Health for life

While the Disease Management Care Blog tries to be an equal opportunity cynic and generally sides with policy underdogs and lost causes, it supposes that its conservative leanings sometimes comes through in its writing. 

That was enough to prompt a series of well-written email exchanges with Greg Brown, a retired educator from the Kansas City area. He did a great job of compactly summarizing the views of supporters of the current version of health orm. 

It seems to boil down to five main arguments:

1. Medicare and Social Security: While passage of these landmark safety net programs was likewise met with deep concerns about the erosion of liberty, their ultimate success cannot be denied.  Most of the persons who are against the Affordable Care Act are ironically happy to have the feds appropriate a portion of their income in exchange for economic security in their old age. They cant have it both ways.

2. This is not buying shoes:  One role of the federal government is to step in when markets fail, and that has been amply demonstrated when it comes to health insurance. While its difficult enough to remember to even buy a product that you may not need, shopping for the best value in commercial insurance is practically impossible.  Proposals to expand this unworkable solution are a pipedream.

3. The public good: Keeping people from going bankrupt in the course of an unexpected illness is everyones interest.  Its ultimately a better bargain for society to proactively manage this with near-universal insurance than to deal with poverty after the fact.

4. Purchasing power: To date, Washington DC has chosen to not flex its purchasing power with providers.  Think of how much cheaper drugs would be if Medicare leveraged this for Part D.  Just wait until the happens in the rest of health care system and how much all of us will all benefit. 

4. Status quo: Even if you dont accept the track record of Medicare, the realities of buying insurance, the merits of a public good and the advantages of purchasing power, the status quo has led the U.S., compared to the rest of the developed world, to be a unsustainable per-capita cost outlier.  Something has to change. and theACA is doing just that.

I am not an expert by any stretch. I am just an interested layman. I really wish Obama had pushed for a single payer or at least a strong government alternative delivery system. But here we are and as imperfect as it is, it is the best thing I see on the horizon right now. It does at least attempt some cost controls, it broadens access, and it may lead to better quality with a focus on health outcomes rather than billable procedures. At least it attempts to address all three.

Image from Wikipedia

(From time to time, the Disease Management Care Blog welcomes commentary from its readers.  Heres an interesting thought.....)

As a long-term reader, I thought the erudite but contrarian and sometimes snarky DMCB might be the best venue to ask others of my ilk to comment on an observation of mine.

I am a primary care provider working at the quantum level of patient care.  I am in my second year of full fledged EHR use.  It is obvious to me from the consultation notes that I receive on an hourly basis that most of my colleagues are also on board.  Journal articles as well as my first-hand experience have convinced me that we have indeed reached the tipping point of electronic record use. 

Since this milestone passed, I have noticed a change in the focus of office notes and consults.  I am seeing neurosurgeons document conversations regarding the safety of patients relationships and whether or not they feel threatened.  Podiatrists routinely document the existence of living wills.  Dermatologists are now savvy about the sexual activity of octogenarians with actinic keratosis. Despite my consultants thoroughness in their care (and conversations with health care students who have rotated through these specialties make me believe that some specialists are using telepathy to document things), I am not seeing traditional assessment and plans at the end of the encounter. 

What I usually see is the same generalized diagnosis code that I sent them with followed by a list of tests cluttered with a erences to various quality metrics that are inspired by systems such as HEDIS®.  The old fashioned differential diagnoses or thoughtful prose concerning the evaluation is conspicuously absent. 

I call this my hypoplastic hypothesis.

As a primary care physician, when I consult a colleague, I am really asking the specialist “Hey, what do you think?” Prior to the advent of the EHR, much of my continuing medical education has come from the insights that I use to get from these consults. Now Im reading about feeling threatened, living wills and sexual activity.
 
How did we get here?

