Fryer's Blog in the Mountains

Patient Portals and the Identity Crisis

Meaningful use stage II is requiring a certain percentage of patients to be able to view their patient health information.  At HIMSS in New Orleans there was a lot of conversation about this.  And many vendors talking about their solutions.  InteliChart is a good example of these portals.  What happens if a patient goes to different doctors?  Different portals.  And most of the security is username + password.  Not much 2-factor authentication in place. 

Then layer in the requirements for the Health Information Exchanges.  Each patient needs to be perfectly matched to every EMR where their records reside.  Name + date of birth does not work so well if you are John Smith or Maria Garcia.  And who has access to these records?  And how does the patient know?  Again, many vendors have their unique solutions requiring everyone to sign up for their particular system.

These systems are being built bass-ackwards.  Here's a novel concept: Have the patients in control of their own identities and they decide when and where other people (or their surrogate like their primary care physician)  can access their information.  And the patient knows everytime who accessed what information and for what purpose. 

Universal identity cards will work as well as a social security number.  They won't.  Instead, patient supply their own credentials and each entity verifies if they indeed trust that that patient is who they say they are.  Can this be done programmaticly?  Yes and it's not that hard.

Look at project VRM:
http://blogs.law.harvard.edu/vrm/2013/03/09/the-vrm-perspective/
http://cyber.law.harvard.edu/research/projectvrm

Create a personal private cloud for each patient.  Then create an oAuth service that each provider entity and HIE can connect.  The trick here is that all authentication and access flows through the individual patient's personal cloud.  Use a certificate authority to create irrefutable credentials and use for 2 factor authentication (added bonus - public /private key encryption)

Time to build it.

Lower Back Injury: Physical Therapy not Surgery or X-Rays or MRI

Just before Thanksgiving I was floored by sciatica.  I started taking a lot of ibuprofen to reduce the inflammation.  By Friday I was able to get off the floor and go see the doctor who prescribed prednisone to further calm the inflammation.  No x-rays.

A lot of my friends suggested I get an x-ray and MRI study.   Very expensive and since there is only a low 30% success rate for surgery, that would be a waste of time and money.  The following week I got a script for physical therapy.  So I went to "Wasatch Physical Therapy at Kimball Junction" (what a name...) on my crutches.

One big advantage of living in Utah is we have the best orthopedic practices in the country.  With all the outdoor sports here, that is a focus.  It's not "let's relieve the pain" it's "Let's get you back on the mountain."  Which is why Tiger Woods came here for knee surgery.

Brandon immediately did an assessment and determined it was a bulging disk on the L4.  He put me on a treatment plan for 3 times a week.  Based on my condition he prescribed various exercises.  Dani took over after a couple of weeks.

The hour routine started off with heat and electrical stimulation while laying on a roller bed.  Then Lexi or Brittany would use localized ultrasound on my back.  Then a lower back massage. 

Early on Brittany was able to pinpoint the exact location of bulging disk through localized pressure.  After the massage Dani would work with me for the rest of the hour on spinal manipulation and stretching. 

After the session they would instruct me as to the different excercises I needed to do during the week based on my prognosis.  In 8 weeks I went from pain and crutches to powder skiing and no pain.

So dump the MRI and get yourself to Physical Therapy.  Only if you don't respond to their treatment will they send you back to the doctor for x-rays or an MRI.

Eight weeks of PT was far cheaper then 1 MRI.  And wouldn't you rather be better or just have some pictures?

Phreesia - Not patient friendly - Two thumbs down

I'm all for electronic checkin for patients at clinics, but I wonder sometimes if the vendors actually use their own products.  Take Phreesia for instance.  Hand the patient a tablet with a stylus and voila! all their information is electronically captured.

Except when a 4 minute paper process turns into a 15 minute ordeal for the patient.  Bad UX design, signatures that have to be entered 3-4 times to be accepted, sporadic issues with the stylus not registering and the unit is very heavy and awkward to hold.......

And before the patient logs out they have to watch a drug commercial.

It's embarassing.

Why pushing patient data is better than pulling

I've always been leery of building systems that hold all of the patient data and depending on access controls to allow external parties to pull them down.  Utah had a data breach impacting up to 780,000 people.  All because a systems administrator setup the password access system incorrectly.

And that is why people use fax machines.  Because I have to send something to you.  You cannot automatically get it.   I believe that our electronic systems should require a person to push the data out, rather than allowing "self-service".

