen to me?”

Our time has come: In my opinion we have some brilliant people speaking to the topic of healthcare reform and its multiple components today. The same personalities have formed organizations that bring patients into the fold of healthcare transformation such as the Society for Participatory Medicine and its Sister E-Patients.net.

Furthermore research has confirmed that some basic tenants of care are major correlates of lower cost and higher health outcomes. These are ease of access to a primary care physician, assurance that the primary care physician treats the patient with comprehensive techniques; assurance that the primary care physicians practice coordinates the patient’s care as he or she develops new conditions and problems and requires interventions from other providers or facilities such as hospitals. Furthermore there is evidence that if the primary care database is queried on a regular basis to identify patients with chronic disease that have not been seen or are experiencing a deterioration in health status that populations can be identified and engaged well before they show up in the local emergency room. This type of procedure is titled Population Medicine.

So here we are with all this knowledge and interest. On top of that we approved a National program for the expansion of electronic medical record technology under the Bush administration. This HITECH bill was primarily a jobs creation bill but it was to create something of immeasurable value for us patients, doctors and our loved ones. A single record or location on the internet called a portal where any one clinician that might have an interest in caring for us would be presented with a thorough historical record of our problems, diseases, interventions, therapeutic outcomes, medicines etc. This alone was worth the billions spent since it could make our safe at a time in history when the institute of medicine was quoting over 100,000 deaths per year due to therapeutic misadventure. I call this permanent record “the life-long plan of care”

This engineering feat was not rocket science: it required technology that we had in place and a social infrastructure that we did not. By social infrastructure I mean an agreement among industry providers, provider specialities, hospital organizations, employers and insurance companies to settle on a standard clinical and business syntax defined by the context of the workflow or data flow and not interfere with the transfer of information between organizations holding information and their competitors since patients are transient. Metaphorically speaking it is similar to my exchanging the service records on my car between competing car dealerships and then downloading a copy for myself at home. In fact here is evidence that it is not happening while the private eHR companies selling their wares are owned by CEOs worth billions! Doctors challenged by data exchange

Crap! We still don’t have it! I am reading about campaigns “give me my data!” #gmmdd because evidently patients are having trouble accessing their records, test result etc.

My friends all tell me that they have been told by their providers and doctors that they have their own portal access their records, talk with their docs and download records. In fact they do. Here in the RTP area of NC I can count seven clinical portals that a patient’s clinical information may reside in. I have tested them all and have no problem downloading my personal or a friend’s personal information from each portal. This leaves me wondering if the campaign should be labeled Give Me My Data or “Wait Wait Don’t Kill Me” ,#WWDKM “I have data and you do not.” This is a much more succinct description of the problem in my world anyway. (credit to NPR for paraphrasing their wonderful show “Wait Wait Don’t Tell Me”)

What scares me is that I understand the cost of sharing information and it is not just some random charge made up by vendors. You see the vendors were given three guidelines to meet for interoperable data. However, during implementation it is possible to modify the system templates thereby creating artifacts as data cross the street from hospital A where Blood Pressure means Blood Pressure and Hospital B where Blood Pressure means Respiratory Rate. These are the CCDA documents that your physicians patient portal allows you to download either in the form of a pdf document or .xml document adhering to CCDA guidelines. So where you and I can download our information, good luck uploading it into another facilities records. So, once again…I am doing what I did in 1981 and hand carrying my test results and visit summaries to each specialist and each hospital that performs surgery. From the surgery perspective it is important because I am diabetic and have a family history of hyperpyrexia; a condition where in reaction to an anaesthetic agent your body heats up to 105 degrees and starts to melt on the OR table.

So as we riot against the machine because we are afraid for our very own lives remember who the villains are: No body! The manufacturers have certified their ability to interoperate. The ONC did not consider a standard where it is suggested that you document your capacity to exchange data in all contexts: Administrative, Financial, Result Observation, Continuing Care Document Architecture Record between every known vendor of eHR software that has received the same level of accreditation. This is an oversight or someone was paid off I am not sure. All I know is that the Epic enterprise EHR is deployed in three hospital systems that I use including their partnering physicians and I am unable to transfer my data between systems without a download and manual entry of results which never make it to my medical record because patient entered data are considered unreliable. Such arrogance! Don’t you think?

