Monday, September 28, 2009

Discharge Summaries Grossly Inadequate at Documenting Pending Test Results

A study in the September edition of the Journal of General Internal Medicine found that "discharge summaries are grossly inadequate at documenting both tests with pending results and the appropriate follow-up providers."

The study found that only 13% of discharge summaries document all pending tests. And only 25% of discharge summaries mention some pending tests. Follow-up providers information was included in 67% of discharge summaries. "The documentation rate for pending tests was not associated with level of experience of the provider preparing the summary, patient’s age or race, length of hospitalization, or duration it took for results to return." The study evaluated discharge summaries at two academic medical centers for patients that had pending test results.

This adds to the communication challenges referring physicians face coordinating care in follow-up to a hospital visit. Yet communications issues are accountable for over half of all preventable errors. And communications issues are twice as likely to be related to deaths as compared to "clinical inadequacy".

The study reported that approximately 41% of patient are discharged with pending test results and 9% of these test results affect patient care management.

Tuesday, September 22, 2009

Why Did Joe Wilson Yell "You Lie"?

Saturday Night Live takes you behind the scenes as Republicans plan for the president's speech to the joint session of Congress.

Thursday, September 17, 2009

Health Wonk Review

Welcome to Health Wonk Review. A special thanks to the stellar group of writers that contributed. And a remembrance to a leader for reform:

"What we face is above all a moral issue; that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country."

Health Care Reform -
"The Great Unfinished Business of Our Society"

Austin Frakt at the Incidental Economist presents Economics Arguments for a Public Option. "Good economics arguments for the public option have finally been made. Will they influence the debate? It may be too late."

Tom Emswiler at New Health Dialogue advocates paying "for expanded coverage, in part, with savings from within the health care system, i.e., by doing a better job than we do now in delivering high quality affordable care."

Doctors Jonathan Skinner, Elliott Fisher, and Jonathan Sutherland from the Dartmouth Atlas Project found that "there is still plenty of potential savings in the U.S. health care system to help pay for health care reform, spending that has nothing to do with health, poverty or urban/rural status... There is a behavioral bias at work, a belief shared across all hospitals that their patients are sicker than average, and this explains why their own spending so high. (This is a “Lake Woebegon Effect” in reverse – the belief that the health of all of their patients are below average.) But this behavioral bias, leading to the denial of the potential for real cost-savings in the U.S. health care system, can potentially derail health care reform – to the long-term detriment of the medical and financial health of the American people."

Bob Vineyard at InsureBlog believes that "nothing proposed will lower the cost of health care, or health insurance. In fact, you could very well see the total cost of health care balloon out of sight and health insurance premiums double overnight."

Elizabeth Carpenter at New Health Dialogue explains why healthcare reform costs close to $1 trillion over ten years. "Subsidies -- financial assistance to help people afford insurance -- are why health reform costs so much. Reform proposals would help many hard-working Americans -- people who make too much money to qualify for programs like Medicaid but make too little to purchase coverage on their own -- buy quality health insurance. People eligible for subsidies would receive a tax credit to help them pay the premium for their choice of plans offered in the new marketplace or exchange."

Mike Allen at Politico's Playbook reports on "what the West Wing is reading: cool new independent web site" Truth About Health Care Reform.

Mad Kane "limericks" Senator Judd Gregg's flip-flop on the use of the Senate's reconciliation rules, supporting it for Republican votes on ANWR drilling, but not for the Dems healthcare reform:
“Majority rule is just great,”
Said Gregg in the drilling debate.
“You’ve got 51 votes,
Then you win.” Check his quotes.
Yet 51 Dem votes don’t rate.

Anthony Wright, Executive Director at Health Access California, raises concerns over the Baucus Senate Finance Committee bill arguing that "the details matter on key issues on affordability, securing employer-based coverage, and the public health insurance option. And some of those details are very concerning." He provides links and context to the current flashpoints in the debate.

Dr. Jaan Sidorov at Disease Management Care Blog reports on the "Senate Finance Committee's Bipartisan (Gang) of Six Framework for Reform: Complicated is Only the Beginning."

Dr. Roy Poses at Brown University School of Medicine writes in Health Care Renewal that "we will not truly reform health care without making the marketing of health care goods and services honest, getting health care professionals to give up their financial relationships with health care corporations to reclaim their professionalism, and getting academic medical institutions, professional and medical societies, and patient advocacy groups to give up their financial relationships with health care corporations to reclaim their missions."

Harvard Medical School Professor Mike Chernew on the Robert Wood Johnson blog notes that as the health reform debate enters its final phases, it’s not surprising that cost containment is among the last, most intractable issues of contention. There are "serious questions about resource allocation that each side must address as we strive to design a sustainable health care system. For example, can we afford to fund access to all care for everyone? Are we willing to change the tax system or to impose other reforms that may lower prices or restrict choices in order to achieve that goal? What role should the government play in creating and managing this system relative to the market?"

