Tuesday, October 5, 2010
Monday, October 4, 2010
2 Brothers Await Broad Use of Medical E-Records
There is no silver bullet for reforming America’s health care system, but medical experts have long agreed that digital patient records and electronic prescribing can help improve care and curb costs.
Using the Nimble service, a doctor can connect via iPad to a patient’s medical records.
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Times Topic: iPad
Just ask the Doerr brothers — John Doerr, the well-known venture capitalist who was an early backer of Google and Amazon, and Dr. Tom Doerr, a physician and software designer.
Dr. Doerr founded a software company in 1999, beginning with an electronic prescribing product and later adding electronic health records. His brother is the largest investor. After more than a decade, the venture has fewer than 500 doctors using its software.
The experience, Mr. Doerr said, has been “a long, slow march.” And Dr. Doerr conceded, “It’s been a lot harder getting to a business that is self-sustaining than I had imagined.”
But the Obama administration’s economic stimulus package contained an ambitious program to encourage the market for electronic health records, with billions in incentive payments to buy and use digital patient records — and eventually penalties for the failure to do so.
The Doerrs’ software company is only one of many hoping to cash in on the national mandate for digital medical records. The companies range from giants like General Electric to specialists like Athenahealth that cater to small physician practices.
They, like the Doerrs, are betting that the law will help create a turning point for the economics of digital health records, opening the door to rapid adoption by doctors and a thriving business at last.
The brothers are also betting that Internet technology and Apple’s iPad can make electronic records far easier to use and less expensive. Last week, they introduced a new product, Nimble, to allow doctors to manage patient information by connecting their iPads to data centers managed by the Doerrs’ software company, ClearPractice.
The Doerrs’ aging start-up is unusual in that it has evolved to extend its reach in health care beyond technology. The lessons it has learned along the way are a microcosm of the challenge of applying technology to health care.
To attack the problem of wayward financial incentives, the Doerrs bought a Medicare Advantage health maintenance organization, Essence Healthcare, in 2007, and shifted it toward paying doctors for helping make patients healthier. It now covers 50,000 people in six states.
They also built up a medical analytics software company, which tracks procedures and patient results for payers, enabling them to manage outcomes instead of just costs. The software also mines data to help hospitals and doctors make more informed decisions about treatments.
Their target market is doctors in small practices, with 10 physicians or less — where digital records are used least. More than 70 percent of the nation’s doctors are in such small practices.
The Doerrs’ three companies are part of the Essence Group, based in suburban St. Louis, not far from where brothers grew up. Dr. Doerr, 53, is co-founder and head of clinical strategy of Essence, and Mr. Doerr, 59, is the largest shareholder.
Though a small private company, Essence has attracted the attention of some experts. Intrigued, Dr. Denis A. Cortese, former chief executive of Mayo Clinic and a professor at Arizona State University, joined the Essence board two months ago. It is trying to bring to small physician practices, he said, the kind of health care championed at Mayo.
“These guys may or may not be successful, but they’ve got the right ideas,” Dr. Cortese said.
The goal, Dr. Doerr explained, is to deliver the better care and lower costs achieved by some large health care groups without being one. Essence, he said, is trying to combine technology tools, cooperative relationships between doctors and insurers, and financial incentives to create the “virtual equivalent” of an integrated system.
The goal also, of course, is to make money. Essence, though, does not have the look of a big winner anytime soon. It has 330 employees and yearly revenue of about $450 million. But the vast majority of the revenue comes from the Medicare insurer, which is like a regulated utility with modest profits.
If the Doerrs’ venture is going to become a money-spinner someday, it will come from software, a business that can grow rapidly and profitably, if successful. For its new offering, ClearPractice worked closely with Apple to develop the Nimble, a service tailored for the iPad.
Using Nimble, doctors do not need other computers in their offices, since most of the software and patient information resides on remote computers in data centers managed by ClearPractice. A doctor’s iPad connects to the patient data and software wirelessly, over the Internet, as if in a computer “cloud,” as this fast-growing model of computing is known.
Doctors pay a subscription fee of up to $499 a month if they choose all the ClearPractice offerings — electronic prescribing, electronic health records and billing software.
“With the right software that is cloud-based, the iPad is going to be transformational in health care,” Mr. Doerr said.
Better Rules Can Help
Christopher Nowinski, a former Harvard defensive tackle, is a co-director of the Center for the Study of Traumatic Encephalopathy at Boston University School of Medicine, co-founder and president of the nonprofit Sports Legacy Institute, and author of "Head Games: Football's Concussion Crisis."
Professional football can be made “safer,” but to be made “safe” depends on your definition of the word. A sport involving full speed blocking and tackling will always cause injury. But injuries and safety are two separate concepts. One way to make professional football safer is to change how we play youth football.
That has not been the case with the risks of brain injuries in pro football. As reported by Alan Schwarz in the Times, the National Football League was not disclosing to players the risks of concussion and chronic traumatic encephalopathy (C.T.E.), the progressive brain disease that eventually leads to dementia, which were well known to academic researchers.
How often do concussions go unnoticed?
Equipment, rule changes and penalties should always be assessed and reassessed in light of new research. I support recent changes in the N.F.L. and the N.C,A.A. and youth programs, including banning the wedge on kickoff return, assessing penalties for helmet-to-helmet hits on defenseless players, as well as changes in concussion management practices.
As for making the season shorter, that’s an interesting discussion that is mostly between the N.F.L. Players Association and the league. It’s difficult to quantify whether there will be increased risk of injury in swapping two preseason games for two regular season games, though starters who might skip the preseason games will now be at greater risk for injury.
I believe there is a separate, and better, way to make professional football safe(r): change how we play youth football. The reality is that the average pro football career is about three years; but a player almost always plays at least 10 years of football (youth, high school and college) before going pro, and some play 15 years prior to getting paid to play.
If we are worried about the cumulative effects of brain trauma, we need to adopt aggressive measures to prevent injury in the children’s game.
The developing young brain is far more vulnerable to the metabolic and chemical changes of concussion. Young people are also biomechanically vulnerable compared with adults. Having larger heads relative to their bodies along with weaker necks means that more force from hits to the head gets distributed to the brain rather than the body. And they have little to no access to medical professionals on the playing field, so there is a greater risk of concussions not being identified or being improperly treated.
The revelation that Owen Thomas, the 21-year-old co-captain at the University of Pennsylvania, who was already suffering from C.T.E. when he committed suicide in April, tells us that some players may enter the N.F.L. already suffering from C.T.E., , Therefore, our greatest opportunity to limit their long-term risk is to change their exposure before the N.F.L..
Football needs “hit counts” like youth baseball has “pitch counts.” In baseball, all kids are subject to restrictions because some may suffer cumulative injuries to their elbows. Yet in football we’ve never thought the brain, which is more important than the elbow, could be subject to the same kind of cumulative injury. That is insanity.
We should limit exposure to brain trauma risks for kids under 18 because they aren’t old enough to accept those risks. By doing that, we can significantly reduce the number of hits they will have suffered by the time they get to the pro level (perhaps by 50 percent). It seems to me that by making youth football safer we can most effectively reduce the risk for cumulative brain trauma going forward for pro players.
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