Some people may tell you that health care IT will solve many of the quality and cost problems in health care.

I don’t believe them.

I know a 70-year old man named Carlos (not his real name) who was hospitalized following a bout of hydrocephalus.  Hydrocephalus is a build-up of fluid in the skull, which affects the brain.  Among other things, people with hydrocephalus can be confused, irritable, and nauseous.  Carlos had all of these symptoms.

Carlos’ problem was fixable by inserting a special kind of drain in his head called a “shunt.”  This kind of shunt is, essentially, a series of catheters that runs from the brain into the abdomen, and which drain the excess fluid.  You can’t see it from the outside, so it’s meant to stay inside of you for a very long time.

For a week after Carlos’ shunt was installed, his symptoms completely disappeared.  But they soon started to re-emerge.  Worried, his family took him to the hospital.  Doctors found that his hydrocephalus was back – the shunt wasn’t draining properly.  They admitted him to the hospital, and the next day they put in a new shunt.  The surgery went well.

But again, about a day later, he started to have the same kinds of symptoms.  The doctors sent him for a CT scan, which showed, to their surprise, no problems with the shunt.  Unsure of what to do, they decided to wait and see if the symptoms resolved.  It was possible, they thought, that the symptoms were from the quick drainage of fluid through the shunt.

A doctor friend (call him Lou, although that’s not his name) happened to be visiting while this was going on.  Lou knew that Carlos had been on certain medications for a number of years.

“Has he been getting those medications in the days he’s been in the hospital?”  he asked the attending physician.

“I don’t know,” said the doctor, who went to check the hospital’s electronic medical record system.  “The meds are listed here, but it doesn’t look like he has been getting them.”

It wasn’t entirely shocking, since Carlos had been in and out of surgery.  Still, it was curious.  “What are you getting at?” asked the doctor.

Lou pulled out his iPhone, and looked up the symptoms of withdrawal from the medications Carlos was taking.  He showed them to the attending doctor:  confusion, irritability, nausea.  Very much what they were seeing and trying to explain as having to do with the shunt.

The attending spoke with the other physicians treating Carlos, and decided to put Carlos back on the medications.  His symptoms went away a short time after that.

One doctor I talked to about this story told me the doctors did the right thing.  Carlos had a history of hydrocephalus and problems with his shunt.  It made sense to rule out issues with the shunt before looking for other answers.

But another doctor I spoke with didn’t agree.  Given that the shunt had just been replaced, it seemed premature to try to explain everything by looking for another defective shunt.  Instead, this doctor told me, someone should have taken a look at his history before sending him for another CT scan.  As this doctor put it, “a patient is not a shunt.”

Carlos’ story tells us something about health care information technology that we may not want to hear.

The IT systems in the hospital were mainly used to order the CT scan, and to keep track of…medications that weren’t being given.  The single most important piece of equipment in Carlos’ case was the brain of the doctor treating him. .

Being a good doctor means asking good questions.  Until a computer can do more than come up with good Jeopardy questions, we must realize that we are still reliant on human judgment, and human fallibility.

And we will be for a very long time.

Dr. Wes connects the news of the Wikileaks document dump to the privacy of health care data:

While a single individual’s private health care information may not carry the gravitas of wartime communiqués, each of us deals with famous patients who might not want their diagnosis, HIV status, or drinking history spread far and wide. For them, this private information might be just as personally damaging as anything disclosed by WikiLeaks.

Wes raises a good point. To which I would add a bigger point.

All of the laws and security systems and everything else don’t mean your health information will remain private. No, the extent to which your health information stays private depends on the honor, reliability and trustworthiness of the people who have it.

Almost everyone who touches health information has those morals. But not everyone. And for them, there is no law, no security system that can stop dishonor. What we can do is call this kind of behavior what it is, and root it out. Leaking confidential health information is despicable.

Good on Wes for taking this opportunity to remind us of that.

David Williams, the Charlie Rose of the health care blogosphere, recently interviewed me.

