The most important lesson in medical care comes from a bank robber who stole more than $2 million and spent more than half his life in jail.

The most important lesson in medical care comes from a bank robber who stole more than $2 million and spent more than half his life in jail. Named after Willie Sutton, the one of the most prolific bank robbers in history, Sutton's law states that when diagnosing, one must consider the obvious. Diagnosticians should first conduct those tests that will confirm the most likely diagnosis, and order them in a sequence that has the highest probability of delivering an accurate diagnosis. This approach also minimizes unnecessary tests and reduces costs.

Sutton's law grew out of a famous response to a reporter's question attributed (perhaps falsely) to Sutton. When asked by a reporter why he robbed banks, Sutton allegedly replied, "because that's where the money is." In reality, he probably said, "Go where the money is… and go there often."

More than 20 years ago, payors and providers experimented with capitated arrangements where IPAs—Independent Practice Associations often constructed from a broad swatch of primary care and/or specialty physicians—contracted with payors to provide services to a population of insured individuals. Although numerous variations of capitation were tried during that time, capitation arrangements did not succeed in reducing costs, increasing provider compensation, or improving quality of care. Many physicians continued to over-utilize services.

Like so many ideas in healthcare, the old, after a time of dormancy, becomes the new. The excitement around accountable care organizations (ACOs) and patient-centered medical home projects is based upon much of the same thinking that excited healthcare policy makers 20 years ago. With ACOs and patient-centered medical homes, primary care physicians would be responsible for both the care and cost of care for patients assigned to them. Those physicians able to keep their patient population healthy while reducing the cost burden associated with treating their population would share in the savings to the payor.

What our healthcare system will look like at the end of 2014, when the final provisions of the Affordable Care Act of 2010 become active, may be fuzzy today, but a rough picture of it can be drawn by following the flow of financial incentives. By 2014 the effects of removing lifetime caps on medical costs, eliminating the process of denying coverage due to pre-existing conditions, emphasizing the use of proven disease treatments, and reducing reimbursement for preventable medical errors and readmissions shifts the care incentive from providing more care to providing only care that is needed.

Healthcare information technology will play a critical role in delivering these new models of care delivery and financing. Only through robust information technology can we track and report on performance, offer clinical decision support to enhance safety and quality, and monitor the health of populations of patients. Healthcare information technology offers the critical tools to move clinicians from their focus on episodic care, where financial incentives were based upon piecework, to much broader population-based care, where financial incentives promote the delivery of favored clinical outcomes that efficiently utilize resources. Therefore, to understand the current and future changes to our healthcare system, you need only to know where the money is and where it is flowing.

Excerpts from: – Show Me the Money? PSQH, November/December, 2010

From the signing of healthcare reform legislation to the release of final rules for "meaningful use," events in 2010 are driving toward a true transformation in the delivery of healthcare in the United States.

From the signing of healthcare reform legislation to the release of final rules for "meaningful use," events in 2010 are driving toward a true transformation in the delivery of healthcare in the United States. Optimism is high that we will finally see tangible benefits from healthcare information technology as measured by enhanced quality, improved access, and lower costs. I recently reviewed some testimony given to a subcommittee of the U.S. Senate Finance Committee that highlighted the role of healthcare information technology in transforming healthcare delivery.

Here are excerpts from that testimony.

"It is with great anticipation I approach this committee today to give testimony on health care issues and the effect new information technologies will have on the delivery of care. Clearly the swirling debate on how to restructure our health care system has raised the awareness of all Americans to this important issue. It is through the management of information, in particular its dissemination, that we can address some of our health care challenges. We need to use new information technologies to provide physicians, patients, providers and payors with the appropriate, relevant information to produce good, acceptable outcomes from appropriate cost-effective care.

"The information technology revolution is changing the way medical care is delivered. These new tools provide physicians with the opportunity to access relevant clinical information on a real time basis to most likely impact on their patient care. Using standards, guidelines, protocols, and information available from profiling using normative data bases, physicians can obtain useful information on their patterns of care. Patients can obtain understandable information on their disease process, thereby becoming an informed consumer of health care. Organizations exist to educate physicians and other health care professionals in the use of these systems. For-profit firms are developing the tools and making the investment needed to convert data into information.

"My final advice to this committee is hold on tight, the medical information superhighway has no speed limit."

