Health Reform Christmas Books

Some books are to be tasted, others to be swallowed, and a few to be chewed and digested

Francis Bacon (1561-1626), Essays

December 8, 2011 -These are books I recommend as gifts for those engaged in health reform. I have written some of them. I know the authors of most of them. I have read all of them.

1. Obama, Doctors, and Health Reform. Richard Reece, 290 pages, IUniverse, 2009, paperbck. $17.12, Ebook $9.99,1-800-228-4467, or amazon. A doctor’s prediction on odds for success of health reform.

2. In Their Own Words: 12,000 Physicians Reveal Their Thoughts on Medical Practice, Philip Miller, Louis Goodman, Tim Norbeck, soft cover, 2010, $11.66. What doctors really think about health reform.

3. Doctor in the House: A Physician Turned Congressman, Michael Burgess, hardcover,2010, $16.43. A view from top-down from someone who has practiced from bottom-up.

4. Sailing Seven “Cs” of Hospital Physician Relationships, James Hawkins and Richard Reece, paperback, 68 pages, $17.95. What practice and hospital-doctor relationships looked like before we had Accountable Care Organizations.

5. The Health Reform Maze: A Blueprint for Physician Practices, Richard L. Reece, 290 pages. Greenbranch Publishing , 800-933-3711, $48.50. Describes the way it is, fiendishly complicated, not the way it ought to be, understandable for ordinary mortals.

6. Innovation-Driven Health Care: 34 Concepts for Transformation, Richard L. Reece, 375 pages, hardcover, Jones and Bartlett, $101.95. It’s never too late to innovate.

7. The Heart of Power; Health and Politics in the Oval Office, David Blumenthal and James Morone, 2009, hardcover, $35.17. The view from Massachusetts General and Harvard Medical School.

8. Remedy and Reaction: The Peculiar American Struggle for Health Reform, Yale U. Press, 324 pages, 2011,hardvoer, $17.49. A balanced book by long-time advocate for reform.

9. Inside National Health Reform, John McDonough,California Milbank books, 2011, hardcover, 339 pages, $22.60. By a Democratic insider.

10. Why Obamacare is Wrong for America, Grace-Marie Turner et al, Broadside-Harper Collins, 259 pages, 2011, paperback, $10.94. How health care law drives up costs, puts government in charge, and threatens constitutional rights.

11. The Truth about Obamacare, Sally Pipes, Regnery Publishing, 2011, paperback, 274 pages, $6.28 paperback, $8.23 Kindle, By a passionate Canadian expatriate who is president and CEO of Pacific Research Institute.

12. Health Care Reform Now! A Prescription for Change, George C, Halvorson, John Wiley & Sons, 2007, 361 pages, hardcover, $16.28. By CEO of Kaiser, a systems thinker and supporter of structural change.

13. Time to Sell? Guide to Selling a Physician Practice: Value, Options, Alternatives, Randy Bauman. 2011, 124 pages, $86.50, Greenbranch Publishing, 800-933-3711. Important because reform pressures are driving physicians out of practice into the arms of hospitals.

14. Road to Reform; The Future of Health Care in America. Eli Ginzberg, The Free Press, 216 pages, 1994, $4. A reminder that more things change the more they remain the same by a veteran of failed Clinton reform.

15. And Who Shall Care for the Sick? The Corporate Transformation of Health Care in Minnesota, Richard L. Reece, 278 pages, 1988, $46.97. A blast from the past by one who was present at the birth of United Healthcare and who predicted doctor shortage.

16. Consumer-Driven Health Care: Implications for Providers, Payers, and Policymakers, Regina Herzlinger, 2004, 892 pages, 43.33, This is still the bible of those who espouse market-driven reform.

Tweet: Christmas is wonderful time to give thoughtful gifts, especially if those gifts require thought.

Book Review: Keys to EMR/EHR Success: Selecting and Implementing an Electronic Medical Record, second edition, by Ronald B. Sterling, CPA, MBA, Greenbranch Publishing, 2011,292 pages, $139,1- 800-033-3711

It ain’t over until the Fat Lady sings – until the EHR is installed, functioning, supported, useful, and showing positive results with patients and doctors.

Veteran Physician EHR User

December 7, 2011 - Among technology advances, none is more complicated or uncertain than selecting and implementing electronic medical records.

In 2004, President Bush committed the nation to universal EHRs. The aim, then, as now, was to develop electronic tools to pay physicians based on outcomes, quality, coordination of care, and wellness, rather than just on volume.

According to John Hamalka, MD, CIO at Harvard Medical School, EHRs are essential if the nation is to address “waste”- overtreatment, insufficient coordination of care, excessively complicated administration, overly burdensome rules, and fraud (“The Promise of Electronic Health Records,” Health Care Blog, December 6, 2011). One way to do this, asserts Hamalka, is to compare physician performance electronically.

