Inappropriate incentives must be corrected. Doctors pay their rent and their staff by seeing more people more often. Insurance companies make more money by delaying payment for services provided under their contracts. Patients get no value from their health policies unless they are sick. So how do we put in place the incentives that will bring about real change?

Large companies have opted in many cases to self-insure, transferring risk for large specific or aggregate outlays to re-insurance companies. In doing this, the company steps into a leadership role relative to the healthcare team.
The company is able to invest in employee education because they will reap the benefits more quickly.
The company can monitor more accurately through third party administrators the level(quality) of the care being provided their employees.
Physician behavior can be modified with the tools available. If physicians are not compliant with quality initiatives, they may be removed from the panel of providers.
Additional incentives may be provided for physicians to be in greater compliance. P4P can become a reality quickly.

Self-funding for healthcare benefits is not available for small businesses. State legislation too frequently prohibits small business from coming together to provide this benefit to their employees. And of course, the majority of businesses in the US are small businesses. And small business employees the greatest number of people.

Small business holds the key. We must find legitimate ways to allow small business concerns to aggregate their need for improvements in healthcare.

Richard May

I agree with the Center for Connected Health's strategy and at my company, VisionTree, we have been taking a different approach that combines an incentive approach with a patient-centered architecture that actually delivers results and benefits back to the provider.

We believe that a patient, once given the tools to empower self-management (diabetes monitoring, integration with sensor devices, health rewards, coaching, messaging) will be a better health care consumer. We believe a solution, tool, or strategic approach will only be successful if the provider and end-user physician will see benefit in adopting the platform and promoting it among their patients.

We have seen tremendous adoption by providing "dual-data access" of key clinical and quality of life data metrics to BOTH the patient and their coordinated care team. An example is a diabetic patient having their glucose readings automatically uploaded into their VisionTree portal where an algorithm runs against the results and sends targeted messaging, provides graphs and analytics, and a rewards component for good management. This is coupled with an alerts and notifications system for any adverse events or negative trends in readings.

Providing this data and results to the appropriate member of the care team through a roles and permissions based system is the other end of this "dual" approach to a technological solution.

There needs to be a give and take in the technological solutions that are being developed and implemented. The benefits of an EMR or an HIT may be transparent to a patient and their family. But extending those technologies, through integration and sensor connectivity will make that patient a better informed health care consumer.

Policy developments and initiatives should mirror this philosophy and focus on incentives for both providers and patients (similar to Richard's comments above). Obama's economic reform team is made up of very bright people, but one person was lacking. An entrepreneur was not on the team.

Any health care reform should include an entrepreneur and a representative from a small business. These are the people that drive the ingenuity and are the end consumers of the health care world. Combined with the capital and IT infrastructure that large organizations can supply, our health care system will be in a much better place in the next four years.

As a physician, I came from what used to be a socialized system in the Netherlands five years ago to practice in the US. In the Netherlands, the move has been away from a single payer system, and full health care rationing. A system of diagnosis related reimbursement is making a big difference in increasing access and focusing o preventative and timely care and cure. This approach remains process, not outcome based.
An unsolved challengewith outcome based reimbursement is that quality of care metrics are different whether patient-based or quality of life/function/cure/QALY based and incentives for one metric can be disincentives for the other.

I strongly agree with your viewpoint that most models ,including the Dutch model, lacks increasing responsibility for one's own health, which is a challenge for chronic disease especially.
As a researcher, I am trying to increase compliance with diabetes complication prevention (diabetic retinopathy), through technology, and even in countries where healthcare is free, compliance can be around 60% -> 40% of patients not wanting to receive preventative care that is free. Models where patients get paid for receiving recommended preventative care do exist, may save insurers / employers / society money, but seem counter to the American way.
Patient empowerment and education (they come together) through more technology is one avenue that seems attractive.
However, only outcome based reimbursements can impact practice here.

Michael Abramoff

The US medical system offers the world's most advanced treatments but currently provides many citizens mediocre care at unaffordable cost.
New technology that both improves quality and decreases cost can be the engine that reforms our healthcare system and creates an important base for economic development through American ingenuity.
Adherence to a physician's prescription decreases the liklihood of expensive hospitalization and deterioration in health that destroys quality of life while raising the cost of care going forward. But adherence levels are now limited to about 50%.
Senticare has developed novel systems which adjust rapidly to changes in medication dosing, train patients at home to take the appropriate regimen without error, and rapidly detect and communicate non-adherence to their physicians.The value of improving medication compliance in the US is estimated at $100-300 billion dollars yearly.

Dr Kvedar:
I received this notice in my capacity as a member of the Medical Technology Committee of the International Electronic and Electrical Engineers. I am a public health physician self-employed as a policy consultant.

From my perspective there is a major psychological barrier in healthcare delivery systems that tends to inhibit the development and provision of effective clinical preventive services and all but totally precludes delivery of preventive services outside the walls of the healthcare facility.

Conventional wisdom seems to be that physicians are there to address the health needs of patients, one at a time, with all group or population-related decisions made on the basis of financial, administrative and policy/political concerns, with little in the way of medical input. With the rarest of exceptions, there is no provision in either health insurance enterprizes of medical centers for addressing patient needs on a group rather than an individual basis. Preventive issues related to diet, exercise, smoking, adherence to medical recommendations, medical literacy, contraception, etc are most effectively addressed outside the walls of the health facility -- especially if they are to be addressed before they result in clinical illness and/or other need for medical care. These issues could be addressed by partnering with the local health department, or by setting up and staffing a public-health-type unit within the healthcare institution. Such a unit would do outreach, heatlh education and mobilization of community resources. Once such a partnership has been developed, or public health type unit established, data from the medical center records could be explored to identify sub-populations in need of specific preventive services. The bold new idea behind this would be use of medical expertise to address health-related issues on a group or population basis, rather than just one patient at a time.

Joel L. Nitzkin, MD, MPH
JLN, MD Associates, LLC

REFLECTIONS FROM HISTORY

On Saturday, Dec. 20, I moderated a local, Community Health Care Discussion, in a metropolitan area [Tampa Bay] that launched the most successful, market-based, U.S. healthcare reform in half a dozen years. After our market confirmed the potential for offering hundreds of basic, proven drugs for $ 4 per month per prescription, the program went national. In less than three years, it transformed retail prescription drug pricing throughout the United States and saved customers more than $ 1.5 billion in a way that the current, federal , Medicare program
[Part D] has yet to do.