Excerpts from: – A True Tipping Point? PSQH, September/October, 2010.

Now that the "meaningful use" rule has been finalized by the Office of the National Coordinator (ONC), many organizations turn their focus to a rapid deployment of electronic medical record (EMR) systems in an effort to achieve transformation of the United States healthcare system. Unfortunately, EMR adoption is just one tool used to transform health care, and not the single transformative activity so many believe it to be. Transformation of healthcare encompasses enhancing quality of care, improving patient safety, expanding access to care, and reducing the cost of care. EMRs deployed to satisfy the criteria for "meaningful use" can impact these factors, but only within a comprehensive framework that recognizes the role of incentives, clinical decision support, and healthcare information technology (HIT) in facilitating transformation.

Introduction of new technology often distracts us from our primary task. Our fascination with the technology leads us to focus on what the technology can do, rather than what we need the technology to do. This misguided use of technology also occurs when it is used for healthcare delivery. Many EMR implementations focused on the impressive features of the EMR software rather than the workflow requirements of the clinician users.

Healthcare transformation requires a comprehensive vision of care delivery that recognizes the interrelationships of the many stakeholders. Technology by itself only helps improve those interrelationships, while the underlying structure that the interrelationships are built on remains.

Therefore, the "meaningful use" criteria are meaningful in that they help ensure the use of EMRs in ways that can enhance healthcare delivery, they do not transform healthcare. The recently passed Patient Protection and Healthcare Reform Act (2010) does much to move us toward a better healthcare system, but it too does not transform healthcare. Transformation requires many factors working together in an iterative process to deliver the expected results. Some of those factors are outlined below.

Until economic incentives of all the stakeholders align, care delivery will remain inefficient and suboptimal in quality and safety. Providers are incented to provide more care, payors are incented to withhold care, and patients, detached from the direct costs of care, have been molded to always expect care. The culture of healthcare in America is based on the false belief that more care is better care.

Transformation of healthcare requires a complete disruption of our current system of healthcare delivery. Clinical roles require redefining. Workflows will change to meet the needs of these new clinical roles, allowing the HIT tools, such as EMRs, to be leveraged to improve care. "Meaningful use" criteria is a nice first step to help ensure the effective deployment of HIT tools such as EMRs. Nevertheless, it is just a very small step towards truly transforming healthcare.

Excerpts from: – Is "Meaningful Use" Meaningful? PSQH, July/August, 2010

The Food and Drug Administration recently announced it is reconsidering its previous decision to exclude health information technology (HIT) tools from regulation as medical devices. When last evaluated in the late 1990s, this decision made common sense. At that time HIT consisted of rudimentary clinical documentation systems, electronic reference materials, and administrative applications. As even these tools were not well integrated with each other and into clinical workflow, they represented more of a digitization of paper-based activities rather than something truly transformational.

Today, HIT functionality far outstrips what was even dreamed about 10+ years ago. In addition, applications function in an integrated manner truly providing the clinician with a clinical experience much different than that offered using paper-based clinical documentation or simple clinical decision support tools.

The role of physicians, nurses, and other healthcare professionals is changing. These providers are becoming more dependent upon the clinical content within the HIT tools, often deferring to "decisions" made by these tools. Such examples include differential diagnosis, prescribed diagnostic and therapeutic treatments, choice of drug, and drug dose calculations. Although the previous rationale for not considering such HIT tools medical devices was based upon the intermediation of the provider between the recommended clinical activity and actual actions taken on behalf of the patient, the strong reliance on these very sophisticated HIT tools today puts this premise into question.

The FDA must study in detail the quality and safety issues inherent in integrated HIT applications before rushing to regulate HIT tools as medical devices. An uninformed effort to regulate HIT tools as medical devices may cause more harm than good. Applying the same standards used for medical devices to HIT tools makes little sense as HIT is neither a standalone application nor strictly a medical device. They are integrated applications that can impact quality and safety in ways far dissimilar to standard medical devices.

Regulation of HIT tools as medical devices is currently premature. Although HIT tools do directly impact patient care and therefore surely require some level of regulation, such regulation cannot be done without the requisite understanding of how HIT works within clinical workflow. The regulations must be constructed to advance HIT use while simultaneously protecting patients.