Unfortunately, a 2011 CDC survey indicated that in 2010 only 10.1% of physicians had “fully functional EMRs/EHRs.” Margalit Gur-Arie, an HIT expert, speculates fully-functioning EMRs will double to 20% in 2012, but no one knows for sure.

One factor driving EHR adoption is the federal government’s “meaningful use” initiative. This initiative will pay physicians a 2% bonus for implementing EHRs and impose a 2% penalty for not adopting EHRs, if doctors comply with a series of complicated rules.

Whatever transpires, selecting an EHR, implementing, living with it, and maintaining it remains a complicated, prolonged, and expensive process.

Enter the book Keys to EMR/EHR Success,Selecting and Implementing an Electronic Medical Record, by Ronald Sterling President of Sterling Solutions, Ltd (www.sterling –solutionns.com). The author’s goal is to help physician practices capitalize on technology to improve patient service, clinical operations, and financial results.

The book’s thesis is that physicians underutilize computer systems. At the same time, Sterling recognizes that installing EHRs is a complicated process requiring checklists, understanding of what’s involved, meeting staff, physician, regulatory, and procedural requirements, and negotiating fine print issues.

His message is: nothing worth doing with EHRs is easy. It takes hard work and systematic analysis.

The complexity of the EHR task is reflected in the book’s 12 chapter headings.

1 – Should I Invest in an EHR?

2 – Evaluating an EHR Investment

3 – Your Practice Management System and an EHR

4 – Compiling a Practice Focused List

5 – EHR and Malpractice Risk

6 – Selecting Products to Review

7 – Reviewing Products for Your Practice

8 – Making a Final Decision

9 – Negotiating a Contract

10 – Implementing an EHR

11 – Activating an EHR

12 - Supporting an EHR

Appendix: List of EHR Vendors.

The list of 186 EHR vendors contains vendor phone numbers and websites. The list will be useful to physicians considering purchasing an EMR system.

Readers will find the chapter on “Negotiating a Contract” fundamental and essential, It addresses the nitty-gritty of what can go wrong in a practice of your size and characteristics. In a 17 page table, the author recommends what to ask for and to specify.

My suggestion for the next edition would be that it more fully discuss physician negative experiences with EHRs and obstacles to EHR use, and that it highlight recent advance and refinements – such as speech recognition entry into EHRs; new business models, such as EHRs made “free” through advertiser’s support, and EHR support for physicians facilitating meaningful use adoption.

Tweet: Keys to EMR/EHR Success is a useful book for physician considering installing EHRs in their practices.

Home Monitoring to Cut Hospital Readmission Rates

One’s home is the safest refuge.

Anonymous

December 7, 2011- I was speaking yesterday to a consultant for troubled hospitals. She told me community hospitals are in dire financial straits.

One reason, she explained, was financial penalties CMS being imposing on hospitals for readmissions taking place less than 30 days after discharge. Many of these readmissions occurred because of preventable complications occurring in homebound patients.

Hospital CEOs said they did not have human or technological resources to monitor these patients at home.

I pointed out that companies like American Telecare in Minneapolis had developed audiovisual devices transmitted over ordinary phone lines in which patients could monitor themselves. These devices had significantly sslashed readmissions. Yes, she said, that's true, but those devices had to have medically trained personnel on the other end responding to the patients, and that cost money hospital did not have.

So goes the debate over remote monitoring. On the other side of the hospital-home divide is the argument presented by the Home Care Technology Association of America, as reported by Jessica Marcy in in yesterday’s Kaiser Health News

“Home care technology can play a critical role in keeping patients out of hospitals and at home, but many providers believe new policies should be used to encourage its adoption.

Advocates for those changes were on Capitol Hill yesterday to push for legislation that would expand the use of such technology, which allows home health agencies and nurses to remotely monitor a patient’s vital signs, like heart activity and blood pressure, and be able to flag troubling symptoms before they become medical emergencies.

Such technology is important as people live longer with more chronic conditions and seek to stay in their homes, the advocates told congressional staff at a presentation sponsored by Philips Healthcare, the National Association for Home Care and Hospice and the Home Care Technology Association of America. It also could be critical as Medicare prepares to penalize hospitals next year for frequently readmitting patients within 30 days for heart failure, heart attacks and pneumonia.

'We have to come up with other solutions to manage these chronic conditions outside the expensive acute care setting,' said Mark Szewczyk, the general manager of remote patient monitoring at Philips Healthcare, a company that provides diagnostic, treatment and preventive care products including many for home health. 'Telehealth and remote monitoring are really going to be solutions in the future. The reimbursement and policy piece is what we’re waiting to catch up.'

