healthy4u

Snack time with the new iGoogle for Android and iPhone

<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEholG9oSlNgGhVUAXdDbuy_JBEUjQvSpreqOLX0AKm0qUyB3dNqNy0XDCU0pW3xxDP9H-lubOMwsfblg3Zm-c3G0cQem9xisp1ThlFWWCCsiAc0hbVKJ-VMvuQovC6KKAFvnbKBmJbpmxen/s1600-h/igoogle.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5346285525123312402" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEholG9oSlNgGhVUAXdDbuy_JBEUjQvSpreqOLX0AKm0qUyB3dNqNy0XDCU0pW3xxDP9H-lubOMwsfblg3Zm-c3G0cQem9xisp1ThlFWWCCsiAc0hbVKJ-VMvuQovC6KKAFvnbKBmJbpmxen/s400/igoogle.jpg" style="float:right; margin:0 0 10px 10px;cursor:pointer; cursor:hand;width: 272px; height: 331px;" /></a>(cross-posted with the <a href="http://googlemobile.blogspot.com/2009/06/snack-time-with-new-igoogle-for-android.html">Google Mobile Blog</a>) We like iGoogle because it lets us "snack" on interesting information all day long. We can read a little bit of news here and there, glance at finance portfolios, take a look at the weather forecast, and then do a Google search. It doesn't require a big commitment of time and energy — it's simply there for us whenever we need it. This kind of availability is even more important on a phone, where it can take a long time to surf. That's why iGoogle is so convenient on mobile devices. When you're waiting in line, you can check iGoogle on your phone for a quick "info snack" — even in areas with mediocre network coverage. But speed isn't everything. Many of you have told us that you wanted to use more of your iGoogle gadgets on your phone. You wanted to see your tabs, too. We read your blog comments and forum posts and put your requests at the top of our to-do list. Today, we're excited to roll out an improved beta version of iGoogle for the iPhone and Android-powered devices. This new version is faster and easier to use. It supports tabs as well as more of your favorite gadgets, including those built by third-party developers. Note that not all gadgets — like those with Flash — will work in mobile browsers. One of our favorite new features is the in-line display of articles for feed-based gadgets. That means you can read article summaries without leaving the page. You can also rearrange gadget order or keep your favorite gadgets open for your next visit. None of these changes will mess up the layout of gadgets on your desktop computer, so feel free to play around and tune your mobile experience.  <object height="295" width="480"><param name="movie" value="http://www.youtube.com/v/B_ICorRs6J8&hl=en&fs=1&"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/B_ICorRs6J8&hl=en&fs=1&" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="480" height="295"></embed></object> The new version of iGoogle for mobile is available in 38 languages. To try it out, go to igoogle.com in your mobile browser and tap "Try the new Mobile iGoogle". Bookmark the page or make it your home page so you can return to it quickly. Finally, please fill out our survey by clicking on the "Tell us what you think" link at the top of the new home page. We'll continue to use your feedback to make iGoogle even better.<div> </div><div>Update on 6/12 @ 8:50 AM: Video added. Check it out!</div><div> <div>Posted by Dan Zivkovic and Zhen Wang, Software Engineers, Google mobile team</div></div>

Snack time with the new iGoogle for Android and iPhone

(cross-posted with the Google Mobile Blog ) We like iGoogle because it lets us "snack" on interesting information all day long. We...

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Wharton on Healthcare IT: Can I Go Home Now?