Below I illustrate and describe my current processes which include the use of MS Healthvault for data consolidation. This will be part 1 of a series that I construct with the objective of embarrassing an industry that has been playing a shell game for three decades with our private and taxpayer dollars. In the end you will hopefully have more clarity on why it has never worked, why it won’t work without a change in societal attitude toward health care as a right vs commodity and how we might change the future by getting clear with our healthcare business leaders and policy wonks now about our understanding of their special interest controlled industry.

I have been reading the same complaints for three decades; I have worked in provider industries and taken advantage of others in accordance with corporate doctrine, I have struggled to get my long-term needs met as well as those of friends, neighbors and family members. I have seen us come around now through three complete cycles of “novel idea that will fix medicine” followed by “new opportunity for new industries to form and to get wealthy on the suffering of patients and the majority of the workers who provide the most nurturing experience while they earn $15.00 per hour. I have had 45-year-old physician friends throw up their hands and walk out the clinic door with tears in their eyes as they dropped their career while still paying their student loans. It goes on and on but I do not. So now, with neuropathy advancing, fingers aching from arthritis as I type I say to you: I might need to rest and bleed for a while but I ask that you carry me to the next gathering to continue the fight.

Community Care of North Carolina goes for the gold: Proving valid reduction in hospitalization among Medicaid enrollees with Chronic Disease

Heck! With health insurance we can afford a cup of coffee!

Heck! With health insurance we can afford a cup of coffee!

I have not been posting much lately due to activities with the Patient Centered Primary Care Collaborative. We are working on an analysis of accreditation standards which will ultimately be used to verify Medical Home processes, procedures and clinical outcomes. Check out their website as you consumer types will have a chance to see what others are doing for you to assure you access to the best in health care as we reform the system over the next few decades.

I am very enthusiastic these days as I am seeing the changes I have hoped for my entire life as person with diabetes since 1966. As a child my doctor was always available to teach how to master my illness and provide tips with mechanisms I could use to reduce my cost: especially when I entered college. My docs have been so cool, I can never adequately thank them. Purchasing a glucometer and testing reagents for me when I was uninsured; providing free laser therapy when my employer dumped the plan I had in favor of becoming self insured. If you want an interesting read see an old post of mine titled Physician heroes.

Today I call your attention to Community Care of NC. The organization that employed me as their clinical informatics lead back in 2002. These folks are using a model of population management and patient care that I had seen work in Massachusetts in the 1990s. To that end my wife and I moved here in 2001 to work for CCNC. They use a centralized partnership between private healthcare industry and public agencies including Medicaid, Public Health, Mental Health and Substance Abuse Services, the NC Medical Society and the local branch or thee Academy of Family Physicians.

The central teams keep improving patient targeting and clinical outcomes analysis using a variety of statistical sources and deliver regionalized community information from 12 different 501c3 Community Care Networks. The individual Networks then put care coordinators, case managers, pharmacists and administrative staff in place to create local flavors of patient centered care. All have guiding physician committees and other staff who collaborate with subspecialists as well as local hospitals. The net result is a care continuum surrounding the sickest individuals where the team focuses on goals set by the patient, their family and the team. They have been doing this for fifteen years now and I can attest to the fact that they are one of only a few Patient Centered Medical Home Networks in the country that are using a web-native care plan accessible to all on the patient team as well as multiple other physician practice improvement web apps totally focused on education, assessment of each doctors population and measurement of patient outcome.

This week they published the proof in the pudding. After long struggles against threats to defund the program they survived. They are now audited in full and have demonstrated hospital utilization rates falling at 10% per year in the chronic disease population. We are talking HUNDREDS of MILLIONS of DOLLARS in savings folks on top of hugely improved clinical outcomes and patient satisfaction with their sense of well-being.

I have always said that I needed a lot of help in my life. Since I knew how to assemble a care team for myself I figured I may as well help others do the same. Today, in 2015 we have the mechanisms in play to reconnect patients with their physicians. Please step up and teach your docs about your needs, wants and struggles as it will take us a while to walk out of the woods.

nc hospitalization trends under CCNC

NC Senate : While the rest of the country profits from North Carolina’s success in Medicaid, you throw the baby out with the bathwater.

 

Heck! With health insurance we can afford a cup of coffee!