You can listen to the audio of our wide-ranging talk on David’s always-interesting Health Business Blog.

We talked about health care reform, health IT, social media, health care quality, patient navigation, and the role of Best Doctors.

Give it a listen, and visit back to David’s blog regularly.

What’s your opinion on the subjects we talked about?

You have a right to your medical record.

It’s true – the record of every test and procedure you’ve had done, any films or studies, your doctors notes.  It’s all yours if you ask for it.

But it’s not that simple.

If you’re sick, your “record” is likely in pieces in lots of different places.  Some of it is in paper files and computers in the offices of each of your doctors, or in the clinics where you had a test or procedure.  It’s in multiple computer systems in a hospital, or in a folder in a radiology department, a container in a pathology department, or the computer system of a pharmacy.  Each of these places has their own policy or procedure if you want your record.  There are forms you have to fill out, fees you have to pay, time you have to wait.

So while you have a right to your record, for practical purposes, you’re going to have a very difficult time actually getting it (by the way, this is something our team at Best Doctors does very, very well).

But let’s say you actually get all of your medical records.  Now what?

A national study called OpenNotes, is trying to find out what happens when patients get easy, rapid access to their records – or at least their doctors’ notes.  The early results are mixed.  Some patients say it helps them understand what’s going on.  But some doctors say it leads to extra time with worried patients, adding to doctors’ already heavy case load.   The final results will yield better insight into both of these issues.

But it all reveals a larger issue:  There is a divide between you, your doctor and your medical information.

As your doctor opens up his paper file and logs into his local computer system to reacquaint himself with you, he is looking only at a fragmented piece of your medical history.  He is likely missing valuable pieces of context about you.  Those gaps may not matter very much.  But they might.

All of this is an argument for having electronic medical records, and of course billions of dollars are being spent on this.  But all you have to do is spend time in a hospital or a doctor’s office to know that we are a very, very long way away from making this a reality.  And so as a patient, one of the most important things you can do is exercise your right to get your records.  Make sure you understand what they say, and use every resource at your disposal to make sure you get the care you deserve.

Following my earlier webinar, I said I would be doing a series of Q&A’s with benefit executives from some of the country’s most innovative companies.  The first one features the insights of Delia Vetter, Senior Director of Benefits of EMC Corporation. She shared her views on employee benefits, health care IT, and how an important company like EMC thinks about the hottest topics of the day.

I think you’ll find her thoughts very interesting.

Delia Vetter, Sr. Director of Benefits, EMC

Evan:  What is EMC’s philosophy on healthcare for its employees?  Do you see it as a burden, just another part of the benefits package, or a competitive advantage in the marketplace?

Delia:  To be competitive in the marketplace, you have to offer a good benefits package. Our philosophy and strategy is to manage costs through better overall health management.  We look to create a culture of health—a healthy environment and behavior that’s beneficial to the employee’s health. Additionally, we make a concerted effort to re-educate employees across the healthcare spectrum through advanced technology and a multitude of programs that are employee/patient centric.

Evan: So when you talk about education, is employee health and wellness an issue?  What works and what doesn’t work to address that?

Delia: We don’t do arbitrary benefit programs. We use data on the aggregate, so we understand the health of our population and how much we spend for each disease and situation. We are data rich. So we understand to the nth degree the types of programs our employees need. We know the top 10 diseases, the top 10 medications, etc. so we can tailor our programs to the population that needs them the most.

We are constantly inquiring about our population’s needs. One example is an autism program where we brought in an expert to speak to employees. After the program was completed, employees gathered and formed a support group. This shows how benefit programs not only help build community within your company, but also build sub-sets of community. Over the past seven years we have made it a goal to create the right culture. Yes, we can offer health plans. Big deal. You negotiate, you roll out the health plans, and you’re done. However, the part that’s the most powerful is to develop the right programs and culture so you really create an environment of health management.

Evan:  How big of a problem are health care costs for EMC?  Given how data rich you are I bet you have some sense of what drives those costs.  Do you have programs that have worked to control costs?

