A Renaissance for U.S. health care: broadband as the canvas

I'm in a country this week where 66% of health providers have adopted 9 of 14 critical electronic health applications, according to a study from The Commonwealth Fund. According to the same study, only 26% of U.S. providers have opted into these functions.

As I amble across cobblestoned and craggy streets, looking up to frescoe'd facades on 500 year old palazzi, church domes and the bluest sky ever, the signs of the Italian Renaissance are everywhere in walkable Florence, Italy.

But it's not all art and architecture, gelato and chianti for me this week. It's also the techno-reality that I'm living in the 21st century, as I connect to you via wireless using iPhone and a netbook from a roof terrace overlooking the Duomo, the Palazzo Vecchio, and the terra cotta roofs of this great Renaissance city.

Having read the FCC's National Broadband Plan during the flight from Philadelphia to Europe, I'm connecting the dots between the New Communications and the creative work of Leonardo da Vinci, Michelangelo, Botticelli, Alberti, Galileo, Brunelleschi, and the countless artisans and visionaries who Built This City...and implications for re-imagining the U.S. health system.

It took the Medici's money and cunning vision to realize the Renaissance.

For the rebirth of U.S. health care's communications infrastructure, we've got the FCC recommendations, and public and private funding to invest in it.

Now, to the vision. Chapter 10 of the FCC broadband report is dedicated to Health Care. In 26 pages, the FCC scopes out the importance of broadband to health, beginning with the observation, "Rising costs would be less concerning if there were results." While expanding broadband throughout the nation to the remaining 100 million health citizens who don't have access to it won't be a panacea for all the nation's health challenges, broadband access will play a key role in the health infrastructure that's going to move American health care into the 21st century.

Ultimately, expanding broadband will improve the U.S.'s ability to globally compete.

For health, broadband will enable data from EHRs to move within a health community, and outside of it so we can learn what works in health care and pay for performance and outcomes. Broadband will set the table for remote health consultations, telehealth and mobile health.

Health Populi's Hot Points: The National Broadband plan is about economic development and expanding access to technology, resources and opportunity to all Americans.

Thomas Jefferson wrote that travel makes a man wiser, but less happy. My personal observations of both the transportation and communications infrastructures in Europe inform my sad understanding - which I've known through data, but now, through personal experience - that the U.S. is sorely behind developed Europe.

The FCC plan for broadband in health is both a primer for what ails the U.S. health system and a recipe book for what needs to happen to bring American health care up to a global standard. Adopting the recommendations can help move the U.S. into the Health Renaissance the nation needs.

Learning from Detroit: costs above coverage and the elastic demand for health

Cost and personal income are the key determinants of whether a Michigander seeks medical care.

As the chart shows, cost is the #1 reason uninsured people in Michigan didn't seek medical care for 55% of the uninsured. But for nearly 1 in 3 insured Michiganders, cost is also the key determinant in whether people go for medical care.

These findings price elastic demand for health services were uncovered in the Cover Michigan survey, conducted by the Center for Healthcare Research and Transformation (CHRT), a partnership between the University of Michigan and Blue Cross Blue Shield of Michigan (BCBS MI). The survey polled 1,022 adults in Michigan, the bulk of whom had health coverage.

Workers in manufacturing jobs are particular worried about losing health insurance coverage; CHRT points out that manufacturing workers are "joining those in the retail and service sectors," who have traditionally felt health-insecure. Manufacturing jobs in Michigan translate to jobs at Ford, GM and Chrysler, et. al.

There's a direct correlation between employment insecurity and health insurance insecurity. 2 in 3 Michiganders are "very worried" about losing health insurance and their job.

Health Populi's Hot Points: This survey has crucial implications for health reform. Coverage alone won't get people to use health services. Education and income play important roles in enabling health citizens to become health literate consumers.

For employers who continue to provide health insurance, it's crucial to also design the plans for accessibility and usability. As companies will levy higher copays and premium shares onto their workers, firms need to make sure these plan designs don't result in unintended consequences -- primarily, moving the worker from the inelastic demand curve of health seeking to the elastic demand where the worker chooses to opt out of seeking care when necessary. This has been a flaw in many consumer-directed plan designs and increasingly in more traditional designs where the stick is used in absence of carrot-motivational nudges.

Michigan provides the scenario of "thinking the unthinkable," with the highest level of unemployment in the country and arguably the most difficult and jobless recovery in the nation. Pay attention to this scenario; it's the snapshot proving the interconnection between jobs, health coverage, and medical care demand.

Data security is Job 1 for health managers thinking mobile

As more health workers go mobile, whether telecommuting or as home health road warriors, managers are concerned, first and foremost, with mobile security as the top ranking required component of mobile user management tools.

Data security in general ranks highly int he minds of health managers, 90% of whom told Forrester that this was a critical or high IT security priority as they were entering 2010.

In a survey conducted for Fiberlink, a communications company, Forrester found that 89% of health care organizations have some employees working out of the office at least one day per week, and 87% of companies have employees telecommuting from home at least once a week. Furthermore, 95% of health companies have employees using smartphones for work -- in addition to laptop computers.

One-third of the health companies polled said that their data have been compromised at least once in 2009.

Health Populi's Hot Points: As health care goes mobile, security is top-of-mind for managers. It's the IT department's major headache for the next few years as the huge challenge of mobile security over phones and computers gets solved. We are just in the beginning of meeting this challenge...

When it comes to mobile health information security, there are two important issues that need dealing with asap. First, many health citizens are already concerned about the security of their personal health information as it moves from paper-based files into digital databases. Surveys among consumers who aren't keen to adopt PHRs or EHRs overall cite security concerns as the #1 reason they like their data kept on paper in files. As health data go mobile over on-the-go laptops and smartphones, the data leakage challenge significantly grows.

At the same time, more data breaches in health happen due to internal causes than external hacks. Thus, policies need to be empowered through technology tools, like on-device encryption and automated policy violation alerts.

The benefits of mobile health are numerous, and health citizens are now being sold on the concepts through various applications, including the power of personal health records and health engagement, the adoption of iPhone health apps, participatory and connected health with providers, and on-line consultation with physicians via American Well, Teladoc, and other emerging video-conference type services. But a PHI breach caused by a mobile health encounter showing up on Larry King Live one evening is a wild card the mHealth industry can't afford to let happen.

