Healthcare Data-Sharing: 3½ Views
View #1. The worldwide picture...Working under the grandiose name of The Interoperable Health Information Infrastructure Test Project, IBM reports that it is developing new electronic systems that will enable the sharing of medical data among hospitals, agencies and patients. The first stage is projected to be in use by year’s end, when it will connect IBM test sites in San Jose, California…Rochester, Minnesota… and Haifa, Israel.
If all goes as planned, this test system will then form the basis of a planned global network. According to IBM, improving healthcare “from the inside out” through the flow of electronic medical information providing patients, caregivers, insurers and various technology suppliers with instant access of fully-protected information and medical records anywhere in the world.
View #2. The more-localized picture...Last month, Massachu-setts initiated two- to three-year regional health IT pilot programs in three medium-sized communities. Involved are physician practices, nursing homes and several other medical care-related facilities.
Objective is to field-test the medical- and cost-effectiveness of using a wide-ranging EMR system within communities, with the eventual hope of taking the system statewide…even national. The communities are Brockton, Newburyport and northern Berkshire. The three will individually deploy the systems, so they will not be wired together during the pilot; that remains as a second-stage project at this point.
View #3. The individual-initiative picture...Several large multispecialty groups of physicians that have developed a state-of-the-art level of EMR software used in specific application service are offering to license their expertise and system knowledge to similar practice groups. Surprise is that they generally are not the “big city” kind of practitioners you might expect to be on the leading edge. A group in Paducah, Kentucky is offering its expertise, setup and training around the state and into Illinois, Tennessee and Missouri. A large Rome, Georgia group is offering similar services around its state. On the other hand, a Robbinsville, Minnesota hospital that owns a major physician practice is promoting its system to several independent-practice groups in neighboring states. In each case interest reportedly is high.
View 3½. The Congressional “turnabout”...A bi-partisan bill was recently introduced in Congress to provide grants and loans to help create regional health information networks. This, the bill-writers claim, will enable at least partial elimination of several broad-based current “restraint of trade laws” that prevent providers from exchanging technology and standards. (IBM and Massachusetts obviously don’t think so!)
Many of the same legislators who once helped install layers of anti-information-sharing bureaucracy in the healthcare field are now loudly proclaiming that a good portion of it must be cast aside and as quickly as possible if we are going to bring healthcare administration into the 21st century.
The bill specifically calls for the Department of Health and Human Services to make 20 three-year grants -- up to ten years in some cases -- to regional health information organizations (RHIOs in government-speak). As an extra incentive, Medicare payments would be increased for providers that adopted IT and would also grant increased Medicaid funds to states that promoted the use of IT systems.
Several forms of supporting legislation are also currently slated to be introduced in Congress. Bad news is that a number of quite-similar healthcare IT bills were brought before Congress in its last session; none passed. Good news is that Dr. David Brailer, the government’s healthcare IT head, seems to be a get-it-done type …and he is prodding them.
New Letters to Learn: PHR
Well-known fact…The federal government wants an Electronic Medical Records system up and running within ten years. Little-known fact…The feds also want a Personal Health Records system in operation within the same time frame. Most everyone understands the meaning of and the goals of EMR. Few people understand much about PHR and how to make it work; except that it will enable patients to learn and carry with them -- in some electronic form -- their own total personal medical histories, effectively right through life.
Your personal PHR should contain every diagnosis of meaning: immunizations…a list of medications…allergies and complaints… lab reports…and more.
A huge undertaking and we haven’t even come to a conclusion about how this information should be gathered, where it should rest and how to both limit and open access to it.
One series of tentative first steps sees each PHR built around hospitals offering patients their own personal secure internet portal which can also be accessed by physicians, with the patient’s permission. Others call this inadequate and incomplete …and insist that patients must type in their own PHR information on their own secure website which also may be accessed by physicians if needed. This last means constant record-gathering, constant updates and the sure knowledge that it is just too complicated and demanding for individuals to keep it complete and current.