Heck! With health insurance we can afford a cup of coffee!

cmis_use

 

 

The graphic report (above right) comes from the CCNC data systems developed by the Community Care of North Carolina Program. It allows communities to identify and assist people in need of support or locate systemic problems such as high utilization rates in local emergency rooms. All of this stuff combined fits into the Medical Home Model that out senate suggests purging CCNC; Yet, as you will note below, this program is a locally managed;public-private joint venture that is used throughout the US to achieve cost reductions in health systems. Please read on:

Yet another testimony to the capability of a Medical Home framework to decrease cost and improve health outcomes was published in today’s NY Times.   Here are the data:

  • The payer: Care First Blue Cross Blue Shield
  • The population size: 1.1 Million!
  • The model: Medical Homes (Community Care of North Carolina an early adopter of this strategy)
  • The savings: $130 Million

The article goes on to explain that results have been mixed in Medical Home Evaluations, demonstrating a need to identify the components that are required to achieve such results.   However, The Patient Centered Primary Care Collaborative Chief Executive Marci Neilson noted that the studies are showing promise as Blue Cross Blue Shield of Michigan demonstrated a $155 Million savings in Emergency Room Visits and Hospitalization through their Medical Home Program last year.   So here’s what I have to say to the Senate: WAKE UP… the people providing the knowledge and structure to the programs now receiving accolades from the media cut their teeth in North Carolina through a fifteen year joint effort between public and private industry. Then, after receiving national recognition they were asked to teach other States the basics of the Medical Home that will reduce cost and improve health outcomes.

  1. Local control with State support
  2. Physician directed care
  3. ACCURATE DATA published frequently, reviewed frequently, converted to focused interventions
  4. Care Coordination and patient education from within the physicians practice
  5. Frequent regional meetings to review success and make adjustments to work-flow and design.

Here is an example from years ago in Greensboro (CCNC ORAL REHYDRATION PROGRAM)  

  • The local Community Care Network discovered that many emergency room admissions were attributed to children experiencing dehydration when they had GI Flu.
  • The CCNC Network (Partnership 4 Health) created an oral rehydration program where they reached out to the community of working mothers who would come home to a child experiencing diarrhea and vomiting.
  • As they engaged the family they taught the mothers to rehydrate their children using pedialyte.
  • They distrusted the rehydration kits to physician practices, public health departments and elsewhere.
  • The people started treating their children at home as opposed to the emergency room.
  • The Medicaid emergency department visit rate for GI distress fell and the tax-payers saved money.
  • All of this with happier children as the most important outcome in my opinion.

So what do you think NC Senate?   How about we keep what works!!! If you need further illustration there are a few thousand of us who would be pleased to teach you: Republicans, Democrats, and Independents alike. 

From the front lines in North Carolina’s debate over human equality

I am so sad to see the level of intentional prejudice in this State.

Here is todays local television coverage of the closure of a critical access hospital (CAH). CAH’s are placed in rural areas throughout the USA and exist strictly to provide life saving healthcare to sparsely populated areas (usually agricultural).

This event is blamed on a corporation “Vidant Health”

In reality, it is not the fault of a corporation; or the pharmaceutical industry, or publicly funded healthcare, or the insurance industry; or the doctors; or your dog.

This is a collapse of civilization. In NC, we have decided to stop caring for those in the lower socioeconomic classes. We have proven this through our elected officials. So the fault lies with us and every life that is lost in transit to hospitals 45 minutes away is our responsibility.

You see:

The Affordable Care Act found the money to expand Medicaid and provide coverage for those with incomes less than 200% of Federal Poverty Level (about $28,000). In doing this, the cost of insurance polices through exchanges decreases. This has been proven in States that accepted Medicaid expansion funding. North Carolina did not.

The money for expanding Medicaid is partially funded by eliminating the large disproportionate share payments to critical access hospitals. You see, they would now bill Medicaid.

Well, NC did not accept the money as a “Statement of our conservative believe in small government”.

Now the hospitals are closing.

Here are my comments to our State Health News today, and more will come of this situation as you watch it play out on the national front. You will note that the good people are here. They are just under-represented.