Professors at the <a href="http://www.wharton.upenn.edu/">Wharton School</a> of the University of Pennsylvania (one of the most prestigious business colleges in the world) had some very interesting observations about healthcare IT yesterday in an article entitled: <blockquote>"<a href="http://knowledge.wharton.upenn.edu/article.cfm?articleID=2260">Information Technology: Not a Cure for the High Cost of Health Care</a>."</blockquote> I have been writing on these same themes - <a href="http://hcrenewal.blogspot.com/search/label/irrational%20exuberance">irrational exuberance</a>, HIT not being a panacea or cybernetic miracle, HIT as a facilitating tool in medicine, not a revolutionary one (but only if "done right"), inadequate research to back up the often grandiose claims, and so forth for over a decade ("Contemporary Issues in Medical Informatics: Common Examples of Healthcare IT Failure", <a href="http://www.tinyurl.com/hit-misadventure">link</a>). I penned such sacrilege, often at risk to my career due the unpopularity of these ideas, itself due to the irrational exuberance of the HIT community (these attitudes were perhaps in part <a href="http://hcrenewal.blogspot.com/2009/05/machinery-behind-healthcare-reform-how.html">manufactured by a healthcare IT lobby</a>). Here are excerpts of what Wharton professors observed. Do read the entire article at the link above: <blockquote> President Obama made information technology a linchpin in his plan to reform health care when he included $19 billion in computerized medical record funding in the $787 billion American Recovery and Reinvestment Act of 2009. The goal: Use technology to reduce costs and improve the quality of care. The reality: Technology could increase health care costs without markedly improving quality, according to experts at Wharton [except perhaps in very highly specialized projects, not easily portable, such as <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=Cardiology%20story">here</a> - and not without its own set of problems - ed.] ... "No one has done the careful research to indicate that if one health care system has information technology and the other doesn't, then the care is different. There are no controlled trials," says <a href="http://www.wharton.upenn.edu/faculty/pauly.html">Mark Pauly</a>, a health care management professor at Wharton. All that technology is no panacea, he warns. In fact, he believes IT could actually raise costs because of culture clashes, training, the implementation of the systems [I would say "the mayhem that often goes on during the implementation" - ed.] and the labor required to maintain the new technology. "The best-case scenario is that information technology will improve quality but not lower costs. The worst case is that there's no difference at all." [I believe if HIT is "done well", we can achieve best case, and lower costs as well to an extent, but there is enormous complexity behind the two simple words "done well" that I'm not sure we've fully mastered as a society yet - ed.] ... That opinion is echoed by other experts at Wharton and the University of Pennsylvania. "The focus on IT in health care is a good thing, but there's way too much hype about it [an understatement - ed.] and misunderstanding about what the benefits will be and how quickly they will come," says <a href="http://www.med.upenn.edu/apps/faculty/index.php/g346/p6433357">Peter Gabriel</a>, medical director of clinical information systems at the University of Pennsylvania Health System. [<a href="http://www.wharton.upenn.edu/faculty/volpp.html">Kevin Volpp</a>, professor of medicine and health care management] agrees that tracking real cost savings from health care IT is a difficult task, but he expects there to be some benefits from spotting and eliminating redundant care. [Agree - ed.] But those benefits aren't likely to add up to big savings, says <a href="http://www.wharton.upenn.edu/faculty/burnsl.html">Lawton R. Burns</a>, director of the <a href="http://hcmg.wharton.upenn.edu/chme/">Wharton Center for Health Management and Economics</a>. "I agree that information technology is important, but it's not the slam dunk it's portrayed to be," he says. The chase to reduce costs, improve quality and expand coverage is deemed the "iron triangle of health care. A lot of us wince [at that goal]," Burns notes. "It's arguable that we can't do any of those things well." <a href="http://www.wharton.upenn.edu/faculty/asch.html">David A. Asch</a>, a Wharton health care management and economics professor, agrees that technology is a big part of reform. "No one is arguing against it, but that doesn't mean that it's not oversold," he says. Gabriel likens the fascination over IT in health care to a shiny new object that's easier to focus on relative to more daunting issues. ... In addition, it's unclear what cultural issues [a big theme in my writings - ed.] will emerge as information technology is adopted. These cultural issues are in the forefront of primary care physician relationships. Experts at Wharton and Penn say physicians are generally skeptical of the technology movement. How much will a technology overhaul add to operating costs? How much will it cost to retrain workers? What's the electronic record learning curve? And what happens when a doctor has a laptop between him and the patient? "Individual physicians just don't know where the money is going to come from," says Pauly. "If IT is tied to reimbursements it could work, but [many] are skeptical." Burns adds that the physician-patient relationship can also be altered. "Technology adoption changes the way you practice. What happens when your primary care physician is looking at his screen instead of you?" </blockquote> All themes obvious to me after an informatics fellowship and term as CMIO at a major hospital, and to a number of my like minded colleagues as well. However, these themes were as hard to get published and recognized (i.e., turned into "memes") as a book against Global Warming ... The Wharton article concludes with this pithy wisdom: <blockquote>Experts say these projects are worth the effort, but the industry should keep its expectations in check [i.e., ditch the irrational exuberance - ed.] and closely scrutinize investments. "To the extent [that] these technologies improve the quality of care and get the patient more involved, I'm all for them," says [<a href="http://pennhealth.com/WagForm/MainPage.aspx?config=provider&P=PP&ID=268">Richard Neill</a>, residency director and vice chair at the University of Pennsylvania's <a href="http://www.uphs.upenn.edu/fampract/">Department of Family Medicine and Community Health</a>]. "But the technology is not a sea change -- just a chance to change."</blockquote> Anyone in Washington listening? Finally, after a decade of writing on these same observations to a public apparently inclined to believe the myths and promised cybernetic miracles nourished by the IT industry, and getting nowhere until some very serious organizations caught on this year and joined in (the <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=JointCommissionAlert">Joint Commission</a>, the <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=NRC">National Research Council</a>, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=UK">UK House of Commons</a>, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=koppel_kreda">JAMA</a>, <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/failurecases/?loc=cases&sloc=workshop">AMIA</a>, Wharton, etc.) I ask: can I go home now? -- SS

Wharton on Healthcare IT: Can I Go Home Now?

