Joyce Frieden

The big box store Sam's Club is setting its sights on the information technology frontier by marketing electronic health record systems for medical practices with one to three physicians.

But not everyone is sold on value of such off-the-shelf systems, and with EHR systems seen as essential to health care reform and the ability to control spending, a lot is riding on just how these products are used in clinical practice.

With the package offered by Sam's Club, a Wal-Mart subsidiary, practices will receive three laptops and a tablet notebook from Dell, a laser printer, and EHR and practice management software from eClinicalWorks. The package, which also includes 12 weeks of on-site setup, customization, and support, costs less than $25,000 for the first physician and up to $10,000 for each additional physician in the practice. Available for purchase online, the package is being sold only to physicians in Georgia, Illinois, and Virginia, with a nationwide rollout planned for later this year.

The plan to sell the EHR system to Sam's Club members grew out of Wal-Mart's successful experience using Dell and eClinical Works EHR systems at its walk-in medical RediClinics. “We have 200,000 medical-type [business members] at our 600 clubs nationwide,” said Susan Koehler, senior manager in corporate communications at the Sam's Club home office in Bentonville, Ark.

Unlike Wal-Mart, Sam's Club has a one-on-one relationship with local businesses that buy supplies at the club, “so we have relationships at the local level with those doctors,” Ms. Koehler said.

Georgia, Illinois, and Virginia were selected for the rollout because “they were a good representation of broad-band access with a mix of rural and small-town community doctors,” she said. Those states also include big cities such as Atlanta and Chicago.

Ms. Koehler would not say how many systems have been sold since the product's launch in early April, but “we're very pleased with the interest” in it, she said.

With discounted hardware from Dell and savings from “interfaces coming out of the box,” Sam's Club could price its EHR system aggressively, explained Girish Navani, cofounder and CEO of eClinicalWorks in Westborough, Mass.

The package does not offer any less customization than if a physician practice was to buy a system individually, Mr. Navani said. “We don't change our implementation process.”

Dr. Michael Woolery, who practices in Coshocton, Ohio, recently bought an EHR system from another vendor, and said he would be wary of an off-the-shelf system. “You really need to spend a lot of time investigating different vendors and looking at different features that vendors can offer,” he said. “It takes a significant amount of time to pick a system and do that conversion and put the data you have already into a new format.”

Dr. Steven Waldren, director of the Center for Health Information Technology at the American Academy of Family Physicians, said that packages like Sam's Club's have advantages and disadvantages. “It's really a product and service package, not [just] a box of software that you order and then get installed,” he noted, yet the disadvantage is that it is prepackaged, “so decisions are made for you when they put it together.”

Workflow is a key factor in EHR selection, Dr. Waldren said. “Does it have the templates you need and want?” If you have midlevel personnel, “how does the signoff process work?” If the workflow “doesn't work for you, what type of customization is possible?” Off-the-shelf systems will cost less, “but there are probably going to be disadvantages around customization and the flexibility practices are going to have,” he said.

Although the package is aggressively priced, it is designed to be customized. MR. NAVANI

The big box store Sam's Club is setting its sights on the information technology frontier by marketing electronic health record systems for medical practices with one to three physicians.

But not everyone is sold on value of such off-the-shelf systems, and with EHR systems seen as essential to health care reform and the ability to control spending, a lot is riding on just how these products are used in clinical practice.

With the package offered by Sam's Club, a Wal-Mart subsidiary, practices will receive three laptops and a tablet notebook from Dell, a laser printer, and EHR and practice management software from eClinicalWorks. The package, which also includes 12 weeks of on-site setup, customization, and support, costs less than $25,000 for the first physician and up to $10,000 for each additional physician in the practice. Available for purchase online, the package is being sold only to physicians in Georgia, Illinois, and Virginia, with a nationwide rollout planned for later this year.

The plan to sell the EHR system to Sam's Club members grew out of Wal-Mart's successful experience using Dell and eClinical Works EHR systems at its walk-in medical RediClinics. “We have 200,000 medical-type [business members] at our 600 clubs nationwide,” said Susan Koehler, senior manager in corporate communications at the Sam's Club home office in Bentonville, Ark.

Unlike Wal-Mart, Sam's Club has a one-on-one relationship with local businesses that buy supplies at the club, “so we have relationships at the local level with those doctors,” Ms. Koehler said.

Georgia, Illinois, and Virginia were selected for the rollout because “they were a good representation of broad-band access with a mix of rural and small-town community doctors,” she said. Those states also include big cities such as Atlanta and Chicago.

Ms. Koehler would not say how many systems have been sold since the product's launch in early April, but “we're very pleased with the interest” in it, she said.

With discounted hardware from Dell and savings from “interfaces coming out of the box,” Sam's Club could price its EHR system aggressively, explained Girish Navani, cofounder and CEO of eClinicalWorks in Westborough, Mass.

The package does not offer any less customization than if a physician practice was to buy a system individually, Mr. Navani said. “We don't change our implementation process.”

Dr. Michael Woolery, who practices in Coshocton, Ohio, recently bought an EHR system from another vendor, and said he would be wary of an off-the-shelf system. “You really need to spend a lot of time investigating different vendors and looking at different features that vendors can offer,” he said. “It takes a significant amount of time to pick a system and do that conversion and put the data you have already into a new format.”

Dr. Steven Waldren, director of the Center for Health Information Technology at the American Academy of Family Physicians, said that packages like Sam's Club's have advantages and disadvantages. “It's really a product and service package, not [just] a box of software that you order and then get installed,” he noted, yet the disadvantage is that it is prepackaged, “so decisions are made for you when they put it together.”

Workflow is a key factor in EHR selection, Dr. Waldren said. “Does it have the templates you need and want?” If you have midlevel personnel, “how does the signoff process work?” If the workflow “doesn't work for you, what type of customization is possible?” Off-the-shelf systems will cost less, “but there are probably going to be disadvantages around customization and the flexibility practices are going to have,” he said.

Although the package is aggressively priced, it is designed to be customized. MR. NAVANI

The big box store Sam's Club is setting its sights on the information technology frontier by marketing electronic health record systems for medical practices with one to three physicians.

But not everyone is sold on value of such off-the-shelf systems, and with EHR systems seen as essential to health care reform and the ability to control spending, a lot is riding on just how these products are used in clinical practice.

With the package offered by Sam's Club, a Wal-Mart subsidiary, practices will receive three laptops and a tablet notebook from Dell, a laser printer, and EHR and practice management software from eClinicalWorks. The package, which also includes 12 weeks of on-site setup, customization, and support, costs less than $25,000 for the first physician and up to $10,000 for each additional physician in the practice. Available for purchase online, the package is being sold only to physicians in Georgia, Illinois, and Virginia, with a nationwide rollout planned for later this year.

The plan to sell the EHR system to Sam's Club members grew out of Wal-Mart's successful experience using Dell and eClinical Works EHR systems at its walk-in medical RediClinics. “We have 200,000 medical-type [business members] at our 600 clubs nationwide,” said Susan Koehler, senior manager in corporate communications at the Sam's Club home office in Bentonville, Ark.

Unlike Wal-Mart, Sam's Club has a one-on-one relationship with local businesses that buy supplies at the club, “so we have relationships at the local level with those doctors,” Ms. Koehler said.

Georgia, Illinois, and Virginia were selected for the rollout because “they were a good representation of broad-band access with a mix of rural and small-town community doctors,” she said. Those states also include big cities such as Atlanta and Chicago.

Ms. Koehler would not say how many systems have been sold since the product's launch in early April, but “we're very pleased with the interest” in it, she said.

With discounted hardware from Dell and savings from “interfaces coming out of the box,” Sam's Club could price its EHR system aggressively, explained Girish Navani, cofounder and CEO of eClinicalWorks in Westborough, Mass.

The package does not offer any less customization than if a physician practice was to buy a system individually, Mr. Navani said. “We don't change our implementation process.”

Dr. Michael Woolery, who practices in Coshocton, Ohio, recently bought an EHR system from another vendor, and said he would be wary of an off-the-shelf system. “You really need to spend a lot of time investigating different vendors and looking at different features that vendors can offer,” he said. “It takes a significant amount of time to pick a system and do that conversion and put the data you have already into a new format.”

Dr. Steven Waldren, director of the Center for Health Information Technology at the American Academy of Family Physicians, said that packages like Sam's Club's have advantages and disadvantages. “It's really a product and service package, not [just] a box of software that you order and then get installed,” he noted, yet the disadvantage is that it is prepackaged, “so decisions are made for you when they put it together.”

Workflow is a key factor in EHR selection, Dr. Waldren said. “Does it have the templates you need and want?” If you have midlevel personnel, “how does the signoff process work?” If the workflow “doesn't work for you, what type of customization is possible?” Off-the-shelf systems will cost less, “but there are probably going to be disadvantages around customization and the flexibility practices are going to have,” he said.

Although the package is aggressively priced, it is designed to be customized. MR. NAVANI

Physicians and their staffs spend the equivalent of 3 weeks, and $31 billion, each year processing health insurance paperwork, according to a study funded by the Commonwealth Fund and the Robert Wood Johnson Foundation.

The survey of 895 physicians and practice administrators nationwide asked respondents about the amount of time their practice's staff spent on various administrative activities.

The researchers found that physicians spent an average of 3 hours a week—or nearly 3 weeks a year—on administrative activities. Nursing staff spent more than 23 weeks per physician per year, and clerical staff spent 44 weeks per physician per year, interacting with health plans. More than three in four respondents said the costs of interacting with health plans have increased over the past 2 years (Health Affairs doi:10.1377/hlthaff.28.4.w533). Overall, the cost of these interactions amounts to $31 billion annually.

"While there are benefits to physician offices' interactions with health plans—which may, for example, help to reduce unnecessary care or the inappropriate use of medication—it would be useful to explore the extent to which these benefits are large enough to justify spending 3 weeks annually of physician time … on physician practice-health plan interaction," the study's lead author, Dr. Lawrence P. Casalino of Cornell University, said in a statement. "It would also be useful to explore ways to make the interactions more efficient."

Physicians in solo or 2-person practices spent many more hours interacting with health plans than did those in practices with 10 or more. And all physicians and staff spent much more time on authorization, formularies, claims and billing, and credentialing than they did on reviewing or submitting quality data.

"To get to a health care system that is high quality and delivers better value for everyone, we have to address the skyrocketing price of health care's administrative costs," said Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation. "Administrative costs will never be zero, but we need to make sure that administrative interactions improve the quality of care by working to make care safer and more efficient, and rewarding health care providers who successfully reduce excessive care and provide the right treatment."

