Stop Thief!

A Harris Interactive poll suggests that public awareness of health privacy concerns is on the rise, according to a report in Modern Healthcare.  The poll is described as an “online interactive” survey, however, which raises concerns about sampling validity.  That caveat aside, it’s interesting to note that there appears to be increasing public awareness of health data theft and data security issues - which, as we have written here before, are rampant.  (We’ve been following health privacy concerns for some time now.)

The poll also suggests that data thefts could be undermining public support for Electronic Health Records (EHR), which is another reason to get this problem under control before it escalates any further.

The Modern Healthcare article also reports that Booz Allen Hamilton was awarded a $450,000 grant in order to

…do an “environmental scan” to get its arms around the problem, then convene a meeting to gather ideas on how medical identity theft should be addressed, and then to write up an action plan recommending ways to deal with the problem.

I would’ve liked to have that contract, and I could’ve done it for a lot less.  We haven’t begun to explore the full implications of rampant health data theft - and we shouldn’t, at least in a public forum.

Still, I suspect the real solution to this problem is going to come from an imaginative entrepreneur, not a Federally-funded study.

(via CHCF’s iHealthBeat; image courtesy Medical Informatics Insider)

Are We Asking the Wrong Questions About Disease Management and Medicare?

A recent study suggests that Medicare’s Disease Management (DM) experiment has failed to cut medical costs. DM advocates argue that Medicare’s methodology was flawed. So what’s the answer? A New York Times article asks: Does Medicare DM cut costs, or should it be stopped?

That may be the wrong question.

As far the first part of the question is concerned, it wouldn’t be surprising if the answer turned out to be “no.” Revenues for disease management companies grew from $78 million in 1997 to $1.2 billion in 2005, according to the Disease Management Consortium, largely on the belief that DM programs cut medical costs and were therefore a good investment for private payers. Yet to date, no study has demonstrated conclusive medical cost savings from DM.

That doesn’t, however, mean that DM is a bad idea - especially for Medicare. 160,000 Medicare beneficiaries have been served by the Medical Health Support program, which provided chronic disease patients with periodic calls from nurses. The nurses give patients medical information, encourage them to seek treatment, remind them about their medical needs, and provide other forms of support.

The DM companies had financial incentives: Either achieve a 5% reduction in medical costs for their enrollees, net of service costs, or return their fees. When it became clear last year they weren’t going to make that goal, Medicare relaxed their requirements. Now, only a net savings is required in order for the vendors to keep their fees. It’s not clear if they’ll reach that goal, either. (The CMS pdf fact sheet politely describes the cost impact of these programs so far as “nominal.”)

It’s too early to draw definitive conclusions about this experiment, especially since the data are not yet publicly available. But here are some thoughts to consider:

• Cost savings may not be the appropriate goal for DM with a population of this kind. Convenience (especially for those with limited mobility or money) and health improvement outcomes are also worthwhile objectives. The program should be evaluated for these indicators, and not for cost alone.
• While the entire program may not be cost-effective, elements of it might be. Medicare should continue the experiment under modified conditions.
• There may be opportunities to reduce program costs and improve efficiencies while delivering similar results.

Senators from the home states of the companies involved, including John Kerry and Lamar Alexander, think the experiment should be continued. The Times implies they’re just providing a constituent service to home state employers, but they may in fact be right. There is more to be learned about the role of DM in Medicare, and in the overall health system.

Overall, the DM industry is likely to experience a shakeout in the next year or two - for both private and public payers. Assumptions about its cost-effectiveness are likely to be overturned. The most likely end result? A re-engineered DM concept, which differs from today’s both in design and in outcome measurements. Medicare can play a vital role in DM research, discovering which elements work, which need to be added, and which can be discarded.

Health Information Online: New & Interesting Developments

People keep trying to provide comparative cost information that health “consumers” can use to make their treatment decisions. Many of us have predicted that someone would try to be the Travelocity of health purchasing, and Carol.com says it wants to be exactly that (as reported in the Minneapolis Star Tribune).

I tried the site. It’s ambitious, and in its own way it’s also overtly political. “Competition has changed every market but health care,” the Flash introduction says. “That’s about to change.” Some would argue that there are many reasons why health care can never fit simple market models, including confusion about what exactly is being bought and sold. (Is it “wellness”? A fix for your specific health problem? Or just a set of individual treatments, none of which can be predicted in advance?)

