Last year, The Health Care Blog started Engage With Grace, asking you to take a moment over the Thanksgiving weekend to discuss your desires for how to live the end of your life as meaningfully as possible. If you would like to reproduce this post on your blog (or anywhere), you can base your post off of this version (which is what I’ve done here, thanks to Alexandra Drane, the Engage With Grace team, and Matthew Holt — via Bob Coffield).

Last Thanksgiving weekend, many of us bloggers participated in the first documented “Engage With Grace — a movement aimed at having all of us understand and communicate our end-of-life wishes.

It was a great success, with over a hundred bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations — our closest friends and family.

Our original mission — to get more and more people talking about their end of life wishes — hasn’t changed. But it’s been quite a year — so we thought this holiday, we’d try something different…

A bit of levity.

At the heart of Engage With Grace are five questions designed to help you start a conversation. We’ve included them at the end of this post. They’re not easy questions, but they are important.

To help ease us into these tough questions, and in the spirit of the season, we thought we’d start with five parallel questions that are pretty easy to answer:

Silly? Maybe. But it underscores how having a template like this — just five questions in plain, simple language — can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion.

So with that, we’ve included the five questions from Engage With Grace below. Think about them, document them, share them.

Over the past year there’s been a lot of discussion around end of life. And we’ve been fortunate to hear a lot of the more uplifting stories, as folks have used these five questions to initiate the conversation.

One man shared how surprised he was to learn that his wife’s preferences were not what he expected. Befitting this holiday, The One Slide now stands sentry on their fridge.

Wishing you and yours a holiday that’s fulfilling in all the right ways.

(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team.)

My mother passed away on April 18. I still have no words, but I have to express my deepest appreciation to everyone who has shared kind words and warm thoughts. It has meant so much more to me over the past few days than you can imagine. From the bottom of my heart, thank you so much.

From the Gazette:

Patricia Mae Deal (née Bias), born March 22, 1948, passed away Saturday, April 18, 2009 at her home in Robinson. She was 61.

Services will be held at 11 a.m. Thursday at the funeral home. Interment will be in Family Memorial Gardens, Low Gap.

Angela Braly has a tough job. She became chief executive of WellPoint in early 2007. Right out of the gate she had to fire her chief financial officer due to “misconduct unrelated” to the company. Not long thereafter, the economy began crumbling, taking an especially heavy toll on health insurers, like WellPoint. Proving that there’s no rest for the weary, though, this year is starting off with the troubling news that the government is forcing WellPoint to temporarily suspend Medicare enrollments due to compliance issues.

Let me say that I think that Angela Braly has done a world of good at WellPoint. Not long after the situation with the chief financial officer, she hired a tough new compliance chief. The National Committee for Quality Assurance praised the firm last year for its work to improve care to minority communities. And, WellPoint was recently named to a list of the “best” employers in healthcare.

Still, the news from the Center for Medicare and Medicaid Services is disappointing, and the company’s response is, quite frankly, inadequate. The Bloomberg story on the Medicare suspension cites “computer mistakes,” “computer failures,” and “problems with [...] computer systems.” The company ousted its chief information officer last May, and finalized its new information technology team in September.

(While simultaneously blaming information technology for its Medicare problems, WellPoint is also talking about “electronic healthcare leadership” on its front page. Note to WellPoint media relations: probably not the issue you want to be promoting for a little while.)

WellPoint isn’t talking details, and neither is CMS. But this sounds like some sort of information systems disaster that, as best as I can tell, must be eating up claims and approval data and processes. WellPoint says CMS got involved six months ago, presumably around July of last year. But the company ousted its CIO in May of last year, I’m betting for the same reasons. Why they couldn’t have righted this problem, or at least convinced CMS that they were on the right track, after almost three quarters of “realignment” is not a good sign.

The bottom line is that, across healthcare, there’s a fundamental disconnect in the prioritization of information technology resources. Gobs of resources are being devoted to attention-getting personal health records and the like, meanwhile the folks in charge of core information systems are left to fight for whatever they can get.