Professors at the Wharton School of the University of Pennsylvania (one of the most prestigious business colleges in the world) had some ve...

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Public CCHIT response to NJ "CCHIT or else" Health IT Bill

In my June 7 post <a href="http://hcrenewal.blogspot.com/2009/06/open-letter-to-mark-leavitt-chairman.html">Open letter to Mark Leavitt, Chairman, Certification Commission for Healthcare Information Technology on Penalties For Use of Non-"Certified" HIT</a> I asked CCHIT's chair pointed questions about a remarkable NJ Bill to make non-CCHIT-certified health IT forbidden for sale or use, with civil penalties, in the state of NJ. His response is posted in the link. I've just become aware of a June 8 public response to the Bill at CCHIT's site "EHR Decisions" entitled <a href="http://ehrdecisions.com/2009/06/08/legislating-health-it-beware-of-land-mines/">Legislating Health IT: Beware of Land Mines:</a><blockquote style="font-family:arial;"> <a href="http://ehrdecisions.com/2009/06/08/legislating-health-it-beware-of-land-mines/"></a>... A number of people contacted me this weekend about a <a href="http://www.njleg.state.nj.us/2008/Bills/A4000/3934_I1.HTM" title="More on the New Jersey bill">bill on the floor of the New Jersey legislature</a> which proposes to make the purchase of non-CCHIT Certified products illegal. I want to make a few facts clear, then share some news about our plans going forward in the new environment created by ARRA. First, I do not believe this is an appropriate use of health IT certification. Our goal, stated in almost every presentation I’ve given, and to which I’ve adhered in my leadership of the Commission, has always been to unlock positive incentives for health IT adoption. <a href="http://www.bridgestoexcellence.org/" title="Bridges to Excellence">Bridges to Excellence</a> provides a role model for integrating health IT into outcome-based, pay for performance incentives. Successfully executed, <a href="http://www.recovery.gov/" title="Recovery.gov">ARRA</a> might too. But the New Jersey bill is nowhere near that. Making software purchases illegal, like dangerous substances? Let’s “just say no” to that idea. Second, neither I personally, nor <a href="http://cchit.org/" title="CCHIT">CCHIT</a> as an organization, have lobbied, advocated, sponsored, or had anything to do with that bill. We were unaware of it until it started showing up on listserves Friday. The bill has never been mentioned in any of our Trustee, Commission, or staff meetings ... </blockquote> A fine answer. Read the whole thing. I was probably one of the first to call this NJ Bill to his attention, under the assumption the leader of CCHIT would know about a bill calling for CCHIT exclusivity and "or else" civil penalties in a major state. (CCHIT's founder HIMSS <a href="http://www.washingtonpost.com/wp-dyn/content/article/2009/05/20/AR2009052003600.html?nav=emailpage">certainly has been cheerleading</a> for all health IT that receives ARRA support to be CCHIT certified. Is it reasonable to assume CCHIT's leader had knowledge of that?)Instead of thanks for my calling the NJ Bill to Mark Leavitt's attention, potentially saving him from far worse troubles over it than my questions (I am, after all, a political nobody!), I got ... well, embellishments ... decide for yourself at the "Open Letter" link above. You're welcome, Mark. Hope you're equally as charitable to the NJ Assembly members who actually made this trouble for you. p.s. the exact wording of a question I asked him on Jun. 7: <blockquote style="font-family:arial;">"Did you, or anyone in a governance or leadership position at CCHIT, play a role in sponsorhip of this bill, through financial contributions, lobbying, advocacy for its proposals, and/or other means to prohibit sale of non-CCHIT certified HIT?"</blockquote> His June 8 post says:<blockquote>Second, neither I personally, nor <a href="http://cchit.org/" title="CCHIT">CCHIT</a> as an organization, have lobbied, advocated, sponsored, or had anything to do with that bill</blockquote>It even looks like I gave him the language for the public response. Again, Mark, you're welcome.And your apology for the embellished section of your response to my simple questions is accepted.Oh wait...Haven't gotten that yet.<div>-- SS</div><div> </div>

Public CCHIT response to NJ "CCHIT or else" Health IT Bill

In my June 7 post Open letter to Mark Leavitt, Chairman, Certification Commission for Healthcare Information Technology on Penalties For Use...