Excerpts from: – Regulate HIT Tools as Medical Devices? Yes and No. PSQH, May/June, 2010

In my last column "Raison d'Être" I wrote about the importance of staying focused on making healthcare IT work to achieve the four important goals noted above: patient safety, quality care, access to care, and cost savings. In March, I addressed the HIMSS membership with these words:

Healthcare information technology is the instrument that will transform healthcare, and it is we—the informaticists, clinicians, management engineers, senior IT executives, IT specialists, and the diverse talents of so many others—who will create the applications, processes and workflows that will improve quality, safety, access and cost-efficiency.

In addition to our effort to transform care delivery through deployment of innovative software, revised processes, and creative workflows, niche applications are becoming available that allow the varied health IT tools to be sewn together to allow us to effectively tap into their potential. Without these applications we could not achieve the necessary integration of systems that permits the construction of meaningful, efficient workflows. Such workflows allow clinicians to deliver quality care safely and efficiently while satisfying the work requirements of caregivers.

The future of health IT over the next five years is in the development of these "glue" applications that allow the seamless linking of large, robust system, such as EMRs or laboratory applications, so that end users can utilize these tools in a coherent, patient-centric manner.

Excerpts from: – Health IT's Glue. PSQH, March/April, 2010

While these healthcare challenges are daunting, I believe the solutions to them must and will come from the professionals sitting in this room and from our colleagues across the country and around the world. Healthcare information technology is the instrument that will transform healthcare and it is we – the informaticists, clinicians, management engineers, senior IT executives, IT specialists and the diverse talents of so many others – who will create the applications, processes and workflows that will improve quality, safety, access and cost-efficiency.

I am confident that we can make this transformation happen because similar revolutions relating to technology and the workplace have happened quite recently. For example, consider the huge changes in how we communicate with each other. Throughout this week, we all will be periodically checking our e-mail inboxes to stay in touch and communicate. According to Merriam-Webster, it was in 1969 that the term “inbox” first entered the American lexicon, to describe a physical tray holding incoming mail and work documents. Over the next 40-plus years, the inbox morphed into an electronic tray where important messages and information are stored. Today, the inbox pervades our working and personal lives, present on our personal computers and mobile smart phones.

In many respects, our health care system still operates like the typical business of 1969 – it is still largely paper-based, it ignores information tools that can facilitate evidence-based best practices, and it functions without analytics to qualify and quantify the care we provide. Medical decisions are made according to implicit criteria – hidden internal knowledge – rather than explicit criteria – external knowledge that can be checked, evaluated, and updated. The Dartmouth Atlas of Health Care provides documented proof of glaring, unacceptable variations in how health care is provided and sheds light on disparities existing across the country. Too many providers are not taking advantage of 21st-century technologies to access 21st century information, choosing instead to provide care the same way it was done 40 years ago.

How can we change this? While enacting healthcare reform legislation remains a critical need, any health care bill will primarily impact reimbursement policy, not the transformation of care delivery.  And, because the task of transforming our health care system to meet the challenges of the 21st century remains to those of us who work in the system, as the HIMSS board chair, I direct these three important messages to your inbox today:

One: HIMSS will play a leading role in the transformation of American health care by effecting positive change in four key areas: quality, safety, access to care and cost.

Two: HIMSS’s purpose – our reason for being – is this health care transformation.

Three: As members of HIMSS, you are the leaders who will create the solutions that will drive this transformation. Through the implementation of compelling healthcare IT solutions, you must transform the way health care is provided in this country. Not the president, not Congress, not clinicians – you. If you don’t do it, it will not happen. You must step forward and you must lead.

As I begin to make the case for why and how healthcare IT will transform health care, I’d like to take us all back to 1981, the year I graduated from medical school. Back then, people spent a good part of each workday managing paper. Upon returning from lunch, a busy executive was handed a pile of pink while you were out messages. She, or more likely he, would find a report draft on top of a bulging inbox. Attached to the report was a brand new, very popular, high-tech item of the day – a post-it note – where the boss scribbled a message to review and advise by writing comments in the margins. On his desk for his signature was a series of letters that his secretary had revised using another technological marvel – white-out. Reminded to call a key contact for advice on an important matter, the executive would quickly thumb through his rolodex to find the telephone number.

