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Richard L. Reece, MD

New Technologies Unveiled To Reduce Costs, Improve Access
The Cleveland Clinic (www.clevelandclinic.org) hosts an annual Innovations Summit for experts in medicine and technology to review the latest advances and medical devices. Each year, the top ten up-and-coming innovations for the following year are listed on the clinic’s Web site along with a “where are they now” list of past picks. This year’s list holds some promising new innovations.

Secure Online Visits Help Family Practitioner Increase Patient Access and Boost Revenue
Lisa Rankin, MD, has been a solo family practitioner in Port St. Lucie, Fla., since 2004. Her practice (http://lisarankinmd.com/) includes two nurse practitioners and a mental health therapist. Rankin also cares for many pediatric patients and performs skin biopsies, massage, ultrasound, and some gynecology. In addition to traditional office-based care, she conducts e-visits with her established patients using the RelayHealth webVisit consultation system. Rankin discussed the RelayHealth system with Richard L. Reece, MD, editor-in-chief.

The Medical Home Model Relies on Significant Assumptions
As Congress considers ways to reform the health care system, a question that needs to be answered is how to save primary care. A number of health care organizations believe the answer to this question lies in creating patient-centered medical homes (PCMHs).

Reform Should Focus on Freedom of Choice
The federal government is closer to reforming the health care system than perhaps it has ever been. The plan may pass both houses of Congress this fall. Although many of the details have yet to be worked out, a rough outline is starting to take shape as this issue goes to press.

The plans Congress is considering include a wide variety of changes for almost all Americans. Among the reforms are rules that may prohibit health insurers from denying coverage to individuals with pre-existing health problems. Medicare or Medicaid coverage could be expanded to include individuals not currently eligible.

In Health Care, One Size May Not Fit All
Discussions about whether the federal government should enact health care reform have revolved around the issues of cost control and providing care for the uninsured. Both of these goals are laudable but skepticism about whether any reform plan can accomplish these goals is widespread. Many opponents ask whether it’s possible to provide coverage to the estimated 45 million Americans who are uninsured and control costs at the same time. It’s a good question.

Is a Patient- and Physician-Friendly Health Care System Possible?
One of the biggest concerns about health care reform is that it will be unfriendly to patients and physicians. Given this concern, here is my idea for a health care system that would be friendly to both parties.

Can Telehealth Improve Care for Patients with Chronic Illness?
Randy Moore, MD, MBA, the chairman and CEO of American TeleCare, Inc. (ATI), has a surprising opinion about reimbursement for telehealth. He believes that to achieve the outcome-improving and cost-controlling benefits of telehealth, we should not pay for it as a stand-alone technology.

PCPs Feel the Need for Innovations
There are not enough primary care physicians (PCPs), and the reasons for this shortage are numerous and difficult to fix in a short time. There are few incentives for medical students to practice patient-centered primary care. Pediatricians, internal medicine specialists, and family physicians face low pay compared with other specialists and have high debt but perhaps heavier workloads, since they need to be on call at unusual hours. In addition, there are not enough residency slots. It takes eight to 10 years to produce a PCP, meaning that even if more medical students began pursuing careers in primary care today, there would be a lag of at least eight years before the number of practicing PCPs begins to rise.

Doctor Gets Patient’s View of Care
As I lay on my back on the hospital bed, after the catheter was removed and the stent inserted, and tethered by intravenous lines and health monitoring leads, a quote from journalist Alistair Cooke came to mind. I was connected to a devilish device called Femstop, a pressure-driven plastic globe, pressing down on my femoral entry site to prevent a hematoma. At that moment, I recalled a quote from a talk by Cooke, “The Patient Has the Floor,” delivered at the Mayo Clinic in 1965. Cooke said, “I wish to talk of the fears of some statesman, lawyer, or other grandee who never appears before a doctor except to have his chest tapped, his knees jerked, his tongue depressed, his innards photographed, his rectum protoscoped, and his juices filtered, measured and pronounced upon. It is, though you may not know it, a permanently humiliating relationship: I mean the relationship between doctors and the rest of mankind. And it is because most people do not care to bring it up in public that I believe it might be useful for me to do so.”

The Many Obstacles to Health Reform
In a way, it is meaningless to talk of universal health care. It may even be misleading to talk of a national health system. It is equally misleading to say we have a “non-system.” We have many systems—public, private, state-wide as in Massachusetts, city-wide as in San Francisco, and regional like the Mayo Clinic and other major health organizations. But we are transforming into a new kind of care: patient-centered care.

The California Dream Remains Elusive
Proponents say large, integrated systems could follow and treat patients wherever they go throughout their lives. Doctors and hospitals within a regional system would have no incentive to provide more care than a patient needs. Computers within the integrated systems would guarantee that no unsafe or duplicate tests or prescriptions were requested. Preventive tests would be promoted. As a result of all of this eliminated waste, costs would be lowered by as much as 20% to 22% at facilities like Mayo and Kaiser. But the dream is not catching on.

Effectiveness Plan Raises Questions
Last month, the federal Department of Health and Human Services announced the members of the Federal Coordinating Council for Comparative Effectiveness Research. Comparative effectiveness research (CER), for better or worse, has arrived. Occasionally, an idea surfaces that seems so simple, rational, and scientific, that it may be too good to be true. CER is such an idea.