Medicare and most private insurers do not reimburse for home health care technology despite its increasing use among providers. Legislation pending in Congress seeks to expand the use of telehealth under Medicare by providing incentives to home health agencies that use it in rural and underserved urban communities and can demonstrate savings. Sen. John Thune (R-S.D.) introduced the Fostering Independence Through Technology (FITT) Act last March with eight co-sponsors.

The bill creates pilot programs and other implementation procedures for efforts to demonstrate health savings and performance targets.

Participants at the event are pushing for its passage this year, believing it might be likely as more lawmakers seek bipartisan cost-saving solutions.

'You wouldn’t need a FITT Act if Medicare wasn’t out of sync with today’s medical needs,' said Suzanne Mintz, president and CEO of the National Family Caregivers Association. 'The fact that Medicare doesn’t cover it is a sign that Medicare was designed as an acute care program for people who didn’t have many years to live.'

About 90 percent of seniors have at least one chronic condition and about 77 percent have two or more, according to Szewczyk.

Home health agencies are increasingly investing in such technology despite limited resources and the lack of reimbursement because they believe it will provide future cost savings. Telehealth sales are growing at an average of about 35-40 percent a year, Szewczyk said.

Speakers at the Hill meeting also noted the support that such systems can provide to patients and their families. 'Family caregivers, despite their numbers, feel very isolated,' Mintz said. 'The idea of being connected to a nurse who can react on the spot … has a very powerful effect.' “

Tweet: Remote home health monitoring devices can help reduce hospital readmissions, thereby decreasing financial penalties on hospitals.

Book Review: Time to Sell? Guide To Selling A Physician Practice: Value, Options, Alternatives, 2nd edition by Randy Bauman, Greenbranch Publishing, 2011, 124 pages, $86.50

Trends, like horses, are easier to ride in the direction they are going.

John Naisbitt, author of Megatrends (1982) and Mindset! (2006)

December 6, 2011- Every once a while, a book on the nuts, bolts, and realities of current physician trends catches my eye and hits my gut.

A Time To Sell? is such a book. The author, Randy Bauman, is president of Delta Health Care. For 25 years, Bauman has advised physicians and hospitals on how to ride current trends.

What impresses me about the book is Bauman’s gift of getting to the meat of the matter – the Whys, Whats, and Whatnots in the headlong horse race of physicians to sell to hospitals. There is no horsing around here. He accurately describes the trends and mindsets of physicians and hospitals as they race to reach deals to survive pressures of health reform.

Here, for your consideration, are quotes from the book:

• ”The trend is unmistakable – physicians continue to sell their practices at a feverish pace. In my role as a practice consultant, I can tell you this trend is taking on tsunami proportions. “

• “I see more and more physicians disillusioned with private practice they are reconciled to selling or merging their practice, and making the best deal they can.”

• “One physician hit the nail on the head when he told me,’I always have to remind myself that’s it never as good as it seems on the best days and never as bad as it seems on the worse days. That’s how I keep my perspective.”

• “In many ways, what happens as physicians sell their practices to hospitals is analogous to a shotgun wedding in which both parties rush down the aisle without sufficient time to plan their life together. And that is where the trouble begins. The reality sets in soon afterward that what has been created is an unmanageable monster.”

The book is more than sound bites. It consists of 10 chapters on what to expect, what to do, what not to do, and what items to check off before you do a deal.

The 10 chapters, with takeaway points at the end of each chapter are:

1. Why Sell?

2. Preparing Your Chapter for Sale

3. Choosing the Right Hospital Partner

4. Valuation – What is Your Practice Worth?

5. Compensation

6. Deal Structure

7. Negotiations

8. Operational and Post-Sale Issues

9. Making It Work

10. Options Other Than Selling

Tweet: Before physicians sell their practices to hospitals, they should stop to consider: this may not be a deal made in heaven.

Practice Fusion Update: “Free” EHRs and “Cloud Computing” Are for Real

What is reasonable is real, that which is real is reasonable.

Georg Wilhelm Hegel (1770-1831), Philosophy of Right (1821)

December 5, 2011 - Twenty months ago, May 23, 2010 to be precise, I wrote a blog “Is Practice Fusion's ‘Free’ EHR for Real?” In the blog, I described the economic model of Practice Fusion, a San Francisco-based startup.

From the physician’s point of view, Practice Fusion’s model was reasonable, it had advertisers instead of physicians pay for the EHR, no installation of hardware was required at the practice site, physicians could use their own computers for data entry, physicians did not need to learn the ins and outs of software, and computing was conducted offsite in “the cloud,” i.e., offsite,by Internet browsers.

In the words of Practice Fusion’s CEO, Ryan Howard,

“The product is provided to physicians fully subsidized. It’s not a “take now, pay later” or get half of the product now and then pays for the rest of it. Every feature that’s included with the product in any capacity is offered at no cost, so it’s truly free. It’s offered with support, training, and hosting. It’s the only totally free model on the market.”