Process reliability, systems uptime, data integrity, all things that can drown out the attractive message of “patient connectedness” — so the real priorities tend to be moved down the priority list, at tremendous long-term cost (ask WellPoint). And while I do believe patient-accessible electronic health records are an important part of where we need to be heading in healthcare, it can’t be at the expense of the actual healthcare information technology infrastructure itself. While that may seem like common sense, remind me again why WellPoint is getting a whopping seven “eHealthcare Leadership Awards”? And WellPoint is by no means alone in that sort of irony.

I started this article by saying that Angela Braly has a tough job. It turns out she’s not the only one with a tough job at WellPoint. Lori Beer, the woman appointed to the chief information officer position just a few months ago, now has the weight of the world (and CMS, which is probably even heavier) on her shoulders.

When I look around healthcare information technology, I see silos. I find software that gets in the way of productivity. I see technology that is not as reliable or as efficient as it should and could be. When I try to think of companies that are actively working to change that… The list is much shorter than I think it ought to be. But there are a few that are dragging all of us forward. I wrote before about athenahealth and the success they’re seeing. I think Allscripts is another company that really “gets it.”

Since the merger with Misys was completed, Allscripts seems to have begun a bit of a missionary project to baptize all of healthcare in the salvation of interconnectedness. Their chief executive, Glen Tullman, sat down for a surprisingly unscripted and sincere chat with with Tim over at HIStalk.

(Glen even answered questions for nearly an hour. I only got a “moment.”)

Seriously, though. Glen Tullman ought to look into evangelism, because I think he might just be able to help some folks see the light (at the end of the healthcare information technology tunnel):

I see the merger of Allscripts with Misys, not only as an opportunity, but as a responsibility. We simply must use our new size [and] scale, our set of solutions and our reach to radically accelerate the movement to create a truly interconnected healthcare system in order to eliminate errors, improve quality and better manage cost. But we believe this must be a mandate not just for Allscripts, but for all vendors. While Allscripts and others provide applications that help address the issues I outlined above, the core problem is that healthcare is not connected – functionally, financially or technically. That can’t continue and we collectively have the tools to ensure it doesn’t. Consider this a call to action to eliminate what I call “software silos.” Now is the time to come together as an industry to create standards, to ensure our systems are actual solutions, and that what we provide is the fix, not the problem.

His interview with Tim back in 2006 was informative, but his new call to action is energizing. There’s a lot of work between talk and action, but Allscripts has both the people, the resources, and the influence to actually push parts of healthcare forward, just like athenahealth is doing.

Sometimes people think I’m like some sort of healthcare Alanis Morissette, that I’m always angry with healthcare information technology. Sometimes, I am. But I also see the progress we are making, alongside the progress I think we still have to make. Companies like athenahealth and Allscripts are two of the companies that I pay attention to today because they’re rewriting the rules for this industry. athenahealth has built a thriving company around a highly disruptive, but also highly successful business model. The other is starting a new chapter (hell, a whole new volume) in its history by declaring war on the proprietary barriers healthcare information technology vendors build (or leave) up.

Given Vieue, I should probably stop getting so excited about athena, Allscripts, and (a few) others. The truth is, though, Glen Tullman is right: making healthcare information technology more accessible is about more than just one vendor, and it is a responsibility, really, for all of us.

Let’s hope more of us enlist.

While they seem to be pretty quiet publicly as of late, I recently heard they’re up to nearly 7,000 providers. By comparison, athenahealth has about 17,000. Like athenahealth, though, Purkinje has been adding new providers at a pretty rapid clip.

Given its strong roots in Canada, Purkinje has been making quite a bit of headway in Ontario, especially. Despite its integrated healthcare system, Canada and its provinces have, so far, lacked a really strong, strategic plan for implementing interoperable electronic health systems. The one advantage to that fact, though, has been that growing vendors, like Purkinje, have been able to establish themselves as competitors to the big vendors like Cerner and the like. (Nevertheless, I have to say that have long been a little underwhelmed by Canada Health Infoway, the national organization charged with promoting national electronic health record adoption.)

Purkinje, athenahealth, and others are firmly establishing the benefits of software as a service. It’s hard to think of anything good to say about the current state of the economy, but maybe this downturn will help push healthcare towards smarter technologies and delivery systems. I recently talked with a physician, whose three-provider practice took out a $180,000 loan early this year to install their first electronic health record system. They had no idea there were companies out there like Purkinje or athenahealth which offer a much lower cost barrier. That three year contract works out to just a little shy of $1,700 a month per physician. Sure makes $399 like attractive, doesn’t it?

