Seeds of Health Improvement Fail on Barren US Soil- V1

From the 1960s to the 1970s, many efforts to improve health, education, and community efforts were successful. Since 1980 the successes have been limited. The US soil appears to be unable to sustain the necessary growth and development to help make interventions in health, education, nutrition, and other areas more effective.

In many ways the progress of recent decades has been about lasting impact from the previous decades. A generation with greater investment will benefit and will also benefit the next generation. The past investments have run their course.

War on poverty, the creation and increased funding of Medicaid and Medicare, support for the National Health Service Corps, Community Health Centers, and other investments have been followed by decades of cost cutting and austerity focus. Funding for humans has been diverted to other areas and the moonshot focus continues. Once it appeared that numerous interventions worked. Even the medical education efforts seemed to work for primary care and rural practice. But national changes in investment have resulted in changes in outcomes.

It is really difficult to see how health policy designers think that primary care can be made better when the dollars are too few to support the teams to deliver the care and the new designs make teams less productive, more distracted, fewer, and more burned out. Technology fixes all clearly has limitations, especially in basic child development, basic education, and basic health care where progress remains about people investing in people.

Governments, foundations, and communities are always hoping to facilitate more efficient and effective services. The Robert Wood Johnson Foundation has asked again and again - How do we give kids the building blocks for physical, cognitive, social, and emotional health? Other foundations measure progress and the results do not look good.

It has taken far too long to understand that it takes more than prenatal care and clinical interventions to address infant mortality and maternal mortality. Many "experts" have had a field day blaming religious leaders, women's health terminations, or states such as Texas for infant, maternal, Medicaid, or other outcomes. The factors that influence these outcomes are more about social fabric than other areas and the United States overall has allowed the social fabric soil to deteriorate. 

This makes it difficult for any number of investments to work as well - until the soil is improved. The likely area most closely related to soil improvements is child well being. By any number of measures we are not doing well.

Health outcomes are shaped by behaviors, environments, situations, and social determinants. 

Quality is in the matrix of relationships (Deming) 

Outcomes orientation should teach the value of these relationships. Instead we have quality efforts that focus on measures, technologies, and other areas that actually compromise the ability of education and health care teams to address their important societal tasks. Measures and technologies and their advocates take on a life of their own while infrastructures fall further behind.

The Status of Physical, Spiritual, and Human Infrastructure

Physical Infrastructure in the United States is also not doing well. For decades the United States worked at all levels to help make transportation, utilities, and other areas more efficient and effective. Now such investments are avoided as are the maintenance costs. Paying more later because of tragic neglect is far too common and should continue for some time.

The Spiritual Infrastructure in the United States seems to be at an all time low. It its difficult to get the American people regarding what the nation should do in many important areas. Congress is a reflection of this impasse. Spiritual infrastructure can have impact far beyond religion but also can be far less. Nationalism can also be a double-edged sword to unify or to divide US.

The Human Infrastructure in the United States most impacts education and health care. Nurses, teachers, public servants, public health, and other humans serve people directly in important health, education, public security, and other areas.

Few would argue that these representatives of human infrastructure are facing greater challenges from more directions, more regulations and standards, increasingly complex interactions, greater scrutiny, and increased burnout as more is required with same or less support.

With decent Spiritual Infrastructure, Physical Infrastructure, and investments in improving the social fabric/soil of living, the human infrastructure tasks are more reasonable, more efficient, and more effective. For example some states can invest far less in education for same or better outcomes. Some places can spend multiple times as much for worse outcomes.

Exceptional Circumstances and Exceptional Challenges

When a nurse, police officer, or teacher is working with a person who believes in future for themselves or others, there is some hope of needed behavioral or other changes. When there is not such belief, the outcomes of encounters become more unpredictable - and often dangerous for all involved. Mistakes are going to be made when people are unable or unwilling to invest the time and effort in addressing each other's needs.

Media Distractions

It is a great sadness of our time that our media and social media are about blame and shame rather than context, reflection, awareness, and problem solving.