I had some difficulty following the process for acid reflux, the condition I’d selected as a test. It came up with only one “price” of $213, from one provider - but what was it for? Diagnosis? Treatment? End-to-end cure? How much will I need to pay for pharmaceuticals? Will I need to return quarterly? Annually? Ever? If it’s just one office visit, it should say so. If it’s a treatment plan, it should say that.

This is not to knock Carol.com’s creators unfairly. They have an interesting take on this often-discussed idea, and according to the Star Tribune they’ve already affected some unit pricing in the area. And I love their attempt to use decision trees to help people figure out what they need. (Try it - it’s interesting.)

But they need to be cautious about over-promising, and they need to recognize that most of their users will be insured - which will make their pricing information misleading, if not irrelevant. Most of all, they need to define the commodity that’s truly being bought and sold in the health market. That’s the hard part.

Meanwhile, Kaiser Permanente seems to be pioneering an different model for Internet interaction with the health process. iHealthBeat summarizes the features of Kaiser’s new member portal (free registration required), as originally reported in the Sacramento Business Journal. Features include appointment scheduling, prescription refills, viewing lab results, and e-mailing doctors (who will presumably write back).

A staff model HMO like Kaiser is the obvious place to develop a successful service of this kind. All the needed information is present under one roof. Since doctors are employees and not independent businesses, they can take time to answer emails without losing income.

The logical next step is to develop a similar service for the majority of Americans who don’t belong to group or staff model HMOs. That will require some leg work and some cooperation, especially among physicians, laboratories, and other diagnostic providers. And it will require financial incentives for providers to participate, including a payment schedule for answering emails and a system for transferring medical information securely.

(Carol.com, on the other hand, charges providers to participate. That may alter the blend of participants away from the lowest-cost providers, especially on the physician side. And who makes sure data is updated?)

What else will it take to succeed? A thorough knowledge of the inner workings of our so-called health “system,” and a clear-eyed look at the motivation of the participants.

In related news, California is posting a list of hospitals willing to provide discounts to uninsured patients, along with a comparison-shopping tool. Two Michigan health systems are posting their prices for common procedures (but note - these are charges, not the payments they typically receive for these services. Caveat emptor and all that.)

Prediction: Not very many people will use these California or Michigan portals. There will be one or more sites that do become popular someday, but they’ll look like a cross between Carol.com, secure email, and a supercharged search engine.

The goal is to create the classic “knowledge pyramid”: Data needs to be organized into information, and information needs to be organized to become knowledge. If somebody builds it, they will come.

Global Warming And Individual Health

Add the fight against global warming to the list of political battles that impact the health arena.  A long-term study of global warming’s impact on medical needs was conducted by Australian researchers in order to help that country’s single-payer system plan for the future.

According to the Sydney Morning Herald, researchers found that  “heat waves - defined as a periods of three days or more in which the average temperature exceeded 35 degrees - produced a seven per cent increase in admissions to hospital and a four per cent increase in ambulance trips.”  The Herald adds that “the number of people admitted for kidney disease increased by 17 per cent (during heat waves), and the number admitted for mental illness increased by seven per cent.”

Melbourne’s Herald Sun (ironic name, that) quotes the study’s lead researcher, Prof. Kevin Parton, as saying that mosquito-borne diseases will also be on the upswing as the result of warming trends.

There are those who will say these reports are “alarmist,” of course, although they rely of widely accepted climatological and medical research.  The study is, unfortunately, not alarmist.   On the upside, the long-term investment opportunities look good for related medical products - including antibiotics, antidepressants, dialysis technology, and bug repellent.

I wish I were kidding.

Bipartisan Support for More Provider Health IT

There’s a place for healthy partisan differences, and a place for bipartisanship. This initiative goes into the latter category. Whether you’re a free-market radical, a single-payer advocate, or something in between, better collection and analysis of information will help the delivery of medical care.

(Single-marketers take note: Primary physicians in Europe and the UK are well ahead of their U.S. and Canadian counterparts in the adoption of IT.)