Delia: Costs are an issue for everyone. Our goal is cost containment through managing the health of the workforce, not from shifting costs.  We are managing cost containment through good health management and the use of technology for education.  We also offer personal health records (PHRs) that stay with employees. With the help of programs like Best Doctors and others that create a healthy workforce, we can take a holistic view in managing the health of our workforce. As a result, we have contained costs and are way below the national average. We are able to contain costs through the use of technology and integrated, targeted programs that meet the needs of employees.

It is critical to educate your population, not just about benefits, but also about healthcare as a societal and corporate issue; as a personal issue.  You have to educate them on quality and better outcomes.  We’ve been on that path for seven years.  When you look at the plan President Obama has on the table, it’s very much in line with what we are already doing.  This big transformation that’s being discussed in the media and in blogs will happen when employers start looking at managing corporate assets and lives, not managing the structure of a plan.

Evan: Now, at the level of the individual employee, are there common concerns you hear about the health care system?  Is it cost?

Delia: The most common concern we hear is how to navigate through the healthcare system and how to understand it.  Employee issues are not about access. It’s more about “where do I turn if I have an issue or don’t understand what to do.” That’s the most common concern or complaint. As an employer, we are constantly thinking about and discussing what types of programs can we offer to help.

In addition, increases in prescriptions or other costs are of concern. However, we have not cost shifted, so our employees appreciate that.  We educate them about the true cost of healthcare. Our PHR helps us educate employees in order to get them past entitlement and help them understand the real cost.  So within the PHR, the employee inputs the healthcare services they received, or the prescriptions they filled. It calculates for them the real cost of care with full transparency.  Then we show how much the employee paid out of pocket.  When they see that, there is a whole new level of appreciation.  Once employees make that connection, they really appreciate the benefits they are provided.

Evan: What are the big trends in the next 2-3 years as it relates to employee benefits and health care?

Delia: We should look towards the Obama Administration as they start to push employers to become more focused on managing workforce from a lifestyle perspective. Additionally, employers absolutely need to invest in technology that drives consumer behavior like PHR.  So over the next six months, I think there will be a shift in thinking.

When it comes to employee health, employers typically don’t worry about it. Their mentality is, “this isn’t something I should worry about. Let the health plan worry about that.” Well, that’s antiquated thinking.  As benefits professionals, we impact the bottom line.  You can’t let someone else manage your dollars. You need to take matters into your own hands. It’s about you as a professional, managing your business and managing your funds. Your health plan is a good partner, but they should not be driving cost efficiency. Employers need to take that on. I think that’s the big shift we’ll see very soon.

Evan: With this and all the other things happening in health care are you planning any big changes?

Delia: What we’re focused on now and what we will be focused on in the future, is the next generation of personal health records.  In terms of plans and plan design, I don’t foresee any changes. We need to continue to illustrate to employees that health benefits are a shared accountability. As a reward for that, we’ll keep things static.

Our focus is on evolving the personal health record to help employees better manage their care and navigate through the system.  PHRs today gather a lot of information like lab tests and help us eliminate redundant tests. Imaging will also be big addition to the PHR. We’re looking to eliminate costs by eliminating waste in the system; creating a system that is patient friendly or patient centric.  It costs valuable time and money for an employee to participate in an inefficient health system. Why subject yourself to more blood work or another x-ray when it’s all there in your personal health records? In short, managing your personal health should be as easy and hassle-free as managing your online bank account. At EMC, we look at our employees as critical assets to our success and in order to be successful, we need to keep them happy and healthy.

New IT systems are impressive and give the appearance you are operating in a state-of-the-art environment.  But do they really do any good if all they are doing is “computerizing the current set-up”?  It’s pretty much what we’re doing in the government’s massive new health care IT program.

It’s the typical problem in failed IT implementations.  A business decides that some new IT system will fix its cost or quality problems, but once they’ve implemented it nothing is really changed.  Only then does it become clear that the real problem was a broken work-flow, or a staff problem, or something else.  Organizationally it can be hard to confront these problems, so it’s not surprising that many businesses choose to go the easy route of just trying a new IT system first.  It’s a sort of magical thinking — and there are thousands of IT consultants who are happy to help businesses spend their money in this way.

