By BRIAN KLEPPER & DAVID KIBBE, MD

By mid-November, the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) must respond to the legal complaint filed in a Maryland federal court by six Augusta, Georgia family physicians.

These doctors are not asking for money, but for relief from the negative effects brought about by CMS’ twenty year reliance on the American Medical Association’s Relative Value Scale Update Committee (RUC) for valuing doctors’ work. They are asking CMS to enforce the Federal Advisory Committee Act(FACA), which requires that regulatory agencies shield themselves from undue special interest influence. In the process, they are asking CMS to rethink Medicare’s approach to physician payment, with a mind toward recognizing and valuing primary care’s ability to treat the whole patient within a larger system of care. They are asking CMS to develop payment policy that supports the needs of patients over those of professional groups.

In a sense, the suit reflects the larger concerns of America’s increasing unrest: a general frustration with a system rigged to benefit the few at the expense of the many, privatizing profits while socializing losses. It calls into question an incentive structure that has resulted in half or more of all health spending providing no utility and translating to exorbitant cost but debatable value. In other words, the case is accompanied by a sense that the system, as it is currently constituted, is failing the American people.

Any simple examination of medical services payment reveals the systematic under-valuing of primary care services relative to procedural services, the direct result of the RUC’s valuation process. For example, in an earlier Health Affairs Blog post we compared a 99214 moderately complex established office visit with a routine cataract extraction and intraocular lens implant. The first has all of medicine as it’s palette. The second is a highly refined, low risk, repetitive procedure that is valued, on an hourly basis, at 12.5 times the first.

Continue reading “CMS’ Opportunity: A Lawsuit Offers A Chance To Reform Physician Payment”

By BRIAN KLEPPER & DAVID KIBBE, MD

This week in a Maryland federal court, six physicians based at the Center for Primary Care in Augusta, GA filed suit against HHS Secretary Kathleen Sebelius and CMS Administrator Donald Berwick. The complaint, spearheaded by Paul Fischer MD with DC-based lead counsel Kathleen Behan, alleges that the doctors have been harmed by the Medicare payment structure developed through the agencies’ reliance on the American Medical Association’s Relative Value Scale Update Committee (RUC).

The suit also claims that the agencies have functionally treated the RUC as a federal advisory committee. But they have not required the RUC to adhere to the Federal Advisory Committee Act’s (FACA) stringent management and reporting rules – e.g., balanced representation, transparent proceedings, and scientifically valid analytical methodologies – that keep the proceedings in the public interest. The plaintiffs request injunctive relief, which would freeze the relationship between CMS and the RUC until the advisory group complies with FACA’s requirements. Of course, compliance would drastically change the way the RUC conducts its affairs, something it is almost certainly loathe to do.

Continue reading “A Legal Challenge To CMS’ Reliance On The RUC”

By BRIAN KLEPPER & DAVID KIBBE, MD

One of American politics’ most disingenuous conceits is that health care must cost what we currently pay. Another is that the only way to make it cost less is to deny care. It has been in industry executives’ financial interests to perpetuate these myths, but most will acknowledge privately that the way we value and pay for medical services is a deep root of America’s health care cost explosion.

When the Resource-Based Relative Value Scale (RBRVS) became the framework for Medicare payment nearly twenty years ago, it equated a medical service’s “value” with four categories of physician work inputs: time, mental effort and judgment, technical skill and physical effort, and psychological stress. The assessment process, handled from the outset by the American Medical Association’s (AMA) secretive, specialist-dominated Relative Value Scale Update Committee (RUC), delineates and quantifies a service’s inputs in terms of its Relative Value Units (RVUs) which, with a monetary multiplier, define its worth.

In 1989, RBRVS’ lead architect, William Hsaio, confidently suggested that the process would be rational and reliable:

We found that physicians can rate the relative amount of work of the services within their specialty directly, taking into account all the dimensions of work. Moreover, these ratings are highly reproducible, consistent, and therefore probably valid.

