Jane on Health

Johns Hopkins Part 3: Getting the Electronic Health Record (EHR) Right

2011-09-21T13:40:00.008-04:00

Today I received a call from Stephanie L. Reel, Vice Provost for Information Technology and Chief Information Officer, The Johns Hopkins University. We discussed the importance of having an EHR system that worked for health care providers and patients. I suggested that she talk to some end users to see what actually works and does not work.

My experiences demonstrated how the EHR system can become a burden for all levels of health care providers and patients. This becomes exacerbated when the productivity of health care providers is measured and calibrated by the inputs and metrics that are captured as part of the EHR. It seems that with all the numbers that are crunched the qualitative aspect of health care interactions are lost. Moreover, the value of the interpersonal dimension of care is diminished if not obliterated by just counting the procedures that are quantitative, i.e., easy to measure. As a result a health care provider ends up spending more time in front of a computer than in front of a patient. This is not what was intended.

All health care providers and patients want an EHR that works. Health care providers need to have an EHR system that helps them input, review, and correct patient information accurately and easily. Patients want information that is accurate so that the precious time with their health care provider is not spent making corrections.

In our case my husband has an excellent physician and I want to make sure that the tools that are at his disposal are useful tools and not impediments. I also want to make certain that during those visits that by their very nature are stressful, that time does not have to be wasted because the EHR failed to do what it was intended to— be a vital tool for patient safety by reducing the likelihood of medical errors.

Johns Hopkins Part 2: Is This Service Excellence?

2011-09-20T13:41:00.004-04:00

The initial response to my email (see earlier post) was from a staff person who was supposed to respond to patient issues. I thanked her for her call and emphasized that it would be better if I received a call from a more senior person who could address my concerns with their EHR system and the ease of its use.

Later I received a call from Ms. Becky Zuccarelli, Director of Service Excellence, who informed me that because of HIPPA requirements that she would need a release before she could talk to me about the patient issue. I informed her that this was not a HIPPA issue as it was not about a specific patient but about their system. While she tried to do what she was trained to do, she was unable to understand the broader implications of the failure of their EHR system to either engage physicians or other health care providers or be responsive to the needs of patients. Ms. Zuccarelli's focus on service excellence missed concerns about system adequacy.

Part of the success of any new system is listening to feedback from users and fixing the problem. Handling a situation is not the answer. I emphasized that they need to fix their EHR system before they kill someone and the fatal mistake ends up being chalked up to medical error rather than avoidable system failure.

I am still hoping for a meaningful response and will keep you posted on what happens next.

Johns Hopkins Part 1: The Electronic Health Record (EHR) that Isn't

2011-09-20T12:02:00.008-04:00

On Friday, September 16, 2011 I sent the email below to Dr. Edward Miller, Dean and CEO of Johns Hopkins Medicine. Let's see the response I get:

Just to share with you two exchanges I had with your staff which indicates a failure in the design and implementation of your EHR system.

1. When I brought my husband in for his regular visit, once again he noted that he did not take the medicines listed on the printout. The response was that it was too complicated to change what was there as it would take too much time and anyway his medicines were properly listed in the notes.

2. When I reviewed the letter for my husbands scheduled infusion his medicine was incorrectly listed as Rituzan. When I called to get it corrected I was told that it was a mistake in the coding but that he would get the correct medicine..and moreover it has been incorrectly listed in the system since March when he first started to get his infusions.

Having worked on many aspects of getting legislation passed with respect to EHRs I was surprised and disappointed by the responses I received. EHRs are for more than billing; they are essential for patient safety. If someone is brought into the ER do you think the staff in the ER have the time to read through the notes to know the medications that a patient has taken? The responses of your staff reflect the failure of your EHR system to meet the needs of the health care providers at the front line as well as those of the patient.

I hope that you are able to make your system work better before someone gets hurt. I look forward to hearing from you about how you intend to fix a system which is not working as it should.

Sincerely,

Jane L. Delgado, Ph.D., M.S.
President and CEO
National Alliance for Hispanic Health
1501 Sixteenth Street, NW, Washington, DC 20036-1401
(202) 797-4321 Executive Office | (202) 265-8027 FAX
jdelgado@hispanichealth.org | http://www.hispanichealth.org

Public Health and Science

2011-05-09T12:11:00.002-04:00

There is an enormous gap between the public health community and the science community. Public health is driven by large data sets and averages. Science is moving into the realm of each person being their own universe of 10 trillion cells and 100 trillion microbes. How do we use the rich data we are able to analyze about the individual with health at the community level? We need to benefit from both.

Public health must become better at measuring multiple factors at the same time while understanding that communities are more than the composite of unique individuals factors. Our analysis of communities and public health needs to keep up with what science is teaching us about individualized health and systems.

For Cinco de Mayo No More Latino Policy Day

2011-05-04T18:14:00.004-04:00

When I was invited to a recent gathering for a Latino Health Policy Day I thought I was reading some script from the 1980’s that read, “In order to reach the Hispanic community invite a group of Hispanics to meet with you one day.” Are we so out of touch with each other that we need Latino Day to hear from Hispanics? I wondered if there was an Anglo Day, and only on that day would the effort be made to include Anglos in policy.

In health to make good policy we need to understand the entire community we serve, and it needs to be a part of how we do our work every day. Today about 1 out of every 6 persons in the United States is Hispanic. Also consider that the combined total population of Canada and Australia is 57 million which is about the size of the population of Hispanics in the U.S (54 million*).

Just not on Cinco de Mayo, but everyday our policies need to take everyone into account and make it possible to tailor what we do to meet individual needs. To have good policy it means that every day is Hispanic Policy day, African American Policy Day, Anglo Policy Day, Women’s Policy Day, and so on. If we do not include all communities we make policies that are bound to miss the mark.

*Unlike Census and others when I give the population of Hispanic persons in the United States I include the 4 million citizens who live in Puerto Rico.

New data has surprising results

2011-05-04T12:42:00.003-04:00

Today the news is that salt is okay and yesterday it was that BMI was not a good measure of health. The eagerness to make news sometimes gets in the way of being informative. One day’s science news is trumped (does that have new meaning today?) by the next day’s new discovery. Typically the data are described, the findings are made into pronouncements, and the need for further research is discussed. The reader is left wondering which facts were correct. Is it any surprise that consumers are confused by and distrusting of science? When information is presented in a way that is unclear people just keep doing what they are most familiar with and ignore the information generated by the new finding. We need to make science relevant to the people we are trying to reach.