  1. Very sad indeed. Within the last week the following has occurred in my personal world of chronic disease management: 1) the endocrinology group that fills the diabetes management subspecialty role for many Medicaid diabetics in the RTP area has stopped taking these patients and (according to my personal MD) they plan to discontinue services for existing patients on Medicaid. 2) The behavioral health group that treats many of the same diabetics for depression has dropped away from their care-team roll as they too are no longer accepting payment from Medicaid.

    Meanwhile, back in the grass roots of Johnston County we have been blessed by three Raleigh Retina Specialists who are willing to continue treating Medicaid patients. This includes visits, laser procedures, vitreal injections for macular edema etc. I begged them not to drop the Diabetes Eyesight Preservation program at Taylor Retina Center and their response was clear: Are you kidding Jeff, we will turn no-one away, this is a serious disease and far too many preventable vision related disability cases are missed.
    A Heart-Felt Hooray for the Good Guys.

    I wish the NC voters could understand the magnitude of dishonesty between legislators and their constituents. I have worked directly with past external review actuaries including Mercer when determining the return or loss associated with NC Managed Care through their CCNC program. The level of detail, down to the adjustment for illness burden and months of enrollment in Medicaid proved to me the sincerity and accuracy of the folks charged with program evaluation. Later (2006-2010) the program and its outcome data were modeled in many States around the country.

    Yet when attending a Medicaid public forum I witnessed a NC employee from the budget office explain away all cost efficiencies by pointing to differences in the percentage of the NC population that are children in contrast with other States. Such an illinformed if not ignorant piece of information to share with the GA. This comment was made as I sat next to a former legislator who is a surgeon. I described the inaccuracy to him and said they may want to get some help with interpreting the data reported on Medicaid estimates. After a few more minutes discussing evaluation methodologies he looked at me and admitted ” We really do not know what questions to ask”.
    I testify to the truth of this statement further acknowledge that it is mine alone.

NC General Assembly Run’s Amuck

Here is what you can plan on seeing frequently in NC Emergency Departments as people with diabetes lose contact with the guidance of their primary care medical homes.
Dying a piece at a time diabetic vascular disease

This letter is to my neighbors in North Carolina, all of you:

I am presently at the Patient Centered Primary Care Collaborative, a national forum of Fortune 500 companies such as IBM, Anthem WellPoint, United Healthcare; Aetna; and clinical groups such as The American Academy of Family Physicians and others. My point is: This is a non-partisan, multiple perspective group of America’s best thinkers in business and industry that convened in 2006 to identify what works with regard to delivery mechanisms, payment reform and consumer engagement.

I am a member of PCPCC and serve as a co-chair on their health information technology committee and adviser to the Patient-Family and Consumers group. Yesterday I was a panel member discussing both topics. Why, because of my experience with my healthcare (diabetes for 48 years) and work with the folks that founded the current system.
After this meeting I will be attending the Colorado Patient Centered Primary Care Collaborative meeting at 1:00 PM this afternoon.

I am interested in Colorado’s perspective since they adopted North Carolina’s successful program: North Carolina Community Care Network which tethers Medicaid Patients to a Medical Home. Our program in NC has been evolving for twenty years: Starting as a simple demonstration and ultimately proving its capacity to manage a diverse population of patients coming through different payers including Medicare, Medicaid and Health-Choice. After joining what has become a national movement to bring patients closer to their primary care physicians Colorado’s pilot initiative has demonstrated reduced-cost per enrollee and improvements in health outcomes. The return on investment is well north of 2:1.

As these programs expand they will be using organizational ideas that originated among the talented North Carolina physicians and allied health professionals in the between 1994 and the present-day. NC tax-payers and the private sector joined forces; offering financial commitment and support staff to ramp-up the rate of adoption of Medical Home processes. Their support of Community Care is due to their effectiveness. This work is now being replicated across the country and is thought to be pivotal to the reduction in cost and the much-needed improvement in National Healthcare Outcomes.

Unfortunately, my neighbors and I in NC will no longer receive the benefit of our State’s recognized excellence in primary care delivery as the NC General Assembly has elected to ignore the desire of the public and take the next step toward the ‘outsourcing’ of Medicaid to a national HMO. “Sorry folks we have been hijacked by gorilla corporate tactics to influence a 3 trillion-dollar industry.”

I must inform you of your success and the magnitude of abandonment.