Flipping cancer the bird: can pop culture cure cancer?

70,000 young Americans between 15 and 39 years of age are diagnosed with cancer every year. This population falls in a gap between pediatric and adult cancer. Newly-diagnosed young adults often find themselves in a no-patients'-land, confronting a lack of targeted clinical trials and knowledgeable clinicians in local health markets.

The National Cancer Institute says that survival rates for this group of cancer patients haven't improved in over 30 years.

That's definitely cause to flip cancer the bird, and that's exactly what the young actor, Zac Efron, has done.

Efron is photographed with a young cancer patient, Emily Hobson, to focus on Stupid Cancer wrist bands, which are part of an awareness campaign for the foundation, I'm Too Young for This (i2y).

The project has a Facebook page, Zac Gives Back, with fans from around the world. Based on a quick Google news search, I found that the Efron/Stupid Cancer story has reached France, Russia, Italy and the Netherlands in just a matter of days since Efron endorsed the Stupid Cancer wristband campaign.

Health Populi's Hot Points: Of course, this isn't the first time that popular culture engages with the cause of health. Pharmaceutical companies have engaged celebrities for years until recently: Magic Johnson represented HIV drugs and Mike Ditka repped Levitra for GSK; Bob Dole pitched Viagra for Pfizer; and, recently, Jim Belushi, Danica Patrick, and Patty Loveless joined with Boehringer-Ingelheim's social media campaign, DRIVE4COPD.

Efron's involvement with Stupid Cancer feels very authentic. He's a young, dynamic performer at the top of his game, and he's paying it forward for his generation in an edgy, smart campaign that speaks not only to his generation, but to all of us who have wanted to give cancer the proverbial finger.

Cancer awareness is not just about Komen and pink ribbons anymore. The young adult cancer community has been long overlooked, but they're growing in activism and health engagement. Pop culture via Efron and i2y is bringing the cause into focus.

Beyond wristbands, it's time for corporate America to engage with this overlooked cancer cohort. Companies market products and services -- not just pills and chemotherapy, but iPods and jeans and cars and financial services and toothpaste -- to people between the ages of 15 and 39. It would be a Smart move to support Stupid Cancer.

Rent, Buy or Wait? A post-mortem of HIMSS '10

It's been a year since the American Recovery and Reinvestment Act and the HITECH Act got the president's signature. Since then, there have been countless meetings of standards-setters, CIO experts and medical informatics pros, all opining on the meaning of "meaningful use," the criteria for certifying electronic health records and the vision for a Nationwide Health Information Network.

As they asked in "Seasons of Love" from Rent, "525,600 minutes...how do you measure a year?" The chorus's response: "In cups of coffee, in inches, in miles, in laughter, in strife." And 525,000 journeys to plan.

That's about the number of physicians who will be affected by the 2009 federal economic stimulus plan, and based on what I heard among those clinicians who haven't yet adopted an EHR, they're barely willing to Rent, let alone Buy, an EHR based on their latest understanding about what's involved with the process of adopting what seems to be a still-evolving set of rules.

Two mantras permeated the Healthcare Information and Management Systems Society (HIMSS) conference's vendor floor: "We Can Help You Connect" (the health information exchange message), and "We'll Make It Meaningful for You." Most vendors are offering various flavors of a meaningful use "guarantee," this word being used in a wide range of ways based on vendors' lawyers' taste for going at risk. As such, meaningful use still seems largely in the eye of the beholder.

This lack of consensus and crispness adversely impacts solo and small practices as they need greater clarity and comfort; the smaller the practice, the greater the risk-per-physician from a scaling perspective.

On the other hand, the connectivity/HIE scenario is something that makes manifest the old saw that all health care is local (with a nod to Tip O'Neill). RelayHealth management told me of their HIE projects in over 50 communities, from Northern California to New Jersey. The drivers in these projects are physician alignment and hospital connectivity to doctors, and brand building in local/regional health markets. The relatively fast proliferation of these projects throughout the U.S. means that health providers see value in the HIE concept.

This local/regional infrastructure is enabling data liquidity and health information connectivity between physicians and hospitals. As Dr. David C. Kibbe characterized it for me, the local HIE projects are de facto "EHRs for a Small Planet." Kibbe is the senior advisor on health IT to he American Academy of Family Physicians, as well as the chair of the ASTM International E31 Technical Committee on Healthcare Informatics. He deeply understands where physicians are on the EHR adoption spectrum.

Far away from the glitz and glamour of the showroom floor is the sleeves-rolled-up reality that local and community health information exchange activity is outpacing bigger, more complex and expensive state-wise exchange building. This means that community hospitals and health centers, local medical practices, labs and imaging centers, have begun the heavy lifting of clinical integration.

The stakeholders who commit to these local projects recognize the value of collaborating in them: benefits accrue in the forms of quality improvement and care coordination for patients who, before, were poorly managed in an episodic, fragmented fashion.

The local collaborations aren't waiting for the larger national or state initiatives to percolate down. This is grassroots health care, and it's got traction.

Here's another riff on the health-care-is-local theme driving health IT adoption that I heard at HIMSS this year. GE Healthcare works closely with the Boston Medial Center. This 626-bed urban hospital is New England's largest safety-net hospital and is Massachusetts' largest provider of medical services to the poor. The institution said it would lost $175 million this fiscal year.

But the hospital remains committed to building its electronic health information infrastructure that serves both inner city Boston and connects with clinics throughout the community. That's the only way to successfully affect population health, reach out to the community and improve health outcomes for some of New England's sickest citizens. BMC's investment in its electronic health information backbone and systems builds connectivity that is making a difference for health citizens in its catchment area. This investment will help the institution sustain itself over the longer term because it will be able to provide care more cost-effectively -- deploying the right resources to patients at the right time.

The message of health care/local is sustainability: while grants and incentives will flow for HIEs and EHRs, only those projects and implementations that ultimately serve the benefit of patients and their clinicians will find value in the spending. As one of my colleagues asked me as we noted the number of 'connectivity'-emblazoned banners on the HIMSS showroom floor, "connectivity for what?"