Edward R. Murrow is a good source of reflection from past to present or from a time when the media worked to inform and educate as compared to media focused upon marketing, advertising revenue, and profits:

But during the daily peak viewing periods, television in the main insulates us from the realities of the world in which we live. If this state of affairs continues, we may alter an advertising slogan to read: LOOK NOW, AND PAY LATER.

Lip Service to People Factors But Not Investment in People to Impact Care

It is a great sadness of our time that our education and health care designers cannot see that outcomes are about people factors, behaviors, situations, environments, investments in each other, social fabric. If they had seen this they would have understood

• The futility of measurement worship with numbers additional costs and compromise of the social fabric
• The discrimination of Pay for Performance as schools, practices, and hospitals serving those with less resources and greater challenges get even less funding or are closed. 
• The futility of health insurance expansion with payments too low to support basic services (cost of delivery higher than payments). Greater investments in the team members to deliver the care allows small hospitals and practices to address the needs of insured and uninsured patients - doing what the current insurance expansion cannot do. 
• Other nations succeed in health and education where we fail because they invest far more in children age 0 - 6 (2% of their GDP) while we spend less than 0.5%. A move to 2% of our GDP invested in the earliest months and years of life could do much to reduce health spending from 17% to 12% or less. Nations such as the US and the UK have insufficient outcomes in health and education and both share bottom of the pack rankings for developed nations. (both from UNICEF)

The route to become a local teaching or health professional should begin, continue, and end locally. There is no longer a need to send children to distant colleges or professional schools when there are classrooms and practices without walls with great needs to address using local community resources - starting age 14 or sooner.

It is quite ridiculous to paying more and more to send a teacher or health professional to serve a population that will be difficult for them to relate to for two to three times the length of any loan repayment.

It is interesting that tele education and tele health are considered solutions for deficits of services when the internet can actually result in education and health care most specific to local needs and least distorted by those with other agendas. Murrow was right. The lights in the box distract, but fall short of the full potential.

Mutual Interdependency

The fact of the matter is that we are mutually interdependent. Physical, spiritual, and human infrastructure are also mutually interdependent. Compromises must be made so that we can move forward with needed investments specific to children, future generations, health care, education, and other areas.

We seem to forget the most important lessons all around - such as civil wars or our own civil war. These are of course places where the social fabric has been devastated with consequences for decades as we still see across Appalachia and parts of the South. New areas left behind are seeded by the old problems as yet unresolved.

Where we improve is about where we all invest. Outcomes are the result of preparing the soil to improve environments, situations, relationships, behaviors, social determinants, and outcomes in health, education, economics, and more.

The investments required rarely look efficient or effective when considering one outcome, but dozens of important outcomes can be shaped by these investments.


Some Can Learn the Most Important Lessons But Not Others

Sidney Kark went to South Africa to "fix trauma" care - to bring western triage and technology to bear. To his credit he did not leave or try to make claims of benefits in trauma care. He saw a greater need. What he discovered was that basic public health, sanitation, nutrition, and other people factors were more important and Community Oriented Primary Care was born. Eva Salber MD was a disciple and helped in the US in Boston, did early research exposing the harm of teen smoking, and facilitated lay nursing health care efforts in eastern North Carolina via black churches. There were other community health activities via her efforts and those of her husband. 

Community Health Centers can also vary in outcomes. Many are found in areas that have greatly improved in health and in health outcomes. One of the two original CHCs begun in 1965 was started in Bolivar County MS and there have been few changes in Bolivar County across 50 years. Investments in Appalachia have been many in type and amount, but the major improvements have been where superhighways, urban areas, and federal jobs impacted the area.

Working to Restore Social Fabric, Health, Education, Community

There is some element of Community Oriented Care rediscovered about every 20 or 30 years or when the usual clinical interventions are exposed as inappropriate, too costly, and lacking in the ability to change health outcomes, especially where people most need better outcomes.

This community idea does not need proving - it needs support and replication.

Essential is that people work together to address community needs as deemed necessary by the community aligning local assets.

What is tragic is that these lessons are lost or mistakes are made that should have been prevented by review of the previous works.

Social Fabric Experiences in Health Care

It is difficult to grasp the important concepts involving education, health, and societal outcomes. I consider it a great blessing to have family and job experiences that have taught me much about these areas. 

