Back to the Future- The New Black Bag, an iPad

In the early 60's, my father started in medicine making house calls.

He would carry his black bag from home to home.  It had all he needed to make a diagnosis and get the patient on the road to recovery.  Now, 50 years later, no one can lift this black bag.  It is too heavy with options. Improvements in care have meant more options, so much to know that no single person can have all the right answers.

Overall, Americans have benefited from medical advances.  We are living longer than in the 1960's.  But, it has also had the perverse effect of fragmentation.  Take the example of my mom, a quadriplegic.  

At times her care sounds more like a text on physiology.  There is someone for the lungs, the kidneys and the neurologic system.  Yet, no one is responsible for her.  In part, this is too much for one person, there is not speciality called "quadraplegia" and all that goes with it.  In part, this is how healthcare is reimburse- money is paid for problems, rather than wellness.

However, I see hope on the horizon.  Like Hermione's magical bag in the Harry Potter series, we can give our providers all that they need as they travel from house to house, or at least room to room.  Collaborative technologies can deliver the community, rather than strictly the provider, to the bedside.  In this world, the black bag is replaced by an iPad or other PDA.  The specialist is available for advice, supporting and reassuring the patient and local provider alike.  This is our future.  We need to learn to scale our healthcare ecosystem, to not rely on the best available locally but rather the the best available from anywhere in sustainable ways.  New economic incentives are accelerating these solutions.  Time to upgrade that old black bag, time to go back to the future.

Alan Pitt Health 2.0 - YouTube

A Gaping Hole in Achieving MU Beyond 2014

Joe Wivoda, Chief Information Officer

The new Stage 2 requirements for meaningful use have a significant focus on patient engagement and information exchange. There are also more requirements for physicians and others to use their electronic health records (EHRs) more completely (e.g. increased use of computerized provider order entry), but the requirements for information exchange and patient engagement represent a significant challenge, and exciting opportunity, for hospitals and clinics, both rural and urban. The requirement to have 5% of unique clinic patients (5% of hospital discharges) actively view their health information will take concerted communication and marketing efforts, but the electronic exchange of summaries of care at transitions will be the most difficult.

The reason this requirement will be the most difficult is because many of the players, such as long term care and home care, have no financial incentive to implement EHR technology that can accommodate electronic exchange. The rule states that 10% of transitions to a new care setting must have a care summary transmitted electronically. Consider a rural hospital as an example: Rural populations are often older than urban, and many care transitions are to home care or long term care (LTC). The numbers are difficult to find, but according to Examining Post Acute Care Relationships in an Integrated Hospital System (Feb. 2009, available from http://aspe.hhs.gov/health/reports/09/pacihs/report.shtml), 35.2% of Medicare patients were discharged to either long term care or home care. Considering that the majority of discharges are to the patient's home, long term care and home care represent the majority of discharges to other facilities.

Many long term care facilities have EHRs that are used for documenting care, but like hospitals and clinics, they vary in their capabilities and level of adoption. Most LTC EHRs are designed around payment requirements; documenting primarily what is required to get reimbursed by Medicare and Medicaid. Since meaningful use does not apply to LTC or home care, their EHRs are not focused on information exchange. Thus, we are faced with the requirement of exchanging information with facilities that have no financial incentive to implement expensive upgrades to their EHRs to accommodate the hospital's requirements so the hospital can get more money. That is a tough sell.

We know that this is the right thing to do for patient safety and efficiency. Hospitals should be looking at their referral patterns and talking with long term care facilities about the benefits of exchanging information electronically. Networks are perfectly positioned to facilitate these conversations. Know that it will take time to implement the technology required, both at the hospital and the LTC facility, so start planning now. Without partnering with LTC it will be nearly impossible to meet the information exchange requirement in Stage 2.