A group of Senators that includes Ted Kennedy, Hillary Clinton, and Orrin Hatch has sponsored  a bill called The Wired for Health Care Quality Act of 2007. It provides $163 million over a four-year period (that’s not very much) to help providers who don’t make very much money adopt news IT strategies. It would also help states create low-interest loan programs for them, and provide funding for local and regional initiatives to collect and share health data.

The bill would also require that HHS designate an organization to create health care performance measures, which is an important step forward. If adopted, this bill will help create the electronic infrastructure for a better health system - whatever you imagine that system to be.

I don’t think there’s enough money in the bill.  It provides $40 million and change per year for four years.  That’s less than a few dozen costly medical cases will cost in each of those years.  But it’s a start, and that’s a good thing.

Will PHPs Succeed or Fail? It’s All About Execution … Which Means Investment

Highmark (Blue Cross Blue Shield of PA) is offering an online Personal Health Record portal, or PHR. As HealthDataManagement.com reports:

Available through a secure page at highmarkbcbs.com, the Pittsburgh-based insurer will automatically populate PHRs with relevant claims and administrative data that includes dates of service, diagnoses and treatments, medications and other information.

The PHR includes tracking technology that enables users to keep records on certain health status measures, such as blood glucose, blood pressure, cholesterol level and weight. Other recordkeeping functions include medication tracking, immunizations, physician information, treatment history and allergies. Members also can enter additional information in their PHR, which is printable to share with clinicians.

Highmark further will offer PHR users personalized plans for improving their health. The PHR includes links to educational materials.

There are a lot of factors to consider in good web portal design - including variations in literacy rates, ease of access, generational/cultural differences in how people interact with a screen, identifying the “teachability moment” in health education, and much more. That doesn’t even touch the issue of content. Execution will determine the success or failure of the PHP concept.

There’s a good opportunity for the right team to build the content and develop design templates for PHPs. The question is: Where is that team? There’s an investment opportunity out there for the right partners …

(courtesy iHealthBeat - California HealthCare Foundation)

Free IT For Doctors, Updated - New York’s Using It For Those Who Treat the Poor

I’ve written about the potential market for IT in the primary care physician arena before (here and here, for example). There is a substantial need for solutions in this arena, and for those that can serve other physician specialties too.

That’s apparently part of the thinking behind New York City’s $19.8 million grant for physician systems that integrate clinical and billing/administrative functions. They’re starting with docs who treat Medicaid patients and the uninsured. That’s a good place to start.

Washington DC has decided to do something similar, starting with eight community health clinics and moving into local hospitals.

I haven’t looked at these particular apps, and I worry about ongoing R&D and support under this model - but I’ll keep watching. And I’m betting there are creative ways to enhance an app of this kind that these programs haven’t yet considered.

Provider Evaluation Tools For Health Care “Consumers”

The San Francisco Business Times notes the infrequent use of California’s new hospital rating site for consumers. I’m not surprised that usage is low, and I think the Business Times draws the wrong conclusions.

As I’ve said before, I think that simpler is better when it comes to organizing health information for the general public. The Times, and at least one of its interviewees, thinks otherwise. They suggest that simplicity may be one reason why the site isn’t being used.

I disagree. I think it isn’t being used because people don’t know it’s there - and because, as I’ve also suggested before, it’s not part of a larger site that addresses the many different contexts within which people will search for health information. Simplicity of organization and presentation, however, is what will make it comfortable and usable for people once they do find it.

Digging up this kind of health information isn’t like conducting a straightforward Google search (a fact that hasn’t gone unnoticed at Google). People don’t go looking for comparative data on hospital costs, because the idea itself hasn’t occurred to them. You have to bring it to where they are - metaphorically (in their learning process) and literally (in their browsing habits.)

That’s why I’ve been promoting the idea of ‘context-driven health data’ for all parties: consumers, doctors, employers, and administrators. The Times also mentioned Vimo.com, which is an interesting start-up designed along just those lines.

They’re in an early stage of development and have a lot of work to do. If they thrive, however, they’ll be going head to head against Steve Case’s Revolution Health. That could be interesting to watch.

Can the ‘Wisdom of Crowds’ Predict a Flu Pandemic?