Physicians Promote Innovative Approaches to Care
Physicians have long used technological innovations to improve care, and, as the Cleveland Clinic (www.clevelandclinic.org) recently demonstrated, they are continuing to do so. The clinic sponsored a Medical Innovation Summit which provides a glimpse at how technology is changing health care.
The innovations are:

Study Shows IT Usage Saves Lives
A recent study sheds light on the value of using information technology (IT) in health care settings. Researchers found that hospitals using automated clinical information systems had fewer complications, lower mortality rates, and lower costs. For all medical conditions, those facilities with high automation scores had 15% fewer fatal hospitalizations, 9% lower likelihood of death for myocardial infarction, 55% fewer deaths from coronary bypass, and 16% fewer complications for all patients.

Supported by a grant from The Commonwealth Fund, the research is significant because the results may compel health policy experts to encourage all providers to invest in information systems that can help cut costs and improve patient outcomes and save lives. The research was published as an article, “Clinical Information Technologies and Inpatient Outcomes, A Multiple Hospital Study,” in the Archives of Internal Medicine (Arch Intern Med. 2009;169(2):108-114).

Business Models Continue to Evolve
For physicians to affect reform and leverage their skills, they need business models with reach and clout. These models must make physicians indispensable to payers, consumers, and hospitals. They must be economically efficient, clinically effective, and sustainable, and satisfy physicians, who often demand a degree of autonomy. And they must offer patients convenient access with predictable and affordable prices.

These characteristics are not easy to achieve and require the leadership of physicians, or possibly nonphysician leaders whom doctors trust. The structure of an organization or practice also must fit within the framework of existing laws and regulations, often set forth and dictated by Medicare, the nation’s dominant payer.

Book Explains Patient’s View of Dialysis
Cindy Barclay, RN, is a critical care nurse with 20 years of experience in the dialysis business, including 14 years as owner and CEO of Quality Dialysis, Inc., a company that provides dialysis services in Houston. Early in her career, Barclay noticed patients were often given little information about chronic kidney disease and the need for dialysis. Few medical professionals explained the disease and its implications, leaving patients and family members confused.

To clear up the confusion, she first wrote a manual for dialysis patients, which evolved into a book, That Damn Dialysis (Claybar Publishing, Inc., 2007, $19.95, or $10 for dialysis patients). It took Barclay two years to write this dramatic tale in the form of a novel about the trials of Cledus Washington, a 50-year-old cabinet maker who has CKD and needs dialysis. Barclay is currently writing a sequel about Cledus’ life after he gets a kidney transplant.

Nephrology Group Finds Creative Ways to Educate PCPs, Patients
James Lewis, MD, is a nephrologist and founder and president of Riverside Nephrology Group in Columbus, Ohio. A graduate of Loyola University School of Medicine, Lewis did an internal medicine residency and a nephrology fellowship at the Cleveland Clinic before founding Riverside Nephrology in 1978. The group has seven nephrologists and operates six dialysis clinics in the Columbus area. In addition, Lewis has been instrumental in developing a vascular access center and innovative ways to educate primary care physicians about referring patients for nephrology care. He spoke with Contributing Editor Richard L. Reece, MD, about the challenges the practice faces.

Conference Focuses on Innovation in Health Care
This fall, officials from the federal Department of Health and Human Services (HHS) invited innovators in health care to attend a conference in Washington, D.C. The invitation came from Benjamin E. Sasse, PhD, HHS’ assistant secretary for planning and evaluation. As the author of Innovation-Driven Health Care: 34 Key Concepts for Transformation (Jones and Bartlett, 2007), I was one of the innovators invited to participate.
Under the leadership of HHS Secretary Mike Leavitt, HHS has been working to advance patient-centered health care with payment systems that stimulate entrepreneurial ingenuity from physicians, hospitals, and others. Many experts believe innovation is of prime importance if the U.S. health care system is to be reformed successfully. But simply discussing innovation is insufficient. As one physician said recently, the word “innovation” means little without specific details involving what form these innovations will take.

Survey Reveals State of Primary Care
In November, the Physicians’ Foundation, a charitable foundation in Boston that represents members of state and local medical societies, including most of America’s 900,000 physicians, released the results of a survey of 270,000 primary care physicians and 50,000 specialists (at www.physiciansfoundations.org). Titled The Physicians’ Perspective: Medical Practice in 2008, the report on the survey revealed a widespread loss of morale, and pointed out that many physicians are sufficiently overworked and demoralized that they wish to quit or reduce their practice hours. The results of the survey were reported on CNN and other major media outlets.

Texas Group Supports National Efforts
As chief executive officer for the past 11 years of the Texas Medical Association (TMA), Louis Goodman, PhD, has been a national leader in defending the cause of physicians. In addition, for the last year, he has served as President of the Physicians’ Foundation, previously known as the Physicians’ Foundation for Health System Excellence, a charitable foundation that represents state and local medical societies. The foundation aims to improve the health system and give private physicians a more prominent role in influencing the direction of health care reform. Goodman has a doctorate in health economics and public policy from New York University. He has worked for TMA for 21 years. Editor-in-Chief Richard L. Reece, MD, conducted this interview.