While dramatically reducing costs, improving access and presumably increasing "compliance" for prescription drugs may represent just one small step toward more comprehensive "healthcare reform" that is needed, we think there are lessons to be learned here in crafting new proposals. Further, our group had the benefit of a Dec. 19th report, by the Congressional Budget Office, which analyzed 115 healthcare plans and reform proposals. Of those, the CBO found that only a requiirement for physicians and hospitals to use healthcare IT as a condition to participating in Medicare" would produce significant cost savings in the next 5-10 years. Fortunately, our group went beyond one of the key issues to be addressed in any "reform"--- cost.

In support of one of Connect Health's recommendations (above), one of our physician participants noted that simply guaranteeing universal health insurance for all was no guarantee of access to care. He cited the first year experience in Massachusetts in support of that position. "Despite having the highest doctor to patient ratios in the U.S., Massachusetts has not [yet] demonstrated the [healthcare industry's] ability to provide actual, universal access to care." It is, at the same time, one of the states that has been most resistent to retail-based, ambulatory care clinics.

I believe that truly "connected health," threaded through emerging national networks of ambulatory care, have huge potential for concurrently improving access, signficiantly reducing costs, correcting the high variation in measurable quality of care and in improving "consumer satisfaction."

Proposals that rest upon hopes of voluntarily changing human behavior when it comes to diet, exercise and remote medical monitoring have a far bigger problem to address, judging from what we have seen over the last 20 years from organizations that have great experience in marketing such services to the public.

Ron Hammerle
Chairman
Health Resources
Tampa, Florida
Ronald.Hammerle@healthresourcesltd.com

Dr Kvedar's bold call to action around effective use of selected patient engaging information technologies is timely and important. We have two decades of research that indicate that getting the right information to the right health care stakeholder at the right time, linked to decision support and an ability to "transact", saves money and lives. While infrastructural improvements like EHRs and health system enterprise deployments of care process improvement technologies are important, we should not and can not afford to overlook the deployment of emerging technologies like remote monitoring, interactive web-sites and "health-savvy" cell phones to support health consumers directly in their move towards sustained health enhancing behaviors! The comments above on outcomes is also critical, and its high time we moved past the simple metrics of cost or physiologic endpoints alone, and start thinking of "value" as an endpoint worth not only measuring but maximizing. Value, often described as the ratio of desired outcomes to incurred costs is critical to unraveling the thousand and one "tradeoffs" that both individuals and society as a whole must grapple with in deciding how best to utilize scarce resources. And until we move towards a "value-oriented" care delivery and reimbursement models, we are likely to make enormous and regrettable errors, over-emphasizing the use of some technologies, and underusing others, especially the ones "called out" so articulately by Dr Kvedar.


Jeremy Nobel, MD, MPH
Harvard School of Public Health

Whenever we address the quality issue we need to be ready to have the economic impact in hand. Too often we focus so much on quality that we lead people to believe that it is an "Either Or" decision: "I either decide to focus on the best practices with the best devices and the cost will be higher," or "I will do less and save money for the system." Much more work needs to be done on documenting cost effectiveness due to improved outcomes.
My other concern discussing HIT and Telehealth is that we need to focus more on the AMA and the ANA. The vast majority of physicians and nurses have little tangible experience with HIT and Telehealth. Many of them have negative experiences due to improperly managed CHANGE when HIT was unilaterally implemented without their acceptance ahead of time.

Joe,

I agree with and support your proposal, and urge you to advocate this approach to policy makers.

It appears that electronic records, even including a simple and inexpensive disease registry, can offer benefits in chronic disease management, including for diabetes and sleep apnea. But the benefits depend on new patterns of managing disease including helping patients to be more involved as well as new patterns of monitoring and interaction by clinicians. Let's ask that Obama and Daschle set up some guideposts and standards that encourage effective change in health delivery, going far beyond new software systems that record information that support traditional behavior.

I posted the above on my blog as part of a continuing effort to inform people living with sleep apnea and other chronic conditions for better solutions to help them manage their health. http://www.photoluminations.com/drupal/node/46" Can electronic health records improve treatment for chronic conditions?

We should be supporting a number of new, flexible initiatives to support a variety of solutions to providing connected health: including at large institutions, independent practitioner groups, and entrepreneurs who may not be affiliated with a medical institution. The biggest benefits are likely to be in improved management of chronic conditions where new approaches using connected health can have an impact.

The risk for Obama and Daschle, is that in the rush to get things done now, in a bold, dramatic fashion, we will get bigger versions of bad solutions. This risk is lurking in health care: a big push for electronic health records, a perhaps necessary but insufficient condition for progress. But it will do absolutely nothing unless part of a massive paradigm shift or two in health care...including making the patient part of the solution.

The patient needs increased access to information and responsibility for making informed decisions. Patients start as children learning to be dependent on others to make decisions for them. InnerLink starts with students and trains them to be health literate and eventually advocates to influence others to make decisions that maintain or advance their health. the Student Health Corps movement in New Orleans has shown the value of the student as a key piece of the households health resources. Support of programs like this in the context of communities with point of care information always available becomes part of patient empowerment. It will take a decade or more to improve the health status of certain neighborhoods, and having the students as part of the solution as a next generation of family or community health providers is one approach that deserves some attention.

Here at the New England Healthcare Institute (an independent, non-partisan research group whose member organizations represent every sector of health care), we believe that high value innovation is the key to fixing the health care system. High value innovations will yield better care and increased access for every dollar spent. Innovation is often viewed as the introduction of new drugs and devices, but it also refers to public and private adoption of new methods of financing, organizing, and delivering care. High value innovation in three core areas – prevention, chronic disease management, and primary care – must be the focal point of national health care reform.

The U.S. health care system today is focused on the immediate costs of the doctor, drug, device, procedure, or hospital stay. No one, not the federal government nor private insurers, is adequately focused on the health outcomes of the patient or on the costs over the life of the patient or the course of a disease. Effectively managing with the long term in mind is what "value" in health care should be all about – saving lives and saving money.

Finally, transforming health care delivery will require the collaboration of all stakeholders in the industry. With our diverse, cross-sector membership, NEHI is uniquely positioned to refocus the system from short-term costs to long-term value.

To achieve true national health reform, leaders in both the public and private sectors should implement the following NEHI Nine policy reforms:

Prevention:
1. As a first priority, gather, analyze, and disseminate data on which prevention efforts work.
2. Promote the use of high value prevention services, especially in obesity and diabetes, in both the public and private payment systems:
• Provide financial incentives to physicians who adhere to preventive service guidelines
• Reduce or eliminate patient co-payments so that preventive services are affordable, particularly to high-risk populations
3. Make a serious national commitment to reducing health risk behaviors in the U.S. Create public-private partnerships to promote healthy behaviors and environments through: Government-funded public health programs, Employer-sponsored health benefits, Public school programs, Broad community health initiatives, Coordinated campaigns for patient outreach and education.