Discussions we need to have

2010-07-28T14:41:00.004-04:00

On July 23, 2010 Senator Webb wrote an Op Ed Piece for the Wall Street Journal, "Diversity and the Myth of White Privilege" that inspired me to write a Letter to the Editor. I was pleased that it was published today (July 28, 2010) as it provided a different framework for understanding why so many of us do the work that we do.

Senator Webb seems fixated only on slivers of history of his home state of Virginia and not the realities of the nation. He ignores that Spanish settlers were on the continent before Jamestown or Plymouth Rock were settled. But the issue goes beyond who was here first.

What is most damaging about his commentary is that it suggests that the only reason we should help African Americans is because of past injustices; and, that no other community has suffered. There are thousands of incidents from the past and the present that depict a different reality. In health those realities get played out in how patients get information, the decisions we make about treatment, and so much more.

We need to understand our beliefs about others if we are going to get past them and provide quality care to all. To save health care resources you need to provide a patient with the care that is needed and not one which is based on false assumptions.

Field Research 101

2010-02-14T23:40:00.006-05:00

It is Valentines’s Day, Chinese New Year, and the beginning of a new decade so there is much to celebrate. Last year was more difficult as those I love spent too much time in hospitals. As I was with them it was an opportunity to watch up close and experience the many facets of our health care system. I found that I had to find the place in myself where I could be calm when all I wanted to do was scream, “Do you hear what the patient is saying?”
It became very clear that the clinical nuances of the individual patient seem to get lost when health care providers focus on their clinical guidelines and not on the specifics of the person in front of them. I watched as very caring and smart providers were rushed and wanted to take the path that was most familiar to them.
Fortunately, on my IPhone I have Epocrates™ and I used it to show how the patient may have a negative response to the medicine they were going to give him. I made the health care provider take extra time and double check. They took the time and checked their system and the medicine was not given.
What would have happened if I had not been there? “Medical Error” may have had another person to claim. Our systems can be brilliant but they can also blunder. The difference between one and the other is usually the act of one human being.
We need health insurance reform for certain. We also need to change the way our health system functions. That would be something we could all celebrate.

The Need for Plain English and Page Limits

2010-02-12T19:20:00.006-05:00

Since we are hitting the reset button on health insurance reform, Congress should also commit to voting out a bill of reasonable length and in straight forward language. After all the U.S. Constitution is an eloquent 4,400 words. Surely Congress can commit to writing a health insurance reform bill that is of a length and language that would allow all Americans to understand the bill. The new process should be that at the outset all legislation had to be written in plain English and with a page limit for the document. A maximum length of 50 pages would be read by most. I have been informed by those whom I trust that laws are necessarily long because they have to cite all the other laws that are being changed. My response to that necessity is to add those as footnotes. Having a long document means that it is only read by a limited set of people (i.e. lobbyists). Of greater concern is that the longer the document the more it becomes burdened by special inclusions and carve outs.

The legislation on health insurance reform should be something that we all can read and understand. It should be concise and understandable by those folks who are most clearly impacted by it; that means most of us. To have real insurance reform can be simply put: we all must have it, exclusions or rates based on pre-existing conditions, gender, or age will no longer be allowed, and because we are a responsible society there will be programs to make sure that persons of modest means can buy into a plan. With that said, that leaves 49+ pages for more details.

Better outcomes for patients ignored

2009-07-09T09:55:00.003-04:00

I posted this to the National Journal Healthcare blog this morning:

I waited to write this blog because I was hopeful that someone would comment on the July 2, 2009 New England Journal of Medicine article, “The Effect of Medicare Part D on Drug and Medical Spending.” What Zhang, Donohue, Lave, O’Donnell, and Newhouse reported was that “Groups that had no or minimal drug coverage before the implementation of Part D had reductions in other medical spending that approximately offset the increased spending on drugs, but medical spending increased in the group that had more generous previous coverage.”

These findings bring to the forefront the reality of our health care system - just because you do the right thing for a person’s best health does not mean that it will reduce cost or have the same effect for everyone. We can all agree that it is better to take medicine than to have “other medical spending” because it means that you are able to manage your disease. This was the outcome for those who had the least coverage before Medicare Part D. For those who had more coverage the findings are harder to interpret.

In the same way that Medicare Part D was the right choice for patient health, expanding health insurance coverage to all, including preventive care coverage, is the right thing to do now. But we must be honest. Just because it is the right thing to do does not mean it will save money.

The key point is that health care is complex and deserves more than sound bites especially because it is about life, death, and the difficultly in measuring the quality of life.

Health Care Costs: More than Dollars

2009-07-08T13:39:00.003-04:00

I posted this to the National Journal Healthcare blog this afternoon:

Today’s New York Times article ”In Health Reform, a Cancer Offers an Acid Test” is the type of analysis and discussion that makes me shudder when I think of how easy it is to misuse the findings from proposed comparative effectiveness research when the focus is just cost. The Times has a chart comparing the average cost of the five types of treatment for prostate cancer. What is lacking is how each procedure impacts the life of the person receiving the treatment.

I propose that all those considering health care reform remember to take the perspective of the patient and health consumer. For each procedure what needs to be included as part of any cost or effective analysis there is also a new measure that takes into account consumer’s assessment of PAID (pain, absence from work, invasiveness of procedure, and disability.) for each procedure under consideration. Patients need more information but it is more than just cost of the procedure.

Reading between the lines

2009-07-08T09:32:00.003-04:00

There has been much hubbub about the New Yorker article comparing El Paso to McAllen and virtually nothing about Richard Cooper’s article, ”States With More Health Care Spending Have Better Quality Health Care: Lessons About Medicare.” (December 4, 2008 Health Affairs – Web Exclusive). It is easy to understand why.

The New Yorker analysis resonates to the mythology that pervades thinking about health - that there is great variability in costs of health care because in some areas physicians are not doing what is good treatment but rather taking actions that will only increase their income. The suggestion is made that where there are high Medicare costs it is because there is much waste and the suggestion is stretched to explain all the waste in health care.