This is clever:

The University of Iowa on Thursday unveiled an electronic market that asks about 100 physicians, nurses, epidemiologists, researchers and public health officials to predict when, where or if an avian flu pandemic will spread around the world, the Des Moines Register reports (Jordan, Des Moines Register, 3/1).

The Iowa Health Prediction Market will put a $245,000 grant from the Robert Wood Johnson Foundation toward creating the Avian Flu Market using the not-for-profit Program for Monitoring Emerging Diseases — the International Society of Infectious Diseases’ online global reporting system (Fox, Reuters/Yahoo! News, 3/1).

The Des Moines Register gives further detail:

- About 100 doctors, nurses, epidemiologists, researchers and public health officials from around the world will act as traders in the market by gathering information and making predictions.

- Traders buy or sell shares based on their answers to yes/no questions that include whether the H5N1 virus will appear in North or South America by July 1, whether more than 300 cases of H5N1 are confirmed worldwide by July 1, and whether there is any human-to-human spread of the virus by July 1.

- Traders can invest all their money - each member has $100 in an account provided by the U of I - in a popular answer or buy cheaper shares in a less-likely scenario to increase the possible payout. When the market closes July 1, administrators will credit traders according to the accuracy of their predictions.

Traders will be recruited through the Program for Monitoring Emerging Diseases, an online global reporting system run by the International Society for Infectious Diseases that rapidly distributes information about outbreaks.

The Avian Flu Market and the U of I’s Influenza Prediction Market, which has successfully predicted when the flu bug would hit Iowa, are spinoffs of the Iowa Electronic Markets, which have gained national attention for accurate predictions in presidential elections.

They don’t just do avian flu at the Iowa Health Prediction Markets. They’re working on regular flu, and the mumps too. Incidentally, the Iowa Electronic Markets just started traded in the 2008 elections today.

Some of these ideas are just trendy, and some are really smart. This one? I’m betting it’s really smart. In fact, if the model continues to be effective, I can think of all sorts of opportunities to use this approach in the private sector, can’t you?

Medsoft - not Microstory. MS Buys Medsoft, Builds Health Division

Esther Dyson writes in the Huffington Post about Microsoft’s purchase of Medstory, a health search engine that can be personalized to your own health profile. She acknowledges that the personalization function isn’t there yet, but it’s a great idea.

The Medstory concept reflects the bandwagon I’ve been on for a long time - one which led to the formation of Health Knowledge Systems, although I haven’t had time to move that aspect of it forward as I would have liked (and that effort’s focused in a different direction - post-injury or illness, with corporate and insurance entities as the end payers).

The idea is this: the design flaw in the Internet as it currently exists is that there’s too much information, not too little. The notion of a “cyberspace commons” for all users is wrong, and we need to shift our thinking toward a “personalized commons,” or a “digital lens” that allows us to see only the information we need to see.

The best place to start is where Medsoft started - with the individual. But there are others who need “lenses,” too - physicians, pharmacists, regulators, journalists, researchers, academics, IT professionals …. the list is endless. Each of these populations needs its own set of lenses, and each is its own market.

Is Microsoft the right vehicle for building these multiple platforms, and does it have the will to take Medsoft to the next level? Only time will tell. Within the world of the “personalized commons” alone, we’re only taking baby steps.

As TheStreet.com reports, the web/health interface is hot again. As for Microsoft, Steve Ballmer’s comments in TheStreet.com’s piece reflect the opportunity and the risk. Opportunity? Hell, it’s Microsoft! Ballmer says the area is “longer term and less visible” than other priorities - and they’ve got 600 people on it.

The risk? It’s Microsoft. They’ve got a lot of things going on right now. The quotes from Ballmer and the head of the health group concentrate on hospital systems, which is fine - but it’s also the most complex area of the health care IT landscape, and one with less impact on healthcare as an overall system - clinical, epidemiological, economic, social, and informational - than others.

Will Microsoft find the will and vision to redesign the healthcare landscape, or will healthcare eventually become part of its business systems division, with a few modules like Medstory on the side?

More, as they say, will be revealed.

(Esther also talks about the limitations created by lack of robust privacy protection systems in healthcare - something else I’ve been prattling on about ad nauseum for some time now.)