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Archive for June, 2009

McAllen Texas: A Less Exciting Explanation

by Jaan Sidorov

Readers may recall McAllen Texas was the topic of an essay in The New Yorker magazine by the impressive surgeon-essayist and Democratic advisor Atul Gawande. The McAllen ‘hospital referral region’ has the dubious distinction of being identified by the Dartmouth Atlas as close to the top nationwide for the amount of total fee-for-service Medicare dollars spent per beneficiary in 2006. That hapless locale was subsequently seized upon by Peter Orszag of the Office of Management and Budget (OMB), Consumer Reports and some notable blogs as the symbol for all that ails American healthcare. Commentators have been accusing the ‘McAllens of this country’ of consciously and unconsciously economically ripping off the system with precious little quality to show for it.

Is there something really special about McAllen or is something else going on?

To illustrate the point, conduct a thought experiment by imaging many bags of pennies (to pay the primary care providers), quarters (for the rest of the physicians) and dollars (for the hospitals) suspended above a huge map of the United States. Mentally open the bags, releasing coins that fall, clatter and roll across the map. Since the distribution of the coins is random, some areas of the U.S map will have no coins, others might have just pennies, others may have dollars and pennies, some will have all three and a few will have lots of all three. Somewhere on that map, however, there will be a pile of coins that is bigger than the rest. Perform the same experiment using Monopoly style plastic clinics and hospitals across a board-map and the same thing will happen. In these thought experiments, the area of the map with the extreme outlier status happens to be McAllen.

It’s hard for non-statisticians/non-economists to think of human behavior in markets as being ‘randomly’ distributed around an average, but it’s true. The best (painfully so) examples of this are the performance of mutual funds, as well as what happens to losing vs. winning teams and their professional sports coaches . The same is true in healthcare: given the overall upward growth in the number of hospitals, specialists and clinics with an inevitable distribution (both high and low) around that trajectory, it is statistically inevitable that there will be a McAllen somewhere in the United States.

It is the nature of our minds to believe there must be something “causing” outliers. In other words, there must be something about McAllen that attracted all those coins, right? That may be true in Miami (which is number 1 in the U.S), but that doesn’t seem to be the case for McAllen as described in the New Yorker magazine article. The gumshoe M.D. reporting clearly shows the McAllen providers are mystified by their status. It’s not as though they planned to take advantage of the system. In fact, they didn’t. That’s because it’s all random.

This is important because most healthcare providers involved in quality improvement learned long ago that ‘identifying’ and then ‘managing’ outliers with targeted interventions is a poor way to promote overall system improvement. Outliers naturally regress to the mean over time and they’re not the problem anyway. Rather, the trick is to reduce overall variation around the mean (reducing the standard deviation) and to move all providers toward a better average level of behavior. That’s a lot of complicated work that, frankly, isn’t as enthralling to editors or the readers of The New Yorker.

While popular media can be forgiven for using simplistic descriptions of extreme outlier anedotes to pander to a political agenda, what about Dr. Gawande? However, the reaction of the OMB is frightening. Short of complete central planning for the entire health care system, random distributions of performance, expense, quality, claims, satisfaction and countless other measures around a mean will be unavoidable. Of all persons, Dr. Orszag should understand that outliers are an ironic certainty, not evidence of malfeasance. Most are anomalies, not proof of anything. They are, in short, interesting, but not necessarily lessons and certainly not the stuff of policy making.

Don’t Give Up on The Personal Health Record

by Mark Scrimshire

This is an extract and re-post from Mark Scrimshire’s blog: ekive.blogspot.com

In the prelude to the recent Health2.0 conference held in Boston, e-Patient Dave’s experience in importing his medical claims records to Google Health got picked up by the Boston Globe. This has sparked a fascinating debate. You need to read Dave’s post.

At the recent Web 2.0 Expo I had time to sit with Jay Parkinson MD and he also ended up commenting on e-Patient Dave’s experience. Jay penned a powerful analysis in the Business Insider of what Dave had written about. John Grohol at e-patients.net described Jay’s assessment as “Hitting one out of the park“. However, I don’t share Jay’s conclusion.

Google Health and Microsoft HealthVault are still in the early stages of their evolution. I don’t think it is time to give up on the idea. Indeed I think it just serves to confirm that we have to put the patient at the centre of the system and not bet on the Health Care Industry successfully building Electronic Medical Records and Health Information Exchanges in order to efficiently move garbage data about as around the industry outside of our purview.