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Get creative with the Google Chrome icon

Two years ago, we invited people around the world to participate in a <a href="http://gmailblog.blogspot.com/2007/07/help-make-gmail-video.html">video project</a> imagining how Gmail messages travel around the world. The response was overwhelming, with <a href="http://www.youtube.com/video_response_view_all?v=VfDW7qAdFGk">971 video submissions</a> in total — many of which were <a href="http://www.youtube.com/watch?v=gR_61WdpcmU">really</a>, <a href="http://www.youtube.com/watch?v=coraBHKcX5M">absurdly</a> <a href="http://www.youtube.com/watch?v=eojiOhMvTAg">cool</a>. Today, we are announcing a new global project. Your task? Film yourself building the Google Chrome icon in a creative way, with whatever materials, as big, small, or crazy as you want. We will feature the best submissions. A handful of Googlers and a couple of <a href="http://www.youtube.com/flippycat">our</a> <a href="http://annathered.wordpress.com/2009/06/11/bento53-google-chrome-bento/">friends</a> created some sample videos for inspiration. Check them out: <object height="295" width="480"><param name="movie" value="http://www.youtube.com/v/bGJOmGL6mYM&hl=en&fs=1&rel=0"><param name="allowFullScreen" value="true"><param name="allowscriptaccess" value="always"><embed src="http://www.youtube.com/v/bGJOmGL6mYM&hl=en&fs=1&rel=0" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" height="295" width="480"></embed></object> <a href="http://www.google.com/landing/chrome/ugc/">Learn more and submit your video</a> by July 22. For more information on this project, visit the <a href="http://chrome.blogspot.com/2009/06/join-google-chrome-icon-project.html">Google Chrome blog</a>. We can't wait to see the clever ways that you build the Google Chrome icon. Posted by Jason Toff, Google Chrome team

Get creative with the Google Chrome icon

Two years ago, we invited people around the world to participate in a video project imagining how Gmail messages travel around the world. ...

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Lessons From Aviation Heroes Towards Healthcare IT

One of my largest concerns about the state of health IT is its safety, and the effects the irrational exuberance about health IT, including coming use/misuse of EHR data, may have on physicians' ability to exercise judgment borne of experience. For more on this, see my essay "The Syndrome of Inappropriate Overconfidence in Computing: An Invasion of Medicine by the Information Technology Industry?" in the Journal of the Association of American Physicians and Surgeons (<a href="http://www.aapsonline.org/">AAPS</a>), Summer 2009, <a href="http://www.jpands.org/vol14no2/silverstein.pdf">at this link</a> (PDF). I believe there is a strong lesson to be learned that is applicable to healthcare and HIT from the aviation industry. Namely, the wisdom of Captain Chesley Sullenberger, who guided a damaged and unpowered jet safely into the Hudson River on Jan. 15, 2009, saving all aboard. The lessons are so obvious, I will not comment on the parallels between Capt. Sullenberger's observations and the issues in healthcare and healthcare IT: <blockquote>Excerpts from: Wall Street Journal June 10, 2009 <a href="http://online.wsj.com/article/SB124454975782297751.html">Hero Pilot 'Sully' Stars at Safety Hearing</a> Transcript Reveals Details From Hudson Splashdown By Andy Pasztor WASHINGTON -- US Airways Capt. Chesley "Sully" Sullenberger, the much-heralded hero of the January airliner ditching on New York's Hudson River, told federal investigators Tuesday that in a matter of seconds he determined only the river was "long enough, wide enough and smooth enough" to put down his crippled jetliner. ... At a time when many commercial airline pilots say they are frustrated by dwindling pay, longer work weeks and eroded pensions, the testimony of the captain recalled the golden age of aviators exuding confidence and sangfroid. [self-possession or imperturbability especially under strain - ed.] Many of the flight attendants and passengers thought the Airbus was headed for land. But Capt. Sullenberger, who started flying at the age of 16 and has been at the controls of everything from gliders to three different jetliners, told the safety board he picked his landing spot with care. The airline's training instructed pilots that if they ever had to ditch, they should "land near vessels to try to facilitate rescue." Responding to questions about the lessons to be learned from the extraordinary landing, Capt. Sullenberger mentioned training to help pilots work together as a team and additional efforts to improve emergency evacuations. But his comments repeatedly swung back to the notion of an airline culture that stresses safety and respects the judgment of experienced pilots. US Airways pilots received classroom instruction in ditching procedures, but Capt. Sullenberger testified that they never practiced any ditching scenarios in simulators. In a pointed remark on the cost-cutting and heightened corporate regimentation that currently drive many airlines, Capt. Sullenberger considered the intangibles of safe airmanship. "The captain's authority is a precious commodity that cannot be denigrated," [see all too typical IT attitudes about physicians in <a href="http://hcrenewal.blogspot.com/2009/06/histalk-has-pair.html" style="font-weight: bold;">this post</a> - ed.] he said. The captain's testimony also highlighted the importance of relying on experience and memory, rather than rigidly using written checklists to deal with unexpected emergencies. With both pilots in the cockpit boasting about 20,000 hours of total flight time, Capt. Sullenberger said that teamwork and experience "allowed us to focus on the high priorities without referring to written" checklists.</blockquote> Cybernetic miracles would not help here and might in fact have caused a different outcome than this, especially if they malfunctioned, caused cognitive overload, or otherwise impeded the pilots' abilities to utilize their expertise: <blockquote>Billy Campbell, one of the passengers on the plane, testified about seeing the left engine engulfed in flames as though it were "a bonfire," and then scampering out of the aircraft as water was seeping in near the tail. "We were so fortunate to have an unbelievable pilot, an unbelievable copilot" and a highly experienced cabin crew, he told the board. [Note not a mention of "great computers", which in fact might be implicated due to faulty speed data in a recent and unfortunate Air France crash with no survivors - ed.] </blockquote> The parallels between Capt. Sullenberger's observations and the observations of those concerned with ever growing exuberance about HIT should be obvious. (If not, spend some time <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm">here</a>.) The lesson can be summarized through a line from another aviation hero: <blockquote>"It's the man, not the machine." </blockquote> That hero was <a href="http://en.wikipedia.org/wiki/Chuck_Yeager">Chuck Yaeger</a>: <blockquote>The most famous Mustang pilot and ace is Chuck Yeager. Yeager was the ultimate fighter pilot. As a young Mustang pilot he once downed five German fighters in one mission. He downed two much faster Me-262 jet fighters, escaped captivity after being shot down over occupied France, and when the war ended, it was still just the beginning of his amazing career. After the war Yeager became a test pilot, and in 1947 he earned his place in the history books as the first man who "broke the sound barrier" in the daring first supersonic flight.</blockquote> The WSJ article concludes: <blockquote>Robert Sumwalt, the safety board member chairing the hearing, said that after listening to the cockpit voice recorder after the ditching of US Airways Flight 1549, he was impressed by the actions of the pilots. "I've never walked out of a flight recorder lab with a smile."</blockquote> I wish I could walk with a smile about the state of health IT, but lately that just has not seemed possible. -- SS

