U.S. Department of Health and Human Services.  HHS.gov  Secretary Mike Leavitt's Blog

Health IT

Hospital Compare

Over the past few months I have repeatedly said we need to make health care more value-driven. Of course, what I mean is that patients need information that helps them make better health care decisions. Specifically, comparative cost and quality of the care they purchase.

Friday (March 28) I unveiled a new Hospital Compare Web site. It will make it easier for consumers and their families to get accurate, practical information when they need to evaluate their local hospitals.

Take a look that it. I would appreciate getting your reaction. (Hospital Compare Web site)

The site assembles basic quality information collected from 2,500 hospitals and compares a series of quality measures, not only indicators of quality, but also price.

Look up hospitals in your area. Some of the data won’t surprise you much, other parts will. In your comments, I’d appreciate hearing if you were surprised in any way about the comparative quality of hospitals in your area.

This is a significant step forward, but my aspirations are higher in terms of the quantity, quality and accessibility of data. During the press conference announcing the release, I said if this were a video game it would resemble the first game I ever played, Pong, more than state-of-the art software like Nintendo’s Wii game. However, we’re making progress fast.

It is my expectation that hospitals all over America will be looking at how they compare and plotting strategies for improvement. People want to provide quality, but they need to know how they compare as a measure. The release of this data and its continual improvement will spur improvement.

So, tell me what you think.

Thoughts On Your Comments

I’m sitting at my desk with a  bowl of soup for lunch.  I have 30  minutes and I’m thinking this might be a good time to respond to a few comments  you have sent. 

First, let me say, I do read the  comments. I just have a hard time finding the time to respond and make new  postings too.  So, I tend to concentrate  on new postings.

Comment on Guatemala  Inauguration
On January 18,  Science Teacher wrote:
Can you tell us whether the topic of H5N1 came up  with any of the representatives of Latin American countries? Is there concern?

Response:
I was  in Central America about a year ago working on  Pandemic issues with the health Ministers.   We have helped them build lab capacity and actually trained more than  200 people from Central America on pandemic  related issues.  It is not a top of mind  issue there, and they still have a ways to go on public health infrastructure.  Gratefully, we haven’t seen any H5N1 positive birds in that part of the world.

Comment on Guatemala  Inauguration
On  January 22, David A. Haley wrote:
Instead of talking about "safe" topics such as India or Guatemala, why don't you address  meaningful topics to the American people, such as what efforts you and the  Administration are undertaking to fix our healthcare system? Hello. Is anyone  home in Washington?

Response:
David, you are right in saying my writings have been fairly  heavily oriented to international work lately. I think if you look back in past  postings I have written about many different topics that fit the criteria you  lay out.  The concentration of recent  writings on international work reflects the fact that I traveled fairly heavily  while Congress was out of session.   International work is an important part of my work and it has a direct  reflection on the health of the Americas.  The safety  of imports is an example. Most of my time in India was focused on products  Americans consume. 

I should also confess that I use this blog as a way to keep track  of what I learn on these trips as a journal of sorts. 

I encourage you to keep reading as there will be lots of meaty  issues to discuss.

Comment on Day 5 in India
On January 17m Robins Tomar wrote:
It would be great if you could write one more post about your  overall experience, changes in feelings before and after your visit and some  recommendations from your experience.

This is just a request if you get time from your busy schedule.  Anyway I will be following your blog to know your opinions about what is  happening around us.

Response:
I would say one of the most of the most important changes in my  feelings were the kind of things that come when one actually sees a place  rather than reflecting what you have heard or read.

Here are just a couple of examples:

  • It is hard to adequately explain the challenges of population as large as India’s and how it impacts every public policy issue.         
  • I’m attracted to the people of India.  I have lots of friends in the U.S. of Indian heritage and seeing India created a new context for our relationship.
    In Utah there  is a community of people with roots in India.  They have become prominent in academic and  financial circles.  As governor, I was  often invited to attend their celebrations and events.  I always admired the way they worked to  preserve their connection to an ancestral home even though many of them have  become major successes in the U.S.  Now that I have seen that home, it is easier for me to understand their view of America and India.   
  • I found particularly helpful the understanding I gained of the small farmers in India and their political influence.  I wrote some about this in one of my postings.
  • The number and size of the drug and vaccine manufacturing facilities in India requiring FDA attention was an important actualization.
  • The intellectual connection between the U.S. and India came as a pleasant surprise.  I knew it       existed but didn’t have a sense of scale.