Closest system that just might work is being offered as “PassportMD” by a physician-affiliated group in Florida; cost to patient: $65 a year. The service reportedly will collect the patients’ records from any number of physicians, which will then be stored on a CD-ROM that can be updated twice a year. The system is in its infancy and still unproven.
Yet the government demands are there and a large percentage of patients would like to see it happen. A national telephone survey
funded in part by the Robert Wood Johnson Foundation found that 61% of respondents would like constant access to their
health information…54% say they would like to regularly review their own medical records…51% want to have a “hard copy” of what
their doctor tells them to do at each visit…49% want to play some part in their own medical decisions.
Another excellent idea and gigantic task targeted to be completed along with EMR by 2015; but this one is starting even farther back.
Then There is RFID
The previous PHR story is broad in range, designed to eventually create a patient’s carry-through-life electronic medical record. One relatively-small -- but important -- first step along the way is being experimented with right now and reports are that it is working just fine.
Siemens and Intel have launched a pilot electronic patient-identification program at a major German hospital. Its purpose is two-fold: to assure that, if needed, each patient’s health information is quickly available…and that the patient gets the proper meds in the correct dosages, from admittance to discharge. Tool being used to accomplish all this is an RFID (radio frequency identification) wristband-tag that is issued to each patient on admittance.
All the usual basic patient ID and information is included in the ubiquitous wristband that has always been a part of the admitting process. But that RFID tag add-on, when electronically accessed, permits doctors and nurses to “read” and track the individual’s past and current general health history, right down to drugs administered. Allergies, if any, will also be included.
All this, of course, will act as an immediate, easily-accessible, safe-and-secure guideline for both patients and caregivers. Unauthorized access to this information is reportedly protected by several “firewalls”.
Segments of these firewalls will be open to patients curious to access parts of their own medical information…and they can even track their record of treatment if they wish.
The Price of "Dropping Out"
An increasing number of doctors who dream of dropping out of the tight payments and restrictive policies of most managed care plans are coming in for that fabled “rude awakening”, as the plans increasingly implement what can only be called “payback”. Led by giants such as UnitedHealthcare and a number of the Blues, increasingly the rule for drop-outs now is that the insurer’s portion of the payment will be forwarded to the patient rather than to the doctor.
Which means slower cash flow, even more paperwork, and a lot of phone calls to patients requesting money that normally went directly to the practice. The doctors are fighting back in an increasing number of state legislatures, asking for the passage of bills which would mandate that the doctors receive direct payment from the insurer for their portion of the fee for service. The insurers recently proved their power in at least one state -- Virginia -- by reportedly applying massive pressure to defeat an assignment-of-benefits bill, merely permitting instead the name and address of the providing physician to be listed on the statement.
Then there is the continuing problem of rates. A Wayne, NJ ambulatory surgicenter is suing Horizon BC/BS over their reimbursement rates for non-network doctors, saying that they are completely out of line with established costs. Horizon admitted that the rate schedule was supplied by a division of UnitedHealthcare. Coast-to-coast, out-of-plan doctors claim they are being driven to sue insurers for increase of their unfair rate structure; in most cases they have faced strong and determined opposition…and little success.
Multi-Dimensional Cancer Drugs
There are several. They are experimental. They are apparently amazing in their ability to strike the tumors from all sides. Until now the best of the newest generation of anti-cancer drugs -- Avastin, Iressa, Hercepitin -- precisely targeted malignant cells and completely “ignored” healthy cells. Which was a giant step forward in the battle.
The even newer generation of drugs -- most in various stages of clinical trials -- appear to be even more deadly against advanced cases of cancer. Because they attack the tumor from a variety of directions…from totally cutting off the blood supply to the recently-infected cell to confusing the “messages” the malignant cells use to grow and spread. In the best of cases, the cancers literally shrink from giant to minute size, allowing patients to resume normal lifestyles. The “best of cases” is running as much as 40% for some of these drugs, which is excellent.