During my time as an Epidemic Intelligence Service officer with the Centers for Disease Control back in the 1980s, I do remember working this way. My first outbreak investigation was a foodborne illness on a cruise ship sailing out of Pittsburgh on the Ohio River. When investigating these type of outbreaks, my first task was to construct attack-rate tables that try to statistically identify the food that made people ill. I built these tables by doing all the calculations on a handheld calculator. No PCs were available to me at that time. Needless to say, it took me a few hours to complete the table and identify the cause of the outbreak.

Back then, we were very comfortable going about our business in this fashion and saw no need to change. Still, over the following several years and continuing into the 1990s, the workplace began to change immensely due to personal computers, e-mail and the Internet. Workers did not need to be encouraged to use this technology. They wanted to use it, even demanded to use it, because it made their jobs easier and made them more productive.

Today, in 2010, we must begin to change healthcare in the same fashion – by creating healthcare IT solutions that are so compelling, so irresistible, that people just want to use them. We cannot rely on incentive programs or executive orders.  We must create demand.

We must create electronic systems so appealing that they make physicians want to leave their paper medical records behind. We must create clinical decision support systems that make it routine for physicians to check their internal knowledge with data and evidence. We must offer workflow solutions that improve the efficiency of using health IT. We must make physicians want, yes, demand the enormous power that IT brings to the practice of medicine.

Creating this demand is important because it will improve quality, safety, access to care and cost-efficiency. Simply, we have to change a paper-based system in which most clinical decisions are made primarily by intuitive judgment – based on the ability to recall disparate facts – into an electronic system enabling decisions to be made according to data and evidence.

We must provide clinical decision support tools that reduce the burden of recalling facts and help to assess patients, form diagnoses, and choose therapeutic paths. Healthcare IT opens the door to this higher level of medical practice, one where both physicians and nurses can concentrate on examining, interacting, and motivating patients while technology handles the burdens of collecting, storing and accessing data. The knowledge of best practices and evidence-based care must be delivered to every single clinician at every point of care so that every patient everywhere receives care according this latest knowledge, rather than according to the habits of a clinician disconnected from this knowledge.

American medicine, right now, is relying too heavily on recalling facts. Perhaps the clearest example of this fact is the Pronovost checklist. Each year, about 28,000 Americans die due to I-V line infections. In response, Peter Pronovost, a Johns Hopkins physician, developed a list of five simple steps that intensive-care doctors should take to prevent the introduction of bacteria when inserting an I-V line. Physicians working at 108 hospitals in Michigan adopted the five steps and reduced the infection rate to essentially zero. A paper about their success was published in the New England Journal of Medicine in 2006. But, today, most American intensive-care doctors still don’t use the checklist. They continue to rely on their ability to remember what to do each time they insert an I-V line. Most times, they get it right. The few times they don’t, people die unnecessarily from infections. This is crazy. Every physician I know wants to help patients, not hurt them. Yet, we are hurting them.

It’s up to healthcare IT to make knowledge such as the Pronovost checklist more readily available and its discovery and use more intuitive. This work will require the design of clinical decision-support systems and other tools that merge seamlessly with patient care activities. This work will not just distribute best practices, but embed them into the workflow of medical practice. This work requires a unique multi-disciplinary effort involving not only workflow experts but also virtually any person connected with clinical care.

Bringing this level of sophistication and beyond to American health care will signify true transformation and will require all of the diverse talents represented within HIMSS. No matter who you are, whether you are a senior IT executive, a clinician or an engineer – whether you come from a hospital, a community or public health organization, a clinical practice, a payer or a pharmaceutical company – or whether your primary interest is patient safety, quality, research, privacy, or return on investment – we need you to contribute to the cause of transforming health care through IT.

HIMSS is reaching out to new groups and communities who must engage in the transformation. For example, our Life Sciences Community initiative actively engages pharmaceutical and life science companies, medical researchers, practicing clinicians, the academic community, and device manufacturers. This initiative concentrates on improving the quality, access and usefulness of data through interoperability and interconnectivity – data that can lead to new medical discoveries and treatments. With Board approval, I recently appointed Debra Bremer, Vice President at Pfizer, as an advisor to our Board to offer guidance in these efforts.