Let’s talk about Vieue.

About a year ago, I finally put together one list of some of the ideas at the intersection of healthcare and information technology that I had been collecting for a while. I shared those ideas with a few friends, and the concepts that survived the sounding board were clarified, revised, and refined further. Eventually the core ideas that made it through got a name: Vieue Health.

I still care (very much) about healthcare and healthcare information technology and I think there’s room for me to positively shake up at least one little corner of the healthcare information technology world. (I think it helps when your plan hopefully skews closer to Jonathan than to Joan.)

All of this to say, stay tuned. There’s a lot I want to say, but frankly I need to find the time to write it all down coherently… (You can see I have a problem with that, right?) In fact, it might help to hire somebody to help me out with this “communications” thing. Let me add that to my list.

I’ve got to get back to actually working on all this, rather than talking about it. In the not too distant future I’ll have a bit more to share. Stay tuned!

We need to remember that we are created creative and can invent new scenarios as frequently as they are needed. Maya Angelou

Last summer, Create West Virginia was, well, created to highlight and promote creativity, technology, and forward thinking to help bring together West Virginians to advance our economy, our quality of life, and opportunities for the people of our state. To say that a little simpler: Create West Virginia is about bringing people together to find creative ways to move West Virginia forward.

I moved away from West Virginia after college, but for about a year now I’ve been spending more time back home, working on Vieue. The challenges West Virginia faces today are greater than ever, but the opportunities are just as tremendous. For many years, our state leaders in business, technology, healthcare, labor, and government seemed to be stuck in the past. That is changing.

In healthcare, in particular, I think West Virginia is truly moving forward, even though we face some of the greatest obstacles. Innovative companies like beBetter and Vested Health are on the forefront of new trends in healthcare. Julian Bailes at West Virginia University and Bob Coffield at Flaherty Sensabaugh & Bonasso are both respected leaders in healthcare and healthcare information technology. Governor Manchin has continued to move the state forward towards a statewide health information network. Mountain State Blue, through its partnership with Highmark, has made tremendous progress in helping doctors digitize. And don’t forget where David Brailer is from.

Create West Virginia has asked folks in West Virginia to talk about their hometown or where they’re from, and the creative things that are happening there. I’m from Boone County, and I haven’t lived there for quite a few years now. I do know they have been making strides in building a new economy for the area, with the successful new business incubator being an important milestone in that effort.

But over the past year, I’ve come to call Snowshoe my West Virginia home. With Vieue, I needed to find a place where a small team of folks could work hard, brainstorm, problem solve, generally break all the traditional rules of project management… And still be in a place where nature was just steps away, where you could breathe and take a moment to unwind when you need to. I’ve been coming here since I was a kid, and so much has changed. Coincidentally, a company called Intrawest has been behind a lot of the changes at Snowshoe over the past decade or so, and they call their process “placemaking.” Seems apt!

West Virginia has so many “places,” we have such a wide range of nature, from valleys and rivers to plateaus and streams to, yes, mountains. “Placemaking” here is really just complementing and not getting in the way of nature, and Snowshoe is a place that has balanced that quite a bit. For that matter, you could say the same of much of Pocahontas County. They call it the “birthplace of rivers,” since eight of them originate in the county (the Greenbrier, the Cherry, the Elk, the Cheat, the Gauley, the Tygart Valley, the Williams, and the Cranberry, if you are keeping track).

It’s pretty great, I think, that the Create West Virginia conference is coming up in just a few weeks, at it’s going to be at Snowshoe. West Virginia has so many creative places, but I think right on top of one of the highest points in the state has to be one of the best. The great thing about Create West Virginia, though, is that it brings all of us together, and Snowshoe is a great creative place for all the creative folks from all the other creative places across the state to converge. It might just be electric. Speaking of which, here’s one last Maya Angelou quote for you: I believe creativity is like electricity. We don’t understand how it works… We just use it.