Lessons From Aviation Heroes Towards Healthcare IT

One of my largest concerns about the state of health IT is its safety, and the effects the irrational exuberance about health IT, including ...

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A Letter from the RUC, and My Reply

The vast amounts spent in the US on health care have not translated into access for many patients, consistently excellent quality of care, and signiticantly improved outcomes. While we spend all this money, the primary care and generalist practitioners on the front lines are increasingly embattled and disgruntled, and their numbers are rapidly thinning. One problem may be the pattern of fees paid to physicians. Fees paid to physicians not only influence costs directly, but provide incentives for physician decision making about what tests and treatments patients receive. We have posted several times, most recently in February, 2009, <a href="http://hcrenewal.blogspot.com/2009/02/what-ruc-again-one-of-worlds-most.html">here</a>, about how the US Medicare system sets fees paid to physicians. Since health care reform is now a hot topic in the US, there has been increasing discussion of the plight of primary care and generalist practitioners, but little consideration of how it arose. What we wrote in February was (with updated links): <blockquote> As we have discussed, the US Medicare system determines what it pays physicians using the <a href="http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale/overview-of-rbrvs.shtml">Resource Based Relative Value System (RBRVS)</a>. This system determines the pay for every kind of medical encounter according to a complex formula that is supposed to account for physicians' time and effort, physicians' practice expense, and the cost of malpractice insurance. The components of physicians' effort assessed are, in turn, technical skill and physical effort; the required mental effort and judgment; and stress due to the potential risk to the patient. To keep the system, which was started in 1990, current, requires addition of new kinds of encounters, which means encounters involving new kinds of procedures, and updating of the estimates of various components, including physicians' time and effort. To do so, the Center for Medicare and Medicaid Services (CMS) relies almost exclusively on the advice of the RBRVS Update Committee (RUC). The <a href="http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-resource-based-relative-value-scale/the-rvs-update-committee.shtml">RUC</a> is a private committee of the AMA, touted as an "expert panel" that takes advantage of the organization's First Amendment rights to petition the government. Membership on the RUC is allotted to represent specialty societies, so that the vast majority of the members represent specialties that do procedures and focus on expensive, high-technology tests and treatments. However, the identities of RUC members are secret, as are the proceedings of the group. This opaque and unaccountable process has resulted in increases outstripping inflation in fees paid for procedures, while fees paid for "cognitive" medicine, i.e., for primary care, and for services that involve diagnosis, management of acute and chronic disease, counseling, coordination of care, etc, but not procedures, have lagged inflation. The effects of the RUC have been amplified by the unexplained tendency of commercial managed care and health insurance to track the RBRVS system when making their own payments to physicians. For further details about the RUC, see these posts on Health Care Renewal (<a href="http://hcrenewal.blogspot.com/2007/03/on-disparities-between-reimbursement-of.html">here</a>, <a href="http://hcrenewal.blogspot.com/2007/12/is-sustainable-growth-rate-main-problem.html">here</a>, <a href="http://hcrenewal.blogspot.com/2008/05/payments-for-patient-centered-medical.html">here</a>, <a href="http://hcrenewal.blogspot.com/2008/07/can-we-fix-medicare-while-pretending.html">here</a>, and <a href="http://hcrenewal.blogspot.com/2008/12/no-such-ruc-new-england-journal-takes.html">here</a>) and important articles by Bodenheimer et al,(1) and Goodson.(2) By the way, why the US Center for Medicare and Medicaid Services (CMS) relies de facto exclusively on the RUC to control the RBRVS system, and why the AMA made the RUC into a secret organization apparently beholden only to the organization's proceduralist members are unanswered questions. </blockquote> The next month, Dr William L Rich III, and Dr Barbary Levy, the Chair and Chair-Elect of the RUC, wrote me a letter to "point out several blatant inaccuracies within your blog entry that severely misrepresent the nature and work of the AMA / Specialty Society RVS Update Committee (RUC)." They then asked me to "retract or correct the inaccurate statements within the aforementioned blog immediately." However, the letter did not specify the supposedly inaccurate statements within the blog post. So, my email response noted that "the letter contains no detail about the alleged 'inaccurate statements.' If you define them, we will certainly consider your views." I never got a reply to this message, therefore thinking the matter to be closed, and I saw at that time no reason to make the exchange public. Apparently, the matter was not closed. A few days ago, two anonymous comments were appended to the post. They stated that my letter had appeared on the AMA web-site, <a href="http://www.ama-assn.org/ama1/pub/upload/mm/380/posesresponse.pdf">here</a>. So it is now public. The comments did not say, and I have so far not been able to find out when the letter was posted, and what its context is within the AMA web-site, including any indication that I had already replied to it in private. Despite these irregularities, however, given that the AMA apparently has chosen to make the letter public, I believe I ought to respond publicly. "Blatant Inaccuracies?" Dr Rich and