If we can’t trust claims information let’s at least focus in on the information we can believe.

How about the medications we are taking, which could be pulled from our prescription records. This is an area where accurate data might actually save our life by avoiding damaging drug interactions.

The moves that the Continua Alliance is taking and Microsoft’s device standards for HealthVault are a push in the right direction. I believe consumer accessible telemedicine devices are the next consumer wave. The data these devices collect belongs in our Personal Health Records where we can choose who we want to share that information with.

So Google, Microsoft and Dossia - Don’t get dispirited. There will be bumps in the road. Let’s tackle the simple stuff first and get value from collecting and sharing basic vital sign, prescription information and family history data that could prove of value to the medical community.

Keeping an open data approach to PHR’s will provide the basic for a flourishing ecosystem that will be able to increasingly make sense of the complex data that will eventually feed from EMRs inside the health care industry.

If anything e-Patient Dave and Jay Parkinson’s commentary just serves to underline the enormous benefits that are there to be grasped if we put the PHR and the consumer - us - at the center of the Health Care puzzle. The consumer/patient is the one common denominator. Patient Self-Management is not knew and it yields real, positive results. It is just that up to now we, the patients, have been working in the dark with snippets of information of uncertain value.

Rising medical costs are going to drive active consumer engagement and this is going to lead to more patient self-management not less. To my mind this means that the EMRs and Health Information Exchanges that are being planned in order to grab a piece of stimulus cash will be handling an ever smaller part of the patient management puzzle. Outside of chronic disease management, an increasing proportion of health management information is going to be managed outside of these EMR platforms. If the industry doesn’t recognize the potential value of the un-tethered PHR then they will be faced with the prospect of operating with less and less of a full picture about the patient. That potentially leads us down a path of practicing more, not less, defensive medicine which will continue to drive medical spending higher.

The patient is at the center of this puzzle.

We are the common denominator.

To the Health Care Industry - Get over it! Give us, the consumers/patients, the tools to help us help ourselves. After all we are the ones that spend 100% of the time living with our diseases and ailments.

If you are interested in this and similar discussions you can join the conversation at HealthCamp. The next HealthCamp event is HealthCampMd which takes place in Owings Mills, MD on Friday June 19th. HealthCamp is about bringing all parties together, including patients/consumers in to a conversation HealthCare that asks how we can rebuild healthcare on a participatory model using Social Networking, Open Standards, Open Source and the best that the web and mobile Internet has to offer. Literally hundreds of people have joined in this conversation in the past year.

American Public Understands PHR, eHealth Privacy Risks

by jennifergorman

This post has been cross-posted from Jen McCabe’s blog Health Management Rx

Six in 10 Americans don’t believe that their medical records or personal information will remain confidential if they are stored and made accessible online, according to a recent survey on health-related issues conducted by NPR, Kaiser Family Foundation, and Harvard School of Public Health.

More than that, 76 percent of those surveyed believe that an unauthorized person could gain access to their electronically stored and shareable health records.

via medicaleconomics.modernmedicine.com
This is good news in disguise:

1. 3/4 of the American public surveyed (1,238 randomly selected participants over 18) is being very realistic about challenges with privacy/security related to EHRs and PHRs.

2. Reflects larger trend towards sharing, less “confidentiality” online (although privacy, security, and confidentiality are all different but interconnected metastasized issues to consider and confront).

3. Americans as a whole are being more pragmatic than Congress (shocker!) about the potential of EHRs (standing alone, magic-bullet style) to ’save’ healthcare… “22 percent of those surveyed felt that the overall cost of healthcare in this country would go down if one were adopted.”

I’d like to see this survey compared to a similar survey performed, say, 3 years after Citibank offered online banking. Or comparatively reviewed when to articles and surveys about Ebay and PayPal.

The scary part:

“Half of respondents reported that their physicians do not currently enter health information into a computer while they are present. Most respondents feel that it’s at least somewhat important for healthcare providers to use EHRs instead of paper records, but 90 percent said that they’ve never tried or been able to access medical test results online.”

And the money quote:

“Seven in 10 respondents said that their doctors would do a better job coordinating their care if an EHR system were adopted.”

70% think docs would do a better job with EHRs. 80% searching for health information online (via Pew, @susannahfox - new research due June 9th).

Any questions?