Chronic illness:
4. Encourage and reward the use of proven best practices for patients with chronic diseases in both traditional (clinical) and non-traditional (employer) settings.
5. Accelerate improvements in the quality and availability of health information technologies that improve the management of chronic illnesses.
6. Expand public and private research to identify high-quality and cost effective delivery systems for chronic care.

Primary Care:
7. Provide payment for innovative ways to deliver primary care, including by non-physicians, by medical teams, and in non-face-to-face encounters.
8. Increase public and private payments to physicians to pay them adequately for both prevention and treatment services, especially for obesity, diabetes and other chronic conditions.
9. Make the redesign of primary care a high priority for the U.S.: initiate research to assess new models of primary care delivery for the future.

Only by realizing these fundamental reforms will the U.S. health care system be equipped to deliver the affordable quality care all Americans deserve.

www.nehi.net

I wish to strongly associate myself with Dr Kvedar's subtle,yet powerful call to embrace comprehensive "Connected Health" approaches to health care reform, as a central tenet for the upcoming Obama administration. Many of us, who have had the privilege of working at the cutting edges of medical technology, have observed a cruel paradox. We frequently define our problems, and consequently seek our solutions, within the framing vocabulary of emerging technology. So, for example, we collectively need a multi-venue, cross-platform, portable EMR. Upon obtaining and deploying the new technology, we are then invariably disappointed that it alone does not deliver the solution we sought, at least not initially. Did we really need an EMR? Yes. But, in afterthought, we often realize that what we really needed was new technology to enable meaningful behavior change, both at the individual and collective (systemic) levels. This is easier said than done, but is nonetheless essential. It is in the application of technology within the complex system of systems of human and system behavior that we gain true value, not in the technology itself. Unfortunately, it is only too easy, especially at the macro policy level, to lose sight of the individual and systemic changes we seek, and get fixated on obtaining first the budget and then the "thing".

This is why I think Dr Kvedar's call for physiologic monitoring, patient feedback & education and data driven coaching at the individual level, and true payment reform (payment for quality and not units of service), at the systemic level, strikes the correct balance. Technology is an enabler of change , not an end in itself. To forget this lesson is to risk paving the cow path - once again.

Conrad Clyburn
Co-Founder, Senior Partner
The Clymer Group, LLC

I frequently hear that the mass adoption of an EMR/EHR is essential to the reform of healthcare. This point has been made both by the incoming administration and by the outgoing administration. I fail to recognize how the implementation of an EMR/EHR in a healthcare setting (where there currently is none) would make healthcare anymore accessible to those who cannot afford it? Granted an EMR and EHR is an important tool in the larger scheme of data sharing, reduction of medical errors, etc.; however, I don't find that in the context of making healthcare more "accessible" the EMR/EHR plays a large role.

I would submit that this is largely a financial issue and thus, "how to pay" for medical services and medical prevention should be the paramount focus of the discussion starting now and into the future of healthcare. Ultimately, the ability to pay regardless of the means needs to drive this issue going forward. Solutions in this area should not be dismissed simply because they are too difficult to address in the current environment.

There are many good things happening in primary care b/c of PCP's implementation of new business models.

There has been a disconnect between PCP's on the front lines and the policymakers, insurers, government, employers and vendors who have difficulty fixing, much less understanding, our workflow problems at the point of service. Most don't know how to run a primary care physician's office because they have never done it (just like I don’t know how to run GM/Ford/Chrysler, Lehman Brothers, an oil and gas company or a restaurant…) Most are not PCP's either. PCP's do know how to run our own practices for the benefit of our patients particularly if third parties are out of the way and it's a simple model. Fee For Service with third parties is passe...It simply isn't working. To think that physicians want to become data collectors for the insurers and the government in order to get paid for "quality" is not only amusing...it's ludicrous. Board certification ensures consumers that their physicians meet certain standards of quality care and the consumer usually has enough sense to know if they are getting quality care. Just look what has happened to pharmacists collecting data for PBM's. They know longer interact as much with patients as health care professionals.

Fee For Care (retainer) and Fee For non-covered medical service models are emerging as new models to decrease the inefficiencies of the present model. Even old school Fee For Service, cash only practices are coming back. It's all about the overhead.

TAKE HOME MESSAGE:
1. Decouple primary care
2. True leaders stay out of the way of people who know what they are doing
(ie – physicians caring for their patients).

The Society for Innovative MedicaL Practice Design is the physician organization of innovative primary care entrpreneurs who have changed their business model to a "direct practice". We have direct financial relationships with our patients (see www.simpd.org ...their are 2 interviews that explain the emerging practice styles we are seeing).

The problems from the physicians perspective are eye opening.
The Physician’ Perspective on Medical Practice in 2008 was published
by the Physician’s Foundation in November (http://www.physiciansfoundations.org/news/news_show.htm?doc_id=728872)

It highlights what most physicians have known for years. We have a primary care systems problem in the US
that only physicians can solve for their patients by adopting new business models.
An overwhelming majority – 78 percent – of physicians believe that there is an existing shortage of primary care doctors in the United States today.
Additionally, nearly half of them – 49 percent, or more than 150,000 practicing doctors– say that over the next three years they plan to reduce the number of patients they see or stop practicing entirely.

I hope the new administration keeps an open mind to physicians who are fixing this
in their own marketplace. We need the leadership of our Congress, Senate and President Obama
to work with innovative physicians who have working solutions in their own marketplace.

SOLUTIONS:
DECOUPLE PRIMARY CARE…
We at SIMPD have found that patients are intelligent as consumers of healthcare.
In order to provide timely access to quality care with your trusted physician, primary care physicians,
we need to divorce (decouple) third parties. Most “direct practices” charge between $100-150/month with small practices (usually 4-600) by cutting out the middleman. This is not for the rich. Many of my patients don’t even have a job or are lab techs, security guards, nannies, uninsured, etc. Some of my patients are scholarship at my choosing. Some trade their services (hair cuts/maintenance/computer guy/etc)…It’s old school….

The consumers choose whether they want health care or other items like a cellphone, the Internet or
cigarettes just like they decide whether they go to McDonalds or a steak house.

