Tuesday, December 22, 2009

Does Anyone Die of Old Age Any More?

The following should come as no surprise to most of us. If you ask wiki.answers.com for the most common cause of death in the US, it has a two word answer.

Heart Disease

The CDC’s FASTATS website confirms this information. The American Heart Association tells us that an estimated 5.7 million people are living with heart failure As little as most people know about health statistics, almost anyone you ask will tell you the same thing.

The CDC’s National Vitals Statistics Report Volume 57 Number 14 shows final death figures for 2006. Totals deaths are 2.426 million, roughly 0.8 of a percent of the population. More detailed figures, broken down by cause of death, for 2005 show 2.448 million.

Major cardiovascular diseases account for 824,000 of the 2006 figures and 856,000 of the rougher 2005 figures, so approximately the same percentage. So the figures are right, right?

Well let me ask a different question. Of the overall US population how many people who die are over the age of 70, or for that matter 80? Well for 2006 the figure for people over the age of 70 was 1.59 million, or about 65%. For people over the age of 80 the figure was 1.07 million or about 44%. That makes sense, most people who die are elderly, and the age that people live to has steadily increased over the last 40 years.

Of the 2.448 million in the 2005 data, 1.39 million of the people who died were over the age of 75, or 57%. But of the deaths due to cardiac disease, a whopping 68% of the deaths were in people over the age of 75.

Put another way, the 582,000 deaths due to cardiac disease in the over 75 population, accounted for a whooping 23.7% of all deaths in the US.

I realize I run the risk of sounding callous when I raise this topic (or ageist) but for me that paints a very different picture. We talk about preventable heart-disease, and within reason I fully support that, but to lengths do we go to prolong life when people go through the natural process of aging?

Does anyone in America die of old age any more? If you where to believe the CDC stats, no. The 105 year great-great-grandmother who has 46 great-great-grandchildren does not die of old age when her heart stops, she dies of heart failure, a disease of the heart.

At some point we, as a country, have to come to terms with our mortality. As much as the baby-boomers want to live forever, we won’t. And can’t. And shouldn’t.

Death is as natural as birth, and coming to terms with death, and learning to age gracefully and live our years with the best quality of life we can is clearly something to be desired. Listing heart disease as the number one killer with no discussion on the role age plays in that statistic does nothing to foster that goal.

I hope to live to be a hundred (God help my children), and when I die I hope to die of old age. Part of the process of reforming healthcare has to be understanding and accepting the process of aging. The debate makes us uncomfortable, and I have no doubt someone will accuse me of being a Nazi proposing death panels, and I am not.

I am simply asking that as we look at aging, and health, and healthcare, and healthcare costs, we re-evaluate how we view aging and quality of life, and if it is appropriate allow that to become part of the national debate in a loving and humane way.

Monday, December 21, 2009

The Role of the Independent Consultant in HIE and HIT

Increasingly I see organizations involved in delivering HIE making the mistake of confusing the roles of consulting and delivery. This has included the burgeoning not-for-profits set up by the state as SDEs, the state government entities set up to handle the ONC and CMS grants, and the regional HIOs themselves.

Whenever I talk about this I have people challenge me and ask me why I see it as an issue. After all, many of the companies who provide HIE and HIT consulting services are staffed by people who have themselves cut their teeth delivering technology solutions. Since they have the knowledge on how to do that, what is the danger on them also being the people who design systems, or set strategy, or help write grant proposals.

The example I give is that if you were looking to buy a vehicle you would probably do research on what you purchase. There are many resources for this – car magazines, web sites, friends, industry magazines etc. What you would probably not do is go to a car retail location affiliated with a manufacturer, or two or three brands, and ask them what you should buy.

The bottom line is if you go to a Mercedes car salesperson and ask them what make of vehicle you should buy, they will probably tell you to buy a Mercedes, unless what you want is so obviously out of their sweet spot they can’t pull it off. They have a financial interest in recommending something they are able to sell.

I’m not saying that in HIT or HIE it is always this clear cut. n some cases consultant will come in as a consultant, and ensure that the work they deliver ensures they remain on as a consultant, and that is just good business sense. In other cases they will recommend a strategy, and then make recommendations on products they may not directly own, but when they have strategic relationships with the companies who do.