Physicians and their staffs spend the equivalent of 3 weeks, and $31 billion, each year processing health insurance paperwork, according to a study funded by the Commonwealth Fund and the Robert Wood Johnson Foundation.

The survey of 895 physicians and practice administrators nationwide asked respondents about the amount of time their practice's staff spent on various administrative activities.

The researchers found that physicians spent an average of 3 hours a week—or nearly 3 weeks a year—on administrative activities. Nursing staff spent more than 23 weeks per physician per year, and clerical staff spent 44 weeks per physician per year, interacting with health plans. More than three in four respondents said the costs of interacting with health plans have increased over the past 2 years (Health Affairs doi:10.1377/hlthaff.28.4.w533). Overall, the cost of these interactions amounts to $31 billion annually.

"While there are benefits to physician offices' interactions with health plans—which may, for example, help to reduce unnecessary care or the inappropriate use of medication—it would be useful to explore the extent to which these benefits are large enough to justify spending 3 weeks annually of physician time … on physician practice-health plan interaction," the study's lead author, Dr. Lawrence P. Casalino of Cornell University, said in a statement. "It would also be useful to explore ways to make the interactions more efficient."

Physicians in solo or 2-person practices spent many more hours interacting with health plans than did those in practices with 10 or more. And all physicians and staff spent much more time on authorization, formularies, claims and billing, and credentialing than they did on reviewing or submitting quality data.

"To get to a health care system that is high quality and delivers better value for everyone, we have to address the skyrocketing price of health care's administrative costs," said Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation. "Administrative costs will never be zero, but we need to make sure that administrative interactions improve the quality of care by working to make care safer and more efficient, and rewarding health care providers who successfully reduce excessive care and provide the right treatment."

Physicians and their staffs spend the equivalent of 3 weeks, and $31 billion, each year processing health insurance paperwork, according to a study funded by the Commonwealth Fund and the Robert Wood Johnson Foundation.

The survey of 895 physicians and practice administrators nationwide asked respondents about the amount of time their practice's staff spent on various administrative activities.

The researchers found that physicians spent an average of 3 hours a week—or nearly 3 weeks a year—on administrative activities. Nursing staff spent more than 23 weeks per physician per year, and clerical staff spent 44 weeks per physician per year, interacting with health plans. More than three in four respondents said the costs of interacting with health plans have increased over the past 2 years (Health Affairs doi:10.1377/hlthaff.28.4.w533). Overall, the cost of these interactions amounts to $31 billion annually.

"While there are benefits to physician offices' interactions with health plans—which may, for example, help to reduce unnecessary care or the inappropriate use of medication—it would be useful to explore the extent to which these benefits are large enough to justify spending 3 weeks annually of physician time … on physician practice-health plan interaction," the study's lead author, Dr. Lawrence P. Casalino of Cornell University, said in a statement. "It would also be useful to explore ways to make the interactions more efficient."

Physicians in solo or 2-person practices spent many more hours interacting with health plans than did those in practices with 10 or more. And all physicians and staff spent much more time on authorization, formularies, claims and billing, and credentialing than they did on reviewing or submitting quality data.

"To get to a health care system that is high quality and delivers better value for everyone, we have to address the skyrocketing price of health care's administrative costs," said Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation. "Administrative costs will never be zero, but we need to make sure that administrative interactions improve the quality of care by working to make care safer and more efficient, and rewarding health care providers who successfully reduce excessive care and provide the right treatment."

In one of her first public acts at the Food and Drug Administration, new commissioner Margaret Hamburg announced that the agency aims to be more transparent about its daily work and decision-making process.

“Over the years, complaints have been made about FDA's lack of transparency,” Dr. Hamburg said in June in announcing the launch of a transparency task force.

“The agency has been referred to as a 'black box' that makes important decisions without disclosing them. The agency can and should communicate in a way that provides more transparency, not less,” she added. The commissioner said it was her goal that the public looks first to FDA for trustworthy and useful information about drugs and devices.

“On President Obama's first day in office, he pledged to strengthen democracy … by creating an unprecedented level of openness” in government, noted Dr. Hamburg, who took over at FDA on May 22. “This will be an agency-wide effort charged with figuring out how to make the FDA and its processes more transparent to the public.”

The transparency task force will include the directors of all FDA centers as well as the agency's associate commissioner for regulatory affairs, its chief counsel, and its chief scientist. All meetings will be open to the public. The task force “expects to submit a written report to the commissioner about 6 months from now,” according to FDA principal deputy commissioner and task force chair Joshua Sharfstein.

Being clearer about why the agency decides things a certain way is one area of interest for Dr. Sharfstein. “People don't understand why the FDA may have done something or not done something,” he said. “In many cases, the agency has an explanation, but you don't necessarily hear that explanation very clearly.”

Dr. Hamburg said she expects that a wide range of recommendations could emerge from the task force's work. Some recommendations “will be in areas that we can implement swiftly, but there may be other types of information that will take more time, and there may be some area where we have limitations within the current law and need to examine whether appropriate changes can and should be made,” she said.

Both Dr. Hamburg and Dr. Sharfstein emphasized, however, that a balance will need to be struck between providing more information and the appropriate use of confidentiality.

Another balancing act will come in terms of clinical trials, Dr. Sharfstein continued. “What is the argument for different amounts of data [being disclosed] at different points in the drug development process, and on the other side, what are the confidentiality concerns and the reasons for them?”

The call for transparency comes at a time when FDA already has a backlog of requests under the Freedom of Information Act.

Asked how she planned to handle personnel needs at a time when the agency is behind in its work, Dr. Hamburg said, “When the recommendations come in, I will work with the task force and others on implementation. Some activity may result in more work, and some may result in decreased work. If we make more information available, there may be fewer Freedom of Information Act requests and citizen petitions.”

The Federal Register notice announcing the task force's formation is available online at www.federalregister.gov

In one of her first public acts at the Food and Drug Administration, new commissioner Margaret Hamburg announced that the agency aims to be more transparent about its daily work and decision-making process.

“Over the years, complaints have been made about FDA's lack of transparency,” Dr. Hamburg said in June in announcing the launch of a transparency task force.

“The agency has been referred to as a 'black box' that makes important decisions without disclosing them. The agency can and should communicate in a way that provides more transparency, not less,” she added. The commissioner said it was her goal that the public looks first to FDA for trustworthy and useful information about drugs and devices.

“On President Obama's first day in office, he pledged to strengthen democracy … by creating an unprecedented level of openness” in government, noted Dr. Hamburg, who took over at FDA on May 22. “This will be an agency-wide effort charged with figuring out how to make the FDA and its processes more transparent to the public.”

The transparency task force will include the directors of all FDA centers as well as the agency's associate commissioner for regulatory affairs, its chief counsel, and its chief scientist. All meetings will be open to the public. The task force “expects to submit a written report to the commissioner about 6 months from now,” according to FDA principal deputy commissioner and task force chair Joshua Sharfstein.

Being clearer about why the agency decides things a certain way is one area of interest for Dr. Sharfstein. “People don't understand why the FDA may have done something or not done something,” he said. “In many cases, the agency has an explanation, but you don't necessarily hear that explanation very clearly.”

Dr. Hamburg said she expects that a wide range of recommendations could emerge from the task force's work. Some recommendations “will be in areas that we can implement swiftly, but there may be other types of information that will take more time, and there may be some area where we have limitations within the current law and need to examine whether appropriate changes can and should be made,” she said.

Both Dr. Hamburg and Dr. Sharfstein emphasized, however, that a balance will need to be struck between providing more information and the appropriate use of confidentiality.

Another balancing act will come in terms of clinical trials, Dr. Sharfstein continued. “What is the argument for different amounts of data [being disclosed] at different points in the drug development process, and on the other side, what are the confidentiality concerns and the reasons for them?”

The call for transparency comes at a time when FDA already has a backlog of requests under the Freedom of Information Act.

Asked how she planned to handle personnel needs at a time when the agency is behind in its work, Dr. Hamburg said, “When the recommendations come in, I will work with the task force and others on implementation. Some activity may result in more work, and some may result in decreased work. If we make more information available, there may be fewer Freedom of Information Act requests and citizen petitions.”

The Federal Register notice announcing the task force's formation is available online at www.federalregister.gov

In one of her first public acts at the Food and Drug Administration, new commissioner Margaret Hamburg announced that the agency aims to be more transparent about its daily work and decision-making process.

“Over the years, complaints have been made about FDA's lack of transparency,” Dr. Hamburg said in June in announcing the launch of a transparency task force.

“The agency has been referred to as a 'black box' that makes important decisions without disclosing them. The agency can and should communicate in a way that provides more transparency, not less,” she added. The commissioner said it was her goal that the public looks first to FDA for trustworthy and useful information about drugs and devices.

“On President Obama's first day in office, he pledged to strengthen democracy … by creating an unprecedented level of openness” in government, noted Dr. Hamburg, who took over at FDA on May 22. “This will be an agency-wide effort charged with figuring out how to make the FDA and its processes more transparent to the public.”

The transparency task force will include the directors of all FDA centers as well as the agency's associate commissioner for regulatory affairs, its chief counsel, and its chief scientist. All meetings will be open to the public. The task force “expects to submit a written report to the commissioner about 6 months from now,” according to FDA principal deputy commissioner and task force chair Joshua Sharfstein.

Being clearer about why the agency decides things a certain way is one area of interest for Dr. Sharfstein. “People don't understand why the FDA may have done something or not done something,” he said. “In many cases, the agency has an explanation, but you don't necessarily hear that explanation very clearly.”

Dr. Hamburg said she expects that a wide range of recommendations could emerge from the task force's work. Some recommendations “will be in areas that we can implement swiftly, but there may be other types of information that will take more time, and there may be some area where we have limitations within the current law and need to examine whether appropriate changes can and should be made,” she said.

Both Dr. Hamburg and Dr. Sharfstein emphasized, however, that a balance will need to be struck between providing more information and the appropriate use of confidentiality.

Another balancing act will come in terms of clinical trials, Dr. Sharfstein continued. “What is the argument for different amounts of data [being disclosed] at different points in the drug development process, and on the other side, what are the confidentiality concerns and the reasons for them?”

The call for transparency comes at a time when FDA already has a backlog of requests under the Freedom of Information Act.

Asked how she planned to handle personnel needs at a time when the agency is behind in its work, Dr. Hamburg said, “When the recommendations come in, I will work with the task force and others on implementation. Some activity may result in more work, and some may result in decreased work. If we make more information available, there may be fewer Freedom of Information Act requests and citizen petitions.”

The Federal Register notice announcing the task force's formation is available online at www.federalregister.gov

Physicians and their staffs spend the equivalent of weeks—and $31 billion—each year processing health insurance paperwork, according to a study funded by the Commonwealth Fund and the Robert Wood Johnson Foundation.