HIMSS12 - Aventura - location based personas for hospitals

With over 1,000 vendors at the 37,000 attendee HIMSS12, I admit getting a wee bit glassy eyed.  Then a friend showed me Aventura.  It's a virtual desktop for use in hospitals.  Yet this is not just another EMR, it is a framework in which all your applications run.

What's cool about it, is that it is location aware (through a tap of a RFID card).  Not only does it hook you up to the nearest working printer, but it changes your applications.  For instance it might be great to IM and email in your office, but not in a patient's room.  There you want to see that patient record.  With an extensive rules based engine, it makes sure you have the tools you need, when you need it.

And for those who carry around an iPad, as soon as you swipe your card, your iPad displays just what you need.

But that's only half of the story.  The person who gave the demo was an actual living and breathing developer. 

Why is this important?  Because when your developers actually work with real customers, great things happen to your applications.

Unions should help Employers with Health Care

There is a lot of consolidation going on in health care.  The result is the rise of oligarchies in delivery of healthcare, devices and pharmaceuticals.  And they have pricing power. 

So where does that leave the worker and their employers?   While they would like to get the most bang for their buck (patient outcomes and quality of care), they have little negotiating power.   And labor unions have that skill.

Seems to me the unions and the employers are on the same side of the table on this one.  Perhaps it would be to their advantage and work together to try to get the highest value for their health care instead of the highest price. 

"Best Practices" is your starting point not your policy

Tom Peter's has a great video on best practices.  I know managers who find the best practice, make it a policy, done.  And they wonder why they are constantly behind.  The trick here is to take the best practice and improve upon it. Best practices are your baseline.

This is so true in health care.  Would you like a physician who uses 30 year old best practices?  Didn't think so.

Healthcare: Where Demand Rises to Meet Supply

This is interesting.  In hospitals in Wisconsin, prostate surgeries double in three months after buying a $2M robot.   While hospitals who didn't, had the same rate of surgeries.  And the rate of prostate cancer itself dropped. 

The outcomes for robotic surgery are no better than other options.  But cost a lot more.

Cardiologists Continue Unnecessary Surgeries

Surgically implanting stents to "unblock" arteries is a $12B business.   That's billion with a B.  Are they effective 24 hours after a heart attack?

No.  Drug therapy is better.

In 2006, Dr. Judith Hochman published a study known as the Occluded Artery Trial showing that stents did not prevent any deaths or new heart attacks compared with drugs alone when inserted more than 24 hours after a heart attack into a totally blocked artery.

So the American Heart Association published guidelines in 2007 recommending against the use of stents more than 24 hours after a heart attack.

So of course the use of stents by cardiologists decreased dramatically, right?

Wrong.

Turns out there was no difference in usage of stents according to a study in the Archives of Internal Medicine.

The procedure costs $20,000 and 50,000 people get it, who shouldn't.  That's $1B a year wasted.  And that doesn't include the cost of complications from surgery (like throwing a clot and causing a stroke, or hospital acquired infections). 

I'm not sure why this is.  Could it be that these cardiologists are:
a) too busy or lazy to keep up with best practices in their field?
b) are smarter than the American Heart Association?
c) need the extra money?
d) don't put the patient's needs first?

I don't know.  But remember we all pay for this through our taxes or our employers are paying for it. 

Put it a different way: If you have a clogged sink would you rather pay $10 for a bottle of Draino or $1,000 to a plumber to replace the pipes.  Both fix the problem.

That's not healthcare rationing, it's common sense.

Physicians and Realtors

Picking a realtor to sell your house is a big deal.  You want to get a fair price and sell quickly.  So you look for someone who knows the market, can examine your house, give you advice on how (and how much) to prep it to sell, and sell it quickly.  And you have lots of tools available to make your selection.  They will show you the market, days on the market, turnover rates and their track record.

Now isn't your health as important as your house?  But try to find out anything about your physician.   How successful are they in keeping their patients healthy?  And if they suggest a procedure at a hospital, how much does it costs and what is the success rate? 

Good luck with that.   At best the only tool you have is over patients commenting on the physician on a web site.  Yet many physicians are making patients sign documents that they won't evaluate the physician.  And try to get a cost estimate from a hospital and compare it to another hospital.  Do we believe that every physician and hospital provides the best care?

And we wonder why health care costs are climbing steeply.