Dr Levy wrote: <blockquote> We would like to take this opportunity to point out several blatant inaccuracies within your blog entry that severely misrepresent the nature and work of the AMA / Specialty Society RBRVS Update Committee (RUC). We request you retract or correct the inaccurate statements within the aforementioned blog immediately. </blockquote> First, as I noted above, the letter never specified which of my statements the letter writers considered "blatant inaccuracies." If there are any specific statements of fact in the post above (or any other post I write) that can be shown to be inaccurate, I will correct or retract them. However, I do not believe the letter by Dr Rich and Dr Levy demonstrated any particular statements of mine to be blatantly inaccurate. The Obscurity of the RUC Membership The letter stated: <blockquote> The RUC does not operate in the shadows. </blockquote> One of my major criticisms of the RUC was that it is opaque. Before I wrote my first post on the RUC, I tried to determine its membership by searching the AMA web-site, easily available AMA publications, and the web. I could find lists of past members, but no current list. In addition, I asked RUC staff by email whether they could provide me the list, or an easy way to access it. They would or could not do so, and the highest ranking staffer I contacted wrote, "we do not give out the RUC members' contact information. We attempt to shield the RUC from lobbying by industry or others." Only after these inquiries did I dub the RUC membership "secret." Dr Rich and Dr Levy suggested that it is not quite secret. It stated that "a list of the individual members of the RUC is published in the AMA publication, Medicare RBRVS 2009: The Physicians Guide." This publication is available from the AMA <a href="https://catalog.ama-assn.org/Catalog/product/product_detail.jsp?productId=prod1170041">here</a> for a mere $71.95. However, the book is not on the web, or in my local or university library, and I have no other way to easily access it. Additionally, although the letter stated, "any individual may solicit AMA staff directly or a specialty society to learn the names of the members of the RUC," the letter was not accompanied by any communication from AMA staff containing this information. Thus, to date, I still do not know who the members of the RUC are. If the letter authors had wanted to show that the membership of the RUC was not meant to be obscure, they could easily have sent me the list with their letter, appended a copy of the pages of the book which contained the list, or asked their staff to provide this information. They chose not to do so. So, while the RUC membership may not be exactly secret, it remains obscure, only barely public, and relatively inaccessible. The Secrecy of RUC Proceedings Furthermore, to support its contention that "the RUC does not operate in the shadows," the letter stated that <blockquote> any individual may attend a RUC meeting upon: (1) the invitation of and notification by a relevant specialty society; (2) an express invitation by the chair of the RUC; or (3) the approval of a written request to attend; and a review of conflicts and potential conflicts of interest. </blockquote> This does not mean that RUC meetings are open, or that their proceedings are public. Instead, as Goodson(2) noted, RUC "meetings are closed to outside observers except by invitation of the chair." Furthermore, he stated, "proceedings are proprietary and therefore not publicly available for review." The letter also personally invited me to attend "the next meeting of the RUC, which will take place April 23-26, 2009 in Chicago." In retrospect, this invitation did not appear serious, since it was never repeated or expanded after my email reply to the March letter. Nor did the invitation include any assurance that I could make anything about this meeting public. I had learned from a previous RUC attendee who will remain anonymous that attendees are obligated to sign non-disclosure agreements. Signing such an agreement might jeopardize my further ability to write anything of substance about the RUC. Furthermore, making all meeting attendees sign non-disclosure agreements effectively makes the meeting secret. The RUC and Primary Care Dr Rich and Dr Levy asserted that: <blockquote> Your publication irrationally and unreasonably paints the RUC as the perpetrator of all physician payment policies that have negatively affected primary care. </blockquote> Furthermore, they argued that the RUC has been good for primary care and cognitive practice: <blockquote> The RUC has made several recommendations that positively benefit cognitive and non-procedural physician specialties. </blockquote> My opinions about the RUC's influence on payments to physicians, and the decline of primary care and generalist and cognitive practice are hardly original. My previous posts were clearly based on evidence and discussion from references 1-4. Let me summarize these arguments, using direct quotes from these references, which perusal of the original articles would reveal are not taken out of context. Primary and generalist practice is threatened by the current payment system. From Bodenheimer et al(1): <blockquote> Incomes of primary care physicians are well below those of many specialists, and the primary care–specialty income gap is widening. ... the lower income of primary care physicians is a major factor leading U.S. medical students to reject primary care careers. Primary care practice is not viable without a substantial increase in the resources available to primary care physicians. </blockquote> From Goodson(2): <blockquote> Medicine's generalist base is disappearing as a consequence of the reimbursement system crafted to save it—the resource-based relative value scale. Current reimbursement incentives substantially favor procedures and technical interventions and offer financial advantages