The survey of 895 physicians and practice administrators nationwide asked respondents about the amount of time their practice's staff spent on various administrative activities, including prior authorization, drug formularies, claims and billing, credentialing, contracting, and collecting and reporting quality data.

The researchers found that physicians spent an average of 3 hours a week—or nearly 3 weeks a year—on administrative activities. Nursing staff spent more than 23 weeks per physician per year, and clerical staff spent 44 weeks per physician per year, interacting with health plans. More than three in four respondents said the costs of interacting with health plans have increased over the past 2 years (HealthAffairs doi:10.1377/hlthaff.28.4.w533). Overall, the cost of these interactions amounts to $31 billion annually.

“While there are benefits to physician offices' interactions with health plans—which may, for example, help to reduce unnecessary care or the inappropriate use of medication—it would be useful to explore the extent to which these benefits are large enough to justify spending 3 weeks annually of physician time … on physician practice-health plan interaction,” the study's lead author, Dr. Lawrence P. Casalino of Cornell University said in a statement. Physicians in solo or two-person practices spent many more hours interacting with health plans than did those in practices with 10 or more physicians; this was especially true in primary care, the researchers found.

“Administrative costs will never be zero, but we need to make sure that administrative interactions improve the quality of care by working to make care safer and more efficient, and rewarding health care providers who successfully reduce excessive care and provide the right treatment at the right time,” Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation, said in a statement.

Physicians and their staffs spend the equivalent of weeks—and $31 billion—each year processing health insurance paperwork, according to a study funded by the Commonwealth Fund and the Robert Wood Johnson Foundation.

The survey of 895 physicians and practice administrators nationwide asked respondents about the amount of time their practice's staff spent on various administrative activities, including prior authorization, drug formularies, claims and billing, credentialing, contracting, and collecting and reporting quality data.

The researchers found that physicians spent an average of 3 hours a week—or nearly 3 weeks a year—on administrative activities. Nursing staff spent more than 23 weeks per physician per year, and clerical staff spent 44 weeks per physician per year, interacting with health plans. More than three in four respondents said the costs of interacting with health plans have increased over the past 2 years (HealthAffairs doi:10.1377/hlthaff.28.4.w533). Overall, the cost of these interactions amounts to $31 billion annually.

“While there are benefits to physician offices' interactions with health plans—which may, for example, help to reduce unnecessary care or the inappropriate use of medication—it would be useful to explore the extent to which these benefits are large enough to justify spending 3 weeks annually of physician time … on physician practice-health plan interaction,” the study's lead author, Dr. Lawrence P. Casalino of Cornell University said in a statement. Physicians in solo or two-person practices spent many more hours interacting with health plans than did those in practices with 10 or more physicians; this was especially true in primary care, the researchers found.

“Administrative costs will never be zero, but we need to make sure that administrative interactions improve the quality of care by working to make care safer and more efficient, and rewarding health care providers who successfully reduce excessive care and provide the right treatment at the right time,” Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation, said in a statement.

Physicians and their staffs spend the equivalent of weeks—and $31 billion—each year processing health insurance paperwork, according to a study funded by the Commonwealth Fund and the Robert Wood Johnson Foundation.

The survey of 895 physicians and practice administrators nationwide asked respondents about the amount of time their practice's staff spent on various administrative activities, including prior authorization, drug formularies, claims and billing, credentialing, contracting, and collecting and reporting quality data.

The researchers found that physicians spent an average of 3 hours a week—or nearly 3 weeks a year—on administrative activities. Nursing staff spent more than 23 weeks per physician per year, and clerical staff spent 44 weeks per physician per year, interacting with health plans. More than three in four respondents said the costs of interacting with health plans have increased over the past 2 years (HealthAffairs doi:10.1377/hlthaff.28.4.w533). Overall, the cost of these interactions amounts to $31 billion annually.

“While there are benefits to physician offices' interactions with health plans—which may, for example, help to reduce unnecessary care or the inappropriate use of medication—it would be useful to explore the extent to which these benefits are large enough to justify spending 3 weeks annually of physician time … on physician practice-health plan interaction,” the study's lead author, Dr. Lawrence P. Casalino of Cornell University said in a statement. Physicians in solo or two-person practices spent many more hours interacting with health plans than did those in practices with 10 or more physicians; this was especially true in primary care, the researchers found.

“Administrative costs will never be zero, but we need to make sure that administrative interactions improve the quality of care by working to make care safer and more efficient, and rewarding health care providers who successfully reduce excessive care and provide the right treatment at the right time,” Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation, said in a statement.

A new report from the Dartmouth Atlas of Health Care finds that, overall, the hospital bed supply per capita contracted from 1996 to 2006, while the numbers of hospital-based employees and registered nurses increased.

The number of staffed acute care beds dropped from 2.82 per 1,000 U.S. residents in 1996 to 2.46 per 1,000 in 2006, according to the report. However, there was great regional variation. For example, the Jackson, Miss., area had 4.44 beds per 1,000 in 2006, compared with 1.45 in San Mateo County, Calif. Not surprisingly, the areas with the most beds also had high numbers of hospital employees.

“As long ago as the 1960s, Milton Roemer described the phenomenon that a built bed was a filled bed,” noted the report, which was written by Dr. David C. Goodman, Dr. Elliott S. Fisher, and Kristen K. Bronner. “Numerous studies since then have found that higher bed supply is associated with more hospital use for conditions where outpatient care is a viable alternative. This includes most medical causes of hospitalization.”

Physician supply continued to expand “modestly,” although numbers varied greatly by specialty, the report said. For example, the number of primary care physicians increased 11% over the study period, compared with 51% for infectious disease specialists and a whopping 198% for critical care specialists. Specialties that experienced declines included cardiothoracic surgery (−17%), pulmonology (-18%), and general surgery (−19%).

The authors made several suggestions for managing hospital capacity and physician workforce growth. To reduce “unwarranted” variations in hospital supply, “Congress could require the Centers for Medicare and Medicaid Services to use its capital payment policies to limit the further growth of hospital capacity in markets that are already overinvested,” they wrote. “Although Certificate of Need programs have generally not been effective, strengthening [such] programs or statewide prospective hospital budgeting processes could be used to more wisely target future hospital growth.”

To better adjust the physician workforce, “a national workforce commission with representation from the clinical professions, public health, health care purchasers, and patients would provide badly needed analyses and research to better direct funds for health workforce training and for provision of care to the underserved,” the authors suggested.

A new report from the Dartmouth Atlas of Health Care finds that, overall, the hospital bed supply per capita contracted from 1996 to 2006, while the numbers of hospital-based employees and registered nurses increased.

The number of staffed acute care beds dropped from 2.82 per 1,000 U.S. residents in 1996 to 2.46 per 1,000 in 2006, according to the report. However, there was great regional variation. For example, the Jackson, Miss., area had 4.44 beds per 1,000 in 2006, compared with 1.45 in San Mateo County, Calif. Not surprisingly, the areas with the most beds also had high numbers of hospital employees.

“As long ago as the 1960s, Milton Roemer described the phenomenon that a built bed was a filled bed,” noted the report, which was written by Dr. David C. Goodman, Dr. Elliott S. Fisher, and Kristen K. Bronner. “Numerous studies since then have found that higher bed supply is associated with more hospital use for conditions where outpatient care is a viable alternative. This includes most medical causes of hospitalization.”

Physician supply continued to expand “modestly,” although numbers varied greatly by specialty, the report said. For example, the number of primary care physicians increased 11% over the study period, compared with 51% for infectious disease specialists and a whopping 198% for critical care specialists. Specialties that experienced declines included cardiothoracic surgery (−17%), pulmonology (-18%), and general surgery (−19%).

The authors made several suggestions for managing hospital capacity and physician workforce growth. To reduce “unwarranted” variations in hospital supply, “Congress could require the Centers for Medicare and Medicaid Services to use its capital payment policies to limit the further growth of hospital capacity in markets that are already overinvested,” they wrote. “Although Certificate of Need programs have generally not been effective, strengthening [such] programs or statewide prospective hospital budgeting processes could be used to more wisely target future hospital growth.”

To better adjust the physician workforce, “a national workforce commission with representation from the clinical professions, public health, health care purchasers, and patients would provide badly needed analyses and research to better direct funds for health workforce training and for provision of care to the underserved,” the authors suggested.

A new report from the Dartmouth Atlas of Health Care finds that, overall, the hospital bed supply per capita contracted from 1996 to 2006, while the numbers of hospital-based employees and registered nurses increased.

The number of staffed acute care beds dropped from 2.82 per 1,000 U.S. residents in 1996 to 2.46 per 1,000 in 2006, according to the report. However, there was great regional variation. For example, the Jackson, Miss., area had 4.44 beds per 1,000 in 2006, compared with 1.45 in San Mateo County, Calif. Not surprisingly, the areas with the most beds also had high numbers of hospital employees.

“As long ago as the 1960s, Milton Roemer described the phenomenon that a built bed was a filled bed,” noted the report, which was written by Dr. David C. Goodman, Dr. Elliott S. Fisher, and Kristen K. Bronner. “Numerous studies since then have found that higher bed supply is associated with more hospital use for conditions where outpatient care is a viable alternative. This includes most medical causes of hospitalization.”

Physician supply continued to expand “modestly,” although numbers varied greatly by specialty, the report said. For example, the number of primary care physicians increased 11% over the study period, compared with 51% for infectious disease specialists and a whopping 198% for critical care specialists. Specialties that experienced declines included cardiothoracic surgery (−17%), pulmonology (-18%), and general surgery (−19%).

The authors made several suggestions for managing hospital capacity and physician workforce growth. To reduce “unwarranted” variations in hospital supply, “Congress could require the Centers for Medicare and Medicaid Services to use its capital payment policies to limit the further growth of hospital capacity in markets that are already overinvested,” they wrote. “Although Certificate of Need programs have generally not been effective, strengthening [such] programs or statewide prospective hospital budgeting processes could be used to more wisely target future hospital growth.”

To better adjust the physician workforce, “a national workforce commission with representation from the clinical professions, public health, health care purchasers, and patients would provide badly needed analyses and research to better direct funds for health workforce training and for provision of care to the underserved,” the authors suggested.

The consensus document is available at www.markle.org/downloadable_assets/20090430_meaningful_use.pdf

WASHINGTON — Just what exactly does “meaningful use” mean?

It sounds like a simple question, but a lot of money is riding on the answer. The Recovery Act, formally known as the American Recovery and Reinvestment Act, stipulates that for a physician to receive up to $44,000 in financial incentives for purchasing an electronic health record (EHR), the record must be put to “meaningful use.” Now the government has to come up with a definition of the term.