Our Payer Community initiative recognizes the shift from the payer playing the role of a transaction manager to one of a care delivery partner focused on improving chronic care management and overall patient outcomes. With Board approval, I also recently appointed Kevin Hayden, President at WellPoint, as an advisor to our Board to provide guidance in these efforts.

Both Debra and Kevin have been working hard with our staff to engage these two communities as we have engaged other industry specialty areas in our effort to transform healthcare through IT. To further involve and educate professionals we need to achieve our goal, HIMSS also has launched a Diversity Business Roundtable, created and delivered numerous distance learning opportunities, and reached out to several academic institutions.

Transforming healthcare requires the development of imaginative solutions. Cedars-Sinai Medical Center in Los Angeles did just that to improve hand-washing compliance, according to a story in the New York Times. Several research studies have reported that health care providers wash or disinfect their hands in less than half of situations where they should, with physicians being among the worst offenders. In an effort to achieve 90 percent or better hand-washing compliance in advance of a Joint Commission inspection, Cedars-Sinai first tried a campaign of e-mails, faxes and posters, but that didn’t work.  Then, a group of physicians and hospital administrators – who dubbed themselves the Hand Hygiene Safety Posse – started handing out bottles of Purell to physicians rounding on wards or as they stepped out of their cars in the parking lot. Also, the posse awarded a $10 Starbucks card as a reward to any physician “caught” washing his or her hands. This tactic improved compliance from 65 to 80 percent but still fell short of the 90 percent goal.

After delivering these discouraging results to the medical center’s chief of staff advisory group of roughly 20 doctors, the hospital’s epidemiologist handed each doctor a sterile petri dish loaded with a spongy layer of agar. “I would love to culture your hand,” she said.

The resulting cultures were photographed. The images were – in the exact words of the epidemiologist – “disgusting and striking, with gobs of colonies of bacteria.”

But here’s the best part – and where IT comes into play: the hospital harnessed the power of this disgusting image by making it into a screen saver that haunted every computer in Cedars-Sinai. Reluctance to hand washing vanished in the face of this filthy evidence and compliance shot up to nearly 100 percent, where it remains today. Cedars-Sinai urologist Dr. Leon Bender said in the Times article: “With people who have been in practice 25 or 30 or 40 years, it’s hard to change their behavior. But when you present them with good data, they change their behavior very rapidly.”

Now, Cedars-Sinai obviously did not employ leading-edge IT sophistication to solve its problem.  But I chose to share this story with you because it’s a wonderful example of fast and practical problem solving. It shows how you can solve an important safety problem, relatively quickly, through multidisciplinary teamwork, data gathering and a little bit of IT. Oh, and let’s not forget about some good marketing. I chose to tell this story because I want you to think of what problem of a similar nature you might solve. And how you can work to gather the team and fix it.

This week we will hear about many other examples of problem solving and achievement. This year’s Davies Award winners, for example, have impressively improved access to care, quality performance, cost-efficiency and safety. The 19 hospitals that have achieved the HIMSS Analytics Stage 7 recognition represent the first of the truly paperless hospitals and give all other hospitals something to emulate.

But I have purposely crafted my remarks today to emphasize that it’s no longer about what others have done or what others are doing.  It’s now about what you and your organization are doing to transform American health care. I suspect that some of you may see yourselves clearly within this context while others may not. Let me suggest to you today that no matter who you are and what your role is, you have an important if not critical role to play to achieve transformation. You can fulfill your role by building a multidisciplinary team with the expertise needed to solve a problem. You can fulfill your role by gathering and sharing data and evidence as you go along. And you can fulfill your role by having the courage to stay the course or to change your mind – whatever the situation calls for. Great science comes from flip-flopping – it’s O-K to change your point of view as you gain new knowledge.

The challenge before us now is to help all health care organizations to achieve the standards set by the leaders. Indeed, we are succeeding in changing the culture. We have reached the tipping point. Health IT isn’t just for early adopters anymore; it is expected of all.

I send this urgent message to your inbox today: the transformation of American health care by improving access, quality, safety and cost-efficiency is a cause to which we all must dedicate ourselves. Identify a project, engage experts different from you, embrace diversity, form a team, try something unique, make mistakes, redouble your efforts, celebrate your successes, and then start again with a new idea. It is you who will discover something new. It is you who will develop the needed solutions. It is you who will effectively implement change. It is you who will transform healthcare. It’s your job to act now upon the message in your inbox and to place your contribution to a transformed American health care system in your out-box in due time. Thank you.