Health Populi's Hot Points: John Halamka -- chair of the Health IT Standards Panel, co-chair of the health IT Standards Committee and CIO of Harvard Medical School -- wrote in his blog's post-HIMSS observations that many of HIMSS' nearly 30,000 attendees came to the party to "better understand how they could participate in the euphoria of HITECH stimulus dollars." But we've seen millions, possibly billions, of taxpayer dollars spent on big-vision health IT programs in the past, Community Health Information Networks (CHINs) and telemedicine pilots among them.

At the end of the day, it's the heavy lifting of patient care and health engagement that are going to be meaningful long after the HIMSS parties, colorful corporate knick-knacks and euphoria pass.

This post was adapted from my column in iHealthBeat.

Designing for meaningful use

In the crush of crowds on the vendor floor at the HIMSS10 exhibition this week in Atlanta, booths are strategically designed with Pantone-matched colors and icons and clever taglines. Sales teams are festooned in corporate logo-emblazoned polo shirts (orange is popular this year). Colorful banners exclaim this year's HIT mantras: lots of "HIE spoken here!" and "We are connectivity."

With all the thought and dollars allocated to health information technology sales and marketing, I wonder how much the line item known as "design" gets? As I spend a lot of time with pharmaceutical companies in the past two decades, I'm getting a deja vu all over again in this regard.

There is no meaningful use in HIT if the central health stakeholders targeted in ARRA stimulus funding -- clinicians, clinics, hospitals, health administrators, and health citizens -- don't embrace, use and delight in the value that HIT delivers. Given the general tenor of CFOs, CIOs and doctors with whom I spoke, the mood one year after ARRA is dazed and confused.

[My "N" is of course not statistically significant but rather a few dozen anecdotes -- still worthy of this discussion]

My context here is motivated by a comment to Health Populi by the clinician-innovator Dr. Jay Parkinson who notes that, without designing health products and services that give the people what they want and where they 'live,' there's no significant adoption and persistence of use.

On the EHR front, I'm encouraged by a few of the offerings I saw and discussed. Top of mind here is Epocrates. Now 10 years old, the company's products are used by most physicians. The physician-facing brand of Epocrates is viewed as trustworthy and authentic -- two key traits that engagement requires, and health engagement in particular. While Epocrates' EHR is just entering alpha/beta mode, the product is expected to be out in Q4. So as I haven't kick its tires, I'm talking on faith in the company and its deep relationship with physicians. Let's also remember that they have a rich track record of well-designed applications with a deep bench of trusted users.

Design will be critical to HIT in these years of meaningful use and implementation. This is a measure-twice (perhaps even thrice) cut-once world. Small physician practices that haven't yet adopted EHRs will be taking leaps of faith in making EHR investments in the coming months. Good design will be the differentiation across the value chain of EHRs, from user interfaces all the way through to implementation, training and support.

Health Populi's Hot Points: In his book, The Design of Everyday Things, Don Norman provides a sort of bible on user-centered design. He says on his blog that, "People want the extra power that increased features bring to a product, but they intensely dislike the complexity that results. Is this a paradox? Not necessarily. Complexity can be managed. The argument is not between adding features and simplicity, between adding capability and usability. The real issue is about design: designing things that have the power required for the job while maintaining understandability, the feeling of control, and the pleasure of accomplishment.

This seems a useful guideline for designing EHRs that will get well-used, and loved, by clinicians. I didn't hear much about these features in Atlanta this week. Perhaps it's just not coming out in the brochures and scripted sales talks? Those need sound design, too.

The self-evident market for mobile health

Two-thirds of physicians own smartphones, Dan Hesse, CEO of Sprint, told the standing-room-only crowd at HIMSS as he kicked off the first keynote session of the 2010 annual meeting. With the emergence of the 4G network in 2010, we've got the infrastructure for delivering remote care with the kind of image quality even the most eagle-eyed radiologist will require, according to this telecomms CEO.

Other parts of the world that spend a much lower percentage of GDP on health care have leapfrogged the U.S. in mobile health. Globally, there are more mobile phones adopted than PCs, TVs, and cars combined. Mobile phones are the fastest adopted technology in the history of the planet, Hesse judged. The other startling statistic he pointed to is that 10 mobile phones are manufactured for every one birth on Earth. !

In health, wireless is the opportunity for patients managing Type 2 diabetes, 60% of whom don’t have the condition under control. Wireless is the infrastructure for cardiologists to remotely examine ECGs for heart attack patients as EMS workers whisk them to cardiac trauma units. Wireless moves caregivers from the bedside to the virtual side of high-risk pregnant mom-to-be leveraging the Intel Health Guide device.

Hesse notes that 4G networks will be deployed in 2010, and that spectrum will be good for securing privacy as well as moving and reading high-resolution medical images. Within four years, more than one-half of connected devices won’t be phones, Hesse predicted. They'll be TVs and devices on bedroom nightstands streaming videos and counsel from health coaches, clinicians and caregivers.

Lest we get tethered to the idea of a device as a phone or a desktop monitor of sorts, consider the tiny pill. As Hesse held up a capsule, that smart pill that can send data and images wirelessly to a physician directly from the interior of a patient. This is the stuff of Star Trek, but it is within reach and not in a galaxy so far away.

Heatlh Populi's Hot Points: The lightbulb moment of the keynote wasn't from Mr. Hesse, but from a video of Dr. William Bria of AMIA shown in the context of Hesse's conclusion. Dr. Bria said, "there has been much hand-wringing over the past 35 years on the (slowness of) EHR adoption among doctors." But, Dr. Bria noted, doctors needed no convincing that the MRI and CT were better tools to enabling sound diagnoses. With better access to quality bandwidth and easy to use devices, adoption and take up of phones and wireless health among doctors will be same kind of experience that opting for CT scanners was – "the value will be self-evident," Dr. Bria forecasts.

Of Hummers, HIMSS and Health Care: context for a week of HIT in Atlanta

Rest-in-peace, Hummer. Last week, GM announced that after 18 years, the gas-guzzling icon of car excess would be tossed to the proverbial scrap heap.

