Archive for the ‘MPPA Publications & Pronoucements’ Category

Population-based versus Individual Healthcare: MN’s Expensive Big Data Collection Efforts Miss The Mark

Monday, May 25th, 2015

Minnesota health care providers are now required to report “quality measures” to the Minnesota Department of Health http://www.health.state.mn.us/healthreform/measurement/adoptedrule/

Many Minnesota and US government policymakers are entranced by managed care practices justified by collecting and then drilling down on Big Data being which is now by law collected from Minnesota health care providers. Governments increasingly rely on vendor companies such as UnitedHealth’s Optum https://www.optum.com/ to do IT and data crunching.

So, MPPA is discussing government mandated health care “quality” data collection and evidence-based medicine. David Sackett, the putative “Father of Evidence Based Medicine” (who at age 80 recently passed away) steered medicine towards scientific evidence in justifying medical practices. He’d agree that it’s both unscientific and illegitimate to apply probability theory to Big Data sets in which the events (or things) studied are neither truly homogeneous nor repeatable a very large number of times.

How does this relate to true scientifically-based medicine? The answer requires a look at probability theory. Probability theory is a branch of mathematics frequently used in statistical analysis. Richard von Mises posed the following simple but revealing question in his great work Probability, Statistics, and Truth:

What does it actually mean to say that the probability of a die coming up as a two-spot is one-sixth?
What the probability fraction actually means is this: if the die is not loaded, and if it is thrown a very large number of times, it will tend asymptotically (See http://en.wikipedia.org/wiki/Asymptotic_analysis) to come up as a two one-sixth of the time. The only way one can really make sure that the die is not loaded, i.e., that the two-spot will come up one-sixth of the time, is to make a large number of throws in order to do an asymptotic statistical analysis.

The rationale for requiring all Minnesota “health care providers” (physicians and other licensed professionals) to submit clinical information to the Minnesota Department of Health transactions is: Only by capturing large numbers of events or numbers (at great cost to society, providers and patients) can government, health plans, employers, and consumers (patients and families) tell which “providers” are doing “quality” practice. And, therefore, which health care procedures, hospital confinements, and medications will be eligible to receive third party dollars.

It is false to say that the “probability of Hillary Clinton (even after the Democratic Party nomination) will be elected President in 2016 is (name the number — 1/2, 1/4, 1/20.. or whatever) because US Presidential elections are not homogeneous events and are not are repeated often enough to do a asymptotic analysis. Likewise, It is false to proclaim that all patients should receive drug X or treatment Y because of the probability of success (good outcome) as deduced from Big Data (even if the IBM Watson computer or United HealthCare Optum does it).

Here is the point: A good deal of “mathematicalizing” [a new word] in social science and health care policy inappropriately applies probability theory to studying individual medical care treatment options, decisions, and patient choices. This is truly false science. And Minnesota policymakers need to become very skeptical of reliance on health care clinical care “quality” collection.

Instead, scientific studies comparing the costs and outcomes of Direct Pay (cash) practices vs. managed care clinics which use provider pay-for performance formulas based on population-based clinical care “quality” data must match a sample of doctors and patients who are free to make make medical care decisions with a similar sample from government-directed managed care. Such studies are not possible using the “quality” data currently being collected by the Minnesota Department of Health. De-centralizing medical care decision-making should be encouraged by Minnesota policymakers and insurance companies. Hopefully state and federal policy will empower consumers (patients and families) financially and encourage them to find and engage doctors and other health care professionals of their choice. This is where Minnesota and the Nation need to go.

Privacy at Stake: Repeal 2015 Minnesota Law Requiring All MN Health Care Providers to Use (Interoperable) Electronic Health Care Records

Monday, March 23rd, 2015

As of January 1, 2015, all hospitals and health care
providers, by Minnesota law section 62J.03, subdivision 8, must have in place an interoperable
electronic health records system (EHR) within their hospital system or clinical practice settings. The EHR mandate (dictate) has a chilling effect on psychiatrists, psychologists, counselors, and many physician’s whose patients desire and require privacy and confidentiality for doing person-centered clinical care.
Therefore, in response to concerns from the mental health and medical practice communities, MPPA at its January 22 Board meeting strongly endorsed changing the 2015 Minnesota EHR provider mandate to a provider choice also requiring patient consent. EHRs are often very useful to store and share medical and clinical care information. And, most Minnesota health care providers in Minnesota are now employed by hospital-clinic systems which have embraced EHRs. So there is no need for a Minnesota law requiring the use of an EHR.