Barry P. Chaiken, MD, FHIMSS
2009-10 Chair HIMSS
CMO, DocsNetwork, Ltd.

This evening, I visited with our French and Belgium HIMSS representatives at a reception at the W Hotel downtown. They traveled almost 24 hours from Paris to Newark to Atlanta. After stepping off their airport shuttle they headed directly into the welcome event. At this time of significant challenges facing healthcare in America, we can learn much from our European colleagues. In turn there is much we can teach them. The strength of  HIMSS is in its diversity. Its enthusiasm and power was felt throughout the room.

At an earlier reception hosted by Evolvent, Inc. I met several distinguished colleagues in the DOD, working hard to endure that our men and women in uniform recieve the best care we can provide. Several shared stories of innovative projects focused on improving care in the combat theater and facilities at home. Our military faces similar challenges to those in the civilian sector. Interest in HIMSS grows from the notion that there is more than enough to learn, requiring that everyone share as much knowledge as possible.

Barry P. Chaiken, MD, FHIMSS
HIMSS Chair, 2009-2010

To honor his contribution to healthcare information technology, the Healthcare Informatics Society of Ireland awarded the prestigious O Moore Medal to H. Stephen Lieber, CEO and President of HIMSS. As current chair of the board of directors of HIMSS it was a fine moment for me, and I am sure the entire HIMSS organization, to see Steve recognized for his decade-plus long effort to promote the use of HIT to improve the quality, safety and cost of healthcare delivery throughout the world. Under Steve’s leadership, HIMSS has grown to more than 20,000 members from all parts of the globe with conferences held in North America, Asia, and the Middle East. At this critical time, Steve provides exceptional leadership to the healthcare arena.

Please take a moment to watch the presentation of the medal to Steve and his acceptance remarks (Dublin, Ireland, November 19, 2009).

Barry P. Chaiken, MD, FHIM

What do you think is the greatest achievement in health IT in 2009?

Advances in technology just offer new tools, while advances in politics, represented by meaningful funding levels, provide momentum for real change. The billions of dollars provided to the Office of the National Coordinator for Health IT established the ONC as a true driver of advances in health IT use. The appointment of a healthcare policy expert David Blumenthal, MD, rather than an informaticist, signals that the Obama Administration is serious about promoting the use of health IT through policy changes that impact how healthcare is delivered in the United States. In addition, recruiting John Glaser, even on his current temporary basis, partners Dr. Blumenthal with one of the country’s leading health IT experts, Therefore, solidifying the funding of the ONC, and appointing Dr. Blumenthal and Mr. Glaser is 2009’s top health IT achievement that will positively impact the use of health IT to deliver safe, high quality and cost effective healthcare.

What would you like to see happen in 2010 to help move forward the adoption of electronic medical records?

When ATMs first appeared in the 1970s, interconnected financial networks did not exist. Customers of a bank could only use their ATM cards in machines provided by their bank. There was no ATM interoperability. The banks soon realized that providing ATM interoperability was considerably less expensive than installing proprietary ATM machines throughout the country. In addition, interoperability gave all banks a national, rather than regional, presence as customers could withdraw funds from any connected ATM. To advance the adoption of EMRs, information technology vendors must honestly embrace interoperability, building their systems to easily accept and exchange clinical data. True interoperability would provide clinicians with more complete patient records allowing for better quality care. Offering a more complete record that provides more value to the clinician strongly works to advance the adoption of health IT applications.

For both industry and government, budgets provide a more reliable picture of strategy than do policy statements. Therefore, there is little doubt that the current administration expects health information technology to play an important role in reducing healthcare costs while improving quality, safety, and access, a high priority of the president.

To accomplish this goal, adoption of technology is not enough. These new tools must be utilized effectively to achieve desirable and measureable results. Therefore, almost all of the incentive funding available to providers for the adoption of health information technology is tied to the “meaningful use” of that technology.

So what is “meaningful use?” Perhaps former Supreme Court Justice Potter Stewart provides some guidance. In a 1964 opinion on an obscenity case (Jacobellis v. Ohio) the late Justice Stewart described hard-core pornography as follows:

“It is hard to define, but I know it when I see it”

In spite of the work performed by many ONC committees to date, many working in healthcare believe the ONC is taking the same approach to defining “meaningful use.”