Update: A lot can happen in a week. On Monday, my mother’s pulmonary specialist said he believed her condition was worsening and that she would likely need skilled nursing permanently. Given her advance directives, this was not good news to hear. I ended up having to argue with the specialist in order to get his “consent” for a second opinion. The second pulmonary specialist agreed that a tracheotomy should be a last resort, not a first option. For the last several days, my mother has been breathing on her own for short periods of time, and with a mask to help her breathe. She will soon be moved down from critical care, and in the next few days she is scheduled to be transferred to St. Francis Hospital for several weeks of recovery…

My mother had a serious heart attack on Wednesday, while she was already in the hospital for a mild heart attack and a bad case of pneumonia. I got into Charleston on Thursday, and have come to call this hospital “home” since then. (It now seems that there is no need for the apartment I rented here earlier this year, when she had several stays in the hospital. As it turns out, you can get used to something resembling sleeping, even while upright in a chair.)

All of this has helped me to realize I have come to much prefer being on the provider side of the healthcare equation.

The only distraction I have found here is pretending to care about the healthcare information technology in place at this hospital, which consists of Soarian, Opus, and still a bunch of paper. No svelte tablets or thin clients or patient room workstations, although one of the nurses does carry around a clunky notebook and there are a few other notebook carts bandied about. Workstation security (and thus information security), sadly, but not surprisingly, seems to be a fairly low priority.

There are disadvantages to working in healthcare and dealing with the healthcare system. For instance, I know that this hospital is below the state and national average for heart attack and heart failure care, but she was able to make that decision in the ambulance, and chose this hospital above my objections. Transferring her now is not an option. Sure, there’s a whole list of what the hospital can and should do to fix their substandard care rating, and healthcare information technology could even help. But none of that really matters, here and now, to me as a son.

Being involved in your care decisions requires you be awake and competent; the ventilator means my mother cannot be involved, and the propofol ensures she is not. The draconian rules surrounding chart access, and the fact that said charts still use advanced dead tree technology, present an incredible challenge just to stay up to date on my mother’s care, even with constantly being here, and even with the most patient and accommodating providers.

Will modern information technology and processes fix everything? No, but smarter healthcare information technology can be a catalyst, a conduit, and a foundation for smarter healthcare.

I really enjoyed thinking out loud, last week, about the pioneering role athenahealth and TriZetto are playing in moving healthcare forward. I liked it so much, in fact, that I might make a habit out of it. This time around, I’m thinking, out loud, about Aflac and Workscape, and their role in the future of human resources…

You surely know Aflac. Yes, the “ask about us at work” duck people. You probably know them best for their “we pay you cash if you get sick or hurt and miss work” insurance products. But, because of the close working relationship they normally have with human resource departments large and small, Aflac has built a growing portfolio of human resources support services for businesses, including managing the administration of coverage continuity, flexible spending, and transit expenses. Aflac is known in the information technology world for their respected (but proprietary) SmartApp customer relationship management software, which allows Aflac to efficiently manage what is, essentially, its own minimal human resource information systems for each of the companies it serves.

While Aflac is a household name, Workscape might be a little bit less well known to folks outside of human resources. But the company is increasingly building its reputation through its innovative use of technology to help companies better manage human resources, including benefits and compensation. The company has signed up companies big and small, from General Motors to FedEx, and even IBM. The key for Workscape is its web-based suite of software that allows businesses to stop having to worry about developing their own human resources information systems or integrating one that’s too big, too small, but never just right. Instead, Workscape adapts, hosts, and manages its solutions for each of its company clients. As an added blessing, employees at Workscape-served companies can then access an online portal, hosted by Workscape, to utilize self-service human resource tools.

While Aflac will probably always be better known for its insurance products, I think continued focus on its Aflac for Business benefits and human resource services could be a real growth area for the company. In fact, as Aflac for Business grows, it could even lead new clients to Aflac’s insurance products. Likewise, I think the future for Workscape is huge: as Salesforce.com and athenahealth and others prove that web-based solutions can really work for business, more and more are looking to other innovators in that field. I think Workscape just might be one such company worthy of the spotlight.

I’ve done work for companies that have “managed” their human resources in all sorts of ways. For one, you basically had to call ADP, which was barely preferable to banging your head against a wall. Just to be clear, I’m pretty sure ADP has never met a bureaucratic hoop or antiquated technology it didn’t like.