In some cases the relationships are even more blurred. HIT and HIE are two areas in particular where people will take positions and make recommendations with almost religious fervor. “Experts” will routinely claim there is only one way to do something, or that something is a standard that is not, or that a framework they select is definitively the model that will become the national standard. This is not done with bad intentions; it is simply the nature of the business.

The reality is also, however, that there are many cases where people will make recommendations that directly benefit themselves while couching them as independent. More than in most industries, HIE and HIT are extremely incestuous. Boards tend to cross-pollinate, the number of national experts is limited and tend to appears at meetings together again and again, and people have either direct or indirect financial interests in products they recommend.

Independent consultant tender to be harder to find, and may well charge more as they don’t get any of the downstream benefits. What you get for that higher fee structure is the knowledge that what they recommend is done so without any expectation of doing the work they are recommending. You cannot realistically ask a Microsoft, or a Medicity, or a Dell (Perot) to write your strategy independently if they can in turn bid on the solution they recommend.

That does not mean that their recommendations are invalid, in fact the more of story a company has to tell of successful implementations, the more valid the solution they propose is likely to be. Nor does it mean that to get a company in to write a proposal and strategic design and then provide the solution is an invalid approach, it is a completely valid approach. What it is not, is independent.

Know what you are paying for, understand what you are getting. Don’t let someone tell you they are making an independent recommendation when they are not. Don’t be afraid to question, or ask about their relationships with vendors and solution providers. Then make a decision based on the realities of what they provide, how they generate their work, and how they make their make money.

Monday, December 7, 2009

Total Cost of Ownership

HIT Concept of the Day

Total Cost of Ownership (TCO) : a structured approach to calculating the costs associated with buying and using a product or service. Total cost of ownership takes the purchase cost of an item into account but also considers related costs such as ordering, delivery, subsequent usage and maintenance, supplier costs, and after-delivery costs. Originally designed as a process for measuring IT expense after implementation, total cost of ownership considers only financial expenses and excludes any cost-benefit analysis.

Thursday, December 3, 2009

Health Information Technology – Remembering the “Why” as we plan the “How”

We now have an army of people working on "Interoperable Health Records", but do we really know what we are hoping to achieve by making them interoperable? Put another way, what is this Health Information Technology buzz-phrase everyone seems to be throwing around?

Technology is everywhere, but technology does not always improve our lives nor make it simpler. Health Information Technology or HIT simply aims to use technology to improve our health. At every step of our lives, someone seems to want to collect data about aspects of our lives, and our health is no different. However, when some needs to make decisions about our health, whether that person be ourselves, a relative or a healthcare professional, that data can end up scattered over multiple locations in many different format. That can make it difficult to get a single, complete view of our health data that enables us to make the best informed decision.

Health Information Technology, when done correctly, helps us manage that data. It helps us take the web of scattered facts, and assemble them into a single structured picture that provides the information to allow us and our clinicians to make the best decisions about our health. It informs us rather then confusing us, and it streamlines our experience in the healthcare system rather than frustrating us.

All of should be done in a way that empowers each of to manage and understand our own health information. Correctly implemented, it ensures that we have control over how and by whom our information is viewed and used, and that our privacy and dignity is maintained at all times.

In doing all of this it is easy to lose focus, to allow our particular view of the world to become the center of what we do and how we do it. In order to guard against this very natural tendency it is worthwhile always remembering 10 core organizing principles:

Principle 1 - We aim to foster health, not health care
Health care is what we do when we treat patients. Health is a state of being. Merriam-Webster defines health care as “efforts made to maintain or restore health especially by trained and licensed professionals” and health as “the condition of being sound in body, mind and spirit”. Our aim is ultimately to promote health, not just to support health care.

Principle 2 – We deal with people, not patients
While for a health care professional their focus may at times be the treatment of their patients, the aim of health information technology overall should be to promote health. Most of us do not spend the majority of our time in the health care system. A healthy child on a school playground is not a patient, nor is the elderly parent having lunch in a restaurant with their son or daughter. Many would argue that neither is the healthy newborn baby in a hospital, nor the happy mother who just had a normal delivery. In the healthcare industry we tend to see all people as patients, yet our aim should always be, health not health care.