I could go on and on, but this will give you a small sense of what the trip did for me.


Comment on Electronic Medical  Records and the Medicare Sustainable Growth Rate
On December 3, Chris Farley wrote:
The US  government/we the people already own an excellent EHR - the VA's VistA system. It is fast, simple to use, incredibly  stable and a large portion of the work needed to make it viable in private  practice is already done. Two organizations have taken it,  "de-veteranized" it and gotten it CCHIT certified. With a small  fraction of that cost, the system could be fully upgraded and modified to meet  all of the needs of the commercial market-place and fully implement the quality  measures and disease registries necessary to adopt pay for performance and  improve the quality and lower the cost of healthcare

Response:
I am a big admirer of VISTA and  the Veterans Administration.  In fact, I  borrowed the National Coordinator of HIT from the VA, Dr. Rob Kolodner.  The problem comes in creating compatibility  between other systems and the VA because most patients, even in the VA system, deal  with multiple providers outside their system.   We need to achieve interoperability.   As you point out, there are some providers who are using the VA system  as a foundation to develop smaller systems and we welcome that.  This answer is short but in the press of  time, I’ll leave it at that.

Comment on Electronic Medical  Records and the Medicare Sustainable Growth Rate
On December 3, Chris Farley wrote:
It is very easy for the Sec of HHS to say that Electronic records  are the answer to rising Medicare costs. It is very short-sighted to ignore the  reality that the numbers of the Medicare-eligible are increasing every month.  Besides, with increased litigiousness of society, has the HHS conducted an  objective study of what percentage of procedures physicians carry out are just  to protect themselves against frivolous law suits?

Response:
There are a number of studies that document the practice of defensive  medicine.  I would support reforms that would  minimize the practice or perceived need.   Many believe that the development of best practice quality measures will  provide some protection.

Comment on Electronic Medical Records  and the Medicare Sustainable Growth Rate
On December 3, Chris Farley wrote:
While agreeing that the current formula is an utter failure, I  would like to point out that Physicians are now working at 2005 reimbursement  levels (far from keeping pace with inflation). The moral of this horror story  is that if professionals are paid their legitimate dues, they will not abuse  the system. It is useful to remember that neither the gas nor electricity  prices; employee salaries nor office rent; neither liability premiums nor cost  of EMRs have stayed at 2005 levels - unlike Medicare payments under this  convoluted SGR formula. I have yet to see any effort by Medicare or any other payee  to actually interact with practices that have had extensive experience with EMRs  to identify real world solutions to real world problems. Until that happens, it  will be unreasonable for Mr. Leavitt to expect physician practices to  voluntarily adopt Electronic records. So if HHS would like to push this idea,  let there be a level playing field and objectivity in assessment of its impact.

Response:
I stand by my belief that the system doesn’t work well.  You would be amazed at the amount of work  Medicare does to estimate what things cost for doctors and therefore what the  reimbursements should be.  The truth is, command  and control regulator systems rarely get it right.  A well informed marketplace where consumers  have information on quality and price will both make the relationship between  doctor cost and charges far fairer.

In a previous entry, I talked about walking through a grocery  warehouse with 50,000 items and asked the manager what would happen if the  government started setting prices on every item.  His answer was right, in my view: “fewer  products, higher cost, and continual arguments.”  I told him, he had just described Medicare  reimbursement.


Well, the soup is gone and my time is up so I’ll conclude and post.

 

Health Information Technology (Written January 22, 2008)

Most readers of this blog won’t get all goose-pimply when I report Tuesday as an important day in the world of health information technology. However, what happened in the 19th meeting of the American Health Information Community (AHIC) will ultimately affect the way all of us interact with medical providers.

At the AHIC meeting a series of significant steps were recommended that will advance the interoperability of health information systems. We moved a step closer to delivering the promise of health information technology -- lower costs, better quality and more convenience for patients.

For those who follow this subject, and other readers willing to learn some about it, I’m going to link this entry to three things:

• First, a short speech I gave at AHIC putting the day’s events into to perspective.

• Second, a press release discussing HHS awarding a contract to design the permanent successor organization to AHIC and a Web site were you can find more information about this.

• Lastly, another press release which tells of AHIC’s acceptance of new standard recommendations on interoperability.