The real challenge will be to get Congress to allow patients to pay for unlimited access to a primary care
physician on pre-tax dollars. The Family and Retirement Health Investment Act of 2008 (S.3626) Sen. Orrin Hatch, R, Utah) does just that. Section 12 of the bill is my contribution. If passed, pre-paid annual physician fees would be considered “medical care” and allowable as a qualified medical expense on HSA’s.

I would like to see bipartisan support for this bill.

SEC. 12. CERTAIN PHYSICIAN FEES TO BE TREATED AS MEDICAL CARE.
(a) IN GENERAL.—Subsection (d) of section 213, as amended by sections 10 and 11, is amended by adding
at the end the following new paragraph:

‘‘(14) PRE-PAID PHYSICIAN FEES.—The term ‘medical care’ shall include amounts paid by patients
to their primary physician in advance for the right to receive medical services on an as-needed basis.’’.

One bill, once a year for unlimited access to your trusted board-certified primary care physician
at a reasonable price on pre-tax dollars through your HSA. (same day access, email, telephone visits without coming to see the physician, guidance through the healthcare system, 24/7 access to my cell and home phone)
Like a car, you need insurance for catastrophic care. I provide all the gas, tune-ups,
car washes, brake jobs, tire balances for a price that is cheaper than cigarettes or Starbucks.
It would be nice to have full support to back the Hatch Bill and allow this to be done
on pre-tax dollars.

Hope is not a solution to this problem. If passed, DEMAND by the public increases …”Where can I find
a PCP that gives access to quality care at a reasonable price on pre-tax dollars?”
If the demand is there, and we teach young physicians how to actually run a practice with a
simple business model, then we will attract our youngest and brightest med students back into
primary care…PCP SUPPLY will increase and provide the medical home patients desire…
that would cut out all the Third Party waste seen in Medicare, Medicaid and insurance on the PCP side.
PCP’s are the spoke in the wheel and by working for our patients, we keep the cost of HC down so there will be more monies for catastrophic care/specialists/hospitals etc….

THE FUTURE:
50% of the physician work force needs to be PCP’s (family physicians, internist and geriatricians)
that provide a medical home. This won’t happen in our lifetime

300,000,000 people…
400,000 PCP’s taking care of 750 patients

For the 46,000,000 uninsured…we need 61,000 Docs…
They just need to learn how to run a small business with a simple and implementable business model.

For more info, view our website and the 2 interviews with me as past president…
Please contact me if you would like a copy of the Hatch Bill, an explanation of the bill, summary of the emerging practice styles we at SIMPD have seen and the Physicians' Foundation survey.

Chris Ewin, MD
past president, Society for Innovative Medical Practice Design
cewin@121md.net
www.simpd.org
www.121md.net
817-423-5121 office

The big risk in healthcare IT is that we underestimate agency cost. Agency cost is the economic concept that someone you pay will work to maximize their benefit, not necessarily yours. With traditional electronic medical records, software companies are motivated to sell their own, proprietary solutions. Hospitals create integrated systems, but only for their network of affiliates. If we put the same effort into open standards, then medical devices, electronic medical records, and personal health portals from multiple organizations could work as a unified, patient-centered system, rather than as specific, expensive tools. Other industries have similar issues, sometimes resolved by market forces, and often requiring better regulation. The new administration needs to address this issue at the Federal level for IT to deliver the healthcare improvements that have been promised of it.

Dr. Kvedar and the Center for Connected for Health are clear leaders in innovative heath care delivery. As a medical director for a BCBS Health Plan for 20 years, an internist practicing at an FQHC for 25 years and a leader in Health Information Technology, I would like to get physicians out of the health care delivery system. I share the concern that the Obama administration is taking the politically correct course in expanding access with out addressing quality or efficiency.

The 40 plus articles generated by the TRIAD Study (CDC) looking at diabetes and managed care recognized that only the Veterans Administration has produced increased quality in the last 10 years. (Managed care improved “process”.) The providers at the VA participated in the improved quality, but were not responsible for many of the changes that lead to the improved outcomes.

The United States has many health care systems and the government funded programs continue to lead in improved quality and efficiency. The VA, one of the largest health care systems in the world based on total dollars, has essentially re-invented itself into a delivery system driven by one of the premier EHRs in the world and a system approach the drives efficiency and quality. The Indian Health System with a similar EHR also continues to improve care when the rest of the delivery system struggles with re-imbursement and productivity driven profits. The Federally Qualified Health Centers have partnered with the Institute of Healthcare Improvement for the last decade to improve care. All of these delivery systems rely on non-physicians to lead re-design to improve quality and efficiency.

GM has health care costs that consume close to 20% of an employees salary and is a primary reason for the demise of the auto industry in America. I will acknowledge that there were bad decisions to market the gas guzzling SUVs, but America needs relieve from the waste and inefficiencies of our multiple delivery systems. For starters, we have a delivery system that has administrative costs that far exceed any other country in the world. The hospital, medical staff and health plan run in-patient care that account for 40% of total cost is totally dysfunctional. Doctors rule and will take their patients to other institutions if not catered to. Hospitals are juggling un-insured, government payments and DRGs against a nursing shortage, specialist interests and institutional inertia.

It is time for physicians to get out of the health care delivery system re-design and turn the responsibility to “systems” people. As physicians, we are to a large degree part of the problem. We are the ones that create the red ink by doing unnecessary procedures, ordering inappropriate testing, and accepting the incredible gouging by the pharmaceutical companies. Academic medical centers that have generally been silent on health care delivery systems need to take a leading role in partnering for health care reform. The Center for Connected for Health is an exception.

The solution is to build a partnership with employers, health plans, government and physicians. For the next 5 years, have health plans and government guarantee selected hospitals and providers groups a guaranteed income. In exchange, place the coordination of care in the hands of “systems” people, CEOs and CFOs that bring corporate structures out of bankruptcy. Implement a health information system such as available through the Center for Connected for Health to collect data and drive reform including the patient centered care and remote monitoring. Provide reconciliation and profit sharing for hospitals and providers as the system becomes more efficient and provide a mechanism. Use the brain trust in motivated providers to come up with ideas to improve quality and efficiency, but leave the design and implementation to the systems people.

After 5 years of guaranteed income, health information technology to guide change and academic analysis, develop a reimbursement system that aligns incentives, rewards team work and measures outcomes. Central to this approach is the chronic care model and patient centers care.

As physicians were are not smart enough collectively to change the reimbursement system. The reality is that government and health plans control most of our destiny. We need partnership, not control. We need information and time, not instant solutions. Health information technology is critical, but totally user dependent. It is time to return to an old concept of taking care of patients first, but to do that we need a whole new set to partnerships and technical tools.

