Recap of August 26 meeting: Are personal health records ready for prime time?

Fifty people filled the room at the August 26^th meeting of LAVA Healthcare. The topic that consumed almost the entire 90-minute session was inspired by these thoughts discussed during our last meeting on July 22^nd:

• Consumers don't know their best course of action because they lack accurate medical and care information at the times when they need to make decisions.
• Physicians are often uninterested in providing this information.
• Perhaps consumers don't care about controlling their healthcare, as evidenced by the failure of personal health records like Google Health and Microsoft HealthVault. 
• Shouldn't we make it easy for consumers to access their health records?
• Do we need national standards for healthcare records?

Big picture issue:
PERSONAL HEALTH RECORDS: ARE THEY READY FOR PRIME TIME? IF NOT, WHY? WHAT CAN WE DO ABOUT IT?

In December of last year I changed my diet and exercise habits with the goal of losing weight, improving my wellness, and reducing my longer-term risk of acquiring cardiovascular disease and diabetes. I have reached my weight and blood-chemistry goals simply by cutting refined sugar, bread and starches (potatoes, rice and pasta) from my diet, and walking a few minutes every day.

Along the way, I started playing with several personal health records systems. I tried Google Health (soon to be discontinued), Microsoft HealthVault, and WebMD Health Record. In one word, these systems are terrible, as we discussed at the meeting.

But how poorly designed these systems are isn't the worst part.

My WebMD health record is automatically updated by Anthem Blue Cross, my health insurance carrier. Anthem BX gets billing claims from my medical providers (doctors, labs, imaging centers, etc.), and Anthem BX automatically posts data from the claims into my WebMD record.

Using screenshots, I used my personal data exactly as it appears in my WebMD records -- an exact replica of Anthem's database -- to demonstrate how useless are the clinical data in the systems because they are wrong. In my case, almost 100% wrong.

The reason is well known in the healthcare industry: medical providers submit billing claims to payors (insurance companies, Medicare, Medicaid) with the sole purpose of getting paid as much and as quickly as possible. This strategy is completely dominated by payors' policies. Among these, we have what might be the biggest cause of distortion: "normal" diagnoses don't get reimbursed.

Let me explain with one example I used at the meeting:

• June 21, 2010: I visited an orthopedist for a dull pain I had been experiencing on my right knee. He determined that it could be either nothing or a meniscus tear. He prescribed an MRI scan as the best and fastest modality to obtain an accurate diagnosis.
• June 29, 2010: I got an MRI scan. Results: no meniscus tear. (For another day: the nightmare I had to suffer to find how much I would have to pay for the MRI at various imaging centers I called.)
• July 6, 2010: The orthopedist prescribed physical therapy to "balance" my gait. My knee discomfort was caused by walking a little "crooked", which put more pressure on the outside edge of the meniscus.
• July 7-August 11, 2010: I visited a physical therapist. Result: fixed the problem.

In sum, I had a discomfort of the knee, which turned out to be nothing.

This is what my clinical records show based on the claims data submitted by the three providers I visited:

• Current tear of the lateral cartilage and/or meniscus of knee. Submitted by the orthopedist for the June 21 visit, probably because it pays better than "knee pain" and certainly pays more than "I don't know yet".
• Knee meniscus tear. Submitted by the imaging center for the MRI scan of June 29. Since the resulting diagnosis of "normal" and the admitting diagnosis of  "rule out tear" don't get paid, they submitted  "meniscus tear" as if I actually had a tear.
• Degenerative arthritis. Submitted by the physical therapist. I don't have a lick of arthritis on my knee (or anywhere else, for that matter). I can only explain this absurd diagnosis as being produced by a random generator of codes guaranteed to get reimbursed.

So there you have it. My medical record for this incident of care is worthless. In fact, it's worse than worthless because it can have very severe adverse effects on my future dealings with medical providers and insurance companies if they see the records without giving me the chance to correct them.

A quick show-of-hands poll of the room showed that two thirds did not know this is how these things work.