The Tale of the Hummer provides a useful parable for American health care, especially for context this week as the annual HIMSS conference kicks off. (Please skip to the end-note to learn more about HIMSS, for those Health Populi readers unfamiliar with the acronym or organization).

Why did GM send the Hummer to its resting place? There are several factors that eroded the demand for the Hummer: among them,

• First, the price of gas, generally trending up; in July 2008, it would have cost $131 to fill the Hummer's 32 gallon tank. That sticker shock hit Americans a few months before the recession officially began in December 2008. But it was the season that ushered in Americans who once would never consider hybrid cars to take a look at them.
• Second, the recession itself. With the economic decline has come more Americans doing more at home, and if choosing to take vacations, opting for the "staycation." That means driving more within a region, which means scrutinizing gas prices as a component of the total cost of the trip.
• Third, an ethos has begun to take hold with the American consumer: value-based shopping. More Americans are purchasing private-label goods from grocery stores and department stores. Today, value is in the eye of the purchaser.

How does the story of the Hummer's demise relate to U.S. health care in 2010? Health care costs have grown at unsustainable rates. The component costs of care are all rising above and beyond the increase of general price inflation. We're not getting good value for our money: we've a wasteful system that consumes too many resources for the outcomes it achieves -- here, think of outcomes as MPG.

In health, the 3 Hummer market dynamics translate as follows:

1. Health price sticker shock has meant higher hospital bad-debts when patients check out of ERs and inpatient beds, fewer prescriptions getting filled, and more recommended tests and treatments getting postponed or skipped.

2. The "staycation" metaphor in health is more health consumers doing DIY-health: sometimes for the better, often resulting in medical mistakes or mis-steps. Choosing to cut prescribed pills, for example, can be short-term fiscally smart, but in the longer term physically harmful.

3. Value-based shopping in health is largely a positive phenomenon when done with full information. The growth of generics has been fanned by both mail order pharmacy for chronic meds, as well as consumers' response to $4 prescriptions for generics offered by big box discounters and retail pharmacies. Value-based care is also permeating the mindset of employers who buy health benefits on behalf of employees.

Health Populi's Hot Points: The moral of the Hummer's Tale is sustainability. Health care in the U.S. is an unsustainable model. We can't just sell it off as an under-performing asset, as GM tried to do last week in selling Hummter the Chinese industrial group, Sichuan Tengzhong. The Chinese govenrment said, "no way." In fact, no entity would buy the U.S. health system were it to be sold on the global open market.

It needs re-engineering. To fix health care, we have to pay for what works: and to pay for what works, we have to measure what we're doing. That's where HIMSS, and health information technology, come in to play.

This week, as many as 30,000 attendees will walk the floor of HIMSS to kick tires on electronic health records systems, wireless devices, digital imaging systems, medical banking systems, and other technologies that will drive paper out of health processes. The intelligence of President Obama's including $19 billion of stimulus funding in ARRA for health care IT was that, with those investments, over the longer term, the U.S. will be able to measure health care processes and outcomes. This will enable Medicare, Medicaid and commercial payers to sort out how much to spend, on what health care services, and to whom.

The promise of HIT, though, can't do the heavy-lifting of healing health care alone without health payment reform.

Most Americans who get health care services are receiving Hummer-style healthcare: it may look fancy, with its innumerable bells and whistles, and perhaps by some be considered "the best in the world." But under the hood, it's incredibly wasteful and unsustainable.

End note: HIMSS, the Health Information Management Systems Society, is the leading organization advocating the adoption and optimal use of health care information technology. The annual meeting attracts thousands of stakeholders representing health care providers, technology developers and vendors, financiers and VCs, government agencies, telecommunications, and other groups interested in health care IT. Last year attracted some 27,000 attendees; this year could bring even greater attendance given the hot topic of health IT.

The #1 focus for employees: physical health, fiscal health

While Congress and the President arm-wrestled through the Health Summit, the private sector doesn't sit still waiting in a frozen state for the result of inside-Beltway-health-baseball.

Employees/consumers and employers have aligning in mutual self-interest when it comes to health care benefits, costs, and disease management, according to a survey sponsored jointly by Deloitte and the International Society of Certified Employee Benefit Specialists, 2010 Top Five Total Rewards Priorities Survey.

This latest recession has focused the minds of companies and their workers and driven the collective priority of managing health costs while maintaining job and retirement security. In this 16th annual survey iteration, Deloitte and ISCEBS assert that this is the strongest alignment of employer/worker interests in the 16th years of conducting the study.

77% of respondents worry about their ability to afford retirement and 60% are concerned about staying employed. While 4 in 10 employees plan to delay retirement, knowing they'll need to save more and pay down debt, the #1 focus is on maximizing health status.

The report states that, "survival mode" is "in full force."

The top 5 priorities for 2010 are:

1. The cost of providing health care benefits
2. The ability of reward programs to attract, motivate and retain talented workers
3. Aligning Total Rewards strategy with the business and brand
4. The willingness of employees to pay for an increasing portion of benefits and manage their own rewards budget
5. The ability of reward programs to accommodate the needs of different worker segments.

Among employees, there's also a growing realization that physical health is a huge component of financial health. Thus, 65% of employees say they'll participate in wellness and disease management programs to maximize their health -- the #1 personal challenge polled by Deloitte. Below this health-maximization priority are to save more money, pay off debt, increase contributions to pensions, and delay retirement. Thus fiscal health and physical health intertwine.

Health Populi's Hot Points: If the recession has been good for anything, it's at least raised Americans' understanding that the loss of job is tantamount to the loss of access to health insurance in the employer-sponsored health system that's unique to the U.S.

With a forecasting hat on, one thing's for certain: employers will be redesigning health benefits in and beyond 2010 and will be -- I'll repeat, will be -- allocating more costs to employees. Thus, the mention of consumers managing their "rewards budget."

So while we line-itemize our monthly spending for eggs, butter, college education, gas, and mortgages, don't forget to add an important line item you've probably not called out before: your rewards budget.

Help wanted: primary care docs, nurses and health information professionals

In the coming months and years, I anticipate that Monster.com and other online job services will grow their revenues from the health industry. Three important studies this month confirm that, while health care eats up nearly one-fifth of the U.S. economy, there are shortages of professionals to fill two important jobs that are growing: primary care physicians (PCPs), nurses, and health information technology (HIT) workers.