Principle 3 – Information informs, data may not
So often we hear discussions about data, but ultimately what we want to provide through HIT is information. To clarify what this means, most of us don’t want to tune to the weather forecast and see a screen of hundreds of barometer and temperature readings for the day. What we want is for that information to be compiled in a way that informs us about what the weather is doing, and allows us to make appropriate decisions we can act on – take an umbrella to work. Likewise the aim of HIT cannot be the aggregation of data; it has to be the presentation of information.

Principle 4 – Technology should enable, not hinder
Technology should never be an end unto itself in health care. All too often we expect people to change how they do things to enable technology to be implemented, even when those changes in process are not in the best interests people they are supposed to be serving.

As an example many clinicians experience, is the frustration of having to type their user names and passwords into multiple (and sometimes the same) computer systems repeatedly during the day while trying to treat their patients. While the security of patient data is critical, systems need to be implemented in a way that constantly innovates so that the technology enables better practices rather than hindering existing ones.

Principle 5 – Technology should lower costs in the long term, not increase them
Technology costs money, but technology should also save money if it used correctly. Often we only see the cost of technology, without appreciating the savings it can bring down the road, and push back on its use. Conversely, however, we need to be honest with ourselves about the total cost of owning technology.

Value is not always monetary and nor should it be, and that also needs to be a factor, but an often-quoted benefit of the value of HIT is reduction of spiraling health care costs. We need to avoid the risk of technology becoming just another input cost to the health care system without providing benefit.

Principle 6 – Technology should help inform us about our health
Much has been written in the press about Personal Health Records or PHRs. Large technology players such as Microsoft and Google are now vying for our records, while new guidelines are set to require that patients have access to their health information. Just as technology provides information to clinicians to better inform medical decisions about our health, that same information should be able to be made available to us as well, even when we are no longer a patient. By having the pertinent information not only about our health but about what decisions were made and why, we become better able to manage our health, and become more likely to take on that responsibility.

Principle 7 – Computers “think” faster than people do, not better
Many of us bristle at this contention, but it is simple truth. A computer can process data and information many times faster than the human brain can, and sift through millions of data points almost instantaneously given a structured set of rules. This does not mean a computer can replace a nurse or doctor; training, experience and critical thinking play central roles in medicine. On the other hand technology can free clinicians up to do what they do best, while using information about patients to look for those critical possible connections out of millions that a physician may miss that could save a persons life.

Principle 8 – Too much information can be as bad as too little
Not having all the information about a patient may not create an issue under most circumstances, but it may result in a clinician missing a diagnosis or even prescribing a drug that can harm a patient, particularly if they are taking other drugs the clinician doesn’t know about - that is after all a prime driver for adopting HIT. Having too much information, however, can create different issues that can be as problematic. Simply compiling data into one huge stack that has to be waded through may result in critical information being missed as easily as not having it available at all. Data compilation cannot be the end goal, the creation of relevant information is far more critical.

Principle 9 – Big data is not always “Big Brother”
Most of us get nervous at the thought that our data may be being compiled into a humungous database that might be used in ways that are not in our best interests. The reality is there are ways to collate data in ways that don’t identify individuals, which can provide information that can be extremely beneficial. Data that span geographies, providers, populations and time, can produce information that can drive improvements in health and costs savings that benefit everyone.

Outcomes can be as varied as being able to identify a higher prevalence of a type cancer in geography, to realizing that a very expensive treatment is actually less effective than a far cheaper one. These in turn could do anything from save you money on your insurance premium to saving your life. The key is always having the controls in place to prevent misuse or compromise of the data, rather than losing the benefits.

Principle 10 – Technology should improve the patient’s health care experience
HIT should not just make life easier for physicians, hospitals and insurance companies. As it is adopted and becomes truly integrated, it should improve the practical experience of the patient. Twenty-five years ago online banking was in its infancy, and was so unfriendly to use that only businesses had a real value from its use. Today it is so widespread that if a bank’s web-site goes down customers are practically inconvenienced in their everyday lives.

Every one of us has probably experienced the frustration of going from our doctors office to the imaging center down the hall and having to fill out the entire patient information form again (“Don’t their systems talk to each other!?”). Or have gone from one hospital to a specialist at another only to have the physical x-rays get lost in transit and have to either wait or have them redone. The flow of information has the potential to enhance and simplify not only the clinician’s work, but the patient’s experience. We should not only embrace those enhancements, but actively be looking for ways to achieve them.