Cooper’s analysis however looks at all health spending instead of the slice represented by Medicare data. Cooper finds that, “Medicare spending per enrollee correlates poorly with total health care spending per capita.” He takes it one step further with the data he presents to state that regional variation in Medicare is not a valid measure of how well the health care system is working.

My question is simple - then why do we keep using Medicare data the way we do?

Best Outcomes for All

2009-06-30T08:56:00.001-04:00

I just finished the first edits on my book (look for it in early 2010) and am so glad that I will be able to write my blog again. The best part about writing a new book is that it is an opportunity to look across sectors and see what is on the horizon that will shape our health and well being. In many ways the new developments left me hopeful. At the same time it became clear that it was time to rethink some of the terms used by the health cognoscenti.

Let’s begin with discarding the conceptual framework of ED (not the one of blue pill fame) but as in “Elimination of Disparities” a term which over the past decade has had increased popularity. Too often ED became the new code for addressing the health care needs and concerns of Hispanics, African Americans, Asian Americans, Native Americans, and other communities.

The research that ensued documented the differences in care and treatment. With ED too many made the assumption that the best treatment would be the same for all. I knew that was a mistake because too often the goal of equal treatment did not sufficiently focus on outcomes.

There are differences among individuals and the best health care for a non-Hispanic woman in Minnesota may not be what is best for a Latina in Santa Fe. If fact, there is a growing body of evidence that the Latina is less likely to practice unhealthy behaviors like smoking and is likely to live longer that the woman in Minnesota.

As we enter one of the most robust debates we have had on health care, the need should not be to standardize treatment but to design systems that achieve the best outcome for all (BOA). The goal should be “Best Outcomes for All”; not on the average but at the individual level. That is something we can all get behind.

Saving money is not always good news

2009-04-04T19:33:00.002-04:00

It will be refreshing when I go to a meeting and people present data in a way that tells the full story. Take the recent thrown around fact that we have spent less money on Medicare Part D than had been projected. Isn’t it great that we saved billions of dollars? The reality is that half of the savings come from the failure to enroll all of the modest income persons who are eligible for extra help in paying for their medicines. While the savings may sound good, the challenge remains to enroll all those eligible in a program that helps them get the medicines they need.

Hispanics Have Highest End-of-Life Costs

2009-03-10T19:07:00.002-04:00

A study published this week in the Archives of Internal Medicine found that in the last six months of life cost for care for Hispanic patients ($31,702) was 60% higher than for non-Hispanic white ($20,166) patients. I have been there at the end-of-life for four people who were very close to me. If the costs are higher for Hispanics than for non-Hispanics whites I would say it is because no one took the time to talk to the patient and the patient’s family.

Hispanics are the group least likely to have a regular source of care. This means we are also less likely to have a relationship with a provider who understands our wishes on end-of-life issues. Ensuring the dignity and comfort all people deserve at the end-of-life is one more reason why health reform is so important. Hispanics must have access to health care providers who can understand their patient’s language and cultural values and can support families in their decisions about end-of-life care. It’s a simple matter of quality of care.

Five Popular Health Care Myths in 2009

2009-03-09T11:54:00.003-04:00

In my latest post to the National Journal Healthcare Blog, I identify five popular health care myths in 2009.

Early Death Means Health Care Savings

2009-02-26T20:56:00.017-05:00

While there is much agreement about the need for health care savings we also need to agree on how we define good health services and outcomes. CBO Director Elmendorf’s comment below needs our careful consideration:

"Even if successful, measures to reduce smoking and obesity—two factors linked to the development of chronic and acute health problems—might not have a substantial impact on health care spending for some time. In the long term, spending on diseases caused by poor health habits could decline substantially, but the impact on federal costs would also have to account for people living longer and receiving more in Medicare benefits (for the treatment of other diseases and age-related ailments) as well as other government benefits that are not directly related to health care (including Social Security benefits)."

--Douglas W. Elmendorf; Director, Congressional Budget Office

Testimony before the Senate Finance Committee

February 25, 2009

Prevention Is Not About Saving Money; It’s About Saving Lives

2009-02-18T15:49:00.004-05:00

There are so many discussions going on about health that it is hard to keep track of which policy would make the most impact. Too often it is a case of holding on to the old models that defined the business of health care. Just as business has learned that fundamental aspects of their models were flawed the best health policies change some of the fundamentals of the current health debate. A good place to start is to rethink the purpose of prevention.

Prevention may save money and it may not. Last month Health Affairs reported that “... hundreds of studies have shown that prevention usually adds to medical costs instead of reducing them.” As The Washington Post pointed out, when prevention works it extends life and there are the costs of using health care over those additional years of life. Also prevention requires reaching large population groups and that requires resources.

The additional costs of prevention is a matter of what we value. The benefits of breathing with ease from not smoking, not dying young from cancer through early detection, or not having a heart attack from starting to exercise are well worth the costs.

The cost savings through prevention is not what should make it worth doing but rather how it contributes to the vibrancy and productivity of our society. Prevention is important simply because it is the right thing to do.

How Business Misses the Boat and the Consumer

2009-02-12T09:53:00.002-05:00

St. John Knits represents what many executive women wear. I have shuddered at the prices but enjoy the basics and the decades of wear classic pieces provide. I also admit that I never paid full price. Many of my purchases were at last call sales and outlets. Nevertheless, these were investment pieces for many women.

So I wondered what George Sharp, Executive Vice President of Design for St. John Knits was thinking when he had Marie Gray (the founder of St. John) send a letter to her customers saying that the basic color black was being replaced by a new shade of black that would be their new standard. The new environmentally friendly collection would be called Caviar.

During these times does anyone think that women want to purchase new basics? Caviar is not black. And basics are basics. This is another example of how business thinking and strategic planning can lead people down a path that is no longer valid.

As for me this means that St. John is no longer the good investment. St. John is showing as much volatility as the market. One of my colleagues who usually paid full price will not buy the new and refers to her old classics as “Period St. John.” The lesson for business is obvious. It seems consumers adapt; and, we are not adapting by just buying more.

Charity Navigator - Why Many Good Organizations Are Not Listed

2009-02-10T12:15:00.004-05:00

Charity Navigator only covers 5,300 organizations and while that may sound like a lot it is only a fraction of the not-for-profits in the U.S.