At a subcommittee meeting of the National Committee on Vital and Health Statistics, which was convened to discuss meaningful use, several speakers explained why having more physicians adopt an EHR was so valuable.

“The financial meltdown … has shown us how we as a nation need to totally transform the U.S. health care system,” said Helen Darling, president of the National Business Group on Health. “We have a fiscal crisis, not just a health crisis; we have to act urgently.”

Dr. Elliott Fisher, professor of medicine at Dartmouth University, Hanover, N.H., started explaining the benefits of EHRs by noting that more health care is not always better care. “Gray area” discretionary decisions about when to refer to a specialist explain most of the regional differences in health care spending and are responsible for most of the health care overuse, he said.

The only way to reduce that overuse is to feed the information—gathered through EHRs—back to the physician “and start to have a conversation” about when certain tests or referrals are necessary, Dr. Fisher said.

Although everyone agreed that EHRs were valuable, speakers' definitions of “meaningful use” of them differed. “Meaningful use might vary by site of care as well as by type of care,” said Dr. David Classen of the Computer Sciences Corp., whereas Dr. John Halamka of the Health Information Technology Standards Panel, a government-funded group that helps ensure EHR interoperability, said his definition of meaningful use was “processes and workflows that facilitate improved quality and increased efficiency.”

Several panelists agreed that EHRs had to allow for three things in order to be used meaningfully: electronic prescribing, interoperability with other computers, and reporting on health care quality measures. EHRs are particularly useful for reporting quality measures because they are a direct source of information and provide very timely data, said Dr. Michael Rapp of the Centers for Medicare and Medicaid Services.

Experts at the meeting also agreed in general that EHR systems need to be certified by a government-approved organization such as the Certification Commission for Healthcare Information Technology to meet the Recovery Act's requirements. But certification alone is not sufficient, because many parts of a certified EHR are not necessarily implemented, said Dr. Floyd Eisenberg, senior vice president for health information technology at the National Quality Forum.

The day after the subcommittee's 2-day meeting concluded, the Markle Foundation held a press conference to release a consensus document on the definition of meaningful use. The document was endorsed by a number of provider and advocacy groups, including the AARP, the American Academy of Family Physicians, the Joint Commission, and America's Health Insurance Plans.

The consensus document provides a “simple” definition of patient-centered meaningful use: “The provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs.

EHRs are useful for reporting quality measures because they provide direct information and timely data. DR. RAPP

The consensus document is available at www.markle.org/downloadable_assets/20090430_meaningful_use.pdf

WASHINGTON — Just what exactly does “meaningful use” mean?

It sounds like a simple question, but a lot of money is riding on the answer. The Recovery Act, formally known as the American Recovery and Reinvestment Act, stipulates that for a physician to receive up to $44,000 in financial incentives for purchasing an electronic health record (EHR), the record must be put to “meaningful use.” Now the government has to come up with a definition of the term.

At a subcommittee meeting of the National Committee on Vital and Health Statistics, which was convened to discuss meaningful use, several speakers explained why having more physicians adopt an EHR was so valuable.

“The financial meltdown … has shown us how we as a nation need to totally transform the U.S. health care system,” said Helen Darling, president of the National Business Group on Health. “We have a fiscal crisis, not just a health crisis; we have to act urgently.”

Dr. Elliott Fisher, professor of medicine at Dartmouth University, Hanover, N.H., started explaining the benefits of EHRs by noting that more health care is not always better care. “Gray area” discretionary decisions about when to refer to a specialist explain most of the regional differences in health care spending and are responsible for most of the health care overuse, he said.

The only way to reduce that overuse is to feed the information—gathered through EHRs—back to the physician “and start to have a conversation” about when certain tests or referrals are necessary, Dr. Fisher said.

Although everyone agreed that EHRs were valuable, speakers' definitions of “meaningful use” of them differed. “Meaningful use might vary by site of care as well as by type of care,” said Dr. David Classen of the Computer Sciences Corp., whereas Dr. John Halamka of the Health Information Technology Standards Panel, a government-funded group that helps ensure EHR interoperability, said his definition of meaningful use was “processes and workflows that facilitate improved quality and increased efficiency.”

Several panelists agreed that EHRs had to allow for three things in order to be used meaningfully: electronic prescribing, interoperability with other computers, and reporting on health care quality measures. EHRs are particularly useful for reporting quality measures because they are a direct source of information and provide very timely data, said Dr. Michael Rapp of the Centers for Medicare and Medicaid Services.

Experts at the meeting also agreed in general that EHR systems need to be certified by a government-approved organization such as the Certification Commission for Healthcare Information Technology to meet the Recovery Act's requirements. But certification alone is not sufficient, because many parts of a certified EHR are not necessarily implemented, said Dr. Floyd Eisenberg, senior vice president for health information technology at the National Quality Forum.

The day after the subcommittee's 2-day meeting concluded, the Markle Foundation held a press conference to release a consensus document on the definition of meaningful use. The document was endorsed by a number of provider and advocacy groups, including the AARP, the American Academy of Family Physicians, the Joint Commission, and America's Health Insurance Plans.

The consensus document provides a “simple” definition of patient-centered meaningful use: “The provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs.

EHRs are useful for reporting quality measures because they provide direct information and timely data. DR. RAPP

The consensus document is available at www.markle.org/downloadable_assets/20090430_meaningful_use.pdf

WASHINGTON — Just what exactly does “meaningful use” mean?

It sounds like a simple question, but a lot of money is riding on the answer. The Recovery Act, formally known as the American Recovery and Reinvestment Act, stipulates that for a physician to receive up to $44,000 in financial incentives for purchasing an electronic health record (EHR), the record must be put to “meaningful use.” Now the government has to come up with a definition of the term.

At a subcommittee meeting of the National Committee on Vital and Health Statistics, which was convened to discuss meaningful use, several speakers explained why having more physicians adopt an EHR was so valuable.

“The financial meltdown … has shown us how we as a nation need to totally transform the U.S. health care system,” said Helen Darling, president of the National Business Group on Health. “We have a fiscal crisis, not just a health crisis; we have to act urgently.”

Dr. Elliott Fisher, professor of medicine at Dartmouth University, Hanover, N.H., started explaining the benefits of EHRs by noting that more health care is not always better care. “Gray area” discretionary decisions about when to refer to a specialist explain most of the regional differences in health care spending and are responsible for most of the health care overuse, he said.

The only way to reduce that overuse is to feed the information—gathered through EHRs—back to the physician “and start to have a conversation” about when certain tests or referrals are necessary, Dr. Fisher said.

Although everyone agreed that EHRs were valuable, speakers' definitions of “meaningful use” of them differed. “Meaningful use might vary by site of care as well as by type of care,” said Dr. David Classen of the Computer Sciences Corp., whereas Dr. John Halamka of the Health Information Technology Standards Panel, a government-funded group that helps ensure EHR interoperability, said his definition of meaningful use was “processes and workflows that facilitate improved quality and increased efficiency.”

Several panelists agreed that EHRs had to allow for three things in order to be used meaningfully: electronic prescribing, interoperability with other computers, and reporting on health care quality measures. EHRs are particularly useful for reporting quality measures because they are a direct source of information and provide very timely data, said Dr. Michael Rapp of the Centers for Medicare and Medicaid Services.

Experts at the meeting also agreed in general that EHR systems need to be certified by a government-approved organization such as the Certification Commission for Healthcare Information Technology to meet the Recovery Act's requirements. But certification alone is not sufficient, because many parts of a certified EHR are not necessarily implemented, said Dr. Floyd Eisenberg, senior vice president for health information technology at the National Quality Forum.

The day after the subcommittee's 2-day meeting concluded, the Markle Foundation held a press conference to release a consensus document on the definition of meaningful use. The document was endorsed by a number of provider and advocacy groups, including the AARP, the American Academy of Family Physicians, the Joint Commission, and America's Health Insurance Plans.

The consensus document provides a “simple” definition of patient-centered meaningful use: “The provider makes use of, and the patient has access to, clinically relevant electronic information about the patient to improve patient outcomes and health status, improve the delivery of care, and control the growth of costs.

EHRs are useful for reporting quality measures because they provide direct information and timely data. DR. RAPP

BALTIMORE — If Medicare is going to pay for genetic tests, what criteria should it use to decide which to cover?

That was one of the questions tackled by a Medicare Evidence Development and Coverage Advisory Committee panel. The 17-member panel included an ethicist, a patient advocate, representatives from the insurance and genetic-testing industries, and experts in cancer, ophthalmology, and cardiology.

Panel members heard presentations on various aspects of genetic testing. Dr. W. Gregory Feero, senior adviser to the director of genomic medicine at the National Human Genome Research Institute, argued that a good family history was vital to deciding which patients should receive particular genetic tests. “Family history is still the cheapest, most time-tested way to get an idea of disease risk,” he said.

Although several new practice guidelines call on physicians to collect family histories, “family history collection by primary care clinicians is actually quite poor,” said Dr. Feero, a board-certified family physician. “I would argue that it's going to get worse with [the advent of] electronic health records, as most systems are not well set up to enable clinicians to collect family health information.”

The Centers for Medicare and Medicaid Services seems to be conflicted on the genetic-testing issue, including its relationship to family history, he continued. On the one hand, at a meeting of the Secretary's Advisory Committee on Genetics, Health, and Society, Dr. Barry Straube, director of CMS's Office of Clinical Standards and Quality, said that Medicare does not cover genetic tests based on family history alone. “In the year 2009, [Medicare] may need to rethink this,” Dr. Feero said.

On the other hand, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) allows Medicare to consider covering diagnostic tests, as long as the test is reasonable and necessary and has been given a grade A or B recommendation from the U.S. Preventive Services Task Force, Dr. Feero noted. Currently, the only genetic test addressed by the USPSTF is the test for the BRCA1 or BRCA2 genetic mutations that increase the risk of breast cancer; however, the task force's guidance recommends only counseling about the test, and does not address how to decide whether the test should be given.

A panel member asked Dr. Feero if using family history to determine whether a beneficiary needs a genetic test would mean that the family history itself becomes the screening test. “That is why I [support] the idea of having a [procedure] code for family history,” Dr. Feero replied, adding that family history can mean different things in different contexts.

Panel members also heard from fellow panelist Dr. Steven Teutsch, chief science officer of the Los Angeles County Public Health Department. Dr. Teutsch is a member of the EGAPP (Evaluation of Genomic Applications in Practice and Prevention) working group, an independent body organized in 2004 by the Centers for Disease Control and Prevention to provide guidance on the appropriate use of genetic tests in clinical practice.

