The recent crop of news clips pertaining to the future of healthcare provider practice is a tad too diverse to suggest a central theme and weave into a coherent narrative, so for this issue we present them as individual items.

“Direct Practice” (aka Concierge Medicine”)

There is nothing new about a fee-for-service model of care delivery. What is new is that the customer is now demanding service-for-fee, also known as value for money, and that some physicians are abandoning the traditional healthcare (non)system to provide it through “direct practice”—the new, politically correct term for “concierge medicine.” When enough physicians have switched to direct practice, the “medico-industrial complex” will collapse, Scott Shreeve implies in the Health Care Blog. Shreeve’s comparison of traditional versus direct practice can be tabulated as follows:

Provider Ratings

The rapid emergence of websites that permit people to rate, review, and (rightly or wrongly) disparage their doctors is another way in which the cage of the medico-industrial complex is being rattled. Individual ratings and reviews may or may not be fair and can do a lot of damage to individual physicians. According to an article in the LA Times, US Federal law asserts that the operators of websites on which consumers post anonymous opinions are immune from charges of defamation, though some police their users’ comments and delete the “blatantly libelous” ones.

Return of the House Call

Most US politicians apparently would not see value for money in healthcare if it hit them on the head. For instance: 500 elderly, disabled, and chronically ill persons enrolled in a special primary care program in greater Boston receive monthly house calls from a clinician who is more likely to be a nurse practitioner than a doctor. A recent analysis of 90 frail elderly patients in the program revealed total healthcare costs were 40 percent lower than for similar patients not receiving house calls. Most of the savings came from prevention or deferment of hospitalizations and nursing home placements. Medicare spent US$440 billion in 2007. You do the math.

But don’t expect our political leaders to do the same.They calculated in the 1960s that house calls cost double an office visit, and promptly started to eliminate the house call. They did not take the extra step of figuring whether the additional cost would be offset by lower downstream costs, not to mention more humane, higher-quality, care. A handful of today’s politicians—such as Massachusetts Senate President Therese Murray—is trying to get us back on the right track.

Google PHR and Hospitals

Beth Israel Deaconess and the Cleveland Clinic are among hospital systems that have begun to share patient medical data from their own EMRs and (with patient consent) with Google Health’s personal health record. Labs and pharmacies are also contributing data. If every hospital, lab, and pharmacy were to join Google Health—or one of its rivals, such as Microsoft’s HealthVault—then the service would become the national EMR system so long sought. But first, the paper charts and isolated databases that still exist in far too many hospitals and doctors’ offices must go. Most doctors and hospitals still don’t share patient information, medical information is still fragmented, and medical care still suffers as a result.

Aetna to Launch PHR + Research

Aetna has joined WebMD, the Mayo Clinic, Harvard Medical School, Google, and Microsoft in competing for patient PHRs. Its free SmartSource service, launched earlier this year, makes suggestions based on the content of the PHR and on the patient’s search topics. But instead of relying on patients to enter their own data (which they may still do), Aetna seeds the PHR with data from its medical claims database. Such data tend to be sketchy and weeks or months old. Google and Microsoft are trying to get clinical data directly from provider EMRs, instead, but that could take them several years.

Case for Closer Inspection of Automated Devices

As software grows more complex and more autonomous, it grows less amenable to human oversight and intervention. At the same time, it grows more dangerous should it malfunction. This is as true of medical devices as it is of aircraft, spacecraft, and nuclear power station control systems. The answer to this increased threat to life is a lower tolerance for mistakes in software code.

A device’s code can be as long as War and Peace. To detect errors, an editor must diligently examine every word, every comma, and every transition. Human editors have neither the brainpower nor the patience for such a task. So a software-based method called static analysis was developed (by the aerospace industry) to do the job.

The FDA’s forensic software unit of 10 mathematicians, computer scientists, and a physicist began using static analysis in 2006 to test software code in devices from wheelchairs to proton beam therapy systems. However, device manufacturers have been slow to follow the FDA’s lead.

Hospital-Vendor Partnership for Pathology Imaging Products

GE Healthcare and the University of Pittsburgh Medical Center have launched a joint venture to develop and commercialize technology for storing and sharing online digital images of human tissue from pathology slides.

The technology will enable doctors, researchers, teachers, and medical students to share vast amounts of biopsy and other pathological information and thereby improve the study and diagnosis of disease.

The joint venture, called Omnyx, expects in about two years to market a product that will digitize a slide in 30 seconds. With current technology, it takes up to five minutes.

Chronic Disease Overtakes Infectious Disease As Leading Cause of Death

The World Health Organization (WHO) announced in May that chronic disease has overtaken infectious disease as the chief cause of death globally and will remain number one until 2030. WHO attributes the rise to population aging in middle- and low-income countries over the next 25 years, and a resultant rise in deaths due to cancer, cardiovascular disease, traffic accidents, and other age-related factors, and to the rise in diabetes, asthma, and obesity.

Caribbean Losing Nurses

Jamaica’s launch of universal care earlier this year refocused attention on the shortage of nurses in Caribbean countries, which lose some 400 specialized and trained nurses to the US, Europe, the Middle East, and Canada each year. Some US hospitals post “Help wanted” ads in Caribbean newspapers. Requests to the US to reimburse the “donor” nations for the training costs have fallen on deaf ears.

EMR and ASR Cut Costs, Improve Quality

Examples of financial benefits of HIT:

• A clinic with more than 100 internists and family physicians boosted average revenue per encounter by seven percent as a result of more accurate charge capture and participation in pay-for-performance initiatives, which were facilitated by the clinic’s EMR, first deployed in 2001.

• A 150-physician clinic reduced its annual transcription bill from US$1.25 million to about $200,000 as a result of deploying automatic speech recognition (ASR) technology enabling physicians to create their own notes and improve on the EMR’s unwieldy, form-based capture of the patient history and physical.