Ahead of the pack is Bayer and Onyx Pharmaceuticals’ Sorafenib which the FDA has approved for limited use in certain types of kidney cancers. Currently Pfizer, AstraZeneca, Amegen and Eli Lilly have similar-acting “multi-dimensional” cancer drugs in clinical trials. There is a potential problem, though, and it is a huge one. The per-patient cost of these various regimens could easily run into the tens of thousands of dollars. Monthly.
Color-Coded Prescriptions
This spring Target Stores’ pharmacies began to offer their new tablet and pill prescription bottles that feature a color-ring label that immediately identifies it with the patient. They are apparently now in phase two…heavily promoting an innovative approach that has been overlooked for years.
Jim’s prescriptions will always be fringed in blue or green or anything “masculine”. Jane’s will be fringed in red or pink or whatever...so there is no longer the chance of any person in a household taking the wrong pills. Patients get to choose the color of their choice among a wide selection and that color becomes theirs for every prescription after that.
In addition, Target has designed distinctive “flattened” bottles for these pills and literally stood them on their head. All this makes the label easier to read without twisting your neck and also permits the bottle to carry a larger label which, in turn, provides more room for easier-to-read type or more patient information right on the bottle.
This is reportedly the first prescription bottle redesign since the introduction of safety caps in the 1970s. And it is all the brainchild of a young visual arts student who offered it first to Target and apparently made the sale on sight.
Outsourcing Drug Trials
It’s now generally accepted that the number of drug trials in the United States leveled off, then dropped since the year 2000. Logically enough, during that same period, the number of FDA-approved investigators -- usually board-certified physicians -- working on these clinical trials was reduced by 11% in the United States. According to a Tufts University study, most of this overall drop-off simply went overseas; they concluded that the number of investigators working abroad on FDA-approved trials has now increased by 8%. In addition, an unexpectedly large proportion of this drop-off was experienced in the northern sections of the country.
GlaxoSmithKline, for example, recently reported that 29% of clinical trials are now carried out abroad and forecast that the figure will rise to 50% in the near future. And admitted it was all done in the name of cost reduction.
Apparently a larger portion of the remaining clinical trials are now being driven to our southern states also for cost-controls. Between 1994 and 2004, the proportion of principal FDA-investigators working in the south grew rapidly to more than 40% of the total force.
More Employees Have to Pay Up
At the turn of the century, 29% of large and medium-sized companies still fully-paid each of their employee’s healthcare premiums…usually after the first 60 or 90 days at the new job. Today that number is down to 17% and dropping rapidly, as employers say they struggle to compete in a global economy.
And in most cases that coverage only includes the person on-the-job. In 2000 just 11% fully-paid the premiums of family members, too. Four years later, that number was down to 6%. These high-benefit companies are mostly scattered in a few industries that have strong labor unions...such as auto, steel, telecommunications, plus federal government agencies. Relatively good coverage is available to most government workers at the state and local levels, but almost always with co-pays. And co-pays themselves are rising rapidly, along with a choice of physicians and other services.
The PPOs that are so popular because they give so much broader choice are costing more, too. Reportedly the average deductible on these plans rose 40% between 2001 and 2004.
So in addition to as many as the 45 million currently uninsured, the United States seems to have grown a whole generation of under-insured, as even HMOs have begun to initiate higher deductibles as well as copays that apply to hospital care. In addition, medical benefit packages are getting more and more complicated and therefore read by fewer employees. Until the time comes when there is a personal need and the employee discovers the plan will pay, but only after passing a high deductible.