When I was an undergrad in Biochemistry, during the dreaded Physical Chemistry course, we learned about the observer effect and the Heisenberg uncertainty principle. Wikipedia defines both as:

"In science, the term observer effect ers to changes that the act of observation will make on a phenomenon being observed. This is often the result of instruments that, by necessity, alter the state of what they measure in some manner. A commonplace example is checking the pressure in an automobile tire; this is difficult to do without letting out some of the air, thus changing the pressure. This effect can be observed in many domains of physics.....However in quantum mechanics, which deals with very small objects, it is not possible to observe a system without changing the system, so the observer must be considered part of the system being observed.

In quantum mechanics, the uncertainty principle is any of a variety of mathematical inequalities asserting a fundamental limit to the precision with which certain pairs of physical properties of a particle known as complementary variables, such as position and momentum, can be known simultaneously. For instance, the more precisely the position of some particle is determined, the less precisely its momentum can be known, and vice versa."

In my opinion we now have a new phenomena that parallel the laws of physical chemistry:  I call it the HEDIS uncertainty principle. 

The actual act of measuring HEDIS® scores and other similarly contrived quality metrics has fundamentally intruded into the quantum level of physician care.  Does this measurement change the behavior of the particles of the system and alter the ultimate structure of the encounter?  Are the data still reliable and the measurements still accurate?  Have the impressions and treatment recommendations indeed become hypoplastic, or has the encounter remained unchanged but the documentation is skewed to HEDIS®? Is the question asked of the consultant answered but not documented?  If not, what does this portend for disease management and health care quality?

I have my suspicions, but I would like to tap the wisdom of the DMCB readers for theirs.

Image from Wikipedia

Germ theory in 1860. The Flexner Report of 1910.  Zombie immortality in 2012  There are only a few watershed moments like these in the history of U.S. health care and, after hearing the other speakers at the recent Star Ratings Congress in Las Vegas, the Disease Management Care Blog thinks its found another one.

 It calls it "desktop analytics."

In its early health services research career, the DMCBs studies consisted of creating study protocols that included data collection and storage, very high end computing, statistical planning and a caully contrived reporting format. The timeline typically spanned over several months, required high end computing, involved fussy Ph.D. level statisticians unaccustomed to exceeding customer expectations and ultimately having to convince a narrow, highly educated, and skeptical audience of the veracity of the DMCBs conclusions at a scientific meeting.

While that is still necessary in traditionally funded research studies, the story is now far different in mainstream health care and insurance settings.  Tapping electronic record or insurance claims data bases are now far easier. Statistical software packages are do-it-yourself and walk users through the basics. Ph.D-level statisticians are unnecessary. Mainstream health workers have a working appreciation of measurement as well as trending and the folks inhabiting the C-suites use their in-house research conclusions in core business planning.  And it can all be done using desktops that cost a few hundred bucks.

At the Star Ratings Congress, the DMCB listened to speaker after speaker who presented highly polished insights about quality and cost that were developed thanks to in-house information systems and analytics resources that would have been unthinkable a decade ago. This advance in data management has enabled providers and payers to spot trends on a month-to-month basis, compare local performance to historical as well as national benchmarks and report outcomes to external agencies on a regular basis.  The research efficiency was astonishing.

It was also so taken for granted. It shouldnt be.  Compared to 10 years ago, the industry has gone from the wheel and fire to the internal combustion engine and automatic transmission.

The DMCB thinks its going to get better too.  While the electronic health record vendors have been notoriously inept at supporting data analytics, its going to just be a matter of time until community-based providers can hit a function key on their keyboards and scan (for example) mammography rates by age, race, zip code and months since last visit.  Insurers will be able to project which enrollees with diabetes on three or more prescription drugs are least likely to take their medicines after controlling for co-pay and weather.

When we finally do figure out how to increase quality and reduce costs, itll be because desktop analytics had finally reached the tipping point.

Coda: This has important implications for the Affordable Care Acts Coordinating Council for Comparative Effectiveness Research.  The Council may find that by the time a prospective CER study is complete that desktop analytics had already found the answer and the much of the industry had moved on.  Stay tuned.