Specific Action plan: Focus incentives on outcomes. Pay for the "what" - the outcomes, not the "how" - method / system to collect information for the outcome. Also, invoke standards on the "what" rather than the "how" -- Standardizing the "how" in an immature and evolving market limits innovation in a significant fashion.

Fully interoperable HIT systems that are proven to improve care and save time are available and they can be deployed in scale for about $1000 / yr or less (even in small practices without IT support).

Below are 2 key sets of data: 1) Congressional Testimony on lack of effectiveness of a well-known CCHIT certified EMR and 2) Reference and findings in an article on what improves care (meta analysis of 80 studies).

Bottom line - Decision support within the point of care workflow is the critical element
Focus incentive on being able to achieve the desired proof or outcomes.

--------------------------------------------------------
CCHIT currently costs about $50K / yr in fees + signifcant vendor cost to modify systems to meet the CCHIT criteria -- in total, putting a huge tax (thousands of $/yr/physician) on the HIT system at large and potentially limiting innovation. It is not due to the certification, but rather payment to physicians to subsidize CCHIT systems and not any other HIT. The issue is that CCHIT systems are not correlated with improved care. Additionally, as stated above in other posts, the Bureau of Primary Healthcare, Indian Health Services and others have been using systems that improve care for years.

------------------------------------------------
http://www.govhealthit.com/online/news/350107-1.html (Nov 2007 - Gov' Health IT)

Current certification methods do not correlate with improved care: In fact there was testimony in front of Congress about CCHIT EMRs not being able to do 4 basic elements of care improvement:

Although e-health records are often touted as supporting disease prevention and better patient care, the systems available to doctors and clinics do not achieve those goals, an assistant commissioner of New York City’s health department told a congressional panel.

Even systems certified by the Certification Commission for Healthcare Information Technology generally lack four features needed to improve population health, said Dr. Farzad Mostashari, who heads New York City’s Primary Care Information Project.

(The functions that improve care)
1) Decision Support Tools: reminders and alerts informing on best practices
2) Population Lists / Registry Function: lists of patients who need care and a way to contact them
3) Performance Measurement: graphs and tables showing whether care improvements are effective
4) Structured Data Collection instead of free-form notes: needed to analyze what’s known for 1, 2, 3 above

[In 2007] Electronic Health Record systems available to physicians and clinics do not support disease prevention or enhance patient care… NYC is working with the vendor to BUILD those features into its system
- Testimony to Congress by Farzad Mostashari MD, head of NYC Primary Care Info Project
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What Makes Healthcare Safer, Better, Faster?
From 80 study Meta-analysis:

BMJ 2005;330:765 (2 April), doi:10.1136/bmj.38398.500764.8F (published 14 March 2005)

*** Automatic Decision Support as part of Clinical Workflow
- Provision of Recommendations rather than just assessments
- Decision support available at the time and location clinical encounter
- Computer-based decision support

Information in practice: Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success .
Kensaku Kawamoto, fellow1, Caitlin A Houlihan, scientist1, E Andrew Balas, professor and dean2, David F Lobach, associate professor1

http://www.bmj.com/cgi/reprint/330/7494/765.pdf

In this issue Kawamoto and colleagues provide some evidence based guidance in a systematic analysis of the ability of decision support systems to improve practice in both statistically significant and clinically meaningful ways (p 765).2 This rigorous review includes only randomised controlled trials and excludes small studies that do not meet 50% of established criteria for methodological quality.3 4 It identifies four independent predictors of effective decision support: systems that enhance practice generate decision support automatically as part of the normal clinical workflow and at the time and place of decision making; they use computers to deliver support; and they offer specific recommendations rather than mere assessments. Ninety four per cent of clinical decision support systems with these characteristics improved practice compared with only 46% of systems that lack one of these features.

"Working in a Japanese Company, I can clearly understand the benefits of annual health checks, and how they relate to the early catching of disease. I have several colleagues who had a heart murmur, polyp, and other problems found early during the routine health exam. Finding disease early, and curing/treating it, is something which must be emphasized in the new healthcare policy. It saves money for the individual, company, and society.

It is a known fact that the amount of money spent by Toyota ($100/car) versus GM ($1100/car) on healthcare is a heavy burden for any company or country for that matter. Furthermore, there are nearly 40 million uninsured Americans. They need an insurance company to help them detect problems quickly, following the approach of Routine Health Exams. Possibly even rewarding the patients who take their prescribed pharmaceutical products (Rx, Self Blood Glucose Monitoring, etc). Having a means to confirm that patients are taking their medication will help save billions. It is a known fact that nearly 50% of patients unilaterally decide to stop taking medication. Have them link in via tele-health or some other means, confirming to the insurance company the effectiveness of the drug, and/ or whether they are indeed taking the prescribed drug.

It is time to take a three step approach : Routine Health Exams, Periodic Non-Invasive Screening For Early Detection of Disease (CVD, Breast Cancer, Prostate, Cervical Cancer, etc), and Feedback Regarding Therapy Effectiveness/Compliance. Reward the patients who follow these steps similar to how car owners are rewarded with lower insurance rates for a good record. Encouraging patients to take their health into their own hands will benefit everyone. It is a known fact, catching problems early will reduce health care costs. After attending several AHA (American Heart Association) conference's, I can see that the technology and methods are there to prevent heart disease, it's just a matter of pulling it all together into a national healthcare policy. This opinion is my own opinion, and does not represent or imply the opinion of any company, or any other person than myself."

One element that seems to be missing in the discussion so far is the explicit role of mobile technologies in the hands of citizens for citizen-focused prevention, care and support, treatment, and on-going monitoring. It can be viewed as an extension of HIT systems as well as a stand-alone independent applications that enable individuals to receive the health information and services they want. mHealth has the potential to create efficiences within the US health care system as well as to extend prevention and treatment services to isolated individuals. For the care and treatment of chronic illness, it will enable more people to be cared for outside of the formal health system and brought in for specialized treatment only as needed. Through two-way communication streams, citizens will become more empowered to address their health needs through targeted algorithms-based information based on individual specifications and preferences. In the US, mHealth is manifesting itself through informal uses by the general public as well as a handful of pilot projects to maximize the benefits of MP3 players for education, mobile phones and sensors for remote patient monitoring, mobile phones and PDAs for access to health information, and maintenence of electronic medical records on mobile devices. As is happening in developing countries at a much more rapid rate, the US ought to consider the role that mHealth can and should play within the broader discourse on eHealth to move from small modest pilots to large-scale implementation and operations research. It should begin by identifying key objectives and priorities within the health system and how each technology platform (PCs, mobile phones, sensors, RFID, etc.) and software solution can be integrated towards achieving better health outcomes, improved quality of care, and cost-savings, etc. alongside key measures of success.