"Thumbel" Control
A new and restrictive form of Carpel Tunnel Syndrome -- commonly referred to as BlackBerry Thumb -- has surged to the surface of medicine and is running rampant among users of hand-helds, especially the BlackBerry e-mail wireless devices that have become a common tool of hard-working business people and closely-connected younger folks. Two major problems are involved; first is that the BlackBerry causes double trouble because it requires both fast-moving thumbs to operate it. And the illness seems to be spreading quickly because the increasingly-popular BlackBerry unit itself continues to get smaller, requiring ever-more-facile movements.
Dr. Stuart Hirsch, an orthopedist at St. Joseph’s Hospital in Paterson, was quick to report the possible extreme danger of overuse…simply because it is a never-meant-to-be-applied use of our “opposing digit”.
Things are getting so bad that, earlier in the year, the American Society of Hand Therapists issued a “consumer alert” warning that the heavy use of any handheld electronic devices can lead to a form of carpel tunnel syndrome and similar conditions. The recommend-ed treatment is not fun…starting with anti-inflammatories and a BlackBerry-defeating thumb splint.
Introducing the "Dynamic Duo"
A pair of experimental next-generation medical robots are visiting patients and presenting treatments in St. Mary’s hospital in London. Well sort of anyway.
Both “Dr. Robbie” and “Sister Mary”, act as the eyes and ears of doctors who have to visually examine patients from as close as another wing in the hospital or 100 miles away.
The five-foot high robots -- controlled by the physicians through the use of a joystick -- enable physicians to communicate with and “see” patients. A camera mounted on top of each robot also enables the doctor to visually scan the patient and evaluate his or her reactions; a camera mounted in the facial area of each robot permits patients to feel “connected” by seeing their examining physicians. Medical records can be reviewed and the results of x-rays and test results can also be discussed.
The verbal interaction -- doctors to robot to patient and patient to robot to doctor -- reportedly works quite well except for the somewhat-annoying metallic “voice” of each robot. The inventors apparently are working to soften that.
Coding Tips
CPT Coding for Treatment of Lateral and Medial Epicondylitis.
Lateral epicondylitis, also known as “tennis elbow,” may be caused by repetitive rotation or supination of the forearm in such a way that the palm of the hand faces forward when the arm is in the anatomic position or upward when the arm is extended at a right angle to the body. It may be caused by playing tennis, or by other recurring motions, such as using hand tools frequently.
Medical epicondylitis, or “golfer’s elbow,” is comparable to tennis elbow, and triggered by frequent pronation of the forearm, and the palm of the hand facing backward when the arm is in the anatomic position or downward when the arm is extended at a right angle to the body.
Symptoms may be temporarily relieved by injection of Lidocaine and/ or corticosteroids in the tendon sheath, CPT code 20550, or the tendon at its origin/insertion, code 20551.
Surgery includes releasing the part of the origin of the extensor muscle from the lateral or medial epicondyle by performing a medial or lateral fasciotomy, CPT code 24350. If an extensor origin is detached in addition to the fasciotomy, CPT code 24351 is assigned. Other codes include fasciotomy with annular ligament resection, code 24352, stripping, code 24354, and partial ostectomy, code 24356, in which a small portion of the lateral epicondyle is removed to increase blood vascular supply and enhance healing.
Transcription Tips
Individual letters are used as descriptive symbols as well as part of a proper noun. Use a hyphen to join some compound nouns with a single letter as a prefix and in other cases, separate them with a space. Check appropriate references for specific terms. Always use a hyphen when this acts as an adjective preceding a noun.
Examples: x-ray, R wave, U splint, C-loop, S-shaped, T cell (T-cell count), u-score method.
Medical Minutia
In all the world, only New Zealand and the United States permit direct-to- consumer advertising of prescription drugs. Most of this effort, of course, is currently on TV, which has been carrying these ads since 1997.
Originally these ads were restricted to print media and had to be accompanied by page-long–lists of risks and precautions, usually in small print. Many of these warnings withered away due to both TV’s time constraints and the fact that consumers simply could not quickly absorb so much detailed information. These were therefore replaced by the a few quick-and-generalized warnings of possible side-effects and the ubiquitous “Ask your doctor”.