“At the end of the day, the question is whether genetic tests can modify outcomes,” he said. Dr. Teutsch also urged panel members to consider the potential harm caused by some of these tests, including labeling, anxiety, additional testing, and false reassurance from negative tests.

“For preventive applications for genomic tests, the bar should be high” for their use, he said. “We want to screen for something important [and] common, and [something] that you can do something about.”

During the public participation section of the meeting, Dr. Richard Wenstrup, chief medical officer of Myriad Genetics Inc., noted that guidelines on hereditary breast and ovarian cancer from the National Comprehensive Cancer Network recommend performing genetic testing on high-risk individuals.

He also said that an analysis of his company's own data from 2000–2009 showed that 5.6% of patients with deleterious mutations developed cancer after age 65. “It's presumable that if they had been identified and tested before developing the cancer, they could have taken preventive measures to reduce their risk,” he said.

Panel member Dr. Neil Holtzman, professor of public health at Johns Hopkins University in Baltimore, said that there had been confusion among some speakers about the definition of screening. He noted that a panel convened by the National Academy of Sciences during the 1970s had defined genetic screening as “a search in the population.”

“A number of speakers have concluded that [in] individuals who have been identified through family history but who are asymptomatic, availability or use of [genetic] tests is defined as screening,” Dr. Holtzman said. “I don't think that kind of testing is screening. It would save a lot of confusion if we defined screening as a search in the population … and not in a high-risk situation where there's a family history.”

During the formal voting, panel members generally agreed that rigorous evidence on survival outcomes would be “sufficient to infer whether or not screening genetic testing is effective for the prevention or early detection of illness or disability.” In terms of the most desirable measures of cost-effectiveness of genetic screening tests, they ranked gains in quality-adjusted life years higher than decreases in incidence of illness or net changes in lifetime illness costs.

BALTIMORE — If Medicare is going to pay for genetic tests, what criteria should it use to decide which to cover?

That was one of the questions tackled by a Medicare Evidence Development and Coverage Advisory Committee panel. The 17-member panel included an ethicist, a patient advocate, representatives from the insurance and genetic-testing industries, and experts in cancer, ophthalmology, and cardiology.

Panel members heard presentations on various aspects of genetic testing. Dr. W. Gregory Feero, senior adviser to the director of genomic medicine at the National Human Genome Research Institute, argued that a good family history was vital to deciding which patients should receive particular genetic tests. “Family history is still the cheapest, most time-tested way to get an idea of disease risk,” he said.

Although several new practice guidelines call on physicians to collect family histories, “family history collection by primary care clinicians is actually quite poor,” said Dr. Feero, a board-certified family physician. “I would argue that it's going to get worse with [the advent of] electronic health records, as most systems are not well set up to enable clinicians to collect family health information.”

The Centers for Medicare and Medicaid Services seems to be conflicted on the genetic-testing issue, including its relationship to family history, he continued. On the one hand, at a meeting of the Secretary's Advisory Committee on Genetics, Health, and Society, Dr. Barry Straube, director of CMS's Office of Clinical Standards and Quality, said that Medicare does not cover genetic tests based on family history alone. “In the year 2009, [Medicare] may need to rethink this,” Dr. Feero said.

On the other hand, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) allows Medicare to consider covering diagnostic tests, as long as the test is reasonable and necessary and has been given a grade A or B recommendation from the U.S. Preventive Services Task Force, Dr. Feero noted. Currently, the only genetic test addressed by the USPSTF is the test for the BRCA1 or BRCA2 genetic mutations that increase the risk of breast cancer; however, the task force's guidance recommends only counseling about the test, and does not address how to decide whether the test should be given.

A panel member asked Dr. Feero if using family history to determine whether a beneficiary needs a genetic test would mean that the family history itself becomes the screening test. “That is why I [support] the idea of having a [procedure] code for family history,” Dr. Feero replied, adding that family history can mean different things in different contexts.

Panel members also heard from fellow panelist Dr. Steven Teutsch, chief science officer of the Los Angeles County Public Health Department. Dr. Teutsch is a member of the EGAPP (Evaluation of Genomic Applications in Practice and Prevention) working group, an independent body organized in 2004 by the Centers for Disease Control and Prevention to provide guidance on the appropriate use of genetic tests in clinical practice.

“At the end of the day, the question is whether genetic tests can modify outcomes,” he said. Dr. Teutsch also urged panel members to consider the potential harm caused by some of these tests, including labeling, anxiety, additional testing, and false reassurance from negative tests.

“For preventive applications for genomic tests, the bar should be high” for their use, he said. “We want to screen for something important [and] common, and [something] that you can do something about.”

During the public participation section of the meeting, Dr. Richard Wenstrup, chief medical officer of Myriad Genetics Inc., noted that guidelines on hereditary breast and ovarian cancer from the National Comprehensive Cancer Network recommend performing genetic testing on high-risk individuals.

He also said that an analysis of his company's own data from 2000–2009 showed that 5.6% of patients with deleterious mutations developed cancer after age 65. “It's presumable that if they had been identified and tested before developing the cancer, they could have taken preventive measures to reduce their risk,” he said.

Panel member Dr. Neil Holtzman, professor of public health at Johns Hopkins University in Baltimore, said that there had been confusion among some speakers about the definition of screening. He noted that a panel convened by the National Academy of Sciences during the 1970s had defined genetic screening as “a search in the population.”

“A number of speakers have concluded that [in] individuals who have been identified through family history but who are asymptomatic, availability or use of [genetic] tests is defined as screening,” Dr. Holtzman said. “I don't think that kind of testing is screening. It would save a lot of confusion if we defined screening as a search in the population … and not in a high-risk situation where there's a family history.”

During the formal voting, panel members generally agreed that rigorous evidence on survival outcomes would be “sufficient to infer whether or not screening genetic testing is effective for the prevention or early detection of illness or disability.” In terms of the most desirable measures of cost-effectiveness of genetic screening tests, they ranked gains in quality-adjusted life years higher than decreases in incidence of illness or net changes in lifetime illness costs.

BALTIMORE — If Medicare is going to pay for genetic tests, what criteria should it use to decide which to cover?

That was one of the questions tackled by a Medicare Evidence Development and Coverage Advisory Committee panel. The 17-member panel included an ethicist, a patient advocate, representatives from the insurance and genetic-testing industries, and experts in cancer, ophthalmology, and cardiology.

Panel members heard presentations on various aspects of genetic testing. Dr. W. Gregory Feero, senior adviser to the director of genomic medicine at the National Human Genome Research Institute, argued that a good family history was vital to deciding which patients should receive particular genetic tests. “Family history is still the cheapest, most time-tested way to get an idea of disease risk,” he said.

Although several new practice guidelines call on physicians to collect family histories, “family history collection by primary care clinicians is actually quite poor,” said Dr. Feero, a board-certified family physician. “I would argue that it's going to get worse with [the advent of] electronic health records, as most systems are not well set up to enable clinicians to collect family health information.”

The Centers for Medicare and Medicaid Services seems to be conflicted on the genetic-testing issue, including its relationship to family history, he continued. On the one hand, at a meeting of the Secretary's Advisory Committee on Genetics, Health, and Society, Dr. Barry Straube, director of CMS's Office of Clinical Standards and Quality, said that Medicare does not cover genetic tests based on family history alone. “In the year 2009, [Medicare] may need to rethink this,” Dr. Feero said.

On the other hand, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) allows Medicare to consider covering diagnostic tests, as long as the test is reasonable and necessary and has been given a grade A or B recommendation from the U.S. Preventive Services Task Force, Dr. Feero noted. Currently, the only genetic test addressed by the USPSTF is the test for the BRCA1 or BRCA2 genetic mutations that increase the risk of breast cancer; however, the task force's guidance recommends only counseling about the test, and does not address how to decide whether the test should be given.

A panel member asked Dr. Feero if using family history to determine whether a beneficiary needs a genetic test would mean that the family history itself becomes the screening test. “That is why I [support] the idea of having a [procedure] code for family history,” Dr. Feero replied, adding that family history can mean different things in different contexts.

Panel members also heard from fellow panelist Dr. Steven Teutsch, chief science officer of the Los Angeles County Public Health Department. Dr. Teutsch is a member of the EGAPP (Evaluation of Genomic Applications in Practice and Prevention) working group, an independent body organized in 2004 by the Centers for Disease Control and Prevention to provide guidance on the appropriate use of genetic tests in clinical practice.

“At the end of the day, the question is whether genetic tests can modify outcomes,” he said. Dr. Teutsch also urged panel members to consider the potential harm caused by some of these tests, including labeling, anxiety, additional testing, and false reassurance from negative tests.

“For preventive applications for genomic tests, the bar should be high” for their use, he said. “We want to screen for something important [and] common, and [something] that you can do something about.”

During the public participation section of the meeting, Dr. Richard Wenstrup, chief medical officer of Myriad Genetics Inc., noted that guidelines on hereditary breast and ovarian cancer from the National Comprehensive Cancer Network recommend performing genetic testing on high-risk individuals.

He also said that an analysis of his company's own data from 2000–2009 showed that 5.6% of patients with deleterious mutations developed cancer after age 65. “It's presumable that if they had been identified and tested before developing the cancer, they could have taken preventive measures to reduce their risk,” he said.

Panel member Dr. Neil Holtzman, professor of public health at Johns Hopkins University in Baltimore, said that there had been confusion among some speakers about the definition of screening. He noted that a panel convened by the National Academy of Sciences during the 1970s had defined genetic screening as “a search in the population.”

“A number of speakers have concluded that [in] individuals who have been identified through family history but who are asymptomatic, availability or use of [genetic] tests is defined as screening,” Dr. Holtzman said. “I don't think that kind of testing is screening. It would save a lot of confusion if we defined screening as a search in the population … and not in a high-risk situation where there's a family history.”

During the formal voting, panel members generally agreed that rigorous evidence on survival outcomes would be “sufficient to infer whether or not screening genetic testing is effective for the prevention or early detection of illness or disability.” In terms of the most desirable measures of cost-effectiveness of genetic screening tests, they ranked gains in quality-adjusted life years higher than decreases in incidence of illness or net changes in lifetime illness costs.

WASHINGTON — Results from trials of a patient-centered medical home suggest that such arrangements result in cost savings and reduced hospital readmissions, according to Dr. Barbara Walters, senior medical director of southern New Hampshire community group practices at the Dartmouth-Hitchcock health care system.

Dr. Walters' organization is involved in a medical home trial sponsored by the Centers for Medicare and Medicaid Services that includes 10 multispecialty groups operating in a fee-for-service environment. During the trial, the practices are responsible for the entire cost of care for their Medicare patient population; they receive per-patient monthly fees for care management.