Chris questions mandates in his post: Senate Proposes “Health Tax” on Fittest Americans.

Louise at Colorado Health Insurance Insider asks "how do you tell a person who is desperately ill that they can’t receive treatment because they aren’t in the right country (or because they don’t have health insurance, for that matter)? I have to imagine that it would be tough for a dedicated health professional to turn away truly sick patients because they aren’t supposed to be here in the first place. What if turning them away amounts to a death sentence?"

Kostub Deshmukh at Hoot Hoot Hoot! proposes a plan that "shifts the cost of the treatment from the insurance provider to the patient, while the safety net of catastrophic insurance protects people from bankruptcies due to illness."

Princeton Economist Uwe Reinhardt expresses doubts about the impact of the proposed "public option," but he also expresses doubts about the co-op approach said to be included in the Finance Committee package. Reinhardt also worries that $900 billion or less will not provide sufficient subsidies to make coverage affordable for all middle-class Americans.

Harold Miller, CEO of the Network for Regional Healthcare Improvement, focuses on the urgent need for payment reform and calls on Medicare to facilitate and learn from the reform efforts already launched by Regional Improvement Collaboratives.

Jason Shafrin at the Healthcare Economist comments that "whether or not you agree with Obama's plan, it is admirable for him to go out on a limb to attempt to solve some of our health care problems. He does, however 'defer reform' for Medicare, since no significant changes to benefit packages or funding was proposed."

UNC Associate Professor Jonathan Oberlander believes that Obama's speech was well received. Oberlander reminds us that Bill Clinton's health care speech was well received, too, but he concludes that the reform fight, while no sure thing, is winnable for the administration.

Ken Terry at the BNET Healthcare notes the lack of details on cost containment in the speech and the probability that, even if a reform bill passes, the legislation will have to be revisited in the near future.

Harold Luft, Executive director of the Palo Alto Medical Foundation Research Institute, focuses on three aspects of Obama's speech: Delaying the implementation of the insurance exchange, malpractice reform, and the proposal for back-up spending cuts in case initial expected savings don't materialize.

Henry Aaron, Senior Fellow at the Brookings Institution, says that by reaching out in his speech to undecided moderates and clarifying his goals, Obama revived a reform effort that had been badly wounded during the August recess, Aaron says.

Brad Wright at Wright on Health documents the history of "Presidential Health Reform Speeches: Then and Now". He comments briefly on the relative importance / unimportance of presidential speeches on legislative outcomes, before comparing and contrasting Bill Clinton's 1993 speech to a joint session of Congress with Obama's recent one, including video and word clouds.

Census of the Uninsured

Anthony Wright at New Republic's The Treatment reports on the political attacks on the 2008 Census' 46.5 million uninsured that "doesn’t just seek to undermine the facts; it seeks to both minimize the problem, and place the blame for being without coverage on the uninsured themselves."

Tinker Ready at Boston Health News reports on the 5.5 - 6% uninsured in Massachussetts in the latest census.

Health Care for Older Adults

Amer Kaissi discusses End-of-life Care: The Big Bad Wolf of Healthcare Reform posted at Healthcare Hacks. "End-of-life care as part of the new healthcare reform bills seems to me like a potential good thing for older Americans. The Big Bad Wolf, after all, is just a little lamb!"

Chris Langston at The John A. Hartford Foundation blog finds that older adults are best served by medical teams--but right now, doctors, nurses, and other medical professionals have little incentive to work together, and efforts to foster team care environments are undermined by each health profession's desire to be in charge.

RN Debbie Leyva at Healthcare & Technology: Innovation at the Intersection describes the value of the internet for improving health care in older adults.

Blogs and Tweets

Suzane Smith presents 100 Twitter Feeds for Women’s Health.

Carolyn Friedman lists 50 Oncology blogs.

Susan White documents 50 Lectures About Your Brain.

Healthcare Technology

Vince Kuraitis at Better Health Technologies' e-CareManagement Blog writes that the HIT "Standards Committee recommendations are like mandating that everyone in the U.S. be required to speak Latin by 2013."

Dr. Glenn Laffel at EHR Bloggers discusses Social Media: Disruptive Force in Medicine. He makes the case for implementing a widespread, systematic approach to HIT education in medical schools and CME programs for physicians.

Michelle Snyder at The Health Care Blog discusses a survey exploring the opinions of medical students on issues ranging from the state of the healthcare system and use of technology in medicine to social networking.

Policy Challenges of Diabetes and Obesity

Julie Ferguson of Workers Comp Insider reports on an Indiana court's ruling that an employer must cover the costs of an employee's weight loss surgery under workers comp, which continues to generate controversy and attention.