The beauty of it was that you could use your own computer and somebody else – people and businesses who wanted access to physicians to sell them products – paid the freight for the EHR. In other words, someone else, not physicians, was paying the bill, thus removing expense, one of the major obstacles to EHR adoption.

I was skeptical of Practice Fusion's approach, but open to persuasion. At the time, Practice Fusion was fairly far down the line of EHR vendors physicians used.

Vendor Physician Users Practices Used in 2010

Epic 45,000
AllScripts 40,000
eClinicalWorks 40,000
GE Centricity 35,000
NextGen 35,000
SOAPWare 30,000
Practice Fusion 18,500
Eclipsys 11,000
Sage Health 10,000 .
Greenway Medical 6,000

I do not know where Practice Fusion ranks now, but it has moved up. It now has 130,000 physician-users, serves 25 million patients, and has 130 employees. It has experienced a 7-fold increase in business.

Practice Fusion has venture capital money, which always helps with a rapidly growing company. Its venture capital investors - Felicis Ventures, Glynn Capital Management, Founders Funds, Western Technologies, Artis Capital Management, Morganthal Ventures, and angel investor, Scott Banister, have invested more than $36 million in Practice Fusion.

Why do these investors have such faith in Practice Fusion?

I suspect there are four main reasons.

• The future belongs to high-speed, wired Internet in physicians’ offices. You can no longer practice without the Internet. More than 90% of physician practice have high speed access, and they are adopting smart phone and other mobile apps at breakneck speeds. Moreover, young physicians come from a generation accustomed to video games and IT applications, and they are reluctant to join any practice that does not have an EHR.

• “Cloud computing,” defined as delivering computing as a service rather than a product ,whereby shared resources, software, and hardware are provided over a network (like the electricity grid), is catching on fast. Physicians are not necessarily interested in mastering nuances of software and hardware or in installing and being trained in their use. They just want to “plug in” into a system, get results, do business, grow, and prosper.

• The U.S. government is putting up $90 million, at $44,000 per physician, in the form of financial incentives if doctors use EHRs that met “meaningful use criteria.” Practice Fusion has developed a systematic approach, which consists of a lot of hand-holding and support, to help doctors qualify for meaningful use bonuses.

• EHRs, through a combination of vendor companies like Practice Fusion offering “free” or “low-cost” services and modifications of existing EHRs using more sophisticated voice recognition and patient entry software are making EHRs more user-friendly and useful to use. Furthermore, a whole new IT industry sub-sector has sprung up – companies training and introducing “scribes” into physician practices. These scribes, often aspiring young people interested in a medical career, enter the patient’s data and history and record the physicians findings, in the process humanizing EHRs and making them more practical to use.

Tweet: EHR vendors, like Practice Fusion, are growing fast by offering “free,” low-cost, government subsidized wireless Internet services.

Doctor Donald Berwick's Parting Shots

The mind travels faster than the pen; consequently writing becomes a question of learning to make occasional wing shots, bringing down the bird of thought as it flashes by.

E.B. White, The Elements of Style, Macmillan, 1992

December 4, 2011 - As I read the title of Robert Pear’s NYT’s piece, “Health Official Takes Parting Shot at ‘Waste”, I thought of E.B. White’s comment on style.

Like White, Donald Berwick, forced to resign this week by Republican opposition as administrator of CMS, is a notable and quotable stylist. He has written a number of memorable books and speeches filled with eloquent thoughts- pro-government, pro-patient, pro-hospital safety, and anti-market - which he says were wrongly used against him.

His admirers consider him the American health system’s potential savior; his critics as its potential destroyer, the apostle of “socialized medicine.”

Here are some of Doctor Berwick’s parting shots on the “extremely high level of waste,” as exemplified by overtreatment of patients, failure to coordinate care, administrative complexity, burdensome rules, and fraud.

• “Much is done that does not help patients at all,” Dr. Berwick said, “and many physicians know it.”

• “I came with an agenda, I wanted to try to change the agency to be a force for improvement, covering one out of three Americans.”

• It’s a complex, complicated law. To explain it takes a while. To understand it takes an investment that I’m not sure the man or woman in the street wants to make or ought to make.”

• “We are a nation headed for justice, for fairness and justice in access to care,”

• “We are a nation headed for much more healing and much safer care. There is a moon shot here. But somehow we have not put together that story in a way that’s compelling.”

• “Government is more complex than I had realized. Government decisions result from the interactions of many internal stakeholders — different agencies and parts of government that, in many cases, have their own world views.”

• “The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.”

• Berwick added, “Republicans have completely distorted my meaning. My point is that someone, like your health insurance company, is going to limit what you can get. That’s the way it’s set up. The government, unlike many private health insurance plans, is working in the daylight. That’s a strength.”

Tweet: Dr. Donald Berwick, resigning as administrator of CMS, takes parting shots at government complexities and distortions by Republicans.