Did you ever wonder why that is the case?

At the National Alliance for Hispanic Health we are of course proud of our exceptional work in terms of health but we also consider ourselves to be a role model for our stewardship of our finances. We were concerned that somehow we had missed being listed by Charity Navigator. So we went through the process of submitting all the information that they required.

We waited and waited and received no response. Our most recent communication from them provided insight into their process.

“Thank you for contacting Charity Navigator. Due to the volume received, we are unable to give status reports regarding charities suggested for evaluation. Please know we have in excess of 1,800 eligible charities awaiting review. Given our limited resources, we dedicate most of our efforts to updating the financial information of those charities already in our database. We add new charity evaluations, but not as frequently as we have in the past. We will contact an organization prior to publication of a rating.”

It seems that that being listed in Charity Navigator is not as informative as some think. Better to do your own due diligence when you want to make a donation.

Meanwhile, we are still hoping that our $100 million donation will come with the next visitor we receive.

The first Obama health care victory?

2009-01-14T10:27:00.004-05:00

This morning I posted comments to the National Journal Healthcare blog on the likelihood that the effort to reauthorize the State Children's Health Insurance Program (SCHIP) will serve as an early Obama Administration healthcare victory. I note that "On the eve of a vote on the already dialed back SCHIP bill the Senate draft has dropped coverage for legal immigrant children and pregnant women." Read the full post here.

The Washington Post Calls for FDA Regulation of Tobacco

2009-01-02T09:20:00.004-05:00

In its house editorial this morning, The Washington Post calls for the regulation of tobacco by the Food and Drug Administration (FDA). This is an effort that we have been working on for decades; it is long overdue.

Here are some excerpts:

• It is inconceivable, then, that the most deadly product legally sold in the United States is exempt from federal regulation. (Meanwhile, the Food and Drug Administration oversees dog food, perfume and, yes, nicotine gum.) The new Congress should pass legislation that would give the FDA authority to regulate Big Tobacco.

• For too long, cigarette makers have decided what's safe for consumers. Their concern for the health of smokers -- or lack thereof -- has led them to disguise the dangers of their products with labels such as "light" and "low tar," and to lure young smokers by peddling candy-flavored cigarettes. The proposed legislation would eliminate such misleading labels and severely curtail Big Tobacco's ability to market to youths. The legislation would also require tobacco companies to disclose the ingredients in their products and place larger warning labels on cigarette packs. Most significant, it would give the FDA the latitude to take further steps to curb addiction, such as requiring the removal of harmful additives.

• The proposed economic stimulus bill will be Congress's top priority, but legislation regulating Big Tobacco shouldn't be far behind. The threat of a filibuster by Sen. Richard Burr (R-N.C.), and of a veto by President Bush, prevented the legislation from passing last year. But with Mr. Obama in the White House, and a strong Democratic majority in the Senate, there are fewer obstacles -- and no excuses. By regulating tobacco, the new Congress can secure an early, bipartisan victory that would help set the tone for the rest of the session.

Paying for our Resolutions for 2009

2009-01-01T12:37:00.005-05:00

Now that we are in 2009 we need to find ways to pay for the health system we want.

How do we raise revenue or reduce costs? Here are seven areas to consider:

1. Increase the tax on tobacco and alcohol with proceeds going to health. (Disincentives for smoking, including citywide smoking bans, have been proven to work.)

2. Enforce clean air and clean water laws.

3. Make companies pay for health consequences of their actions.

4. Encourage widespread use of health information technology.

5. Use mobile phone/messaging systems to support consumers in managing their own health.

6. Reinvent the school nurse/clinic model.

7. Create luxury taxes with proceeds going to health.

Unfortunately, what we do now is either play a shell game with costs or reduce services and resources from the groups that squeak the least. Both of these are unacceptable. The reality is that since we want to provide more people with health care and we want better care for all, total costs will increase.

If we want more, then we will have to accept that our total costs will be more too.

Resolutions For 2009 - “Ten Things to do in 2009 to Improve Health”

2008-12-31T11:32:00.000-05:00

As we welcome in 2009 a year filled with hope and promise I thought it would be a good time to make up a list of Ten Things to do in 2009 to Improve Health.

1. Make it the norm for everyone to have health insurance and access to care.

2. Pay health care providers to communicate with consumers in the language the consumer understands.

3. Give consumers information in a useful format; there are more people who can watch a DVD than there are persons who can read.

4. Give consumers questions they can ask and provide answers so they understand what they may be told.

5. Encourage each person to talk about the level of care they want and include end of life issues.

6. Develop solutions for long term care that include a mix of private, public, and home based alternatives.

7. Encourage the sale of fresh vegetables and fruits in all communities.

8. Work to increase opportunities for persons of all ages and sizes to engage in physical activity.

9. Have EPA enforce clean air and water standards so we can breathe freely and safely drink tap water.

10. Remember that health care is more than science and numbers it is about body, mind, and spirit.

And a healthy and happy New Year to you too!

Future Health Solutions - Part II (of many)

2008-12-30T14:22:00.003-05:00

Health is full of “trendy” words or things that sound good until you look at it more closely and try to decipher what will be the real impact. For example, much is written about the need for evidence-based medicine. Sounds like a good idea but the implication is that either, before, medicine was not based on evidence, or that now we have a better way to analyze the evidence. Unfortunately, much of what is discussed today is evidence based on studies that are over a decade old and are based on research on non-Hispanic white males.

It is not surprising that existing evidence-based protocols fail us as individuals. Too often the data that define the evidence do not include the other 2/3 of the population that is female or something other than non-Hispanic white. The evidence fails to acknowledge what we have documented during the first part of the 21st century, i.e., that there are gender differences and that there are differences in how individuals metabolize medicines and everything else we ingest or absorb. The challenge remains to acknowledge that there are persons excluded from our current models of evidenced based medicine.

It is no wonder I shudder when I hear that future treatments, and of course the reimbursements to which they will be linked, will be based on the existing evidence.

Future Health Solutions - Part I (of many)

2008-11-05T14:44:00.002-05:00

American politics offer a spectacular view of what makes our country great. While we had a major election and shift in government there were neither tanks in the street nor bullies to keep people away from the polls. We waited on long lines to exercise our American rights and show the world who we really are. Although some of us may take our comforts for granted we have much to be proud of and that will see us through the economic turmoil which is still to come.