for expensive care, thereby encouraging specialty services. The continued and sustained incentives for medical graduates to choose higher-paying specialty careers and for those physicians in specialty careers to increase income through highly compensated professional activities have been associated with the dwindling of the generalist workforce. The lack of incentives for medical graduates to choose generalist careers in internal medicine, family medicine, and pediatrics has had a profound effect on the workforce mix and, ultimately, US health care expenditures. </blockquote> The RUC has been the major influence on the physician payment system leading to these problems. From Bodenheimer et al(1): <blockquote> In summary, the RUC process favors increases in procedural and imaging reimbursement for 3 reasons: specialty society influence in proposing RVU increases, the specialist-heavy RUC membership, and the desire of RUC specialists to avoid increases in evaluation and management RVUs. With their ability to create new codes and influence RVU updates, many procedural specialists can influence fees in a way that observers find to substantially overvalue procedural and imaging services. Moreover, high fees may encourage physicians to increase the volume of profitable services, leading to even higher income gains and greater spending growth. </blockquote> From Goodson(2): <blockquote> The RUC has powerfully influenced CMS decision making and, as a result, is a powerful force in the US medical economy. Furthermore, by creating and maintaining incentives for more and more specialty care and by failing to accurately and continuously assess the practice expense RVUs, the decisions of CMS have fueled health care inflation. Doing so has affected the competitiveness of US corporations in the global market by contributing to years of double-digit health care inflation that have consistently increased the costs of manufacturing and business in the United States over the last decades. The current mechanism fails to provide sufficient checks and balances and is skewed and dysfunctional. The resource-based relative value scale system originally developed to achieve full value for cognitive services currently threatens the sustainability of the generalist base. As a result, a large portion of the population will lose access to the continuous and personalized care provided by generalist physicians whose repertoire of clinical skills and interventions coupled with access to specialty and diagnostic services are essential for ensuring efficient and effective health care delivery. </blockquote> Dr Rich and Dr Levy are entitled to their opinions, but I would argue that there is considerable evidence and opinion suggesting that the current dysfunctional physician payment system is a major cause of the decline of primary care and cognitive practice, and simultaneous rise in health care costs and decline in health care access in the US. Furthermore, there is also considerable evidence and opinion suggesting that the RUC has singular responsbility for the dysfunctionality of the payment system and how it is skewed in favor of procedures as opposed to cognitive services and primary care. Summarizing: the Opacity of the RUC, and its Negative Effects on Primary Care and Cognitive Services So, I stand by my statement that the RUC process is opaque. Instead of saying "the identities of RUC members are secret, as are the proceedings of the group," I would be willing to now say, "the identities of the RUC members are obscure and difficult to ascertain, and the proceedings of the group are secret." That is not much of an improvement. If the RUC leadership wants to make its membership transparent, all it needs to do is post it on the web. If it wishes to make its proceedings transparent, all it needs to do is publish them as well. If it makes such changes, I would happily and publicly applaud them. If the RUC leadership wants to show that their members are not influenced by individual conflicts of interest, transparency about the committee's membership would inspire more trust than making the information as obscure as possible. Furthermore, there may be more reason to be concerned about the effects of institutional rather than individual conflicts of interest on the RUC. Most RUC members appear to represent specialty societies. Rothman et al claimed that industry funding of professional medical societies is "pervasive."(5) If the RUC leadership wants to show that their committee as a whole is not affected by institutional conflicts of interest of its specialty societies, it ought at least to disclose the relationships of those societies and their leaders with companies that stand to profit from increasing utilization of the specific services whose use is influenced by the incentives which the RUC largely determines. Finally, if there is a "wedge between cognitive and procedural specialties" it was driven a long time ago, particularly by a payment system that progressively favored the latter over the former, and by a bureaucratic burden that fell disproportionately on the former. But blaming the messenger is a time-honored, if not necessarily honorable tactic. References 1. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. Link <a href="http://www.annals.org/cgi/content/full/146/4/301">here</a>. 2. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310. Link <a href="http://jama.ama-assn.org/cgi/content/short/298/19/2308">here</a>. 3. Ginsburg PB, Berenson RA. Revising Medicare's physician fee schedule - much activity, little change. N Engl J Med 2007; 356: 1201-1203. 4. Newhouse JP. Medicare spending on physicians - no easy fix in sight. N Engl J Med 2007; 356: 1883-1884. 5. Rothman DJ, McDonald WJ, Berkowitz CD et al. Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest. JAMA 2009; 301: 1367-1372. Link <a href="http://jama.ama-assn.org/cgi/content/full/301/13/1367">here</a>.