Electronic Medical Records and the Medicare Sustainable Growth Rate

[Note: This afternoon, I notified Congress we (the Administration) support a requirement that doctors adopt e-prescribing and electronic medical records in order to get the full Sustainable Growth Rate update (HHS statement). I've written more below about why I think this is important.]

When I was a boy, there was a Tennessee Ernie Ford ballad titled, “Sixteen Tons.” It told the story of a coal miner who bought all of life’s necessities from the company-owned store on credit. 

Apparently, the miner in the song spent more at the company store than he earned, but the company store just kept running his tab up higher and higher, making it more and more difficult for him to ever pay it back. It created a hopelessness reflected in the song.

The chorus of the song was:

"You load sixteen tons, and what do you get;
Another day older and deeper in debt.
Saint Peter don’t you call me cause I can’t go;
I owe my soul to the company store."

This week, the Congress will begin working on the Medicare Sustainable Growth Rate (SGR) or what people call the “doc fix.”  The doc fix is a ritual crisis brought on annually by a terrible system Congress put into place in 1997 to manage the amount Medicare pays doctors for various procedures.   

Here’s how it works: Each year, the Secretary of Health and Human Services is required by law to establish a target for the rate of overall spending on Medicare Part B. (Think of that as the total of all the miners’ wages)

If, collectively, doctors bill Medicare for more than the target, the Secretary of HHS is then required by law to make it up on future updates. (The mining company reduces the future wages to pay off past debts at the company store)

However, the doctors just keep billing more and more procedures to Medicare and spend far more than the target.

This has gone on now for more than 10 years and Medicare has now paid so much more than the target that the formula in the law dictates that doctors receive negative updates, cutting the amount they get paid for each procedure. This year, the SGR hole is so deep the law requires HHS to reduce the future rates we pay doctors by 10%.

So, each year Congress steps in and overrides the system by instructing Medicare not to cut the reimbursement rates.  Consequently, the amount that doctors get paid at least stays the same or is a little more.

Here’s an important point.  When Congress overrides the law, it doesn’t fix the system or pay off the deficit which is now so large it would require nearly $200 billion to pay off the backlog. 

This is a lousy system and it hasn’t reduced Medicare costs.  The total expenditures just keep going up.  Why? When rates per procedure don’t go up, doctors have simply done more procedures.

Moving toward a long term solution

Long term, the solution to this problem is to change the way we pay doctors.  At least some portion of their payment should be based on how successful they are in keeping people healthy, rather that just the volume of procedures they perform.  Sometimes that is called pay for performance or value-based health care. Whatever you call it, we cannot make progress unless doctors adopt a system of electronic medical records. Such a system depends on being able to gather quality data electronically.

Electronic medical records are widely accepted as providing significant long term efficiencies. The technology is maturing but doctors have not adopted them in sufficient numbers to create critical mass. 

Doctors want Congress, in the next couple of weeks, to once again override the Sustainable Growth Rate law.  It will cost taxpayers at least $4 billion. This year it’s a 10% reduction they will be overriding.  Next year it will be 15%.  We just dig a bigger and bigger hole. We need to begin the process of moving toward a longer-term solution.

It is the position of the Administration that any new bill overriding the SGR law should require physicians to implement health information technology that meets department standards for interoperability in order to be eligible for higher payments from Medicare. 

The benefits of utilizing interoperable health information technology for keeping electronic health records, prescribing drugs electronically and other purposes are clear.  This technology will produce a higher quality of care, while reducing medical costs and errors, which affected an estimated 1.5 million Americans last year through prescription drug errors. 

Such a requirement would accelerate adoption of this technology considerably, and help to drive improvements in health care quality as well as reductions in medical costs and errors.  I’m confident that many members of Congress are of a like mind on this issue and I look forward to discussing it with them in the next few days.   

Health IT

I’m returning from Chicago where we had a meeting of the American Health Information Community. This is the Federal Advisory Committee HHS initiated to advise the Secretary on health information technology standards. I won’t report on the meeting. We Web cast it and it’s available on the HHS Web site if you’re interested (http://www.hhs.gov/healthit/community/meetings/m20071113.html). I do want to reflect on a subject the meeting caused me to begin thinking more about.