Solo rural practice learning from the people in Nowata OK was most important. Few understand just how much more important the first years of practice are for learning in many dimensions as compared to the short formal years of training. 

The State of Tennessee invested in me and in a rural FM fellowship development.  

HHS through HRSA invested in me in the rural minifellowship. The minifellows were as much teachers and mentors as learners. The right fabric can accomplish much. During the minifellowship activities it was great to meet Eva Salber and learn from her - one of the disciples of Kark.

At the time I did not realize it, but later I began to comprehend the value of my particular family medicine training at Waco. This training was the result of local community efforts to extend health access (a reason why the Mega CHC effort funded from above is so misguided). 

Asset based improvements have helped many communities. 

Gerald Doeksen was influential regarding the importance of economic activity to rural and small places spanning the 1980s and continuing to recent years. Studies that dismiss the consequences of losses of rural physicians, practices, and hospitals are quite appalling in their assertions.

Theresa Hilton was one of the most influential people I ever met and it was a great honor to send her students for her to mentor in Columbus NE as she constantly pushed health, public health, health access, and care where needed. It is indeed unfortunate that the National Health Service Corps would award programs that matched students to mentors in this program and through HPDP at Community Health Centers, and then take the funding away - or have it taken by a Congress that appears to understand less about people, outcomes, and future generations.

I give my thanks for all of the above and for supportive wife, her teaching experiences, and for children to illustrate much of what is essential in life.

Sowers, Seeds, and Outcomes

It only takes a few seeds to fall in fertile ground - but our nation suppresses the seeds and fails to prepare the groundwork. Half enough for primary care, public health, basic legal assistance, housing, nutrition, jobs, child development results in barren ground - making it harder for any seeds to survive, much less replicate.

Matthew 13 New International Version (NIV)  The Parable of the Sower 

That same day Jesus went out of the house and sat by the lake. ² Such large crowds gathered around him that he got into a boat and sat in it, while all the people stood on the shore. ³ Then he told them many things in parables, saying: “A farmer went out to sow his seed. ⁴ As he was scattering the seed, some fell along the path, and the birds came and ate it up. ⁵ Some fell on rocky places, where it did not have much soil. It sprang up quickly, because the soil was shallow. ⁶ But when the sun came up, the plants were scorched, and they withered because they had no root. ⁷ Other seed fell among thorns, which grew up and choked the plants. ⁸ Still other seed fell on good soil, where it produced a crop—a hundred, sixty or thirty times what was sown. ⁹ Whoever has ears, let them hear.”

Cancer Gets a Moonshot and STDs Get No Shot at All

The Quality of Outpatient Care Delivered to Adults in the United States, 2002 to 2013

The Devaluation of The Doctor and Its Effect on The American People by Dr. Alaina George

Value Is Also Low Cost and Good Outcomes - Commentary by Alan Morgan: For a model of efficiency, quality care, look at performance of rural hospitals

Wall Street Hears of Obamacare Large Practice Emphasis Mistake  "What I know now, though, is that having every provider in health care “owned” by a single organization is more likely to be a barrier to better care. 

Casalino indicates the value of small practices in preventable hospitalization.

Demographics of Distribution and Maldistribution in Valuing the Crucial FM Care Role in the

Six Degrees of Discrimination By Health Care Payment Design

Value Failure By Those Who Promote Value

Does Anyone Understand that High Cost High Need Patients Drive Consumption?

Medicaid As Savior or Betrayer of Access

Selling and Swelling a Bigger HITECH Bubble

Six Degrees of Discrimination By Health Care Payment Design

Value Failure By Those Who Promote Value

Most Visited Early Blogs

Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care 

Finance-me-cratic Constants in the Bureaucratic Universe 

Meeting Primary Care Needs in the Last Half of the 21st Century

 Exploring the Health Consequences of Disease Focus

 

Basic Health Access: Does Primary Care Experience Matter?

 

Of all the forms of inequality, injustice in health care 

is the most shocking and inhumane.

Martin Luther King, Jr. 