Dartmouth-Hitchcock got a $6.8-million bonus in 2008 because of the money the groups saved Medicare, and the 3-year project has been extended an additional 2 years. “On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund,” she said at the sixth annual World Health Care Congress.

Key to the clinical intervention was the transformation of the registered nurses' role. “Our nurses used to be 'triagers' and traffic cops. We didn't take their licensure and their scope of their ability to practice into account,” Dr. Walters said. “Now they are health coaches, patient advocates, and referral coordinators.”

Training staff in proper coding also helped. “We needed to train all of our doctors” because, like it or not, severity adjustment and the total cost of care is assessed by the diagnoses that go on the claims form, she said.

Dartmouth-Hitchcock also developed a registry that “allows you to look at [an] individual patient and get a snapshot of all the key indicators that help their health,” Dr. Walters said.

Protocols were developed for postdischarge phone calls. “The nurse calls the day after you get out of the hospital, checks to make sure patients understand which medications they're supposed to take, which medications they're no longer supposed to take, and gets them into their primary care doctor, their medical home,” Dr. Walters said.

As a result of these changes, every single practice in the pilot had lower risk-adjusted costs of care and admission rates and better quality measures than a comparison group, she said.

In addition, while hospital readmission rates are typically upwards of 20%, “we talked to the Cleveland Clinic; they got theirs down to 14%. In one of our communities where we're the only provider, we got it down to 9%,” Dr. Walters said.

The results have spurred Dartmouth-Hitchcock to partner with CIGNA in developing a pilot medical home project. In that project, the practice hopes to improve on the Medicare model and get primary care physicians to reap more financial benefit from any money saved. Dartmouth-Hitchcock wants to include ongoing payments for care management, “which is the biggest [implementation] issue across every group that we talked to,” Dr. Walters said. “There's lots and lots of nonvisit care that you can apply” if the payment system allows for it.

That's easier to do in a system like Kaiser Permanente, where one entity owns the whole delivery system, she continued, “but those of us who practice in a fee-for-service world, where we only get reimbursed for individual-based care when patients come in, we need some slack in the system for us to be able to build the infrastructure so we can do e-visits, nurses can develop care plans, and nurses can call patients before a visit and have the lab work done when they show up” to visit the doctor. The CIGNA program began in April, so no results are available yet, she said.

Health care organizations increasingly are looking at patient-centered medical homes, according to Edwina Rogers, executive director of the Patient-Centered Primary Care Collaborative in Washington, D.C., whose 475 members include large employers, primary care physician associations, health insurers, trade associations, academic centers, and health care quality improvement associations.

Ms. Rogers cited research from Johns Hopkins University showing that adults who have a primary care physician coordinating their care had 33% lower costs of care and were 19% less likely to die.

The 3-year-old collaborative is currently involved with 22 pilot medical home projects in 16 states. The model used by the collaborative includes a monthly care coordination fee in addition to fee-for-service payments and performance bonuses.

Figuring out which outcomes to analyze and report on “is the hardest part to do,” Ms. Rogers said. A group led by the U.S. Department of Health and Human Services is “trying to figure out standard outcome measures.

'On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund.' DR. WALTERS

WASHINGTON — Results from trials of a patient-centered medical home suggest that such arrangements result in cost savings and reduced hospital readmissions, according to Dr. Barbara Walters, senior medical director of southern New Hampshire community group practices at the Dartmouth-Hitchcock health care system.

Dr. Walters' organization is involved in a medical home trial sponsored by the Centers for Medicare and Medicaid Services that includes 10 multispecialty groups operating in a fee-for-service environment. During the trial, the practices are responsible for the entire cost of care for their Medicare patient population; they receive per-patient monthly fees for care management.

Dartmouth-Hitchcock got a $6.8-million bonus in 2008 because of the money the groups saved Medicare, and the 3-year project has been extended an additional 2 years. “On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund,” she said at the sixth annual World Health Care Congress.

Key to the clinical intervention was the transformation of the registered nurses' role. “Our nurses used to be 'triagers' and traffic cops. We didn't take their licensure and their scope of their ability to practice into account,” Dr. Walters said. “Now they are health coaches, patient advocates, and referral coordinators.”

Training staff in proper coding also helped. “We needed to train all of our doctors” because, like it or not, severity adjustment and the total cost of care is assessed by the diagnoses that go on the claims form, she said.

Dartmouth-Hitchcock also developed a registry that “allows you to look at [an] individual patient and get a snapshot of all the key indicators that help their health,” Dr. Walters said.

Protocols were developed for postdischarge phone calls. “The nurse calls the day after you get out of the hospital, checks to make sure patients understand which medications they're supposed to take, which medications they're no longer supposed to take, and gets them into their primary care doctor, their medical home,” Dr. Walters said.

As a result of these changes, every single practice in the pilot had lower risk-adjusted costs of care and admission rates and better quality measures than a comparison group, she said.

In addition, while hospital readmission rates are typically upwards of 20%, “we talked to the Cleveland Clinic; they got theirs down to 14%. In one of our communities where we're the only provider, we got it down to 9%,” Dr. Walters said.

The results have spurred Dartmouth-Hitchcock to partner with CIGNA in developing a pilot medical home project. In that project, the practice hopes to improve on the Medicare model and get primary care physicians to reap more financial benefit from any money saved. Dartmouth-Hitchcock wants to include ongoing payments for care management, “which is the biggest [implementation] issue across every group that we talked to,” Dr. Walters said. “There's lots and lots of nonvisit care that you can apply” if the payment system allows for it.

That's easier to do in a system like Kaiser Permanente, where one entity owns the whole delivery system, she continued, “but those of us who practice in a fee-for-service world, where we only get reimbursed for individual-based care when patients come in, we need some slack in the system for us to be able to build the infrastructure so we can do e-visits, nurses can develop care plans, and nurses can call patients before a visit and have the lab work done when they show up” to visit the doctor. The CIGNA program began in April, so no results are available yet, she said.

Health care organizations increasingly are looking at patient-centered medical homes, according to Edwina Rogers, executive director of the Patient-Centered Primary Care Collaborative in Washington, D.C., whose 475 members include large employers, primary care physician associations, health insurers, trade associations, academic centers, and health care quality improvement associations.

Ms. Rogers cited research from Johns Hopkins University showing that adults who have a primary care physician coordinating their care had 33% lower costs of care and were 19% less likely to die.

The 3-year-old collaborative is currently involved with 22 pilot medical home projects in 16 states. The model used by the collaborative includes a monthly care coordination fee in addition to fee-for-service payments and performance bonuses.

Figuring out which outcomes to analyze and report on “is the hardest part to do,” Ms. Rogers said. A group led by the U.S. Department of Health and Human Services is “trying to figure out standard outcome measures.

'On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund.' DR. WALTERS

WASHINGTON — Results from trials of a patient-centered medical home suggest that such arrangements result in cost savings and reduced hospital readmissions, according to Dr. Barbara Walters, senior medical director of southern New Hampshire community group practices at the Dartmouth-Hitchcock health care system.

Dr. Walters' organization is involved in a medical home trial sponsored by the Centers for Medicare and Medicaid Services that includes 10 multispecialty groups operating in a fee-for-service environment. During the trial, the practices are responsible for the entire cost of care for their Medicare patient population; they receive per-patient monthly fees for care management.

Dartmouth-Hitchcock got a $6.8-million bonus in 2008 because of the money the groups saved Medicare, and the 3-year project has been extended an additional 2 years. “On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund,” she said at the sixth annual World Health Care Congress.

Key to the clinical intervention was the transformation of the registered nurses' role. “Our nurses used to be 'triagers' and traffic cops. We didn't take their licensure and their scope of their ability to practice into account,” Dr. Walters said. “Now they are health coaches, patient advocates, and referral coordinators.”

Training staff in proper coding also helped. “We needed to train all of our doctors” because, like it or not, severity adjustment and the total cost of care is assessed by the diagnoses that go on the claims form, she said.

Dartmouth-Hitchcock also developed a registry that “allows you to look at [an] individual patient and get a snapshot of all the key indicators that help their health,” Dr. Walters said.

Protocols were developed for postdischarge phone calls. “The nurse calls the day after you get out of the hospital, checks to make sure patients understand which medications they're supposed to take, which medications they're no longer supposed to take, and gets them into their primary care doctor, their medical home,” Dr. Walters said.

As a result of these changes, every single practice in the pilot had lower risk-adjusted costs of care and admission rates and better quality measures than a comparison group, she said.

In addition, while hospital readmission rates are typically upwards of 20%, “we talked to the Cleveland Clinic; they got theirs down to 14%. In one of our communities where we're the only provider, we got it down to 9%,” Dr. Walters said.

The results have spurred Dartmouth-Hitchcock to partner with CIGNA in developing a pilot medical home project. In that project, the practice hopes to improve on the Medicare model and get primary care physicians to reap more financial benefit from any money saved. Dartmouth-Hitchcock wants to include ongoing payments for care management, “which is the biggest [implementation] issue across every group that we talked to,” Dr. Walters said. “There's lots and lots of nonvisit care that you can apply” if the payment system allows for it.

That's easier to do in a system like Kaiser Permanente, where one entity owns the whole delivery system, she continued, “but those of us who practice in a fee-for-service world, where we only get reimbursed for individual-based care when patients come in, we need some slack in the system for us to be able to build the infrastructure so we can do e-visits, nurses can develop care plans, and nurses can call patients before a visit and have the lab work done when they show up” to visit the doctor. The CIGNA program began in April, so no results are available yet, she said.

Health care organizations increasingly are looking at patient-centered medical homes, according to Edwina Rogers, executive director of the Patient-Centered Primary Care Collaborative in Washington, D.C., whose 475 members include large employers, primary care physician associations, health insurers, trade associations, academic centers, and health care quality improvement associations.

Ms. Rogers cited research from Johns Hopkins University showing that adults who have a primary care physician coordinating their care had 33% lower costs of care and were 19% less likely to die.

The 3-year-old collaborative is currently involved with 22 pilot medical home projects in 16 states. The model used by the collaborative includes a monthly care coordination fee in addition to fee-for-service payments and performance bonuses.

Figuring out which outcomes to analyze and report on “is the hardest part to do,” Ms. Rogers said. A group led by the U.S. Department of Health and Human Services is “trying to figure out standard outcome measures.

'On 35,000 Medicare patients, we saved $10 million for the Medicare trust fund.' DR. WALTERS

WASHINGTON — The upcoming ICD-10 diagnosis and procedure coding system is more complicated than its predecessor, ICD-9, but it will allow for a greater level of clinical detail and will be better able to keep up with advances in technology, several speakers said at a meeting sponsored by the American Health Information Management Association.