The freefall in the investment community and the government bailout surely indicate that our capitalism needs to be tempered with decisions that take into account the greater good. What has that got to do with health? Absolutely everything. Ethics must guide decisions not only in the non-profit world but also in the for-profit sector. We can craft an uniquely American health solution that involves both the private and public sectors...but only if the greater good guides our decisions in both sectors. After an election it is our resolve as a nation to work together and solve problems that will lead to solutions which are totally American. The best is yet to come.

Uninsured ER Overcrowding . . . It’s a Myth

2008-10-22T14:00:00.006-04:00

Perhaps the most frequent scapegoat for the crisis in our health system is the uninsured. For decades the litany of attacks on the uninsured has been they are overcrowding emergency rooms and using scarce resources because they do not go in for regular ongoing care. But buried in today’s newspapers, ensuring that it will get scant attention, was reporting on new research released by the Journal of the American Association (JAMA) that turns conventional wisdom on its head.

The study found that the uninsured are less likely than those with insurance to use emergency rooms. In fact, while 17% of persons in our country are uninsured, they only represent between 10% to 15% of emergency room visits.

When you talk to people who are uninsured they tell you that they do everything they can to take care of themselves; after all not everyone gets sick leave. They also avoid emergency rooms because they are already living at the edge and are concerned that the costs they incur from an emergency room visit will push them off the precipice to which they are clinging.

According to the JAMA study, insured patients represent the majority of increased use of emergency rooms over the past decade. So while providing health insurance to those who cannot afford it is critical, it does not go far enough to make our health system what we know it should be. Access is about more than having coverage.

Science Speaks and EPA Listens . . . Sometimes

2008-10-16T16:38:00.005-04:00

Today, the EPA announced it was following the advice of its Clean Air Scientific Advisory Committee to set standards for lead in air that are 10 times stricter than we have today in order to protect children’s cognitive development. This follows on the heels of the decision by EPA in July to recommend the ban of carbofuran, one of the most toxic pesticides still in use.

Since EPA is being receptive to science click here to send EPA Administrator Johnson a letter calling on EPA to revisit its March decision on ozone standards. EPA ignored the very same committee's recommendation and set standards for ozone that were higher than recommended. According to published research that move is estimated to result in 5,650 unnecessary deaths annually. That’s not to mention the thousands of cases of cardiac events (heart attacks and respiratory illnesses) that could have been prevented.

Clearly, there’s still much work to be done to clean our air; following the scientific recommendations is a good place to begin.

And for this we have government?

2008-10-06T13:55:00.004-04:00

The October 6, 2008 USA Today article “Sleuths go door to door to sniff out Medicare fraud” is a good example of how we can go so very wrong with how we focus on reducing costs. I do not know what other people read but for me it was a waste of government dollars to send out the sleuths. What did they discover? That an 86 year old man was able to go on walks and therefore was not eligible to get the home health care costs of having a nurse go to the house to give him his injection. Sounds odd?

While we all celebrate that the man could take a walk; walking involves being able to move your feet while injecting yourself involves your hands. It seems that Medicare only pays for the nurse to go to the home if the person is homebound. The sleuth who discovered the man commented that the man’s nervousness about giving himself an injection was not sufficient reason to qualify him for the nurse visit. Is it reasonable to expect that every 86 year old person should be able to inject themselves? Did anyone take into account the savings that Medicare accrued since the man was able to live at home because he had this help? Moreover, the reporter confused the work of the nurse and that of the health aide.

While the sleuth may have been using the Medicare standard; it is obvious that the standard has to change. We need to have more sanity in how we care for each individual. Blanket rules such as this do more damage than good— rather than cover they suffocate.

Our Future....Hispanic Students

2008-09-17T11:15:00.008-04:00

Our future is tied to this generation of youth. If you are the parent, grandparent, teacher, mentor or friend of a Hispanic college student looking to a future in a science, technology, engineering, or math (STEM) field please encourage them to visit alliancescholars.org.

Yesterday the National Alliance for Hispanic Health (the Alliance) announced the opening of the Alliance/Merck Ciencia (Science) Hispanic Scholars Program. We are making two types of awards:

High School Seniors -- $42,500 Scholar Package. Promising Hispanic high school students from Brownsville, TX; Elizabeth, NJ; and Los Angeles, CA are invited to apply to become one of ten Alliance/Merck Ciencia Scholars that will be selected in the Spring of 2009. Scholars will receive up to $20,000 in scholarship (up to $5,000 each of four years of college) and up to $22,500 in summer internship stipends (up to $7,500 each of three summers). Scholars will also receive mentorship and professional development support to complete a Bachelor's degree in a STEM field and pursue a STEM career.

College STEM Majors -- $2,000 Scholarship. Hispanic college students from all 50 states, the District of Columbia, U.S. territories and Puerto Rico pursuing a Bachelor’s degree in a STEM field major are invited to apply for a $2,000 one-time scholarship of which 25 will be awarded in the Spring of 2009.

This program of the Alliance and the Health Foundation for the Americas (HFA) is being conducted in partnership with the Merck Institute for Science Education (MISE) with support from The Merck Company Foundation.

Just this morning the Census Bureau released new data showing that there are 1.7 million recent Hispanic high school graduates enrolled in college. Innovation in communication, genomics, and earth sciences all hold the prospect for a golden age of discovery....but only if our youth have the educational background to lead such discovery. At the Alliance we are working to help secure that future of hope and prosperity for all.

The Consumer and Direct to Consumer Advertising

2008-09-12T09:26:00.002-04:00

How consumers make health care decisions is complex. Consumers do not make health decisions in the same way that they make choices about objects they purchase.

For this reason and many other reasons I was surprised at the backlash that pharmaceutical companies met when they began to push for direct to consumer advertising. The outcry was that consumers would see their health care provider and demand a particular drug. Really? More than likely what happened was that the consumer would TiVo the ad (along with their favorite program) and then skip it because it was “simply advertising.”

However, in some cases the consumer had new information and actually now had something to ask their health care provider about. For example, very few knew about ED and those that experienced it were reluctant to speak about it. This is no longer the case.