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

Basic Health Access Web   Basic Health Access Blog   World of Rural Medical Education

Copyright 2016

Cancer Gets a Moonshot and STDs Get No Shot at All- V1

We are all responsible for this failure regarding the STD epidemic. After the smoke clears from all of the politicians and activists who are promoting their own reason for the STD epidemic, there are many reasons.

Those who promote their cause are delaying actions that would address the causes - and are helping to spread STDs.

This will be more of a listing than a blog, but people need to understand how we are all responsible for the STD failures of our nation. 

25 Reasons Why We Fail in STDs

1. We have not grasped that resistant organisms require steady changes in the treatments. 

2. Some drugs that could treat STDs more effectively are not available or are too costly. 

Drug companies have also required so much for some drugs that budgets are shot to deal with many areas - such as STDs. As demand goes up, prices also go up, fewer are treated, and demand goes up. This is a death spiral

4. Public health spending is half what it should be and austerity focus has long prevented more spending. Also organized medicine separated from public health a few decades back. 

5. Austerity focus at the county and state and national level has elected more political leaders, but has resulted in a number of direct and indirect contributors to the STD and other epidemics. Counties have been doing all that they can to minimize health care costs.

6. Traditional health care eats up 3 trillion dollars leaving very little for basic services, mental health, primary care, public health, STDs, etc.

7. Coordinate local efforts to break the sex, prostitution, drug, STD, drug and human trafficking connections

8. Yes it is true that political games have resulted in impairments of women's health, but where is the emphasis on men's health?

9. College health care is incapable of the many STD, mental health, and other challenges.

10. The nation continues to waste billions on fraud, abuse, ebola preparedness, etc.

11. Primary care in the nation is being destroyed by low payment and accelerating cost of regulation.

12. Drug companies create shortages of drugs and charge too much to allow much care.

13.  Lab companies charge too much for STD tests such that the tests are less available, 

14. Clinics that treat STDs some of the time are bare budget and lab results for STD tests are too slow

15. The technology tools to address the epidemic are held up by profiteering

16. The STD stream of resistant organisms coming from other nations is not being addressed (jobs, college, technical training). 

17. Care is increasingly inconvenient for the purpose of STD care.

18. Screening guidelines have been relaxed and fewer women are screened for much of anything.



19. People have sex - obvious, but important to understand

20. Sex tends to be private, controversial, and poorly discussed

21. Sexual body parts are private and poorly discussed

22. Teens don't talk much

23. Married people and families don't talk enough. Breakdowns of family and marriage and essential communication promote epidemics.

24. A decent program could have substantially reduced syphilis - but when levels are lower the attention is minimized along with dollars for screening and treatment, allowing a return.

25. And what do we do about intolerance and discrimination - which is why our nation fails to support public health, STD treatment, primary care, mental health, and more of the basics?

What should be done?

• Double public health spending and primary care spending and take this spending design out of the hands of politicians and out of the hands of traditional government agencies that have marginalized these basics while sending dollars to highly specialized care.
• Declare a public emergency and force drug and lab corporations to cooperate at a reasonable margin, cut deals for longer patents, and do whatever is necessary to lower costs for emergent treatment applications. 
• Double mental health spending, especially with regard to drug abuse
• Establish walk in STD treatment at urgent cares and primary care offices paid at higher rates to incent rapid, convenient services. Pharmacies could also participate in testing and treatment.
• Consider studies of one time patient incentives paid when those who positive for STDs test negative at follow up.
• Needle sharing programs
• People could access testing online with deliveries of testing and followup and recommendations for treatment. 
• Target STDs to eliminate where feasible with savings of hundreds of billions later for billions invested now efficiently and effectively - the STD Moonshot
• Consider genetic testing and tracing of organisms but only in a way that facilitates treatment (not spending so much that it impairs treatment or the workforce to do treatment)

The Quality of Outpatient Care Delivered to Adults in the United States, 2002 to 2013

The Devaluation of The Doctor and Its Effect on The American People by Dr. Alaina George

Value Is Also Low Cost and Good Outcomes - Commentary by Alan Morgan: For a model of efficiency, quality care, look at performance of rural hospitals

Wall Street Hears of Obamacare Large Practice Emphasis Mistake  "What I know now, though, is that having every provider in health care “owned” by a single organization is more likely to be a barrier to better care. 