Is this happening in the push for health care IT?  It sure seems like it.  The latest proposals for Regional Extension Centers call for tens of millions of dollars to be spent on localized teams of implementation experts, tasked with helping physicians practices across the country spend billions of dollars to implement electronic health records.  And the government is serious about it: if doctors don’t get the new IT systems in place, they will suffer  financial penalties.

But is anyone asking about how the work flow of physician practices operate, and how they ought to operate?  Or how an EMR will affect doctor-patient relationships?  Or even exactly what we want these new systems to actually do, other than computerize what is currently not computerized?

The concern I often hear from doctors is that no one is listening to them in the headlong rush to implement new IT systems.  It’s an old story, and sounds a lot like the things you hear in the early stages of misdirected IT implementations.  But it doesn’t have to be this way.  Groups like the Massachusetts eHealth Collaborative have been busy for years doing the very hard work involved in figuring out the way care is delivered, and then helping to implement solutions to support better work flows.

Hopefully, these Regional Extension Centers can become something more like this – a quality improvement engine that helps physicians understand and improve their work flows, and then implement IT.  If not, we run the risk of living out the satire Monty Python foresaw decades ago.

Preventable disease is a terrible burden, made all the more tragic by the fact that it can be avoided.

Policymakers in Washington take this a step further, claiming that we can save huge amounts of money by systematic programs to prevent disease and encourage wellness.  The document explaining the Republicans’ new “Patient Choice Act” says that wellness and disease prevention can save trillions of dollars (.pdf).  President Obama seems to agree, saying these programs like these can create “serious savings” that represent “huge amounts of money in the long term.”

There’s one problem:  study after study says it’s not true.

Earlier this year, the prestigious journal Health Affairs published a study on this topic.  The author reviewed the results of nearly 600 studies (abstract at link, full article requires subscription) on the cost-effectiveness of various prevention programs.  The findings are overwhelming – less than 20% of these programs saved money, while more than 80% actually added more to medical costs than they saved.  How can this be?

It isn’t that complicated when you think about it.  Take high blood pressure.  If every American with high blood pressure took blood pressure medication, we would have lower rates of heart disease and stroke, and of course, eliminate the costs associated with those avoided conditions.  But as the study points out:

the accumulated costs of treating hypertension are nonetheless greater than the savings, because many people, not all of whom would ever suffer heart disease or stroke, must take medication for many years.

Studies have shown similar results for other chronic diseases, like diabetes and asthma. There is also important data showing that even screening programs for cervical, breast and colon cancer cost more than they save.

Does this mean we shouldn’t do these things?  Of course not. For each life that is touched by avoiding a chronic disease, finding a tumor early on, staying out of the hospital, there is enormous value.  But the value is not financial. It’s something we do because it’s right, and it’s inherently good.  There are no formulas to measure this.

Health care is very expensive, and the burden of that cost affects us all.  But to talk seriously about this problem we need to confront an inconvenient truth:  there is more to health care than just dollars and cents.

Doctors and patients complain all the time about how badly our health care system works.  It shouldn’t be a surprise — neither doctors or patients designed it.  But the internet, and especially blogs, have changed things.  Once the little guy couldn’t possibly have a meaningful seat at the table in making policy, today bloggers are among the most influential political forces in America.

Doctors are the emerging political force on the web.  Their blogs tell the stories of what it’s really like to practice medicine, and often give the most insightful prescriptions on how to make things better.

But the best doctor-bloggers aren’t political.  They simply describe the world as it really is, from inside their offices, to the hallways of their hospitals, to their real-life experiences with patients.  Like the best doctors, they aren’t afraid to just call it like it is, and do it with a sense of humor.

Doctors have a chance to transform health care in a way no other group can — and doctor-bloggers are in the vanguard.

Dr. Val blogs today about cash-only physician practices, as well as other concierge-style practices.