“ICD-9 badly needs to be replaced,” said Nelly Leon-Chisen, director of coding and classification at the American Hospital Association. “It's 30 years old, and the terminology and classification of some conditions are obsolete.”

There are two parts to ICD-10, formally known as the International Classification of Diseases, 10th revision, which goes into effect in the United States on Oct. 1, 2013: ICD-10-CM, which is the clinical modification of the World Health Organization's ICD-10 diagnostic coding system; and ICD-10-PCS, an inpatient procedural coding system developed under contract to the Centers for Medicare and Medicaid Services.

ICD-10 “will have better data for evaluating and improving quality of care. It will provide codes for a more complete picture,” she added, noting that the new code set will allow health officials to be “better able to track and respond to global health threats.”

Because ICD-10 can more precisely document diagnoses and procedures, it will bring better justification of medical necessity for billing purposes, “but not from day 1,” Ms. Leon-Chisen said. “It will take a little while” for people to adjust to the new codes. The new system also may reduce opportunities for fraud, she added.

Ms. Leon-Chisen outlined a few basic differences between ICD-9 and ICD-10 diagnosis codes:

▸ ICD-9 codes contain 3–5 characters, whereas ICD-10's contain 3–7 characters.

▸ In ICD-9 codes, the first character can be alphabetic or numeric, but in ICD-10, the first character is always alphabetic.

▸ ICD-10 codes can include the use of a placeholder “x,” but ICD-9 codes can't.

She gave an example, showing the differences between the two revisions. Under the ICD-9 coding system, a patient with a pressure ulcer on the right buttock might receive a diagnosis code of 707.05, “pressure ulcer, buttock.” Under ICD-10, the same patient would get L89.111, “decubitus ulcer of right buttock limited to breakdown of the skin.” A pressure ulcer on the left buttock or a more severe one including necrosis of the bone would get a different ICD-10 code.

Sue Bowman, director of coding policy and compliance for the American Health Information Management Association, noted that ICD-10-PCS can have even more complexities. For example, under ICD-9, there is only one code for artery repair; under ICD-10-PCS, there are 276 codes. However, “once you work with it, you're struck by the logic of the system,” she said. “It's really not that difficult.” Under the ICD-10 code structure, each character has a specific meaning. (See box below.)

One issue that Medicare officials and others dealing with ICD-10 are wrangling with, Ms. Bowman noted, is when—or whether—both ICD-9 and ICD-10 should be “frozen”—that is, when no more new codes should be added to either code set so that they will be stable while people are making the changeover from ICD-9 to ICD-10. Both code sets are currently updated annually, she said.

ICD-10 Resources

Sue Bowman of the American Health Information Management Association recommended these resources for more information about ICD-10:

National Center for Health Statistics/CDC

www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

Centers for Medicare and Medicaid Services

www.cms.hhs.gov/ICD10

The American Hospital Association's ICD-10 Resource Center

www.ahacentraloffice.com/ahacentraloffice_app/ICD-10/ICD-10.jsp

American Health Information Management Association

www.ahima.org/icd10

WASHINGTON — The upcoming ICD-10 diagnosis and procedure coding system is more complicated than its predecessor, ICD-9, but it will allow for a greater level of clinical detail and will be better able to keep up with advances in technology, several speakers said at a meeting sponsored by the American Health Information Management Association.

“ICD-9 badly needs to be replaced,” said Nelly Leon-Chisen, director of coding and classification at the American Hospital Association. “It's 30 years old, and the terminology and classification of some conditions are obsolete.”

There are two parts to ICD-10, formally known as the International Classification of Diseases, 10th revision, which goes into effect in the United States on Oct. 1, 2013: ICD-10-CM, which is the clinical modification of the World Health Organization's ICD-10 diagnostic coding system; and ICD-10-PCS, an inpatient procedural coding system developed under contract to the Centers for Medicare and Medicaid Services.

ICD-10 “will have better data for evaluating and improving quality of care. It will provide codes for a more complete picture,” she added, noting that the new code set will allow health officials to be “better able to track and respond to global health threats.”

Because ICD-10 can more precisely document diagnoses and procedures, it will bring better justification of medical necessity for billing purposes, “but not from day 1,” Ms. Leon-Chisen said. “It will take a little while” for people to adjust to the new codes. The new system also may reduce opportunities for fraud, she added.

Ms. Leon-Chisen outlined a few basic differences between ICD-9 and ICD-10 diagnosis codes:

▸ ICD-9 codes contain 3–5 characters, whereas ICD-10's contain 3–7 characters.

▸ In ICD-9 codes, the first character can be alphabetic or numeric, but in ICD-10, the first character is always alphabetic.

▸ ICD-10 codes can include the use of a placeholder “x,” but ICD-9 codes can't.

She gave an example, showing the differences between the two revisions. Under the ICD-9 coding system, a patient with a pressure ulcer on the right buttock might receive a diagnosis code of 707.05, “pressure ulcer, buttock.” Under ICD-10, the same patient would get L89.111, “decubitus ulcer of right buttock limited to breakdown of the skin.” A pressure ulcer on the left buttock or a more severe one including necrosis of the bone would get a different ICD-10 code.

Sue Bowman, director of coding policy and compliance for the American Health Information Management Association, noted that ICD-10-PCS can have even more complexities. For example, under ICD-9, there is only one code for artery repair; under ICD-10-PCS, there are 276 codes. However, “once you work with it, you're struck by the logic of the system,” she said. “It's really not that difficult.” Under the ICD-10 code structure, each character has a specific meaning. (See box below.)

One issue that Medicare officials and others dealing with ICD-10 are wrangling with, Ms. Bowman noted, is when—or whether—both ICD-9 and ICD-10 should be “frozen”—that is, when no more new codes should be added to either code set so that they will be stable while people are making the changeover from ICD-9 to ICD-10. Both code sets are currently updated annually, she said.

ICD-10 Resources

Sue Bowman of the American Health Information Management Association recommended these resources for more information about ICD-10:

National Center for Health Statistics/CDC

www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

Centers for Medicare and Medicaid Services

www.cms.hhs.gov/ICD10

The American Hospital Association's ICD-10 Resource Center

www.ahacentraloffice.com/ahacentraloffice_app/ICD-10/ICD-10.jsp

American Health Information Management Association

www.ahima.org/icd10

WASHINGTON — The upcoming ICD-10 diagnosis and procedure coding system is more complicated than its predecessor, ICD-9, but it will allow for a greater level of clinical detail and will be better able to keep up with advances in technology, several speakers said at a meeting sponsored by the American Health Information Management Association.

“ICD-9 badly needs to be replaced,” said Nelly Leon-Chisen, director of coding and classification at the American Hospital Association. “It's 30 years old, and the terminology and classification of some conditions are obsolete.”

There are two parts to ICD-10, formally known as the International Classification of Diseases, 10th revision, which goes into effect in the United States on Oct. 1, 2013: ICD-10-CM, which is the clinical modification of the World Health Organization's ICD-10 diagnostic coding system; and ICD-10-PCS, an inpatient procedural coding system developed under contract to the Centers for Medicare and Medicaid Services.

ICD-10 “will have better data for evaluating and improving quality of care. It will provide codes for a more complete picture,” she added, noting that the new code set will allow health officials to be “better able to track and respond to global health threats.”

Because ICD-10 can more precisely document diagnoses and procedures, it will bring better justification of medical necessity for billing purposes, “but not from day 1,” Ms. Leon-Chisen said. “It will take a little while” for people to adjust to the new codes. The new system also may reduce opportunities for fraud, she added.

Ms. Leon-Chisen outlined a few basic differences between ICD-9 and ICD-10 diagnosis codes:

▸ ICD-9 codes contain 3–5 characters, whereas ICD-10's contain 3–7 characters.

▸ In ICD-9 codes, the first character can be alphabetic or numeric, but in ICD-10, the first character is always alphabetic.

▸ ICD-10 codes can include the use of a placeholder “x,” but ICD-9 codes can't.

She gave an example, showing the differences between the two revisions. Under the ICD-9 coding system, a patient with a pressure ulcer on the right buttock might receive a diagnosis code of 707.05, “pressure ulcer, buttock.” Under ICD-10, the same patient would get L89.111, “decubitus ulcer of right buttock limited to breakdown of the skin.” A pressure ulcer on the left buttock or a more severe one including necrosis of the bone would get a different ICD-10 code.

Sue Bowman, director of coding policy and compliance for the American Health Information Management Association, noted that ICD-10-PCS can have even more complexities. For example, under ICD-9, there is only one code for artery repair; under ICD-10-PCS, there are 276 codes. However, “once you work with it, you're struck by the logic of the system,” she said. “It's really not that difficult.” Under the ICD-10 code structure, each character has a specific meaning. (See box below.)

One issue that Medicare officials and others dealing with ICD-10 are wrangling with, Ms. Bowman noted, is when—or whether—both ICD-9 and ICD-10 should be “frozen”—that is, when no more new codes should be added to either code set so that they will be stable while people are making the changeover from ICD-9 to ICD-10. Both code sets are currently updated annually, she said.

ICD-10 Resources

Sue Bowman of the American Health Information Management Association recommended these resources for more information about ICD-10:

National Center for Health Statistics/CDC

www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

Centers for Medicare and Medicaid Services

www.cms.hhs.gov/ICD10

The American Hospital Association's ICD-10 Resource Center

www.ahacentraloffice.com/ahacentraloffice_app/ICD-10/ICD-10.jsp

American Health Information Management Association

www.ahima.org/icd10

WASHINGTON — It ain't easy being diabetic.

Life is filled with additional responsibilities: the finger sticks, the glucose monitoring, hemoglobin A1c testing, foot and eye exams. So how can things be made easier for diabetes patients and their physicians?

One answer is technology, according to several speakers at a diabetes meeting sponsored by Avalere Health. And for Amand Iyer, president and COO of WellDoc Inc., a Baltimore-based software company, that often means the cell phone.

Cell phone use can help to overcome one of the biggest barriers in the adoption of new technology: cost, said Mr. Iyer, who is a type 2 diabetes patient. “Wireless operators are measured on two things: average revenue per user, and the amount of marketing dollars they invest to [regain] a lost subscriber, which is $343 per lost subscriber per year,” he said. “If you can extend the wireless operator's contract for 1 year by providing a 'sticky' health application, they're willing to share that $343 with you.”

That's exactly what WellDoc is doing: marketing one program as a “virtual coach” that diabetes patients can load onto their phones. “You register online or on the phone and provide your demographic information, phone number, and the drug regimen you're on, and when you're finished, you get a text message that says, 'Click here to download the software,'” Mr. Iyer explained, noting that it will work on most commercially available cell phones. The software has blood glucose target ranges, high and low alerts, and [information on] what to do for hypoglycemia, and it can be modified for patients with multiple comorbidities such as diabetes and heart failure, he said.