Casalino indicates the value of small practices in preventable hospitalization.

Demographics of Distribution and Maldistribution in Valuing the Crucial FM Care Role in the

Six Degrees of Discrimination By Health Care Payment Design

Value Failure By Those Who Promote Value

Does Anyone Understand that High Cost High Need Patients Drive Consumption?

Medicaid As Savior or Betrayer of Access

Selling and Swelling a Bigger HITECH Bubble

Six Degrees of Discrimination By Health Care Payment Design

Value Failure By Those Who Promote Value

Most Visited Early Blogs

Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care 

Finance-me-cratic Constants in the Bureaucratic Universe 

Meeting Primary Care Needs in the Last Half of the 21st Century

Exploring the Health Consequences of Disease Focus  

Basic Health Access: Does Primary Care Experience Matter?

Of all the forms of inequality, injustice in health care 

is the most shocking and inhumane.

Martin Luther King, Jr. 

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

Basic Health Access Web   Basic Health Access Blog   World of Rural Medical Education

Copyright 2016

Selling and Swelling a Bigger HITECH Bubble- V1

Cherry picking has become essential for those who provide or insure health care. Choose the easiest route will capture more dollars with less cost of delivery - and this will earn more bonuses and assure no penalties. Changes since 2010 will reward those already doing well and will penalize those already behind. Cherry picking has apparently moved to top importance for those who promote digital solutions.

The digital leaders continue to present A Beautiful Day in the Neighborhood or Community as you will see. But which community, theirs or ours? 

Leaders are cherry picking the information to present, when they promote further digitalization and ignore the consequences such as:

• The massive additional cost of digitalization is a factor contributing to a 1 percentage point increase in health care costs from July to August of this year alone. The clock is now ticking to determine future reimbursement based on the next 3 years of outcomes. Health care entities are trying to do everything possible to look good in the next few months. Quality matters little as what matters is the appearance as measured. 
• Health care cost increases. They are not improving, as is constantly promoted. When you add massive cost of delivery in areas such as Health Information Technology and Care Micromanagement with non-delivery costs increasing by tens of billions a year more, you will raise costs, worsen delivery, or both.  EHR changes have been enough to help cause increased costs and overall inflation while not cutting costs or improving quality as was claimed years before. 
• The distraction of team members from health care delivery and patient interactions as their payment support is cut, as their duties are devoted to appearance rather than patients, and as they are asked to do more with less.
• The decreased productivity of team members resulting from EHR as indicated in studies that reveal two hours of EHR for every hour of patient care (Annals IM) 
• The increasing power of corporations such as software corporations that are now taking their share of health care spending are the ones now playing a role in shaping designs their way. Leaders, associations, and the media promote their products and policies.
• The tremendous opportunities that have been given for hacking, fraud, and abuse inside and outside of health care. Portals are indeed places of opportunity.
• The shifting of dollars and jobs outside of the United States due to digitalization and support services. 
• The diversion of dollars from 2621 counties with lowest concentrations of physicians and lowest concentrations of health spending by design have lost billions of much needed dollars and jobs as their revenues are forced to be sent to places in the United States with top concentrations of jobs and dollars. Disparities have been made worse than they already are.
• The suppression of market forces due to rapid regulation - market forces that would have acted over time to improve the EHR software as it was applied
• The lack of improvement in health outcomes or in the health of the population
• The lower efficiency of health care delivery - essentially a move to lower value by those who claim to be focused on value.
• The declining morale of team members dealing with countless EHR requirements that are meaningless and are not specific to patient care
• The direct and indirect costs of updates, costs of changes in software, HIT personnel, maintenance, down time, hacking, reputation of the health system due to hacking, increased security ...
• Forced sales of software resulting in lower productivity and the prevention of better software that would have taken more time and that would have cost more, but would have saved much more in terms of lost productivity. Suppression of market forces by regulation hurt nationwide health care productivity in many ways.

Only 40% of employed physicians and 31% of self-employed physicians were satisfied with their EHRs. 