To its credit, the ONC is working to offer providers a hard and fast definition of meaningful use backed up by exactly defined, collectable measures. By statute, the secretary of health and human services has until December 31, 2009, to issue an interim rule on meaningful use. As the rule must go out for comment for a minimum period of time, a final rule is not expected until late Q1, 2010.

Source: Making Meaningful Use “Meaningful” – PSQH, November/December, 2009

As for our lessons learned, the individual mandate is necessary to achieve universal coverage and the employer mandate helps get you there.

Additionally, a competitor to the insurers must be established, whether a public option or a non-profit regional option, to incent the insurers to better manage costs.  Currently, these options do not exist in Massachusetts. The state now subsidizes healthcare insurance for those who cannot afford it by paying private insurers to cover these individuals.

Realistically, the Massachusetts reform plan is just a partial framework for what is needed nationally, not the entire plan. Any federal effort must be more broadly based and far reaching, something states, due to existing rules on trade, Medicare, and Medicaid, cannot achieve on their own.

Success requires all stakeholders to sacrifice a bit of their pie or fiefdom. Right now that is not happening fast enough or in significant areas to deliver meaningful reform. For example, there is a good argument presented by physicians for tort reform, but there is little talk about linked changes in licensing that can help identify and retrain poor physicians.

The goal needs to be universal coverage. Actually, we have that already. Unfortunately, it is very inefficient and possibly the dumbest deployment of universal coverage possible. (See – Marking 33 Years of Universal Health Coverage) Although the uninsured eventually get care now, it is the rest of us through our insurance and taxes who pay for it indirectly. And for those unfortunate enough to get seriously ill, they often lose their homes and life savings. About 50% of all bankruptcies in the U.S. are related to medical bills.

How we get to universal coverage is through a holistic approach that addresses access, quality, and cost. Considering the number of powerful stakeholders – physicians, insurance companies, pharmaceutical companies, hospitals, and consumer groups - passing any meaningful legislation would be an amazing accomplishment.

Paying $7,300 per capita per year for healthcare is way too much considering the poor outcomes we get from spending all that money. Other countries pay less and receive more value. And if you want to make the argument that the U.S. healthcare system is better at this procedure or that treatment, considering we are spending at least 40% more than the other countries, we should be trouncing those other countries on all measures of quality, safety, and clinical outcomes. Sadly, we are not.

If George Steinbrenner expects the Yankees to win the World Series every year considering he spends 40% more than any other team on payroll, is it wrong for us to expect the same from our spending on healthcare? Should we not receive the best care in the world?

Anyone who thinks healthcare is not broken is not paying attention to the facts. How it gets fixed, is debatable. Whether it is broken, is not.

According to a report by Milt Freudenheim in the New York Times (And you thought a Prescription Was Private, August 9, 2009), it sure doesn’t look like it.

More than two years ago (Patient Information: Who’s Your Daddy) I warned that for-profit entities might use private patient data to market products to consumers.

Patient data may be used to target relevant product ads to individuals based upon the data contained in the medical record.

Today, patient information is actively being used to target market products and services to patients. Large pharmacy chains such as CVS Caremark and Walgreens regularly utilize pharmacy information to identify patients to whom they send out email messages, coupons, and flyers. Although the data they utilize is de-identified, they employ reverse lookup utilities to reconstruct the information with patient identifiers.

At a meeting with several health information technology leaders at the HIMSS 2008 Annual Conference, Google’s CEO, Eric Schmidt, was cautioned about the use of patient data contained within Google Health. Although WebMD and Microsoft currently acknowledge the privacy rules outlined in ARRA apply to them, Google disagrees. Freudenheim quoted in his article a representative of Google who said:

Google is bound by the privacy policy that people agree to when they sign up.

WOW. To this day I still have not met anyone who reads those legal notices we all are asked to accept before using software or accessing certain websites. To rely on the acceptance of the privacy policy upon sign up as a defense for using patient information in any commercial way deemed appropriate seems weak and suggests exploitation.

Excerpts from: – We Need Privacy Now – PSQH, September/Ocotober, 2009