As consumers we do not ask enough questions. And while some health care providers bemoaned that they had to talk to their patient about why the medicine they were asking for was the wrong one for them, other providers saw it as an opportunity to engage the consumer in their own care. Conversations with a consumer are a good and essential part of health care. This needs to be encouraged and we need to reimburse providers for this one-to-one education. And of course in a multicultural world, the conversation must be in the language that the consumer speaks.

9/11

2008-09-11T10:32:00.001-04:00

My daughter goes to college 90 miles north of New York City. On her campus September 11 is remembered in a way to respect the lives that were lost. In Washington, D.C. there are variety of commemorations too including those personal ones…a moment of silence, a prayer…something to make us recall what time can make too easy to erase.

On September 11 we lost many precious lives. They deserve a moment of our time to reflect on how the events of that day changed every part of our lives.

We are not Canada or Sweden

2008-09-04T13:50:00.002-04:00

Having just visited Sweden and other countries in the region, and heard about their health system first-hand, I am reminded that our system is different because we as Americans have different expectations. We expect more from our health care system but paradoxically we do not want to pay higher taxes.

Think about your typical American; they want answers in real time. In Canada and Sweden consumers have to wait for everything from a visit to a specialist to test results. That same approach would be unacceptable in the U.S. and might even be considered malpractice in some instances.

More to the point is that in the United States we made the decision in 1965 to provide a level of health care to persons over 65 regardless of income that is unheard of in most other countries. We care for older folks. All this makes our American health care system, with all its flaws, operate under a different set of values and constraints; the comparison to some of these other national health plans is useless and too often misguided. And it’s an important distinction to make as a new Congress and Administration will take up health care reform and policy wonks start declaring that the grass is greener in Canada and Sweden.

Top 10 lessons I learned when I went to the hospital.

2008-09-02T17:30:00.002-04:00

That most people say they are happy with their health care is not very meaningful when you consider that most people are healthy.

Like lots of other people, I have gotten to know the most about health care when I have been sick or have had to care for someone else.

Here are some key things I have learned:

1. Public or private insurance gets you in the door but not necessarily the care you need.

2. There is a shortage of health care providers.

3. Mistakes happen.

4. Patients and providers want answers immediately.

5. There is little time left for patients and providers to get to know each other.

6. There are communication problems even when everyone speaks the same language.

7. People have to take more responsibility for their own health records even when they do not want to or do not have the skills.

8. It is important to make clear what one wants.

9. While evidence based medicine is a factor to consider; clinical judgment must also be valued.

10. You need to have someone with you.

We have a lot of work to do to make our health care system better.

Economics does not apply to health.

2008-09-01T20:35:00.003-04:00

Our biggest mistake has been to use economic models to explain consumer behavior towards the purchase of health care. The underlying economic assumptions of the “rational consumer” or “all things being equal” are not valid. When we purchase health care we make a decision that may not be seen by others as rational but to the individual represents a valid choice.

Even if there’s just a small chance a treatment may work, if you are in pain or suffering, any chance is better than none and you want access to that treatment. It may not be rational but it’s human nature.

The rules for how we make decisions about health are just not the same as when we buy a cell phone or any other item. Health is neither a brand nor a commodity. Each individual addresses health choices at a very personal level.

After all, it is about one’s life and you just can’t buy another one.

Finally, on another note, we're thinking of all the families who have been displaced and otherwise affected by hurricane Gustav today. And our prayers are with those who lost family members to the storm.

Trimming the Fat or Cutting Muscle?

2008-08-29T19:13:00.001-04:00

Too often those who beat the drums of cutting out the fat in the health care system ignore the reality that at some point there’s just no more fat to cut. The enthusiasm for saving dollars is now cutting connecting tissue and muscle too!

I’ve seen it most in visiting friends who are taking care of older family members. Our health care system is not prepared to handle the increase in older patients and the support they need.

Families and friends are often surprised and too often overwhelmed by the amount of attention they must provide even in the best of health care settings to make sure their loved ones get the care they need. Cost cutting has created a shortage of nurses, social workers, and all the members of a health care team. It has put a stopwatch on the time our health care provider can talk to us making the profession more difficult to practice and frustrating patients who no longer feel cared for.

We just can’t trim more from health care expenditures when the number of older people (and by definition sicker people) is getting larger.

Tax credits and insurance pools will only take us so far…we need to accept that health will be a larger portion of our country’s GDP. That is inevitable. The challenge is to create a system that is better and covers many more lives. That will take more and new dollars.

What do you think?

The fat in our bodies

2008-08-21T08:27:00.001-04:00

When I was growing up women were always looking to see how much fat they had on their bodies. Times have changed - today men and women are monitoring the fat on their bodies. Yet recent research shows that when we are looking we are not seeing what is most important.

All we see is bumps on our bodies but that does not tell us what makes up those bumps.

Those bumps or excesses are made up of two kinds of fat cells. The brown fat cells burn energy and keep us warm us while the white fat cells store energy. It seems highly likely that each person will vary in the amount and distribution of these two kinds of fat cells. This latest discovery means that we now have to better understand what kind of fat people have and where it is located. Could it be that all those comments about storing fat in your thighs is true for some because that is where some people have more white (storage) fat cells? For certain fat is more than just globs on our bodies to suck out or cut out; they are part of our delicately balanced endocrine system.

While research progresses, the best course of action to be healthy is still the same Spectacular Seven: do not smoke (and if you do stop), eat as healthy as possible, exercise, nurture healthy relationships, see your health care provider on a regular basis, take any medicines as prescribed, and be patient.

Dateline Minneapolis: Hospice is part of life.

2008-08-20T23:45:00.005-04:00

As I was eating dinner at the restaurant in the hotel today in Minneapolis, a gentleman from Oklahoma and his wife were being seated at the next table. He said how much he enjoyed my morning keynote address at the National Hospice and Palliative Care Organization's 2nd National Conference on Access to Hospice and Palliative Care. After he sat down he turned around and looked at me and said, “Let me be accurate. I didn’t enjoy it but I felt challenged. You stepped on my toes. Thank you.”