The Cost of Care Tipping Point Has Been Violated

America is at a tipping point in cost of health care. It has not been enough to spend more and more each year for drugs and immune technologies, highly specialized treatments and procedures, profits, insurance costs, and more. The workforce has been distorted to higher cost as well. Systems can generate so much more revenue via more subspecialized care that workforce and workforce costs have consumed more spending. Administrative cost acceleration has taken over where subspecialization left off. This brings us to the 2010 to 2016 time period.

The nation is just beginning to fall off the cliff into massive increases in health care demand due to demographic changes and the usual increases in technology by those who deliver health care - other than digital. 

A massive new influx in digital costs along with the administrative cost increases that accompany such changes is a most unwelcome development. The rise to 17% of GDP spent upon health care has not been stopped and is likely to continue as even more plan on profits from health care.

The complexities of population changes are a strain on team members, as are rapid changes in drugs, procedures, and care process. Team members have clearly been pushed over the tipping point with forced rapid adaption to poorly designed software and other massive regulatory changes. 

But we still see promotions of digitalization from the highest levels as seen in Health Affairs.

Progress in Digitizing Health Care by Karen DeSalvo and Vindell Washington

The two authors note "Over the past seven years, the United States has seen a historic health IT transformation, moving from a primarily paper-based health system to one where virtually everyone has a digital footprint of their care because of the dramatic uptake of electronic health records (EHRs). Recent data have helped quantify just how rapidly technology has transformed clinical settings."

My Comments - Proponents see transformation in terms of adoption of EHR.  The transformation of health care delivery is quite different from transformation to EHR. There are winners and losers in each new policy change. The recent post Time to Burst the HITECH Bubble indicates that the transformation has been the wrong direction - to higher cost, to strains on quality and to decreasing access. This is what happens when you are so immersed in innovation and what could be that you forget about what really is. The designers have lost touch with what is actually coming. 

Massive Data But at What Cost and What Benefit?

The authors note "Today, nearly all hospitals (96 percent) and nearly eight in 10 (78 percent) physicians use certified EHRs. This transformation is the result of 2009’s Health Information Technology for Economic and Clinical Health (HITECH) Act, when fewer than one in 10 hospitals and 17 percent of physicians used EHRs. This rapid uptake of technology reflects the unyielding effort by clinicians and health systems across the board who helped usher in this new era of medicine. The result of this effort is a vast amount of electronic health data now exists which simply did not seven years ago."

My Comments

Health Is About Home - Most health care issues happen at home, with a small proportion involving clinics, and a very small percentage involving hospitals. The data is an incomplete representation of health or health issues and has been demonstrated as limited for application to health care. The data missing could fill volumes for each patient. The missing data about situations, environments, behaviors, and social determinants shape outcomes better than those collected for health care delivery, especially billing or payment. Once again the focus on the micro prevents understanding of the macro and overall outcomes.

Distributions of Services Shape Data - Most data is collected on a relatively few people with chronic illnesses as well as people closest to dying. The information is least applicable to the general population. Half of Americans rarely use care and have little need for digital EHR. One per cent spends 100 times more than the bottom 50%. But they are paying for it - as are all Americans in one way or another. 

Misrepresentation of Motivation - The authors attempt to indicate that clinicians and health systems voluntarily acted. They had little choice except to do this. The new digital way is quite obviously the result of costly and burdensome regulation. 

Small Health Care Compromise - The rapid chaotic change has also caused problems especially to small health care. Given the rapid shrinkage of small health care with closures, mergers, and acquisitions, the digitization task has been made easier - in fact it was a major factor. The costs of digitization were so high that many providers had to close or be absorbed. Resistance is futile has been a clear message - a message with many consequences.  Physicians Question Value of Employed and Largest Practices with Merger Acceleration

None of our digital leaders talk about small health care and how it does a better job with local patient and community focus compared to a conglomerate or how it has improved prevention of hospitalizations compared to larger practices. 

Geniuses just legislated and regulated away involvement and engagement and yet consider their efforts a success.

Global Competitive Advantage - Not Hardly

The two authors note - "This transformation represents more than simply digitizing paper health records. It also puts us at a global competitive advantage and is leading to real-world impacts in the clinical setting. Systematic reviews of academic literature found that 84 percent of studies showed that certified EHRs had a positive or mixed positive effect on quality, safety, and efficiency of care. Other recent studies found that EHRs can reduce adverse events among cardiovascular, surgery, and pneumonia patients and that switching EHRs did not result in adverse safety events."