Comments posted on the LAVA Healthcare LinkedIn page:

"Regarding your fascinating WebMD PHR example, I could not attend the meeting, but I wanted to share some of what I have seen in the areas of the industry I have worked. There are even consulting companies that specialize in this gray area/black box 'payment optimization'! While payors have claimed that they have all this great data, at least today, this is not really true - often, the payors have a data disaster. In fact, a significant portion of auditing work that goes on inside of insurance companies is due to the need to verify that the billed claim matches and is validated by the actual medical record - something that is often done manually, is very difficult, expensive, and quite error prone in most health plans. One example of this is verifying 'medical necessity' - which is also often defeated by medical record systems that optimize the wording of the text in the documented medical record in such a way as to ensure payment by an insurance company (walking a fine line). This is the same text that may provide little use as PHR later." Jon Saltzman

"I concur. I work at Children's Hospital LA in a research group whose aim is to apply machine learning and other computational methods to digital health data from the pediatric intensive care unit. In much of our current work, we are largely disregarding both coded diagnoses and even provider notes because the clinicians I work with assure me that these have much more to do with billing and liability than with the care delivered. Sad but true, but this is why my colleagues and peers are pretty skeptical of the irrational exuberance surrounding electronic/personal health records. The devil is in the details, and most {E,P,D}HR systems suffer from poor implementation and improper use, not to mention the fact that they are horribly overpriced. These systems need to adopt the design principles (ubiquitous, automatic data capture, beautiful UIs) of the most successful web properties." David Kale

Recap of July 22 meeting: Are consumers oblivious to the economics of their healthcare?

The July 22 meeting was sold out, with all 50 seats in the room taken by a lively group of healthcare entrepreneurs, innovators, service providers, and capital providers. The 90-minute meeting covered three main areas: a big-picture issue, a long presentation by one innovator, and short presentations by two other innovators. Each of the three presentations was followed by feedback from the audience.

Big-picture issue: Are consumers oblivious to the economics of their healthcare?
Is this a major problem? Minor problem? Not a problem?
If it's major, what's being done about it? Can anything be done?

The short summary of the discussion is, yes, consumers aren't fully engaged in the true costs of providing them with healthcare. Some of the comments and anecdotes shared by the audience are:

• Consumers are oblivious to some portion of the costs, but cost-sharing of premiums, higher deductibles, and higher co-pays are changing this.
• Consumers aren't engaged in wellness protocols, which causes higher care costs later in life.
• Insurance companies should segment subscriber populations based on their positive and negative behaviors (e.g., obesity, smoking, etc.)
• Prices of healthcare services are very obscure to consumers, who lack easy-to-understand pricing information at all times: from the time they make appointments with medical providers until they get explanations of benefits from insurance companies and bills from the providers.
• It's more than pricing: consumers don't know what's their best course of action because they lack accurate medical and care information at the time they need to make decisions. Physicians are often uninterested in providing the information.
• Physicians don't see patients as customers.
• Perhaps consumers acutally don't care, as evidenced by the total failure of personal health records like Google Health and Microsoft HealthVault.

A summary of possible solutions proposed by the audience:

• Look abroad to healthcare delivery models that work.
• Identify best practices, and practice evidence-based medicine.
• Eradicate the notion that consumers are idiots.
• Provide transparent, easy-to-understand pricing, and make it easier for consumers to shop for providers, especially for diagnostic procedures like MRIs.
• Ration healthcare, especially for end-of-life care of terminal patients.
• Make it easy for consumers to get access to their health records.
• Have national standards for healthcare records.
• Legislate what insurance companies are allowed to take as middlemen.
• Get government out of healthcare.
• Legislate a single-payor system to eliminate the greed factor.
• Provide incentives for entrepreneurs to execute solutions.
• Medical providers should use social media to engage younger generations who are starting to consume healthcare services as they get older.

Innovation presentations

We had three presenters:

• Ted Margison of Pebble LLC (picture below). For 10 minutes he explained his idea on improving care coordination, and was peppered with many comments and questions. Ted is a process-improvement specialist who has previously built and sold a software company. He's new to healthcare, and started formulating his idea while observing major medical errors and ineptitude at a highly prestigious Los Angeles hospital during the treatment of a relative with a major, end-of-of-life disease.
• Maoz Lev of the Southern California College of Osteopathic Medicine, a private medical school.
• Richard Burke of RxTimer Cap, an inexpensive solution to help patients adhere to their medication protocols.
• Lev and Burke presented for 90 seconds followed by a few minutes of audience questions and comments.

My commentary: The big-picture discussion was very engaged and lively -- which was excellent -- but perhaps too superficial with plenty of anecdotes that could have used more extensive thought-through cause-and-effect brainstorming. The innovation presenters were, at best, weak in their messages and engagement with the audience. I have to work on improving all of this.

Ted Margison of Pebble LLC explaining his innovation to the group

Inaugural meeting a success

Forty-eight people from all corners of metropolitan Los Angeles had an enthusiastic 90-minute discussion at the inaugural meeting of LAVA Healthcare on June 24. Moderated by Richard Koffler, chair of LAVA Healthcare.

> Slides.