I put my fork down and asked him how I could help. He wanted to know what was the best way to reach people who were not like him. What could he do? I reminded him that his greatest strength in reaching out to others was his deep sense of humanity and that reaching out to different communities is difficult because there is no cookie cutter. Although people may want to sell a single method to reach any group the fact is that there is no magic way to reach every person with a message about hospice.

Later in the day I spoke to another person who was pleased that they now had brochures about hospice in 20 languages. I couldn’t help but grin at their belief that somehow a brochure was going to be the bridge for discussions of life and death. Years of work on all sorts of health topics documents that brochures even when properly translated will not accomplish what needs to happen. Brochures are a tool; in and of themselves they accomplish nothing.

What do we need? We need conversation. End of life issues are difficult and the conversations difficult. We need trained and trusted advocates that can help us decide what our wishes are, have the conversation with those we love, and write it all down. It’s a loving step that gives us decision making authority and gives the comfort of clear directives to those we love in the most difficult of times. But it’s a step that requires more than a brochure, it requires one-to-one support. Making clear one’s preferences and planning for our own end of life care is a way to celebrate the full cycle of life.

You can call us at the National Alliance for Hispanic Health for support and speak to a trained health advocate in Spanish or English at 1-866-783-2645.

Philanthropy and the Hispanic Community

2008-08-20T21:36:00.001-04:00

As we consider the impact of our evolving demographics one thing is certain; the philanthropic community must step up to the plate and respond to the needs of the Hispanic community in a meaningful way.

For too long Hispanic oriented programs were at best an appendage to ongoing foundation programs. In the best of instances Hispanic initiatives were placeholders for future programs. More often than not, however, in the absence of data about the Hispanic community the response of the philanthropic sector was to apply the lessons learned from other segments of the population to Hispanics and thus further diminish the unique Hispanic experience. In some instances foundations spent their resources on tasks to help them study and think. Throughout all of these exercises time passed and today the Hispanic population has grown to a level that is not adequately reflected by today’s funding priorities.

Looking at the foundations in California, Texas, and New York it is evident that only a negligible amount of the dollars actually ends up addressing the concerns of Hispanics. Moreover, there is a reluctance to fund Hispanic programs unless they are cloaked in conceptual frameworks that provide a comfort level to the funder. For example, endowment campaigns for Hispanic organizations may need to be rethought and many of the rules about fundraising principles may need to be retooled.

Yet the voice of the Hispanic community is not as strong as one would expect. Today Hispanics are 1 out of every 6 people in the United States; and yet that number is not reflected in the boards, staff, or programs of the philanthropic sector. We have a long way to go but with responsible leadership we will get there.

2042 is the new 2050

2008-08-14T06:51:00.004-04:00

For a while we heard that by 2050 whites would be less than 50% of the population in the U.S. Today’s announcement that by 2042 less than 50% of the U.S. population will be white documents that demographic changes are happening even faster.

By 2050 the four major groups in the U.S. will remain the same (whites 46 percent , Hispanics 30 percent, blacks 15 percent, and Asians 9 percent) although the growth in the different segments will vary.

These data provide an opportunity to prepare for the future of our country. At the very least we all need to work together to make sure that all segments of the population are as healthy as possible so that each individual can lead a full and productive life.

After all... life, liberty and the pursuit of happiness are fundamental to the American way...and of the three life is first. Clean air, clean water, safe food, and quality health care should be the first items on everyone’s agenda.

CNN.com offers a more detailed analysis of this Census Bureau announcement.

Hispanics Without Health Care Insurance; One Size Does Not Fit All

2008-08-13T07:40:00.004-04:00

Data from the new study on Hispanics and health care released today by the Pew Hispanic Center and the Robert Wood Johnson Foundation are consistent with existing findings.

The critical part is that 1/3 of Hispanics have no health insurance but it seems that of those nearly 25% still manage to have a usual source of care.

One size fits all is a 20th century model of health care delivery -- it does not work for any body.

Here's an excerpt from the release:

More than one-fourth of Hispanic adults in the U.S. lack a usual health care provider, and a similar proportion report obtaining no health care information from medical personnel in the past year. At the same time, more than eight in ten report receiving health information from media sources, such as television and radio...

The Skinny on Weight

2008-08-12T18:54:00.003-04:00

“Fat and healthy not an oxymoron” or “Fat and fit” were attempts to capture what was conveyed by recently published research in the Archives of Internal Medicine. Basically, over half of the overweight people turned out to be okay while nearly 25% of normal weight people were at risk for heart problems.

The more accurate headline would have stated metabolic health is linked to many factors and weight is only one of them. Moreover, whether a person is thin or has excess pounds is not the best way to determine a persons risk for heart problems. Your health is made up of many factors that include everything from your genetic package to the air you breathe. That being said this study is another reminder that as engaged health consumers we need to go for regular check-ups to see how our bodies are functioning, i.e, blood pressure, cholesterol levels, triglycerides, etc.

Narcissism aside, health is not about how we look but about how our body is working.

CNN.com has an AP story on this study.

Tuesday Health News

2008-08-05T11:58:00.008-04:00

Tuesday is health news day for many daily newspapers and other news groups. Here is a roundup of what's making news this Tuesday:

The Los Angeles Times reports on concerns that nanotechnology that imbeds miniscule silver particles into consumer products (from socks to plastic containers) to kill germs may make its way into human cells causing toxicity.

An article in the New York Times reports that more than 11 million adults (18-64 years of age) in the U.S. with a chronic illness are also uninsured.

Reuters reports that the Food and Drug Administration (FDA) has cleared six flu vaccines for the 2008-2009 flu season with protection against additional strains of flu to make the approved vaccines more effective.

The Washington Post today reports on efforts of National Alliance for Hispanic Health member La Clinica del Pueblo in Washington, DC to support healthy diet and activity habits which Hispanic immigrants bring to the U.S. but lose as they adopt North American health norms.

Tuesday Health News

2008-07-29T17:39:00.016-04:00

Tuesday is health news day for many daily newspapers and other news groups. Here is a roundup of what's making news today:

The Burbank Leader reports on how California restaurants are getting a head start on elimination of trans fats before the 2010 deadline which became law in California last Friday.
The Boston Globe covers the FDA consumer warning issued today to not eat the green substance (tomalley) found in lobster cavities because of high levels found of the toxin that causes paralytic shellfish poisoning.
WebMD reports on a study that finds an increased risk for stroke for nonsmokers married to a smoker.
The New York Times has a brief on a possible connection between friendly bacteria and lower rates of childhood asthma.