Let's talk about the doctors, first. The Journal of the American Medical Association (JAMA) reports this week that doctors cut back their working hours since 1998 to 2008. At the same time, the second chart shows that doctors' pay, adjusted for inflation, has fallen in the same period. The charts tell the story.

Mean physician fees fell 25% between 1996 and 2006, which may have resulted in the reduced number of hours worked. That is only part of the story, as many physicians take on non-patient care tasks (e.g., investing in ancillary health businesses such as physical therapy or labs). Some choose to spend less time per patient.

The researchers calculate that the 5.7% decrease in overall physician hours translates to a loss of 36,000 physicians all things being equal. With fewer incoming medical students opting in to primary care, this is more evidence for a primary care physician shortage forecast.

As for nurses, a report from AMN Healthcare, surveying nurses' job satisfaction, also anticipates a worsening of the nurse deficit in the U.S. According to the 2010 Survey of Registered Nurses: Job Satisfaction and Career Plans, 40% of nurses in the U.S. plan to alter their career path in the next 1 to 3 years. At the core of this is broad dissatisfaction and concern for a declining level of health care quality. Only 59% of nurses would choose this career path if they had to do it all over again. The immediate concern is that 6% of the nurses said they would leave the hospital setting int he next 1 to 3 years, which if it comes to pass, would result in a reduction in the number of nurses in the U.S. of 70,000. The U.S. Bureau of Labor Statistics forecasts a shortage of over 260,000 nurses for 2025.

As tens of thousands of health IT stakeholders flock to Atlanta next week for the annual HIMSS 2010 meeting, it's useful to ponder the labor implications of the ARRA stimulus as well as the continued adoption of all sorts of HIT in health. A survey by Beacon Partners published this week finds that the biggest hurdle for EHR adoption is internal resources -- not vendor shortcomings or lack of ready solutions. Hospital executives are concerned about the lack of leadership commitment to adequately funding, staffing and maintaining EHR adoption projects. 45% of resondents said they weren't sure they actually had the resources required to adequately adopt and implement EHRs over the next few years.

According to the American Society of Health Informatics Managers, between 50,000 and 200,000 new jobs will be created for health IT pro's by 2015. Thus, a sure forecast is a deficit of skilled, competent HIT workers for U.S. health providers and other settings where HIT happens.

Health Populi's Hot Points: Here's a novel thought for health reform: let's fund a jobs bill for health -- to employ upwards of 500,000 professionals for primary care, nursing, and HIT. It's a sure shortage, and a sound return. Perhaps this is a health issue that could curry favor across the parties -- perhaps...

More from me directly from the floor of HIMSS next week in Atlanta...stay tuned, and Health Populi will translate the HIT-hype through the lens of the dismal scientist...

Can GE, Intel and Mayo bring good things to home monitoring?

Three major consumer and health industry brand names are coming together to launch a telehealth home monitoring project: GE, Intel and the Mayo Clinic. Each organization has a deep bench and history in the health vertical, covering different segments of the market.

With this project, 3 industry leaders partner to learn about home health monitoring's challenges and opportunities in real-life, with real people. The project goal is to evaluate the effectiveness of daily in-home monitoring technology measured in 2 ways: reduced hospital admissions and reduced visits to the emergency room.

For the project, Intel brings its Health Guide into the mix; GE offers a comprehensive portfolio of medical, digital, and bio/clinical products; and, Mayo brings its clinical expertise and, most importantly, patients who are managing chronic diseases. These will be 200 high-risk Mayo Clinic patients served by the Rochester, MN, provider. These patients will monitor vital signs on a daily basis through the Health Guide technology. The platform allows for videoconferencing between the patient at home and the care team back at Mayo to permit patient-provider connectivity.

Health Populi's Hot Points: This project will test Participatory Health in a high-risk population. It will provide important insights into patient engagement in a population that's been largely written off by other disease management programs in the past based on ageism, lack of good design of technology, and absence of a consumer-centric ethos.

Mayo has long been a patient-centric, wired organization. Their commitment to continuing to lead and innovate builds their brand as one of consumers (and I speak globally) most favored health brands. Intel has been studying how people manage activities of daily living, including health functions, for a long time, making a strategic investment in the future of home health, broadly writ. And GE Healthcare, for all of its moving parts in health, certainly has the clinical and digital building blocks for the infrastructure of home health monitoring.

The three partners are the bluest-chip in the industry, so those pieces of the home health innovation puzzle fit nicely into this challenge. The largest challenge facing the team is patient engagement: how will the 200 high-risk chronically ill, over 60-year-old people fare in this project? The chart illustrates that 2 in 3 American adults like the idea of home monitoring technologies at home to help "me" manage my health. Interestingly, seniors polled were the most interested in these technologies, bringing those who like home monitoring tech to 3/4 of the population.

So, generally speaking for seniors, most will probably like the idea of this project. The next hurdle is how to design the front-end technology (Health Guide and vital signs devices) such that people will find them easy, and perhaps even fun and engaging, to use. Here's where we'd like to see Apple, IDEO, or other design-minded firm involved.

I have, sincerely and personally, great hope for a positive outcome for this project.

Employers say health engagement is low, but tactics seem more actuarial than action-oriented

While the stock market and companies' profitability improves, much of that has been done on the backs of employees: through reductions in force and job cuts, and re-working of benefits.

Health benefits are a prime target for cost management as companies try to survive through the long recovery. Combined with insurance companies' cost increases (most notably and recently Anthem's announcement of up-to-39% increases in premium costs), employers who choose to continue to provide health insurance to employers are in a bind.

According to the 15th annual survey from National Business Group on Health/Towers Watson, employers faced cost increases of 7% in 2009 compared with 6% in 2008 -- twice the rate of general inflation.

They're blaming much of their eroding ability to provide health insurance on employees themselves -- that is, employees' poor health habits. The second chart shows that 2 in 3 employers rank employees' poor health habits as the #1 reason they're having trouble managing costs.

The rate of employers who are confident that they can continue to offer health benefits fell 5 percentage points between 2008 and 2009, from 62% to 57%.

The top-line for employers is that 83% have already or expect to revamp their health strategies in 2010.