“Only a crisis - actual or perceived - produces real change. When that crisis occurs, the actions that are taken depend on the ideas that are lying around… The great advances of civilization, whether in architecture or painting, in science or literature, in industry or agriculture, have never come from centralized government… achievements [of great innovators] were the product of individual genius, of strongly held minority views, of a social climate permitting variety and diversity.” Milton Friedman, Capitalism and Freedom, 1982

Connected Health and its lead-implementations outlined in Dr. Kvedar’s posting are the “ideas that are lying around…the product of individual genius, of strongly held minority views.”

In this time of crisis, other “ideas that are lying around” will come from powerful stakeholders in our existing, broken healthcare system. Ideas from Johnson&Johnson, Merck, BCBS and their kin. Stakeholders with much to lose if there is too much change. “Business as usual” stakeholders with deep-pocket links to government.

We are in perhaps the worst recession since 1927. Programs that promise healthcare reform alone will not be funded. Those that promise economic stimulus and, as a byproduct, healthcare reform, will be funded.

The correct priority of the economic stimulus package is to keep people employed, and so keep them spending. We must accept that this can be most effectively done through those “business-as-usual” stakeholders who resist radical change.

Our job is to ensure that the ideas of Connected Health, with their job-creating flag flying high, get a good share of the Administration’s stimulus funding.

We must lobby for a lofty goal: that a Meaningful Proportion (20%) of government stimulus funds should be allocated to a series of smaller, but potentially game-changing programs.

Including Connected Health.

We are right with you on prevention and individuals' ownership of their own health and behaviors. At this point, especially in MA where everyone must have health care coverage, there is additional incentive to get healthy and stay healthy. Consumers need and want information on what steps they can take to achieve a healthy lifestyle. If we turn to the schools to educate our children about healthy choices and healthy behaviors and look to business leaders and owners to provide basic information about health and wellness, an enormous number of residents would have access to the kind of information they need to start on a new, healthy track. If we look at the workplace alone, half of the 6.4 million MA residents are employed. As has been proven by the spectacular EMC employee wellness program, these programs have a positive impact not only on the employee but on their families as well (not to mention that EMC has reduced their health care costs by $190 million since 2004. They call it Health Care Cost Avoidance) . Some employers do it on their own, some need incentives soooo.....

President-elect Obama should be encouraged to promote the passage of Senator Tom Harkins bill S.1753 Healthy Workforce Act of 2007. This bill amends the Internal Revenue Code to allow employers a 50% tax credit for the costs of providing employees with a qualified wellness program. It defines "qualified wellness program" as a program that is certified by the Secretary of Health and Human Services and that consists of a health awareness and education component, a behavioral change component, and a supportive environment component. It also requires the Secretary of the Treasury to institute an outreach program to inform businesses about the availability of such wellness program tax credit.

Real and robust healthcare reform is an exciting new reality.

The dialogue now underway in Washington DC and across the nation will likely come to be viewed as the turning point in re-conceptualizing healthcare and systematically bring about, through demonstration and pilot projects and at scale, new healthcare financing and care delivery paradigms that overcome vexing and longstanding healthcare challenges.

All options should be on the table. If we are to vanquish the high cost, unequal access and uneven quality healthcare juggernauts, through nonpartisan enlightened public policy, all participants in the healthcare value change should be directed to think differently and contribute vigorously, in word and action, to the healthcare reform mission.

Real reform will require steadfast political will and an enduring commitment to a social compact that promises high quality and affordable healthcare for all. If we are to stand firm on these principles, a culture of ongoing experimentation and objective evaluation is required.

That potent combination of political will and enduring commitment is present today. Economic, demographic and public health realities suggest it is a growing phenomenon and will remain at the forefront of the national consciousness for the foreseeable future. For the next decade and beyond, healthcare reform is likely to be ongoing, pervasive and manifold.

As we work to unearth new care delivery and healthcare financing models, the convenient care, preventative care, consumer empowerment and capacity building attributes of Connected Health should figure prominently in the discussion. Those on this blog and many others have much to contribute to this dialogue. In Connected Health, there is a wealth of knowledge, experience and insight. In addition to improving health outcomes, increasing access to care and reducing costs, Connected Health products and services can increase the utility of the electronic medical record, open up new and creative avenues of care delivery, serve as a catalyst for the creation of new insurance products and payment models, shift some of the burden of care to lower cost clinical/paraprofessional clinical providers, create a new industry of high quality/low cost healthcare products and services, unleash new competitive energies to ensure health and wellness and the ability to age independently, spur job creation in the technology, academic, provider, payer, policy, etc. sectors and contribute to helping to build and maintain a newly competitive and robust US economy.

For all of the reasons mentioned above, these are enormously exciting times to effect change, add to the social good and work together to bring about the healthcare system that we desire, deserve and need. This connected health industry and the individuals behind it stand ready to share knowledge and work together to bring about new and effective solutions to overcoming our country’s healthcare challenges and sharing those solutions globally with others.

Joseph L. Ternullo, JD, MPH
Associate Director, Partners HealthCare System’s Center for Connected Health
Adjunct Faculty, Northeaster University, Informatics Law

Dear Dr. Kvedar:

IEEE-USA Medical Technology Policy Committee supports the concepts of Connected Health you describe. True healthcare reform cannot be achieved without increased emphasis on patient-centric care and quality of healthcare delivery. We recommend the following actions to improve healthcare delivery and quality:

1. Increased emphasis on the role of public health in improving the quality and reducing the cost of healthcare. Public health departments are well situated to participate in the sort of lifestyle management programs that can help to switch the emphasis from chronic care to preventive medicine. This in turn requires increased sharing of information among agencies - something that cannot be done without an adequate IT network. Funding should be provided to enable Regional Health Information Organizations (RHIOs) and Health Information Exchanges (HIEs) to create viable business models. And implementation of the necessary technology requires not only adequate funding, but also a renewed understanding of the critical role that public health agencies play in the healthcare system.

2. Use of leading-edge technologies that will play a major role in transforming the healthcare IT network from a passive transport medium to an intelligent network by implementing some of the concepts of the semantic network. Chief among these, in our opinion, is the use of ontologies, which show how items of knowledge are related to one another. To illustrate the power of this concept - an ontology that relates drugs to their chemical composition, to their therapeutic use, and to genomic variation could be used to predict the effectiveness of a specific drug regimen for a person with a specific genetic makeup. These are the kinds of technology innovations that can revolutionize the delivery of medical care.