HIV/AIDS Always a Priority

2008-07-28T23:12:00.003-04:00

I worked in the U.S. Department of Health and Human Services (DHHS) Immediate Office of Secretary Margaret Heckler when she first announced the new health care crisis that we now know as AIDS. Since the very beginning of the epidemic CDC tracked how many Hispanics had AIDS. We have always been hard hit by AIDS' impact in our communities. Recent coverage by the Washington Post missed the opportunity to describe the experience of our community. I appreciated that the Post today tried to correct their reporting by including my Letter to the Editor in today’s editorial section.

There is much that we still have to do to help all those in our communities who have HIV/AIDS as part of their daily lives.

Add to Your "Must Do" List and Save a Life

2008-07-25T18:12:00.010-04:00

The EPA surprised health advocates yesterday by proposing to ban carbofuran on both domestic and imported food. That's good news for all of us. Carbofuran is one of the most toxic insecticides still in wide use and poisons our food supply and our drinking water. EPA is accepting comments for 60 days on the proposed ban and needs to hear your voice that this is a good thing. Carbofuran's manufacturer, FMC, has vowed to fight the ban.

Of course EPA is an agency run by lawyers and not known for making public comment an easy task. So here's a sample letter with all of the relevant docket numbers and authority codes. Just click here to download the letter.

About 1 million pounds of carbofuran are used in the U.S. each year and it's even more widely used outside of the U.S. What's more, studies showed that when birds wandered into a field sprayed with carbofuran, 84% of them died . . . yet we allow farm workers to be exposed to this same chemical as part of their work!

As health advocates, we need to raise the noise level on this issue. The Washington Post did a half page story, but its gotten scant coverage elsewhere. The New York Times today only did a small blurb.

So make this a "must do" and save a life. Write today to the Environmental Protection Agency (EPA) and let them know you support the proposed ban of carbofuran.

Scholarships in Science for Hispanic Youth

2008-07-24T16:21:00.007-04:00

I am thrilled that over the next five years the National Alliance for Hispanic Health and our partners will award at least $475,000 every year in scholarships and internships. The new Alliance/Merck Ciencia (Science) Hispanic Scholars Program was featured yesterday in testimony at a U.S. House Education and Labor Committee hearing on innovative business-education partnerships to help keep America competitive.

As one school superintendent told us, “this is going to change my kids lives.” It is a change that is long overdue. You can help by letting students know that they can call the Alliance at 1-866-783-2645 to get a science scholarship guide including information on our new scholarship program. In a time of financial difficulties for so many of our families it’s a bit of good news and who knows the student you help could become the next Hispanic Nobel Prize winner!

In related news, Education Week published a terrific feature story today by reporter Scott J. Cech about SciTech Summer Camp, developed by HENAAC and partners, aiming to get Hispanic high school students excited about the STEM fields (science, technology, engineering, and mathematics) through hands-on projects.

Needle in a (Jalapeño) Stack

2008-07-22T16:53:00.000-04:00

The Food and Drug Administration (FDA) has found the source of the salmonella outbreak in the U.S. that sickened hundreds of people. FDA inspectors found a jalapeño pepper from a distribution center in McAllen, Texas that was a genetic match with the outbreak serotype, Salmonella Saintpaul. Talk about finding a needle in a jalapeño stack!

There’s been a lot of frustration about the 15 weeks it took to examine tomato and pepper producers and to identify this outbreak source. What has not been talked about is what a gargantuan task this was for the FDA. There are over 10 million tons of tomatoes grown in the U.S. alone each year and over 125 million tons worldwide.

It’s time for lawmakers to give the FDA the budget it needs to do its job. The Senate Appropriations Committee just last week approved a $325 million increase for the FDA after years of budgetary neglect and it needs to become law. As consumers we also need to recognize that we can never be 100% protected. However, we can reduce risk by making safe food practices, like safe storage and washing fresh fruits and vegetables, a part of our daily routine.

And as a lover of my salsa, I want to say a word of thanks to the FDA inspectors and scientists that rarely get thanks, but have dedicated their lives to protecting the public’s health and this week found a needle in a jalapeño stack.

Tuesday Health News

2008-07-22T10:45:00.000-04:00

Tuesday is health news day for many of the major daily newspapers and their news websites. Here is a roundup of links for what's making news today and some Alliance news:

source of the salmonella that sickened hundreds of people: jalapeños grown in Texas. But more reports of people getting sick are still coming in and the case is not closed.
The Washington Post today reports on the high number of undergraduate women that have experienced "emotional, physical or sexual violence stemming from personal relationships before or during college."
HealthDay reports on a Johns Hopkins University study of Hispanics with diabetes:
The Wall Street Journal's health journal columnist Melinda Beck writes about gastroesophageal reflux disease (GERD) in babies.
Meanwhile, WSJ's Sarah Rubenstein writes about what the government is doing to try to reduce inflated costs some seniors pay for prescription drugs under Medicare Part D.
San Ysidro Health Center, one of the partner community-based organizations of the National Alliance for Hispanic Health, has a terrific exercise program serving the Latino community of San Diego, La Prensa San Diego newspaper reports.
On September 6th the Family Health Centers of San Diego and NAHH will host the second annual ¡Vive tu vida! Get Up! Get Moving! San Diego outdoor event at Chicano Park . Thousands of people are expected to participate. Hoy newspaper of Los Angeles reported on our ¡Vive tu vida! event held in L.A. on July 12.
Last week the Chicago Tribune wrote about the Alliance's Su Familia helpline which offers free information and referrals each year to thousands of Hispanics nationwide.

EPA Devalues Worth of Human Life

2008-07-20T12:03:00.002-04:00

The U.S. Environmental Protection Agency (EPA) earned front-page coverage after it was revealed that the government agency has lowered its official estimate of life's value!

Leave it to EPA to devalue the worth of a human life. I guess that inflation missed having an impact on our human worth. And really...is this how we want to make our environmental decisions? How do you factor in the costs of a compromised life because of the increasingly toxic environment in which we live? The EPA has a mandate to protect the public health and yet continues to play a numerical shell game with our lives.