HEALTHY ONLINE

Two articles published in the latest NEJM issue are devoted to “our finite resources” and the inevitability of rationing care. First Dr. Howard Brody is attempting to rephrase the issue as one of “waste avoidance” and is delving into the ethics of practicing waste avoidance which is defined as withholding non-beneficial care. Of course non beneficial is not a cut and dry label, so Dr. Brody is envisioning that “[a]n ethical system for eliminating waste will include a robust appeals process”, where “[p]hysicians, as loyal patient advocates, must invoke the process when (according to their best clinical judgment) a particular patient would benefit from an intervention even if the average patient won't”. While the sentiment is commendable, I am not clear who exactly should physicians appeal to “according to their best clinical judgment” and I am not certain where the newly empowered and engaged patient go. Or is all this empowerment and engagement talk just a cruel joke? The second a...

The Patient Protection and Affordable Care Act (PPACA) of 2010 mandates that certain administrative simplifications should be made to reduce overhead costs of health care. Since administrative complexity obeys the conservation laws of physics, for every bit of complexity that is removed, a new chunk of bureaucratic complexity must be added to the system. With that in mind, CMS has created and is proposing to grow an array of financial incentives and penalties for health care providers. This collection of carrots and sticks is intended to be used as so many levers to control and fine tune the practice of medicine by encouraging adoption of health information technology, measuring processes and steering physicians to low cost treatment methods. Since confusion is abundant, and confusion leads to anger, fear and sometimes outright panic, which in turn causes folks to dump perfectly good private practices on the first hospital that knocks on their door, I thought it would be beneficial t...

Today, the Office of the National Coordinator for Health Information Technology (ONC) has released a Request for Information (RFI) regarding the governance of a Nationwide Health Information Network (NwHIN). The document outlines ONC’s current thinking on the subject and poses 66 questions to the public. The NwHIN is the proposed vehicle by which secure and presumably trusted health information exchange is facilitated and accelerated. The NwHIN consists, or is envisioned to eventually consist, of a set of standards and policies to govern health information exchange over the Internet. It does not include the actual infrastructure for such exchange. Below is a brief summary of the RFI highlights and the obligatory commentary on the proposed governance methodology. Highlights The 64 page document, as its title clearly states, is focused on creating trust in the exchange of health information at a National level. To that end, ONC is proposing to define a set of policies and regulations to...

Escher - Relativity, 1953 The public comments for the proposed rules for Meaningful Use Stage 2 are closing now. After reading the public submissions of several organizations, I decided not to comment, since what I wanted to say was covered by much better heeled organizations, and I am not convinced that individuals can influence government in any shape or form nowadays. Instead, I thought that this would be a good time to look back at Meaningful Use Stage 1 and see if there are any lessons to be learned, something that CMS did not deem necessary to do before moving up the escalator to Stage 2. This is a bit peculiar considering that only 5% of physicians were able to attain Meaningful Use so far, and according to a new study published in Health Affairs , less than 14% of physicians said that their EHR has all the bells and whistles necessary for Meaningful Use Stage 1. Since Meaningful Use Stage 2 is largely an amplified version of Stage 1, it may be useful to look back and identify ...

IBM "cloud" computing - circa 1975 There is no self-respecting innovator in Health Information Technology (HIT) who has not spoken or written about the horrific state of Legacy EHR products, which are slowly but surely being deployed in more and more health care facilities as a result of Meaningful Use incentives and changing reimbursement models. A couple of months ago I saw an EMR in a small practice. They’ve been using it for 15 years and it was a DOS based system with the ubiquitous neon green text glaring on a black and sometimes blue background. Aha! That must be a Legacy EMR, and sure enough the doctor was looking to replace it with a more modern product, but which one should he get now? After all, the last thing you’d want is to have him buy yet another Legacy EMR. According to dictionary.com , a Legacy system is a “computer system or application program which continues to be used because of the cost of replacing or redesigning it and often despite its poor competitiv...

The year is 2018 and President Tofu is fortunate to have a majority in both houses of Congress. America elected President Tofu when it became weary of partisan politics and developed a taste for a President with no preconceived notions and fully capable of absorbing the flavors of whatever surrounds him at the moment; a pragmatic, businesslike President for tough and fast-changing times. American small businesses are still hurting from the lingering effects of the Great Recession, but its larger bastions of business savvy are thriving in a booming global economy bringing cheap products to the impoverished masses armed with $5 cell phones, $10 netbooks and empowered by a Khan universal education system (the other Khan, not Genghis). Many Americans are also benefiting from this expansion in some ways. For example, after the 2016 passage of the historical and liberating Student Protection and Affordable Education Act (SPAEA), many parents decided to take advantage of the Khan system, now ...

H. Bartow Farr, III, Esq. The Patient Protection and Affordable Care Act (PPACA) has finally met its challengers in the highest Court in the land and following the three days showdown, there’s nothing left but watchful waiting for the Supreme Court to hand down its final decision. All media outlets from left, right and supposedly middle are covering the events and hundreds of experts are ready to make predictions based on the inflections in one Justice’s voice. I made a point to not read any of that, and if you are an informed citizen who still insists on making his/her own mind, the very impartial SCOTUS blog is the place to go for links to the audio and transcripts of all oral arguments and all briefs submitted to the Court. By this logic you should probably not read what follows below either, but if you do, this is an unorthodox (neither left nor right) look at the proceedings from a citizen's point of view, a perspective that struck me as lacking in the proceedings themselves....