We had a discussion about electronic prescribing of medicine. The technology necessary to electronically receive and fill prescriptions exists in most pharmacies in the United States. However, only a small percentage of doctors use it. The benefits are unchallengeable. E-prescribing is not only more efficient and convenient for consumers, but widespread use would eliminate thousands of medication errors every year. At the AHIC meeting, we announced standards that will help to get us there. We are starting with standards for providing medication history and for formularies so that providers have the information they need to write correct prescriptions. These two standards alone could go a long way to eliminating errors.

Most doctors haven’t invested in the necessary technology to do e-prescribing. The reasons are complex and range from a perceived lack of financial incentives to a reluctance to give up the familiar prescription pad. It is not expensive. This change needs to happen and, from my standpoint, sooner rather than later.

The last several years we have been nudging the medical family toward this. This fall, we eliminated the capacity for providers who have an e-prescribing tool to fax prescriptions paid for by Medicare to pharmacies. That has motivated some to use electronic systems. However, we need to do more, I think, including using our power as a payer to motivate the change.

When I was Governor of Utah, I spent time with members of the Highway Patrol. I discovered that after a drunk driver was ticketed it took the patrolman nearly three hours to fill out a stack of forms that was a quarter-inch thick. They then made four copies of the stack and mailed them to various parts of the government for processing.

I ordered laptops installed in patrol cars and had an electronic system developed that allowed users to process documentation in a fraction of the time. The system had undeniable benefits of efficiency and safety because patrolmen could spend more time on the road and less time in the office doing paperwork.

There was a problem I hadn’t considered. Many of the officers didn’t keyboard and frankly some of them were resistant to learning. Ultimately, I had to say, “Look, we are at a point where we can’t afford to have people on the highway patrol who can’t type. If you want to work here, you need to develop the skill to fill your reports out efficiently using a computer. We’ll help you learn, but this is now a requirement of your job.” The patrolmen that didn’t have the skills developed them and the system functions well.

E-prescribing needs faster implementation. We have been through all the public processes necessary to develop standards. The technology is readily available and widely distributed. Electronic prescribing will enhance the safety and convenience for patients. Large health care providers, including Medicare and Medicaid, need to move toward making it a mandatory part of medical practice soon.

Defining Personalized Medicine

The term personalized health care is often used these days. It is an exciting outgrowth of our better understanding of the human genome. We now know that our genetic makeup impacts the way we respond to certain treatments.

For example, in this month’s issue of Biological Psychiatry, there’s an article (Lee et al. 2007) about a link between a certain genetic variant and the drug Zyban, which helps people quit smoking. It seems that people who have the variant were less likely to have resumed smoking six months after taking Zyban.

There are numerous medicines doctors prescribe now only if a certain genetic condition exists. In other words, treatment is personalized based on genetic history of a patient.

I worry when we use the phrase personalized medicine, for some, it creates a mental picture of a patient having one-of-a-kind pharmacology developed specifically for them, based on their phenotype, environment and genetic make-up.

That model, while appealing, raises doubts. Intuitively, people develop questions about the scalability and sustainability of trying to treat a population of people in that fashion.

The vision we are moving toward, in my mind, is best described as mass personalization. Using a thorough understanding of a person’s genetic and clinical history, a doctor will select a combination from a group of biological and chemical treatment tools.

I sense our vision will be better understood and accepted if we begin to paint a picture more familiar and comfortable to patients, providers and payers. As consumers we have become quite familiar with mass customization in many of the things we purchase.

When I bought my first set of golf clubs, I bought a set the golf professional had on the shelf. After many years, I decided to buy new ones. The technology has improved and there were several aspects of my game that would fall into the category of needing treatment.

This time, I was confronted with a different experience. The golf professional and I measured my height and arm extension (my phenotype) and inventoried my game (genetic and health history) until we knew what the best length and flexibility of the new golf clubs shaft should be, the angle of the housel, the weigh distribution of the club head and grips to fit my touch.

The golf professional said to me, “now that we know how you align your clubs (medication) with your game (ailments), we can fit you properly. We carry ten different models of club with different combinations; the X20 Long has most of the attributes you need.”

I bought a set of clubs, off the shelf that was personalized to me. This company is now engaged in mass customization.

Now, I want to say, tongue in cheek, I have a vision of the golf improvement in the future. It personalized golf. There will emerge a system of electronic golf records. These records will be interoperable between golf courses so no matter where I play, each shot will be tracked. The genetic tendency I seem to have for slicing the ball will be well documented. So, as I need golf clubs in the future, they will be personalized to remedy my ailments.