The FDA does not screen or pre-approve commercials for prescription drugs; however, it does monitor them.
Auditing the News
Deciding it was time to “get organized” in 21st century style, the University of Pittsburgh Medical Center recently announced that it is consolidating and standardizing its IT infrastructure in a $400-plus million eight-year plan with IBM, further increasing “Big Blue’s” apparent technology leadership in the healthcare field. (See “Healthcare Data…”, on cover page). Announced purpose is to “stay ahead of the curve” by reducing operating costs and supporting new applications. Till now Pitt has been mixing the technology of many companies…including Hewlett-Packard, Sun Microsystems and Hitachi.
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The FDA has approved the first of a new class of drugs -- called incretin mimetics -- to combat Type 2 (adult onset) diabetes. It will sell under the name of Bysetta,
Bysetta is a synthetic version of a peptide found in the venom of the “Gila monster” a poisonous lizard found in the southwest U. S. and in Mexico. Reportedly it reduces the risk of the patient’s blood sugar levels dropping dangerously low as it can with insulin injections. Initially it will require twice-a-day injections, but trials are now underway of a version that would require just one injection a week.
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Add the state of Washington to the increasing number of states fighting the federal government for the right to reimport prescription drugs. A bill has been passed and signed by the governor to permit Washington pharmacies to purchase prescription drugs from Canada, the U.K. and Ireland…thereby stretching the dollars available to supply drugs for state workers and low-income residents.
Problem is that governing bodies such as the states are currently restricted from reimporting due to the fed’s blanket ban, which individuals of course have been skirting for years.
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After long and bitter arguments, psychologists in Louisiana and New Mexico who complete specialized training and pass exhaustive exams are permitted to write prescriptions after consultations with MDs. Psychologists in 32 other states are seeking similar legislative approval.
Backers of such legislation claim it would reduce patient costs and offer greater access to mental health care in the face of long waits to schedule appointments with psychiatrists, who of course now have exclusive Rx rights in this overall field.
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Traumatic brain injuries -- on average, 80,000 a year -- are an affliction of young adults and frequently caused by auto and motorcycle accidents. The CDC calls it a “silent epidemic” simply because medical research has usually skirted the problem, convinced that little or nothing could be done to repair the damage.
Now several groups of “neuroscientists” who have refused to accept this “why try” attitude are slowly-and-painfully working on ways to encourage the brain to seek out its own alternate pathways …making all-new connections between delicate areas that skirt the once-normal paths that have been destroyed by such accidents. Their small but increasing number of success stories seem to prove that the impossible just may be possible!
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National prescription drugs sales have increased an average 11% a year for the past five years. Last year sales by the pharmaceutical industry totaled an amazing $250 billion; the vast majority were by prescription, but some over-the-counter formerly-prescription drugs were included in the final figures. It all totaled up to about $850 for every American man, woman and child.
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Trouble in paradise. Hawaii is facing major physician shortages in two fields -- obstetrics and orthopedics -- because of fear of lawsuits and rapidly rising malpractice insurance.
OB-GYN insurance has risen on the islands by 53% in the past five years because insurers say they are financially responsible for birth-related injuries for the life of the child. Orthopedists say they are at particularly high risk when they care for trauma patients simply because the required emergency treatment leaves little time to check a patient’s medical history.
There are now only 48 orthopedics in the Islands; over 40% of Hawaii’s obstetricians say they plan to retire or leave the specialty in the next five years.
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A tiny newborn-size cap filled with cold water put in place immediately after birth, is the latest device -- still in trials -- being used to combat possible brain damage during a difficult delivery that might have caused the child some loss of oxygen during the procedure.
Purpose of the “Cool-Cap” is to lower brain temperature, thereby slowing down metabolism and temporarily decrease the brain’s energy needs until the child can again breathe normally.
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