3. Engineering techniques can be used to improve the quality of care and reduce medical errors. Something as simple as better enforcement of handwashing between patient encounters can have a dramatic effect on reducing hospital-acquired infections. Implementing basic engineering concepts such as the use of protocols and checklists can dramatically reduce the number of medical errors in a wide variety of procedures.

4. A paradigm shift from a centralized model of healthcare to a distributed model in which home telehealth and remote monitoring, combined with a patient-centric approach, move the healthcare "center of gravity" from the hospital to a community-based model in which the focus is on prevention, not chronic care. Again, this paradigm relies not only on ubiquitous availability of IT infrastructure, but also on a change in practitioner culture in which information is freely shared and widely distributed.

Best Regards
Thomas C. Jepsen
Chair
IEEE-USA Medical Technology Policy Committee
tjepsen@mindspring.com

REFORMATION OF THE U.S. HEALTH CARE: A tall but doable order.

On the 14th October 2008 quasi-nationalisation arrived at the home of free market capitalism.

In the surroundings of the White House Rose Garden, President George Bush announced the government’s immediate buying of shares (at the taxpayer’s risk) in nine of the biggest banks in America. This announcement, which followed an earlier move in September through which the US housing finance was brought under direct government control, was one of the last few remaining ammunitions with a potential to control the depth of the recession.

It is under the shadow of such extraordinary economic circumstances coupled with an unhealthy and growing budget deficit, rising unemployment and a malaise and fragile (if not broken) world economy that president-elect Obama and his team are having to devise new plans not only to cope with the economic downturn but also to meet the mammoth task of delivering the promises made as a part of the mandate for change.

In addition, America can only ignore at her peril the findings of a 2003 study “Fiscal and Generational Imbalances” by J Gokhale and K Smetters in which a $45 trillion budget black hole was identified. And the relevant point here is this – at the time Medicare spending was responsible for the lion’s share (82%) of the $45 trillion.

The authors go on to provide a number of intractable solutions such as cutting Social Security and Medicare benefits by 56% or raising payroll taxes by 95%. This news is so bad that scarcely anyone wants to believe it. There are clear parallels here with the comparatively much smaller issue of sub-prime mortgages and the ensuing devastations once the curtains were lifted.

The above economic realities will most likely exacerbate – with potentially devastating consequences - if the health care reforms (or any other reform for that matter) were to be conceived in isolation of these realities.

The question is no longer the choice between the private or the single-payer (government-run) health care system, neither of which is any longer fit for purpose. Given that without doubt both systems in their current form are unsustainable it is bewildering how at difficult times each sees the other as the promised land. In the words of Henry Ford, “If I had asked my customers what they wanted, they would have said a faster horse.”

The question is how best can we devise and implement a sustainable 21st century health care delivering the aspirations of the Obama - Biden’s Plan at the same time as addressing the longer term financial implications facing America.

As already discussed elsewhere on this site (See Discussion => Revolutionizing Healthcare) there is undoubtedly a need for both “evolution” and “revolution”. The evolution element requires changes to the regulations, costing, delivery and management of the existing health care system.

The revolution element builds on making widely available a number of relatively new initiatives able to help achieve a more sustainable health care system moving towards an acceptable cost/quality and or cost/productivity equation. For example initiatives such as those:

i) Deploying flexible, robust, but non-expensive technologies in health care fields where practical, intelligent, task automation and remote disease management is not only feasible but can also reduce operational costs at the same time as improving health outcomes. For example refer to the excellent work undertaken by the connected health team or see (http://jtt.rsmjournals.com/cgi/content/abstract/13/suppl_1/59).

“An Ounce of Prevention is Worth a Pound of Cure” – Benjamin Franklin.
ii) Dealing with incentive based life style change, and early disease detection. The former aiming to reduce the risk of developing an illness in the first place and the latter aiming to reduce the final impact of the disease through it’s early detection. The current Health Risk Assessment systems marketed for use in this area tend to suffer from the lack of an evidence-based approach. One of my research & development teams will soon release a system addressing this issue.

As the largest U.S. industry, health care provides 14 million jobs (2006 figures) and is expected to generate 3 million new wage and salary jobs between 2006 and 2016. This is more than any other industry.

Can the design of the proposed 21st century health care system ensure the employment stability of the health care industry? After all, the efficiency gains we are after are bound to mean some unemployment. More crucially is there any scope for additional revenue streams from beyond the U.S. borders?

Some aspects of the proposed health care reforms offer an international business opportunity made possible mainly through economies of scale and innovative solutions, technologies and business models of a nature not available until recently. For example being able to remotely and automatically monitor say a diabetics condition on a 24/7 basis and to automatically provide quality algorithm driven advice remotely whether the patient is in Mumbai or Minnesota offers huge business potential, reverses the current flow of so called “health tourists” and can play a major role in mitigating climate change by reducing travel based CO2 emissions.

Back in the early 1930s and taking office in the depth of the Great Depression another Democrat - President Franklin D Roosevelt stated:

“The country needs and, unless I mistake its temper, the country demands bold, persistent experimentation… We need enthusiasm, imagination and the ability to face facts, even unpleasant ones, bravely. We need to correct, by drastic means if necessary, the faults in our economic system from which we now suffer. We need the courage of the young. Yours is not the task of making your way in the world, but the task of remaking the world which you will find before you. May every one of us be granted the courage, the faith and the vision to give the best that is in us to that remaking!”

On that occasion America suffered, persevered and emerged triumphant. There is no reason why this success just like the history itself can not be repeated.

Sepe Sehati
sepesehati@googlemail.com

Dear Dr. Kvedar:

What we need is a new paradigm in healthcare delivery to address many of the issues faced by healthcare delivery. A complete transformation is needed to move healthcare delivery from a centralized system to a distributed model in which home / remote care that involve patient and family playing a critical role. But the transformation can happen only when there is paradigm shift in attitude of the major players. Right now, the major players are very slow in visualizing the advantages of technology and reacting to bringing these changes. Industries such as banking, telecommunications, airlines, etc. have moved aggressively in order to serve their customers much more effectively. For example, the payers should allow technology to play a role by bringing telehealth and connected health tools much more aggressively to make delivery more efficient.

Let us hope that the policy makers focus on bringing the following changes in next four years:
1. Bring payment reforms in order to allow the use of technology more effectively - reward use of technology than panelizing.
2. Make patient and family part of the disease management process by bringing right tools and technology to the patient home.
3. Let us aim to bring healthcare for all by utilizing technology to reduce inefficiencies in care delivery.
4. Help us compete globally by managing healthcare costs with use of telehelth and connected health tools more aggressively.