In fact, because there will be so many golfers like me with electronic golf records, researchers will be able to gather data to invent new tools to cure the common slice and three putt green.

All kidding aside, we do need to begin defining personalized medicine in ways people can understand. We have the technology now to make health care much more personal and much more efficient.

More on this later.

www.hhs.gov/myhealthcare


Lee A.M., Jepson C., Hoffmann E., Epstein L., Hawk L.W., Lerman C. et al. (2007): CYP2B6 Genotype alters abstinence rates in a Bupropion smoking cessation trial. Biological Psychiatry 62: 635–641.

Written Friday, August 17, 2007

I’m sitting on an airplane, headed to Africa. It’s a 15-hour flight, so I’ll write for a few minutes before trying to sleep.

I just finished reading the first volume of the briefing material. This looks to be an extremely valuable trip. I’ll be in South Africa, Mozambique, Tanzania and Rwanda. I want to see, first hand, HHS and U.S. Government research, programs, staff and partners in action, especially in the President’s Malaria Initiative and our work on HIV-AIDS. I also hope the trip reinforces partnerships with those countries. I’ll be doing some public diplomacy events in each country. I worry not enough people know all the things our government does in health diplomacy. We need to tell the story better. Health is a universal language; people always appreciate it.

The schedule is packed every day so it is unclear to me how often I’ll be able to post thoughts. At very least, I’ll have someone post pictures from time to time. We will be going into some remote areas and I’m not sure what my access will be to the Internet.

Speaking of the Internet…

Today we had an important meeting at HHS related to electronic medical record standards. The development of standards for interoperable health information systems is one of my most significant goals. I believe the standards required to make this electronic medical records system work have to be collaboratively developed among various stakeholders. About two years ago we created the American Health Information Community for that purpose. Rather than try to write much about it I will ask one of my colleagues to insert a link here to the AHIC website: http://www.hhs.gov/healthit/community/background/

People have been talking about interoperable systems for years but the standards to make them work haven’t materialized. So, those who invest in electronic health records are isolated. Many others put investment off, waiting until the systems mature.

This is an extraordinarily complex problem but the biggest challenges aren’t technological; they’re sociological, i.e. conflicting economic interests and turf. AHIC has successfully created a place and process to sort through them in an orderly way. We are starting to make serious progress which you can read about on the website.

Our plan from the beginning has been to get the standards development process started inside the government and then once it is functioning create a non-profit entity that operates under a highly democratic governance system so the progress can be accelerated and perpetuated. I call the transition moving from AHIC 1.0 to AHIC 2.0.

The government will have to be the biggest participant in the process, but to get these things right, the entire health sector has to be at the table in a meaningful way. The federal government will not only be the biggest participant but we have also committed to use the standards developed there. The President signed an Executive Order last August making clear that all the federal agencies, including Medicare, Medicaid, the Veterans Administration, and Department of Defense etc. will adopt the standards. We need to insist those we pay do the same thing, over time.

Today we held a meeting with interested people and organizations to invite their help in creating the non-profit entity and its governance.

The last several years I have become rather interested in collaboration as a large scale problem solving tool. I’m persuaded skillful organization of collaborations is a 21st century skill set. It is a close cousin to network theory. In fact, I think collaboration is the sociology of network building.

Our world is intuitively organizing itself into networks. Networks require standards to operate. The skills to navigate the creation and governance of networks constitute the next frontier of human productivity. Organizations and societies that learn to solve complex problems using these skills will begin to out pace their competitors.

The development of AHIC 2.0 is a significant venture. I’m optimistic it can produce a vitally important institution but it will require our best statesmanship to overcome the natural tension of competing economic interests and turf.

If readers have a chance to look through the AHIC website, I’d be interested to hear your thoughts.

One last thing...

My heart has been with my fellow Utahn’s who are suffering through the coal mine disaster near Huntington. As Governor of Utah, I got to know the people of that area well and I went into the mines several times, so I have a picture in my mind of the environment those rescue workers and the trapped workers are working in. I’m grateful for the courageous action of the rescuers; sad for the families and community; mindful of the excruciatingly difficult decisions the mine safety people are faced with. They are all in my prayers.

-Mike Leavitt