Here are the facts as described above:

NC has demonstrated wonderful cost savings with their community designed care coordination and case management programs. You may hear them referred to as Community Care of North Carolina. They are composed of 14 different not-for profit organizations assigned the task of providing care while controlling inflation in Medicaid. I worked with the team on assembling programs that would provide unbiased expert evaluation on their health and cost outcomes, those that become national benchmarks.

Your communities responded to the call for participation in Medicaid reform. Now, all of us that thought we were included have been abandoned: And believe it or not: Our Governor is one of the good guys: After he put a great deal of effort into learning about what works and listening to the feedback of local healthcare experts he supported the implementation of Accountable Care Organizations and the continued use of Community Care of NC as the service providers.

How do I know this? I had coffee with Fortune 100 executives yesterday who have been trying to help the Governor and NC Physician networks. I cannot disclose anything other than this. The detail is disgusting and speaks to issues that most in our country worked through in the 1970s. Suffice it to say that your elected officials were able to locate an HMO plan outside of NC that is able to tell a wonderful story. Since the legislature (as members have directly admitted to me) do not understand healthcare data and population analysis they have hired consultants to assist. These consultants pale in comparison to the experts that have recently met with Governor McCrory in an attempt to save the State of the Art system currently in place.

All systems of care need improvement today. Clinics and providers are not all the same. That said, we have plenty of successful models in NC to draw from.

Regardless of the following truths your General Assembly has decided to dispose with advice from the recognized experts in the field.

The Nations’s  industrial leaders are adopting your healthcare services design because they are confident that it works.

• Our State is a respected leader across the USA through the success of its bilateral Medicaid Managed Care model that evolved through your feedback and the constant vigilance on regional measures of cost benefit and cost efficiency.
• You have been abandoned while distracted by a conservative argument for small Federal government. The influence from outside our State is present and sizable.
• Through the invocation of States rights, our GA turned down sufficient funding to care for an extra 400,000 poor people in this State. Our uninsured would be insured otherwise and hundreds of jobs would be created to perform the needed individual health assessments, identification of clinical disorders and implementation of a course of treatment.
• You are handing over the health management of the woman next door: You know the one who works two jobs to feed her family to an external, antiquated delivery concept that demonstrates only two things:
o Reduced cost
o Reduction in health and wellness with loss of access to primary and specialty care.

Since no-one could imagine our legislature retreating from previous commitments I thought it might be a good idea to take this year and advance the treatment of diabetics by concentrating on our well-known problems with untreated diabetic eye disease among the poor. I was counting on the Community Care Networks to take our patients, established a collaborating group of eye doctors and created the program outline for a Diabetes Eyesight Preservation Initiative.

Due to the changes in attitude and changes in latitude expressed by the GA last week a program to treat diabetics at high risk for becoming blind at a cost roughly 50% of local hospital charges is being placed on hold. I can not ask my ophthalmology friends to plan on Medicaid reimbursement with the knowledge that the payers could change overnight. Two bad I guess for several hundred people who have been unable to receive specialty eye care.

I hope my readers understand what I am saying. I have difficulty describing such a complex and corrupt industry to my friends and family. The General Assembly has knowingly ignored your desire and taken action that will –in the eyes of our nations most published professionals likely do harm to the poor.

Additional note one day later:

I have been informed by my endocrinologist that the practice will no longer accept NC Medicaid. This is due to the uncertainty of the GA final budget.

I am retired today and have no reason to distort the truth. I am fortunate to have wonderful people in my life outside of NC who validate or challenge my conclusions. Without my friends I would question my sanity and think I was caught in the twilight zone.
\I am willing to work with others toward a system that is faithful to its original design requirement: Provide room for the poor and middle class (now the same, check your retirement account) to succeed in a country of opportunity. Have we lost it?

If anyone would like to publish detail, simple facts to expose the reality do not hesitate to contact me. I have data and information regarding this topic that will stand in court and my family has no fear to work with others in an attempt to expose the material prior to the 2014 election.

New Bumper Sticker Idea: NC General Assembly : Perfecting Legal Genocide

 

 

HIT at its best

Check out Telcare Cellular Enabled Diabetes Management Platform.

Now we have a example of a technology applied to address consumer and physician hassles.

One device for measuring, cloud storage, analysis and communication for the patient.

For the doctor: This could be the ultimate registry platform for diabetes specialists.

I am pumped…..well I use a pump but I was referring to something else.

Telcare.