Krishna Gazula
President & CEO, iHAS Inc.
kgazula@ihasCollaborate.com

If President-elect Obama was sitting at my fireside this New Year’s eve, I would give 3 messages over a good glass of wine.
First, the paradigm shift needs to be towards client driven rather than physician/institution driven. Part of this is prevention before cure, but equally important is that the empowerment of clients to shop around for care and advice more than they can at the moment will likely lead to raising standards and lowering cost. Steps the government could take are resisting lobbies in the direction of “mother knows best”, providing incentives to citizens to lose weight, stop smoking, adhere to therapies, etc. Last but not least the federal government should ensure that all citizens have access to internet for learning and consultation. Service industries would be stimulated, whether fitness centers, diabetic coaching, or net communities. Better information, education, and incentives to take personal responsibility are needed.
Secondly, let us pluck the low hanging fruit. For me this is medication compliancy. It is widely accepted that 50% of clients do not take their medication properly, and that elderly patients in particular are over-prescribed. This is damaging for the individuals (think of untested co-morbidities or self-dosing), wasteful in the extreme, and the knock-on costs of poor compliancy are filling our hospital beds and care homes. Simple steps can make a difference. Use of available technology to monitor compliancy, and active involvement of pharmacists to review medication regimes, are possible directions. It is naïve to rely on free market initiatives to address this problem. An additional benefit of federal initiatives to compel medication monitoring in selected cases would be that the resulting evidence base, combined with monitoring of vital signs and outcomes, will give much better data about efficacy.
Thirdly, the connected health revolution needs open standards. I am an active member of Continua which cooperates closely with ISO/IEEE. This is a non-partisan group driving for international and open standards for personal connected health. Yet we also have organizations like HITSP which also contains idealistic individuals also wanting to make a difference but who do not involve themselves in ISO/IEEE. Critics of HITSP would say that HITSP is more of an initiative driven by vested interests. As a non-American myself I am not allowed to participate in HITSP and unable to make a judgment, but I do see several bodies trying to set standards for this emerging market. My urgent advice to President-elect Obama would be to make a choice for open standards, bring the best minds together, and for US industry to work on solutions that are sellable to the rest of the world and that can be deployed rapidly in North America at least. Please, make a clear choice.

I would personally endorse the statement: “The combination of payment reform emphasizing quality and population health management strategies including connected health would be powerful additions to the health care reform initiatives already being planned ...” with the reinforcement that this enhancement is best framed as complementing and extending rather than competing with the EMR.

As I consider the intersection of HIT with the health (and care) of the population, I believe there are 2 key and inter-related promises we should support for our patients:

1) You will never be seen for care without all of your health information that is appropriate to your care being immediately available to you and your provider at that time and place, and
2) Your ability to receive, understand and benefit from care should not be exclusively tied to you having to come to a facility for your care – we will do our best to recognize need, reach out and provide you with information, counsel and resources based on your preferences and circumstance.

The initial commitment captures the most tangible impact of the EMR for both patient and provider in the context of conventional illness related care, which will remain with us for a long time ahead. As a clinician and patient who has had the personal benefit of EMR supported practice for 15 years, I am intolerant of care delivered otherwise. I’m also confident that the successful EMR will be necessarily patient-centered and only fully realized when it is organized around actual patients, not the myriad and often competing needs of providers of care.

The second pledge recognizes that people, even those with chronic health conditions, spend but a very small fraction of their time in the immediate company of professional providers of care and optimization of population health will only follow expanded engagement and support of all at risk in their own ongoing care. Further, the key opportunity today in chronic condition care may well be the patient who is unaware of potentially beneficial services or not being actively “seen”, not those already enmeshed in our current care systems.

The EMR and population health management tools ranging from registries to predictive modeling to remote monitoring are necessarily complementary and ideally synergistic, and a durable strategy will require explicit support for both.

The Health Care Community Discussion I conducted in Boston on December 17 raised issues that support the patient-centered approach that Joseph Kvedar, MD addresses above.

“Prevention needs to be a force in the health care system,” said one participant. Ideally, good nutrition and exercise can truly prevent the onset of certain conditions. But prevention also exists on another level. Patient-centered management of chronic illnesses such as diabetes and congestive heart failure can prevent drug errors and the consequences that come with them, emergency room visits, and widely fluctuating blood glucose levels. Without realizing it participants were asking for Connected Health technologies which address all of the above.

Technologies that assist those who already have a medical condition are essential. There however needs to be public policy to promote healthier lifestyles which avoid or delay the onset of disease. After all, one way to reduce health care costs is if citizens do not need sick care services. This will require a combination of knowledge and technology (such as monitoring tools) that can support individuals to take responsibility for their nutrition, exercise, and other preventive measures.

Helene Fuchs
HF Associates
HeleneFuchsOnLine.blogspot.com

The revolution in science and technology has caused deep changes in human development and its values, with positive and negative impacts on all spheres of society, particularly on human health. Latin America is faced with several development challenges, chief among them are public health epidemics, environmental degradation, vulnerability of rampant poverty, geopolitical climate, impediments towards expansion of education and social services, and limited trade competitiveness.
Today the threat of infectious diseases like pneumonia, tuberculosis, diarrhoeal diseases, malaria, measles and HIV/AIDS have assumed global proportions and is threatening hardwon gains in health and life expectancy. The threat is hanging over the civilization like a Damocles Sword. Contagious diseases like AIDS are now the world's biggest killer of children and young adults.
In Peru it has been heartening to see the establishment of strategic alliances between public institutions and civil society organizations, through the various collaboration methods using ICTs. The community effect is reflected in the promotion of greater familiarization with the use of the Internet, and assisting medical team's involvement and access with the activities of the community.
One sees with capacity building activities through knowledge and experience sharing plus skills building of relevant healthcare personnel, the quality of proper and trusted healthcare for all those living in developing countries is reinforced. ICTs can be of much help and the axis of e-Health is the greater power acquiring the patient or user. Health information technology is transforming and will continue to transform health and healthcare in Latin America.
It is essential to build human networks, with the support of ICT, that motivate and harness, in dynamic and systematic form, the interaction between people, thereby strengthening the generation, dissemination and exchange of information and knowledge based on their professional, institutional and social objectives.

Lady Murrugarra
http://www.upch.edu.pe/tropicales/AIDSITS/
http://tics2007.wordpress.com