They’re both emerging models of primary care in which the doctor basically opts out of the traditional insurance system. By doing that, doctors typically see fewer patients, spend more time with each patient. They can even make more money per patient, by getting rid of the overhead otherwise tied up in doing medical billing. It sounds great, and it is, for patients fortunate enough to be in a practice like that. But it has its share of critics, who worry that these kinds of practices leave behind those who are less well-off.

But what if a doctor set up a low-cost concierge practice, catering to people without insurance? Wouldn’t that be a great idea?

One doctor tried it, and the state of New York tried to shut him down.

The doctor’s name is John Muney, and he created a program in his practice where patients pay $79 a month and get unlimited office visits, including certain tests and some in-office surgeries. It doesn’t cover treatment or other specialists, and is targeted at people who have no health insurance. The state of New York says that Dr. Muney’s patients actually bought insurance policies from him, and he needed a license for that. In the state’s view, every time he collected the $79 monthly fee — or even solicited people to join — he was breaking state insurance law.

New York is not the only state to look at this issue. Earlier this year, the Maryland Insurance Administration released a report (.pdf) in which it said programs like these might run afoul of state insurance law if fees charged in the program exceeded the “market value” of the services offered. The regulator recommended other restrictions on what services could be offered, and warned that programs that didn’t meet these criteria might be considered insurance. By contrast, in Washington State, there has been a law on the books since 2007 (.pdf) that expressly allows for concierge practices. Interestingly, in the run-up to the passage of that Washington law, it was the state’s largest health insurers who were most vocally opposed to retainer-based primary care practices.

At last report, Dr. Muney was trying to negotiate a deal with the state to let him continue. It will surely be interesting to see how the politics of his conflict plays out — he has called on Governor Patterson and President Obama to help him change the law in New York. While most other states haven’t taken up this issue, given the increasing popularity of this practice model, expect that they will.

I’ll be sure to post updates and share my key learnings.  Stay tuned.

LIVE UPDATE (12:27pm): First panel is about the Health Dividend, which seems to mean the savings available from healthier lifestyles and wellness. Hal Rosenbluth SVP Walgreens just presented and highlighted the very aggressive move they are making into clinics at their stores and related wellness services. He said that almost all Americans live within five miles of a Walgreens so this is a great platform for community wellness. He also talked about how proud he was of the very high rates of appropriate use of antibiotics, which he said was a major problem in the market.

Mark Bertolini, President of Aetna, says management engagement is key to getting results. He said he has a blog to communicate this with employees and added a colorful comment: “When you’ve talked about wellness so much and you think you might throw up, you’re halfway there.” He went on to report 92% customer satisfaction and said their cost trend last year was 3.3%, ascribing it to their wellness programs. As a result, there have been no premium increases for employees as a result, which is what is communicated to employees.

Redbrick Health’s CEO, Kyle Rolfing, said we should have a way of underwriting individuals on the basis of whether they are engaged in living a healthy lifestyle. Sounds like those incentive programs for participation in wellness.

LIVE UPDATE (1:18PM): Moderator says questions from the audience reflect “great cynicism” about the ability to actually change employee behavior.  He then asks if we should be thinking more in terms of penalties instead of encouragement?  Panelists think it’s not one size fits all but it’s not clear the audience is buying it.  Rolfing says we should be cynical and that traditional approaches won’t work.

LIVE UPDATE (1:28PM): New speaker, Scott Beeken, VP Benefits at American Financial Group (AFG) says they have a surcharge on smokers but their data shows that their smokers cost them less per person than non
smokers.

LIVE UPDATE (1:51PM): AFG went with a small number of big rewards to drive employee participation – said if there was 70% participation in a wellness program, an employee would win a brand new Saturn Sky.  Had a few other prizes of at least $5k value – they beat all expectations.  And giving away a few big items was actually cheaper per employee than small rewards typically seen in these programs.  Lots of enthusiasm with employees.  Describes the “gambling instinct.”  AFG has 2% trend.