Concerns about patient data privacy abound in all clinical settings, large or small. That’s why MPPA strongly advises that our Minnesota policymakers empower patients (and their families) to decide what they do and/or do not want to be recorded and/or sent out to others of their “interoperable” electronic health care records.

Two MN law legislative bills would replace the current health provider EHR mandate with provider choice, HF 1559 and SF 1677 https://www.revisor.mn.gov/bills/bill.php?b=house&f=HF1559&ssn=0&y=2015. However, neither bill received a legislative committee hearing this legislative session due primarily to objections from the Minnesota Department of Health. Nor was HF 1560 heard, a bill which requires patient consents for using EHRs and designating where clinical information will be sent http://www.house.leg.state.mn.us/bills/billnum.asp?billnumber=HF+1560.

The Minnesota Department of Health is the governmental agency supporting enforcement of the EHR mandate and has opposed ending the MN EHR mandate.

MPPA recommends that concerned citizens contact the Health Department (Comissioner Dr. Ed Ehlinger) https://www.facebook.com/mnhealth, their State representative and State senator http://www.gis.leg.mn/OpenLayers/districts/ Tell them all your personal reasons for wanting the EHR provider mandate repealed this year.

The StarTribune Commentary by psychologist Peter A. Zelles (below) typifies the many concerns MPPA is hearing. Concerned citizens need to speak up now to change the Minnesota EHR mandate!


Article by: PETER A. ZELLES Updated: March 22, 2015 – 7:10 AM
State mandate for electronic health records needs two key revisions.

Some good advice I’ve given my children is to never put anything on the Internet they wouldn’t put on a billboard. That advice applies to all Minnesotans, since our most private information is about to be made available on the Internet: our medical data. Minnesota is one of the first two states to mandate that all health care providers use an “interoperable” electronic health care record (EHR), allowing all doctors to view every other doctor’s notes — supposedly privately and with a purpose. Since 2014 has been dubbed “The Year of the Hack,” we can presume this medical data will be invaded.

It is including psychological records that concerns me most. With decades of experience as a clinical psychologist, a consultant and a teacher, I have to believe this mandate can easily mean the end of psychotherapy as a useful treatment.

Perhaps no other form of medical treatment is more based on privacy and confidentiality than psychotherapy. Patients come to speak the unspeakable. Much like the sacrament of confession, psychotherapy relies on a closed door and a belief that what is spoken stays behind that door. It’s why we don’t practice psychotherapy in public settings. Once notes are posted, any suggestion that our treatment is private is untrue.

What do people tell us behind our closed doors? About the affair they are having, or had, or thought about having. About abuse and tremendous vulnerabilities that may be deeply shameful. Even with privacy, it takes time to build trust enough to speak what has never been spoken before — the events that drive their symptoms, the anxiety and depression. For relief, patients expose themselves in tremendously vulnerable ways.

Proponents of the law suggest that we can limit what we post by keeping a separate record that details more delicate information. If being a forensic consultant has taught me anything, it’s that there are no private medical records. For psychotherapists, posting any information about patients is wrong, because it violates our duty to protect privacy in this most vulnerable setting. As the U.S. Supreme Court’s decision in Jaffee vs. Redmond said that without confidentiality, there cannot be psychotherapy. There aren’t crises requiring immediate access to psychotherapy records; they can be accessed more securely, in plenty of time if needed.

The law as written apparently allows no one to opt out of the EHR. Anyone who wants out must opt out completely. No health care provider can opt out. Patients who pay cash for their medical care may be able to avoid having their records posted, circumventing a loss of confidentiality, but not most of us.

Imagine this: You’re having sexual or marital problems? You had an abortion? You’re depressed and feel it’s a personal failing to need treatment? You’re being treated for the effects of childhood sexual abuse? It’s all available on the Internet — and to every other medical professional you may see.

There are two important ways this law must be shaped:

First, we should exclude any amount of a mental health record because of the catastrophic effect to psychotherapy.

Second, we must allow individual patients to decide what they do and do not want posted to their electronic record. If we don’t want a particularly sensitive medical concern in the EHR, we should have the right to exclude it. If a physician believes it is important to include, let them counsel us — just as they would about a medicine we may not want to use.

My own patients range from the powerful and affluent to the middle class to those on Social Security, Medicare and public assistance. All of them deserve privacy at my office. Let’s pause before throwing caution to the wind and irretrievably losing access to confidential and meaningful mental health care.

Talk to your legislators and the Minnesota Department of Health before it is too late. The rules for EHR are still being formed. Now is when we can be national leaders in forging a system in which the sharing of health records is both meaningful and reasonable.

Peter A. Zelles, of St. Paul, is a clinical psychologist