What strategies will they implement? The chart gives some indication as to where employers' collective minds are relative to addressing health plan costs and design. In 2010, 3 of the top 4 most popular strategies are benchmarking, auditing eligibility, and claims analysis. Incenting the completion of health appraisals is a fourth common approach.

Health Populi's Hot Points: Employees' poor health habits rank as the #1 reason employers believe affordable health plan coverage is out-of-reach. This challenge ranked in employers' top 3 challenges to coverage in 2009, as well.

In another survey question, employers rank the lack of employee engagement to be the biggest obstacle to changing health habits and behaviors, with 58% of employers agreeing with this. The second most formidable obstacle to changing health behaviors is seen as the lack of sufficient financial incentives to encourage participation in programs, cited by 31% of employers.

Think design and action-orientation here: it's not actuarial calculations and eligibility checks that engage employees into better health habits. Those are largely cost-cutting tools. It's the well-designed nudge, the well-designed copayment plan (where we learn a lot from the Asheville Project and Pitney-Bowes), innovatively-designed tools (think: mobile phone), and designing fun programs that will engage employees to think, act, and sustain healthy lifestyles.

Looking for Mr. Expert - global citizens trust specialists

This year, it's academics, experts, and industry analysts we trust -- as for a "person like yourself?" Not as much -- but in health, it is different.

The Edelman Trust Barometer for 2010 finds that specialists are the most credible sources for information about companies. Edelman cites a 'trust rebound' since last year, except for general news media, including radio news, TV news, and print news which are seen as less trustworthy year-on-year.

Conversations with friends and peers also lost ground as a credible source of information on companies.

What's most striking this year is that consumers' views on corporate reputation aren't based primarily on the quality of goods and services provided by the firm or their level of innovation. Top-of-mind are "transparent and honest practices," and whether the company is one that "I can trust."

Global citizens say the most important factors for bolstering corporate reputation are:

• Transparent and honest practices, and a company I can trust, both cited by 83% of global citizens.
• High quality products and services, 79%
• Communicates frequently, 75%
• Treats employees well, 72%
• Good corporate citizen, 64%
• Prices fairly, 56%
• Innovator, 48%.

Edelman also found that multiple information sources enhance credibility. Their recommendation is to "build a mosaic of trust by cultivating a wide circle of expert spokespeople, communicating through variety of channels."

Health Populi's Hot Points: The recession has driven people to information sources they can really, truly trust. This survey points to a sobering global consumer looking for assurance and safety. Overall, citizens globally are looking for transparency and authenticity, and expertise in the issues they care most about.

For U.S. health citizens, in this shaky era of health coverage and complex information, expertise is key. In the first iteration of Edelman's Health Engagement Barometer, trust and authenticity were found to be the most important factors driving health engagement with companies involved in health (think: health plans, pharmaceutical and medical device manufacturers, health-y consumer goods, etc.). The most credible sources of health expertise were found to be doctors and health professionals ("mine" or others), my pharmacist, scientists and researchers, and leading medical centers.

But nearly as highly credible as these professional "experts," Edelman's HEB found other "experts" in a health citizens' life highly rank: my friends and family who may be experts on "me," and "people like me" in terms of sharing a medical condition or other personal values. When it comes to trust in health, there are many flavors of expertise.

As Edelman recommends based on the 2010 Trust Barometer results, connecting with citizens via many channels and touchpoints builds credibility. That holds especially true for health in 2010.

Health reform illiteracy - when people oppose reform in 2010, they don't really know what they're opposing

Highly educated Americans support health reform; those with no college education don't. 10% of Republicans support President Obama's proposals for health changes; 77% of Democrats do.

The schisms between groupings of Americans who support health reform in February 2010 versus those who don't are wide, and many, depending how you slice the data. The Harris Poll conduced in late January 2010 starkly illustrates these gaps between supporters and detractors of health reform coming from the President's pen.

Most tellingly, The Poll finds that it doesn't much matter what the details are: "support for, or opposition to, health care reform has little to do with what is actually proposed," Harris's polling data indicates.

Ironically, there are several important elements of health reform that majorities of Americans, across segments, support:

• Transparency of costs and quality, supported by 87%
• Administrative simplification, supported by 76%
• Piloting new reimbursement programs, supported by 75%
• Creating an insurance exchange, favored by 73%
• Preventing illegal immigrants from obtaining coverage, supported by 2/3 of Americans
• Allowing kids to stay on parents' insurance plans until they turn 25-26, supported by 65%.

The biggest opposition overall is for an individual mandate, opposed by 2 in 3 Americans.

The Poll was conducted online between January 18-25, 2010, among 2,576 adults age 18 and over.

Health Populi's Hot Points: Underlying these statistics is the fact that while there is broad support for many key elements of health reform, Americans are concerned about the taxes required to support these changes as the economic recovery continues to be job-less and housing markets haven't yet bounced back.

As specific details are supported in theory, the President and health reform policy writers haven't packaged and communicated the value proposition to Americans overall. Given that the most educated Americans with post-graduate degrees show the most support for reforms, perhaps the complexity of the health system and outline of health reform has been just too obtuse and customer un-friendly to the public-at-large.

I've been concerned about health literacy and health plan literacy for many years. Now I've got angst about health reform literacy.

Anthem price hikes: poster child for an imperfect health market

Anthem is robo-calling enrollees to kvetch about health plan price hikes of up to 39%. Then they're asking these customers whether they plan to dis-enroll -- that is, to quit their health plan enrollment. The move would impact as many as 700,000 health citizens in California.

Let me take you back to your freshman economics class (and if you didn't take that class, let me enlighten you on the 101 version) of "the market."

A perfect market, Samuelson told us in his standard Econ 101 text, was dependent on:

• Lots of buyers and lots of sellers
• No-cost entry and no exit barriers
• Perfect information, where prices and quality of products are known to all buyers and all sellers
• Homogeneous products, that is that the product for sales from one seller is near-identical to that from another seller
• No costs incurred when making a purchase/sale.

And of course, sellers seek to maximize profits in perfect markets.

Health Populi's Hot Points: If there's a picture to include next to the Webster's Dictionary definition of "imperfect market," it's of an uninsured American health citizen seeking health insurance on the individual market. This is, more often than not, a "no-go" proposition.