The software also includes a learning library with information on diabetes self-care, and a mobile logbook that users can access on a computer so they can see how well they're meeting their targets. And the cell phone acts as a “nerve center” that communicates with the patient and whomever else he or she chooses, such as a physician, caregiver, or diabetes educator.

Patients can enter useful data for alerting themselves and physicians to preset trends—for example, if the patient is hypoglycemic twice in a 10-day period. Physicians can receive the information in whatever way suits them best, Mr. Iyer said.

One doctor may say, “Send it to me in a fax the day before [the patient] comes in,” Mr. Iyer said. “Some doctors have said, 'Hey, can I get the software on my phone? Because I just made this medication change for this brittle patient and I want to see how he is tracking.'”

Mr. Iyer's company also is working with a glucose monitor firm on getting a wireless chip installed right on the meter. “Patients would pull their strips as they do normally, get the feedback on the meter, and get all their alerts and reminders right off the meter.” His company is developing similar modules for other diseases, including heart failure, hypertension, and dyslipidemia.

At Partners in Health, a group practice affiliated with the University of Pittsburgh Medical Center, one technology application that has gotten a good response is electronic “office visits,” according to Dr. Grant Shevchik, the practice's medical director. Patients fill out online questionnaires—“the only physician visit where the patient records the history”—and the messages are sent directly to their physicians for a response. The new service generated 286 “visits” from Aug. 28, 2008, to Jan. 31, 2009, Dr. Shevchik said.

“Our oldest patient who has done this is 82,” and many of the others are in the 35- to 44-year-old age group. “These are not the 22-year-olds,” he added.

Not only is the service “affordable, convenient, and efficient,” it also has a CPT code (99444), he noted. The code can be used only once during a 7-day period and the visit must be patient initiated, it must involve a timely response, and there must be permanent storage of the visit information.

At Johns Hopkins University in Baltimore, employees with chronic illnesses such as diabetes can take advantage of Telewatch, a telephone monitoring program, said Dr. Ines Vigil, associate medical director at Johns Hopkins HealthCare, a health plan that includes 47,000 university employees.

“The employee can call in and type in their blood pressure, last cholesterol-screening results, their symptoms, and their stress levels, and it gets rolled into a system that our nurse case managers and clinical screeners are able to follow over time,” Dr. Vigil explained. “The system will red-flag something if it's abnormal.” If a patient calls in an abnormally high blood pressure or glucose level, “our clinical screener will inform the case manager to give the member a call,” she said. More than 1,000 people are participating in Telewatch, she said, noting that patients with more serious chronic illnesses talk with nurse case managers more regularly.

One program is a 'virtual coach' that diabetes patients can load onto their phones. MR. IYER

WASHINGTON — It ain't easy being diabetic.

Life is filled with additional responsibilities: the finger sticks, the glucose monitoring, hemoglobin A1c testing, foot and eye exams. So how can things be made easier for diabetes patients and their physicians?

One answer is technology, according to several speakers at a diabetes meeting sponsored by Avalere Health. And for Amand Iyer, president and COO of WellDoc Inc., a Baltimore-based software company, that often means the cell phone.

Cell phone use can help to overcome one of the biggest barriers in the adoption of new technology: cost, said Mr. Iyer, who is a type 2 diabetes patient. “Wireless operators are measured on two things: average revenue per user, and the amount of marketing dollars they invest to [regain] a lost subscriber, which is $343 per lost subscriber per year,” he said. “If you can extend the wireless operator's contract for 1 year by providing a 'sticky' health application, they're willing to share that $343 with you.”

That's exactly what WellDoc is doing: marketing one program as a “virtual coach” that diabetes patients can load onto their phones. “You register online or on the phone and provide your demographic information, phone number, and the drug regimen you're on, and when you're finished, you get a text message that says, 'Click here to download the software,'” Mr. Iyer explained, noting that it will work on most commercially available cell phones. The software has blood glucose target ranges, high and low alerts, and [information on] what to do for hypoglycemia, and it can be modified for patients with multiple comorbidities such as diabetes and heart failure, he said.

The software also includes a learning library with information on diabetes self-care, and a mobile logbook that users can access on a computer so they can see how well they're meeting their targets. And the cell phone acts as a “nerve center” that communicates with the patient and whomever else he or she chooses, such as a physician, caregiver, or diabetes educator.

Patients can enter useful data for alerting themselves and physicians to preset trends—for example, if the patient is hypoglycemic twice in a 10-day period. Physicians can receive the information in whatever way suits them best, Mr. Iyer said.

One doctor may say, “Send it to me in a fax the day before [the patient] comes in,” Mr. Iyer said. “Some doctors have said, 'Hey, can I get the software on my phone? Because I just made this medication change for this brittle patient and I want to see how he is tracking.'”

Mr. Iyer's company also is working with a glucose monitor firm on getting a wireless chip installed right on the meter. “Patients would pull their strips as they do normally, get the feedback on the meter, and get all their alerts and reminders right off the meter.” His company is developing similar modules for other diseases, including heart failure, hypertension, and dyslipidemia.

At Partners in Health, a group practice affiliated with the University of Pittsburgh Medical Center, one technology application that has gotten a good response is electronic “office visits,” according to Dr. Grant Shevchik, the practice's medical director. Patients fill out online questionnaires—“the only physician visit where the patient records the history”—and the messages are sent directly to their physicians for a response. The new service generated 286 “visits” from Aug. 28, 2008, to Jan. 31, 2009, Dr. Shevchik said.

“Our oldest patient who has done this is 82,” and many of the others are in the 35- to 44-year-old age group. “These are not the 22-year-olds,” he added.

Not only is the service “affordable, convenient, and efficient,” it also has a CPT code (99444), he noted. The code can be used only once during a 7-day period and the visit must be patient initiated, it must involve a timely response, and there must be permanent storage of the visit information.

At Johns Hopkins University in Baltimore, employees with chronic illnesses such as diabetes can take advantage of Telewatch, a telephone monitoring program, said Dr. Ines Vigil, associate medical director at Johns Hopkins HealthCare, a health plan that includes 47,000 university employees.

“The employee can call in and type in their blood pressure, last cholesterol-screening results, their symptoms, and their stress levels, and it gets rolled into a system that our nurse case managers and clinical screeners are able to follow over time,” Dr. Vigil explained. “The system will red-flag something if it's abnormal.” If a patient calls in an abnormally high blood pressure or glucose level, “our clinical screener will inform the case manager to give the member a call,” she said. More than 1,000 people are participating in Telewatch, she said, noting that patients with more serious chronic illnesses talk with nurse case managers more regularly.

One program is a 'virtual coach' that diabetes patients can load onto their phones. MR. IYER

WASHINGTON — It ain't easy being diabetic.

Life is filled with additional responsibilities: the finger sticks, the glucose monitoring, hemoglobin A1c testing, foot and eye exams. So how can things be made easier for diabetes patients and their physicians?

One answer is technology, according to several speakers at a diabetes meeting sponsored by Avalere Health. And for Amand Iyer, president and COO of WellDoc Inc., a Baltimore-based software company, that often means the cell phone.

Cell phone use can help to overcome one of the biggest barriers in the adoption of new technology: cost, said Mr. Iyer, who is a type 2 diabetes patient. “Wireless operators are measured on two things: average revenue per user, and the amount of marketing dollars they invest to [regain] a lost subscriber, which is $343 per lost subscriber per year,” he said. “If you can extend the wireless operator's contract for 1 year by providing a 'sticky' health application, they're willing to share that $343 with you.”

That's exactly what WellDoc is doing: marketing one program as a “virtual coach” that diabetes patients can load onto their phones. “You register online or on the phone and provide your demographic information, phone number, and the drug regimen you're on, and when you're finished, you get a text message that says, 'Click here to download the software,'” Mr. Iyer explained, noting that it will work on most commercially available cell phones. The software has blood glucose target ranges, high and low alerts, and [information on] what to do for hypoglycemia, and it can be modified for patients with multiple comorbidities such as diabetes and heart failure, he said.

The software also includes a learning library with information on diabetes self-care, and a mobile logbook that users can access on a computer so they can see how well they're meeting their targets. And the cell phone acts as a “nerve center” that communicates with the patient and whomever else he or she chooses, such as a physician, caregiver, or diabetes educator.

Patients can enter useful data for alerting themselves and physicians to preset trends—for example, if the patient is hypoglycemic twice in a 10-day period. Physicians can receive the information in whatever way suits them best, Mr. Iyer said.

One doctor may say, “Send it to me in a fax the day before [the patient] comes in,” Mr. Iyer said. “Some doctors have said, 'Hey, can I get the software on my phone? Because I just made this medication change for this brittle patient and I want to see how he is tracking.'”

Mr. Iyer's company also is working with a glucose monitor firm on getting a wireless chip installed right on the meter. “Patients would pull their strips as they do normally, get the feedback on the meter, and get all their alerts and reminders right off the meter.” His company is developing similar modules for other diseases, including heart failure, hypertension, and dyslipidemia.

At Partners in Health, a group practice affiliated with the University of Pittsburgh Medical Center, one technology application that has gotten a good response is electronic “office visits,” according to Dr. Grant Shevchik, the practice's medical director. Patients fill out online questionnaires—“the only physician visit where the patient records the history”—and the messages are sent directly to their physicians for a response. The new service generated 286 “visits” from Aug. 28, 2008, to Jan. 31, 2009, Dr. Shevchik said.

“Our oldest patient who has done this is 82,” and many of the others are in the 35- to 44-year-old age group. “These are not the 22-year-olds,” he added.

Not only is the service “affordable, convenient, and efficient,” it also has a CPT code (99444), he noted. The code can be used only once during a 7-day period and the visit must be patient initiated, it must involve a timely response, and there must be permanent storage of the visit information.

At Johns Hopkins University in Baltimore, employees with chronic illnesses such as diabetes can take advantage of Telewatch, a telephone monitoring program, said Dr. Ines Vigil, associate medical director at Johns Hopkins HealthCare, a health plan that includes 47,000 university employees.

“The employee can call in and type in their blood pressure, last cholesterol-screening results, their symptoms, and their stress levels, and it gets rolled into a system that our nurse case managers and clinical screeners are able to follow over time,” Dr. Vigil explained. “The system will red-flag something if it's abnormal.” If a patient calls in an abnormally high blood pressure or glucose level, “our clinical screener will inform the case manager to give the member a call,” she said. More than 1,000 people are participating in Telewatch, she said, noting that patients with more serious chronic illnesses talk with nurse case managers more regularly.

One program is a 'virtual coach' that diabetes patients can load onto their phones. MR. IYER