Next Health Wonk Review

Brady Augustine at medicaidfirstaid hosts the next edition of Health Wonk Review.

Wednesday, September 9, 2009

EHR Certification and Transition Steps Defined

On September 3, the Certification Commission for Healthcare Information Technology (CCHIT) unveiled their plans for certification under ARRA. CCHIT plans two program concepts: 1) comprehensive certification which meets or exceeds federal standards and and 2) modular certification related to security, privacy and interoperability meeting federal standards.

Federal standards for HHS Certification will mean that a system meets the "minimum government requirements for security, privacy, and interoperability, and that the system is able to produce the Meaningful Use results that the government expects." HHS Certification will not be a 'seal of approval' nor an indication of the relative value of systems.

CCHIT's action were in response to ONC's Certification and Adoption Workgroup recommendations presented at the August 14 HIT Policy Committee meeting.

The Certification and Adoption Workgroup's recommendations include:
  • Focus Certification on Meaningful Use
  • Leverage Certification process to improve progress on Security, Privacy, and Interoperability
  • Improve objectivity and transparency of the certification process
  • Expand Certification to include a range of software sources: Open source, self-developed, etc.
  • Develop a Short-Term Certification Transition plan
The Certification Workgroup emphasized the need for more explicit requirements for information exchange

Unlike CCHIT today, certification criteria should be established independently of the organizations performing the certification. Multiple certification organizations will be allowed to perform testing after they become accredited. Vendors need certification from any one testing organization.

Wes Rishel (Gartner) has argued that "when the choice of certifiers is made only by the vendor, not the organization that relies on the certificate, this creates an inevitable pressure to be the certifying organization that is the least thorough in its process"... "Arguably, if physicians could chose the certifying organization they would not pick the one with weakest accreditation. After all, they have to live with and use the product. But under the “any certifying organization will do” approach, this is not the option that will be presented to physicians. They will be asked to choose among products each of which is rated by several organizations, some of which are focused on the baseline requirements for certification and others of which use any number of criteria for judging products."

As such, accreditation is a lynch pin in the Workgroup's recommendations to "insure that multiple certification entities use identical criteria and provide a 'level playing field' so that all certification organizations offer the same level of scrutiny."

HHS Certification would also serve as qualification for the Stark exception.

Providers would be allowed to achieve meaningful use through use of certified components.

In one sure-to-be-controversial recommendation, the Workgroup recommended that the “lock down” requirements of EHR software should be removed to address concerns of the Open Source community.

Self-developed software may also be certified, on a site by site basis.

The transition

The certification transition "includes a concept of 'Preliminary HHS Certification' so that vendors, who take a risk on the content of the final regulations, can be ready as quickly as possible when final regulatory approval is obtained" which should be valid through 2011."

"This certification is called “preliminary” because the meaningful use criteria and the certification criteria will not yet have completed their paths through the regulatory process.
When the regulatory process is completed for Meaningful Use, presumably in early 2010, then, if necessary, establish a short “regulatory gap certification” for any necessary changes from preliminary certifications. After completing this “regulatory gap certification”, the National Coordinator should certify those products as qualifying under the statute, with a goal of having HHS Certified products in the marketplace in early 2010."

"For vendors who already completed CCHIT 2008 certification, we recommend providing an optional shorter, expedited process. Request that CCHIT submit, as soon as possible, a proposal for “2008 Gap Certification,” which will apply only to vendors who already completed 2008 Certification. The 2008 Gap Certification must cover any missing privacy capabilities (e.g., audit trails, consent) required by statute It must also cover capabilities for Meaningful Use, and expanded interoperability capabilities. Once approved by ONC, the completion of 2008 Gap Certification should also qualify products for “Preliminary HHS Certification.” Those products will be required to complete the “Regulatory Gap Certification Process” before the National Coordinator similarly certifies those products. Working with CCHIT and the Policy Committee, the ONC should investigate whether similar gap certifications are appropriate for products that achieved 2007 certification."

Thursday, September 3, 2009

Health Wonk Review - call for submissions

Health Wonk Review will be hosted at Healthcare Technology News on Thursday September 17. With Obama scheduled to address a joint session of Congress on Health Care Reform on September 9th, this promises to be an extraordinary edition of the Review.

"Health Wonk Review is a biweekly compendium of the best of the health policy blogs. More than two dozen health policy, infrastructure, insurance, technology, and managed care bloggers participate by contributing their best recent blog postings to a roving digest, with each issue hosted at a different participant's blog. For participants, it's a way to network and share ideas, and for those readers who don't live in this space every day, it's a way to sample some of the latest thinking and the 'best of the best.'"

Submissions are due by 9 AM Wednesday September 16. Please include information on the article (including URL, title, description and author) and the blog (title and URL). Send your submission to

In the meantime, you can check out the latest Health Wonk Review at the Lucidicus Project.