You can tick off most of the prerequisites for a perfect market - lots of sellers, free entry/exit, perfect and free-flowing information, etc. - when it comes to the sale and purchase of health insurance in the U.S. We've got monopoly and oligopoly supply sides in regional markets. There's not even close to free-flowing, easy-to-understand information on policies or quality or clear pricing relative to the value-proposition of the individual health policy.

Of course, sellers - health plans - do indeed seek to maximize profits. That's their promise to shareholders.

There is indeed something perfect about this scenario: it's the perfect argument for health reform, and for a public option, in particular. If traditional health plans were keen to construct a simple, low-cost health insurance plan by now, they would have done so by now. The scene is ripe for disruptive innovation.

Intent, the new demographic: what the mobile web means for health

"'Intent' is the new demographic," say the folks at Ruder Finn, the PR agency. What are people trying to achieve every moment of the digital day?

According to the firm's Mobile Internet Index, people are spending 2.7 hours a day on the mobile Internet. The Index survey studies what reasons people have for using their mobile phones. This isn't about deep-dive education; instead, the mobile web is for connecting, quick transactions, life in-the-moment. Immediacy is the currency of the mobile web.

The illustration shows Ruder Finn's first iteration of the Intent Index, which analyzed peoples' use of the Internet, broadly (not just mobile).

The key 'intents' of mobile web users have to do with learning, having fun, socializing, personal expression, advocating, doing business, and shopping, according to Ruder Finn. Underneath these intents are actions: under "having fun," for example, are being entertained or escaping; for "learning," one can be keeping informed or educating oneself; and, as for "socializing," there's connecting but separately, discussing.

Health Populi's Hot Points: Ruder Finn's MII doesn't break out "health" as a personal intention. But based on what we see in terms of peoples' values in using the mobile web, we can intuit more than a few healthy uses for it.

Over-arching is the citizen's value of immediacy. For the health-citizen, immediacy means access to support, nudging, clinical facts, and monitoring on a 24x7 basis if one chooses to most fully engage in managing a chronic condition, or staying well. Think of this as "health-intentioned."

As B.J. Fogg, director of Stanford University's Persuasive Technology Lab, wrote in Texting 4 Health, "We don't merely adopt mobile devices: we marry them." The mobile phone is with us for all the times we need to test our blood glucose, check whether a generic drug is available to subsitute a branded medication, or reach out for support from a fellow migraineur.

For those health citizens and providers who choose to take advantage of it, the mobile web will be the next platform for health -- whether via cell phone for receiving messages via Text4Baby, via smartphone or full feature phone for managing carb intake via a health app like SparkPeople or Keas, or empowering health workers in Malawi through the open source network of FrontlineSMS:medic.

Heart-broken: President Clinton has access to great heart care, but the average heart patients can't afford what they need

With President Clinton's stent operation of February 11, Americans are reminded of the epidemic of heart disease which will cost the nation $503 billion in 2010. Heart disease and stroke kill 1 in 3 Americans.

But 25% of heart and stroke patients say they can't afford the treatment they need, whether they lack insurance coverage or don't have the money to pay for services, medicines, and procedures.

The situation is tougher for stroke patients than CVD patients: 32% of stroke patients don't have sufficient coverage to deal with their conditions.

16% of heart/stroke patients under 65 don't have any health insurance at all. The main reasons for that? Affordability and job losses. Nearly 50% of heart/stroke patients say they've tried to buy insurance on their own and the premium was unaffordable.

Among the key health issues driven by personal economics among heart/stroke patients are that:

• 46% delayed or put off getting needed health care
• 43% did not fill a prescription
• 42% delayed or put off a routine check up
• 35% cut pills in half or skipped doses of meds
• 31% delayed or put off a screening test that helps identify disease earlier
• 28% delayed or put off a recommended medical test of treatment for heart disease or stroke
• 20% tried alternative medicine or therapies instead of seeing a doctor or filling a prescription.

The American Heart Association sponsored this survey, which was conducted between December 29, 2009 and January 5, 2010 by Synovate. A total of 1,015 interviews were conducted online among people with a heart condition, or having had a heart attack or stroke.

Health Populi's Hot Points: Heart-broken is how we could describe the U.S. health system for one-half of Americans with heart disease and stroke issues, as the AHA survey demonstrates. As Congress's willingness to accomplish health reform wanes, patients managing the #1 killer in the U.S. wait in vain.

Dr. Clyde Yancy, President of the AHA, calls this, "The urgency of now."

With the average age of the survey respondents of 55, they have 10 years to wait for Medicare. By then, will Congress have dealt with bolstering the Medicare plan?

And lest we forget, there's no cure for heart disease.

Your doctor tends to use electronic health records if you're older or richer: a new riff on meaningful use

There's a new survey on EHRs out that most industry news outlets have headlined, "More doctors have gone digital." This, directly from the survey's title, Doctors Gone Digital, conducted by GfK Roper Public Affairs & Media for Practice Fusion, the EHR developer.

Forty-eight percent, or nearly 1 in 2 patients in the U.S., has noticed that their doctors have their records stored digitally on a computer. This is, of course, good news indeed. But under the proverbial hood of the survey data, you find a subtext: that if you're older or more affluent, your physician is more likely to have access to electronic health records.

A slightly higher percentage of patients over 65 (52.6%) have digital records, compared with only 40% of people 25-34. Furthermore, 52.9% of people with incomes over both $50K and $75K have access to electronic health records, compared to 46.5% of patients with incomes between $20-29.9K.

What's also worth pointing out is that GfK's consumer segment called The Influentials has a much higher access to EHRs: 62.% of this cohort say they see EHRs in their doctors' offices. The Influentials cohort is based on an index built on survey responses that have a high political activity such as signing a petition, writing a letter to an editor of a newspaper, making a speech, writing an article, being an office in a civic organization, and the like. Consumers who have done at least four of these things are considered "Influential." They are the thought leaders in GfK's analysis.