My comments 

For decades the incredibly high cost of American health care has been noted as a major reason for America to have a global competitive disadvantage in our economic engine. Health care cost allows other nations to steal our business. Digitization is a route to higher costs and outsourcing more health care dollars. 

Once again the designers are making a claim that is the exact opposite of the reality that they have brought about. 

A ten year 300 million dollar intervention by Robert Wood Johnson Foundation attempted to bring about transformation but had no significant impact upon population health and quality outcomes.

The US Health Care Ranks as Least Efficient

More Digital Distraction

Digital is one more distraction from interventions that could address cost, quality, and access. Population and health outcomes are about changes in the people, not health care.

The article goes on to promote interoperability, but fails to note serious and growing concerns about data security and privacy. What Americans need most is to be left alone by expensive and invasive health care. Real changes in health outcomes are about people changes and better support for people, parenting, early childhood development, early education. 

Real changes in health care delivery are about support of team members to deliver care, not greater administrative burdens and distractions from their care giving with fewer left to deliver care due to higher cost of care delivery from accelerating administrative and non-delivery costs. 

More Digital Diversions Compromising Primary Care

How much harder is it for primary care 

• When billions more each year are subtracted from 150 billion in total operations, 
• When shrinking the support for this 5% of spending to attempt to address 55% of encounters for 100% of the population. How much worse is it in 2621 lowest physician concentration counties with 40% of the population and only 25% of primary care spending - locations dominated by small practices and lowest paying Medicaid patients, and lower paid Medicare patients - who are paid even lower by a payment design that discriminates. And now these are settings that have 3 times the higher penalty rates from readmissions penalties. These are the truly underserved areas that will have additional penalties from MACRA as well.

Perhaps the leaders will want to comment regarding the lack of evidence basis in Pay for Performance and well as the inherent discrimination?

High Satisfaction - Not Hardly 

High satisfaction levels from providers that were previously not satisfied in just 2 years seems questionable. Since most did not change their software package and the changes have been minimal, what changed? The answer is not much. EHR Demands Leave Docs Burned Out, In Critical Condition.

Cherry picking the right studies or literature may get you the information that you want, but this is not the reality.  Physician morale is crashing due to EHR that was never ready for prime time and has not improved to meet these standards. Studies have demonstrated the tremendous distraction and lost productivity and high cost.

There was not even a hint of any of the limitations in this promotional piece. 

Digitizers assume people want to be digitized and that they want to have their information digitally shared. Many of them do not want this. The benefits are greatly exaggerated and the drawbacks are minimized. 

The HiTech Bubble is Swelling.

The digital leaders have not choice other than more selling.

Whose Community Do Health Care Leaders Support?

The authors note; "We received an overwhelming response from the community. Companies that provide electronic health records used by 90 percent of U.S. hospitals, health care systems with facilities in 47 states, and over two dozen professional associations and stakeholder groups have agreed to implement these three core commitments that will help ensure that health information flows."

My comments

• Beware statements such as "We received an overwhelming response from the community" therefore please jump on our bandwagon. This is actually a sad reflection regarding the overall situation. Jump on the bandwagon should be a Red Flag that brakes are needed, not accelerators. It is time for thought and reflection rather than more rapid implementation.
• Which community? It is obvious that the word "community" spoken by innovators is not the same word community as spoken by those who deliver care. Electronic communities or largest system communities or top concentration communities (or academic communities or the medical-industrial complex) are quite different from what Americans consider their community or what a physician considers my community. 
• It is helpful to reflect on the words above and see who health care digital leaders want to please. Who has the top priority in their minds? Such is the degree of the obsession and the divisions between Digital Leaders and the American People.

If you cherry pick the right information
and ignore the information that indicates problems,
you can continue to
Sell and Swell a Bigger HITECH Bubble.