At another company, you could spend hours on hold waiting for a frustrated human resource agent to figure out what to type into his or her computer to get it to do some seemingly elementary function, all the while said company was still throwing away millions to implement an already-deprecated human resources information system.

In any case, I would much rather have dealt with the friendly folks at Aflac or the convenient self-service tools of Workscape.

I imagine widespread deployment of electronic personnel records that are convenient, accessible, and, to a certain extent, portable will probably be a reality sooner than the same can be said for electronic health records. We’ve made it there in the financial world… Once our human resource and medical files catch up… Well, by that point Saint Peter will probably be reviewing all my electronic records for admissions purposes…

Good luck, though, to Aflac and Workscape. For your enjoyment purposes, just imagine if the following highly-trained goat was employed to recycle unnecessary human resources paperwork… Yes, that’ll be the day…

Sometime in late 2004, I started taking note of this interesting, little (but growing) enterprise out of Massachusetts called athenahealth. I became interested in the company, with its lack of capitalization and spacing, after it got (what I believe was) its first mention on HIStalk. Naturally, Tim couldn’t pass up the opportunity to poke at athenahealth’s branding, pointing out the company’s “insufferably cute breaking of the polite laws of grammar.”

Grammatical quirks aside, athenahealth has had a fairly remarkable run of growth since, including a ridiculously popular initial public offering last fall. While the overall economic doldrums have put a damper on the company’s share price, athena has continued to add thousands of new physicians to its rolls.

TriZetto is another interesting company, with somewhat less name recognition, in a sector I think I’ll call healthpay (with apologies to HIStalk for the grammar and American Express for the similarity).

Both work on moving money around the healthcare system, and both are trying to improve accuracy and efficiency in the healthcare billing process. TriZetto has focussed more on getting insurers and payers on board (and thus network hospitals and physicians), while athena has targeted getting physician payees signed up directly. (To a certain extent, athena has even buddied up to payees by aggravating payers a bit.) Whether you’re going after the goose or the gander, both athena and TriZetto have their respective feet well in the door for a market that, I think, could be a real driver for personal and electronic health records.

Think about it. Very little gets done in healthcare that isn’t billed to somebody, one way or another. Therein you have procedure, diagnosis, medication, and allergy code information, however binary (and sometimes, however inaccurate). Since moving everyone in healthcare over to detailed electronic charting remains a long-term goal (let alone portable, accessible, and shareable electronic charts), a billing-system-based, all-in-one-place health record would be a pretty decent start. athena is getting there, and so is TriZetto.

Most physician offices, and many hospital workstations have a personal computer of one variety or another. Web-based solutions like what athena is building seem to be the right direction. Hell, if a practice will at least accept credit cards, why not key in procedure and diagnosis codes into the credit card terminal and get Discover, Visa, MasterCard, and American Express into the personal health record business as well. At least we know they’re already great at sharing information…

Seriously, though, as great as RHIOs and HIEs and PHRs and EMRs are (did I miss any?), the reality is we’re moving far too slowly in the direction of getting everyone and all that information networked together. Smart diagnosis suggestion, adverse event prevention, and test results sharing aren’t going to reach anywhere near their full potential until your pharmacy, general practitioner, nutritionist, specialist, emergency department, urgent care, and DMV records are all somewhat reliably linked together.

And God help us if we let some ridiculous “network” like the credit reporting system develop. The day TransUnion, Equifax, or Experian announce personal health records is the day I’m gonna take all my friends and move to Canada, and we’re gonna die of old age…

“Hello, Mr. Deal? Yes, this is your personal health record bureau monitoring service. Yes, sir, you pay $19.95 a month for our service. You don’t recall subscribing to our services? Well, in any event, sir, I just wanted to be sure you were aware that your gynecologist renewed your prescription. You can pick that up at your convenience at your neighborhood pharmacy in Québec. Oh, yes, actually it does look like your usual pharmacy might be in Los Angeles. You may need to dispute that part of your personal health record. What’s that? Oh, you don’t see a gynecologist, either? Well, you should. Should I go ahead and schedule an appointment for you?”

Please, athena, please hurry…