A Letter from the RUC, and My Reply

The vast amounts spent in the US on health care have not translated into access for many patients, consistently excellent quality of care, a...

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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoToJESLTB0NMkouQuQyT2iQBSu1X-Fj5tOUQ2sKNtg2fKEjB5-OubNPnK58xtJDdVaefyjvVU16fuEKnwAhhgxPRZEHs2pQkDEwGmgM-7a8FJL9WVspwrkw6LitNH1THMGpNORx8ac1zu/s1600-h/io.JPG" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5345743922032044642" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoToJESLTB0NMkouQuQyT2iQBSu1X-Fj5tOUQ2sKNtg2fKEjB5-OubNPnK58xtJDdVaefyjvVU16fuEKnwAhhgxPRZEHs2pQkDEwGmgM-7a8FJL9WVspwrkw6LitNH1THMGpNORx8ac1zu/s400/io.JPG" style="float:right; margin:0 0 10px 10px;cursor:pointer; cursor:hand;width: 300px; height: 156px;" /></a><a href="http://code.google.com/events/io/">Google I/O</a> has come and gone, and we've been working to get all of the content online so those of you who couldn't be there could experience some of the excitement. At the conference, we shared <a href="http://www.youtube.com/watch?v=S5aJAaGZIvk">our thoughts</a> on the future of the web along with some exciting announcements including a <a href="http://code.google.com/apis/wave/">developer preview</a> of <a href="http://wave.google.com/">Google Wave</a>, our new collaboration and communication tool, and <a href="http://www.google.com/webelements/">Google Web Elements</a>, which makes adding a bit of Google to your website or blog as simple as copy and paste. In addition, I/O featured <a href="http://code.google.com/events/io/sessions.html">80+ sessions</a> of technical insight, and over 140 companies joined our <a href="http://code.google.com/events/io/sandbox.html">developer sandbox</a> at the conference to showcase the web applications they've been building using Google developer products. <div> </div><div>All of these sessions, along with interviews and screencasts from many of the sandbox developers, are now available for you to <a href="http://code.google.com/events/io/">watch online</a>. Also, to get a real feel for the happenings on the conference floor at Moscone Center in San Francisco, check out our <a href="http://code.google.com/events/io/map/#level2">interactive map</a> to watch session videos embedded in their actual conference rooms, or browse our <a href="http://code.google.com/events/io/photos.html">photo gallery</a>. You can stay tuned for further updates on all of our developer products at the <a href="http://google-code-updates.blogspot.com/">Google Code Blog</a> and <a href="http://code.google.com/">code.google.com</a>. We had a great time getting to meet all of developers building amazing apps using Google technology and want to thank the 140 other companies that participated. See you next year! Posted by Azhar Hashem, Google Developer Products and Mike Marchak, Google Code Team </div>

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