Recent Articles and Studies

Indicate 1 in 2 Physicians Demoralized

New technology must be better than what I already use; otherwise there is no reason to change.  In 2009, the Department of Health and Human Services led many to believe (incorrectly) “using electronic health records will reduce administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care.”  Few, if any, of these goals have materialized.  IT experts are tinkering with the grand design of a documentation method that has satisfactorily served physicians for hundreds, if not thousands, of years.  It is no small undertaking; a certain degree of diligence is required for conversion to experience success... Non-physician health leaders are missing the forest for the trees as they search for innovative ways to enhance data collection while overlooking the accumulation of critical information to support proper medical decision making.

Today's advertising and headlines indicate worsening problems.

As healthcare providers arebeing asked to accomplish more with fewer resources, the American HeartAssociation offers a helping hand in filling the gaps. 

House Republicans Call tell CMS to stop mandatory involvement in payment reform in Modern Healthcare

Use your clinical expertise to effectively demonstrate how Epic’s software helps physicians and healthcare organizations focus on efficient, high-quality and personalized patient care. As a physician at Epic, you can make a far-reaching impact on healthcare and on practitioners around the world.

AAFP President Notes I don't want to treat a computer

Free Guide Helps Physicians Debug Bad EHR Contracts

Most physicians are unhappy with their EHRs and tech support, but more employed physicians are satisfied than are self-employed physicians. Only 40% of employed physicians and 31% of self-employed physicians were satisfied with their EHRs.

Providers are going through rapid change in how their business is conducted, delivered and paidfor. When you combine this change with industry consolidation and payer shifts,the uncertainty can be paralyzing. A few insights to help untangle the knot.

Advertising leads abound for Practice Management corporations that project ever larger systems with even higher levels of digital advancements. Patients and physicians will have vast data and search capabilities. Care will be better, safer, more coordinated, with less cost, and more patient focus. It appears to be open season upon the American people. It is hard to tell who is making more promises that will never be able to be kept. 

No one is asking why or how much or what the consequences will be.

Down the Health Care Drain with Health Professional Burnout

The US Health Care Ranks as Least Efficient

What next Mr. President now that the managed care diagnosis (overuse) and the managed care solution (risk shifting, micromanaging doctors) have been exposed as contributing to worse rather than to better?

Studies in 2005 indicated the tremendous cost of EHR - “To achieve an NHIN (national health information network) would cost $156 billion in capital investment over 5 years and $48 billion in annual operating costs. … $156 billion is equivalent to 2 percent of annual health care spending for 5 years.” (Rainu Kaushal et al., “The costs of a National Health Information Network,” Annals of Internal Medicine 2005;143:165-173, 165.) It is interesting that this was a Commonwealth Fund supported research project, but the ramifications of this huge cost on small practices and access never seems to register.

Recent Posts and References

Time to Burst the HITECH Bubble

Six Degrees of Discrimination By Health Care Payment Design

Assertions that Small Practices Can Prosper Are Not Helpful

Recovering General Surgery Is Impossible

Primary Care Must Rise from the Ashes of the Last 20 Years

Patients Should Be Changed, Not Physicians - Physician Behavior has been changed  -  the wrong way

Revisiting Basic Health Access in a Land of Smoke and Mirrors

Time Talent and Treasure to Measure Is Not Quality

The Mess that is MACRA - Kip Sullivan at The Health Care Blog

Value Failure By Those Who Promote Value

Bundling or Bungling, Once Again Into the Fray

Solving Mental Health Takes More than Race and Place

Burying More Americans By Health Design

The Mystique of Medicaid Expansion

More Geriatricians Will Not Solve the Geriatric Care Crisis

Prevent MACRA to Do No Harm

Poor Payment Dictates Poor Training Outcomes in Primary Care Training

No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure

Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

The Federal Cause of Shortage Areas and Access Barriers - The Federal Design for payment shapes the breadth, depth, and locations of shortage areas due to lowest payments for Medicaid and Medicare and other plan designs that pay least 


Most Visited Early Blogs

Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care

Finance-me-cratic Constants in the Bureaucratic Universe

Meeting Primary Care Needs in the Last Half of the 21st Century

Exploring the Health Consequences of Disease Focus

Basic Health Access: Does Primary Care Experience Matter?

Primary care can be recovered and should be recovered, 

but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

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