Health Populi's Hot Points: As we celebrate the one-year anniversary of ARRA, the American Recovery and Reinvestment Act, and its inclusion of nearly $20 billion in stimulus funding for EHRs, this survey data does signal it's time for a toast. But it's early days, and we can identify a digital divide in physician practices. This is not news per se: larger practices have an economic model that leverages their ability to adopt EHRs and spread the investment across a larger number of physicians. So the value proposition for acquiring EHRs has been easier to calculate, generally speaking. There have been exceptional solo and small practices that are successful EHR users.

Nonetheless, this study raises an important issue: we have disparities in health among patients in the U.S. We have disparities in digital health information adoption among physicians . There are also digital divides in health information adoption among patients and health citizens; broadband isn't neatly or evenly spread around the U.S. (rural/urban/suburban differences exist). Nor do the sickest patients have equal access to broadband services, as data from the Pew Internet & American Life Project points out.

As we get closer to doling out the EHR stimulus funding, it would be useful and equitable to keep in mind another tenet for meaningful use: that it's meant to be meaningful for all patients, not just for some.

With a margin of error of 3 percentage points, the numbers are close to the averages. But I'm raising the issue now as something to keep in mind as we all look forward to further physician adoption of EHRs, and improved access and quality for all Americans.

Crossing the chasm toward participatory health - what the Keas-Pfizer partnership means

Adam Bosworth has been working very hard since he left Google Health to build an application that engages, inspires, and assists health citizens to manage their health. That effort is called Keas, and this week the project welcomes a partner that should further help people along their health journeys.

For some people fortunate enough to be well, they may want to engage with daily lifestyle choices that increase their chances of staying well.

For those people diagnosed with a chronic condition they want to manage, life is more complex beyond managing daily white carbohydrate intake, fat calories, and pedometer-measured steps.

For people with diabetes or MS or ulcerative colitis, there are potentially hundreds of small decisions made daily that impact health, for better or worse. Some of those choices are if, when, and how much to take of prescribed medications.

Keas has been partnering on phone-based care plans with Dr. Greene, the pediatric expert; DiabetesMine, the pioneer portal for engaged diabetics; Healthwise, the proponents of information therapy; and, CVS MinuteClinic, the pharmacy retailer.

This week, Keas announces a partnership with Pfizer, the largest research-based pharmaceutical company in the world. Here's the press release on the Pfizer website.

Health Populi's Hot Points: This arrangement is an important event for the pharmaceutical industry: it demonstrates one Big Pharma company's willingness to engage more closely with patients beyond the prescription pad.

Based on the press release, Pfizer sees working with Keas as a way to help their prescribing physicians support patients outside of the physical physician practice. Furthermore, this bolsters participatory health in that patients can bring their Keas Care Plans back into the physician office dialogue during an office visit.

On a separate note, I've confirmed the fact that Keas will be releasing an iPhone app sometime in 2010. This will increase Keas's mobility off of the desktop and phone web browser, further enhancing health citizens' ability to bolster healthy choices on-the-go.

Watch this space. Keas will continue to develop innovative partnerships, all with an eye toward empowering and supporting people in their personal health journeys, whatever their individual goals.

DIY health care comes to the workplace: employers get into cold/flu prevention

While coughs, colds and seasonal allergies have always been a retail health category, this recession has bolstered the workplace channel for messaging and products.

BigResearch's Workplace Media group has found that 85% of working consumers are concerned about this year's flue and cold season. Two-thirds of workers planned to get a flu shot. And, 9 in 10 workers would likely welcome and use an offer for flu/cold products delivered through the workplace.

The H1N1 virus drives most working consumers to take extra precautions this cold/flu season.

Other key findings are that:

• 3/4 of employers will offer flu prevention tips to employees this season
• 1/4 of employers will offer products to prevent and treat flus and colds
• More hand sanitizers and anti-bacterial cleaning supplies are showing up in office settings
• Employers are looking for ways to educate employees like informational brochures and posters for the breakroom.

2009/2010 Cough, Cold & Flu Season in the Workplace Research Findings report is based on research among 898 U.S. adults conducted in September 2009.

Health Populi's Hot Points: These data suggest a useful continuum-of-care when it comes to cold/flu prevention in the workplace, beginning with prevention messages communicated in posters (think: "wash your hands"), to workplace-provided hand sanitizers and treatment remedies (e.g., perhaps coupons for OTC products, links to local pharmacies).

Workplace Media sees that recession is driving workers to spend more on flu/cold remedies this year given workers' concerns for job security. The Consumer Intentions and Actions survey finds that, while American workers are more positive about the economy in general, their spending is on needs more than wants. OTCs for managing health fall into the 'needs' category.

The proof of this is in the data: spending on OTC cough/cold/flu meds was up in December 2009. Workers purchased 28% more cough medicine on a weekly basis in 12/09, and 20% more cold/flu meds weekly in December more frequently than the general U.S. population.

Coupling this evidence with the growth of worksite clinics solidifies the fact that the workplace is certainly a key locus for health.

What's 19 cents worth to you in 2019? The rise and rise of health care costs

Here's a health economics riddle: what do one dime, one nickel, and four pennies get you in the year 2019?

Health care costs' value carved out of every single dollar.

That's the forecast coming out of the Centers for Medicare and Medicaid Services (CMS) in a report in Health Affairs, as of this year the payor of more than 50% of the health care bills in the U.S. Ironically, the government's taken over health care, with or without Congressional Democrats or President Obama's direct hand in the scenario.

That's $4.5 trillion, the entire economic output of the United States of America.

Health Populi's Hot Points: This CMS report illustrates another aspect of America's Whac-a-Mole health system. When one part of the health economic goes down, another goes up. In this case, when the private sector health payors -- employers -- drop insurance, cut back , lay off employees so insurance enrollments fall -- the public sector payor, Medicaid, picks up the slack. That is, when Governors and the Fed's (that would be your tax dollars at work) can afford to do so.

Thus the CMS actuaries found that the Federal share of Medicaid costs grew from $185.7 billion to $247.7 -- a 33% increase in just 2 years.

This is not rocket science: health care costs have been increasing faster than the general economy and inflation for many, many years. The outcome reported in the CMS report isn't unexpected -- just worse than it had been thought, given the downtrodden state of the economy.

So save your pennies...er, nickels...er dollars. You're going to need them in 2020 to pay for your health care.