Continue reading “Rethinking The Value Of Medical Services”

By BRIAN KLEPPER & DAVID KIBBE, MD

In a remarkable recent interview, Donald Berwick MD, Administrator of the Centers for Medicare and Medicaid Services (CMS), eloquently described his vision of value-based health care.

Paying for value is an incentive…The underlying idea of improvement is that American health care, historically built in fragments, often cannot achieve for patients what it really wants to achieve…Health delivery system reform refers to really reconfiguring care into much more seamless coordinated-care operations so that people, especially those with chronic illnesses, experience continuity of care over time and space.

So when patients come home from the hospital, there is a smooth handoff, and all the necessary information follows them. When they are seeing a specialist, that specialist is coordinating care with their primary care doctor.

This description probably resonates with most health care professionals as a better approach than the current paradigm’s fragmentation and lack of continuity of care. But as with many things in health care, it won’t be easy getting to a value-based health care approach in Medicare and Medicaid. Despite wide acknowledgement that fee-for-service perpetuates our health system’s most undesirable characteristics, the mainstream of American health care seems stuck. One wonders whether CMS can rise above the special interest lobbying, get beyond the interminable pilots and decisively act on payment reform with the conviction required to help save health care from itself.

Still, the idea of value-based reimbursement begs questions. What payment methodology will incentivize the best quality and most efficient care? What path can take us there? Continue reading “Creating Value-Based Incentives For Primary Care”

By DAVID C. KIBBE, MD and BRIAN KLEPPER, PhD

Finally, we have a Final Rule on the Medicare and Medicaid EHR incentive programs. The rules and criteria are simpler and more flexible, and the measures easier to compute. But they are still an “all or nothing” proposition for physicians, who will have to meet all of the objectives and measures to receive any incentive payment. Doctors who get three-quarters of the way there won’t receive a dime. And a lot of uncertainty remains about dependent processes that CMS and ONC must quickly put in place, like accreditation of “testing and certifying bodies,” and the testing schemas for certification. All in all, we expect most physicians in small practices to sit on the sidelines until the dust settles, likely in 2012 or 2013.

Nevertheless, while it is good to get Meaningful Use behind us, it may be better still seeing beyond it. After all, the incentive payments for becoming a “meaningful user of certified EHR technology” are merely a small down payment on the savings that could be realized if health care supply, delivery and payment are affected by the changing policy and market environments over the next 5 years. The EHR incentive programs are meant to prime the pump by putting approximately $25 billion, give or take a few billion, into the hands of physicians and hospitals who adopt EHR technology during the 5 years between 2011 and 2016.

During that same time, by comparison, reductions in waste, duplication, and unnecessary procedures might mean savings of $100 billion to Medicare alone,# depending on whose estimate you believe and how effective you think the reforms will be in replacing payment for volume with payment for value. It might be a lot more. Conservative estimates are that 30% of our total national health care expenditure of $2.5 trillion, or over $800 million, is unnecessary and could be eliminated through real reforms. Some authoritative estimates argue that half or more of care costs are unnecessary, so the target jumps to $1.25 trillion a year.

Continue reading “Beyond Meaningful Use: Three Five-Year Trends in the Uses of Patient Health Data and Clinical IT”

By VINCE KURAITIS JD, MBA and DAVID C. KIBBE MD, MBA

Pop quiz: Among early-stage companies that are successful, what percentage are successful with the initial business model with which they started (Plan A) vs. a secondary business model (Plan B)?

Harvard Business School Professor Clay Christensen studied this issue.  He found that among successful companies, only 7% succeeded with their initial business model, while 93% evolved into a different business model.

So let’s take this finding and reexamine our human nature. In light of these statistics, what makes more sense:

• Defending Plan A to your dying breath?
• Assuming Plan A is probably flawed, and anticipating the need for Plan B without getting defensive?

We question many of the assumptions underlying HITECH Plan A. We also want to talk about the need and content for Plan B in a constructive way.

In this essay we’ll discuss:

1) The Need for HITECH Plan B

2) Questioning Assumptions — Issues to Reconsider in Plan B

a) Rewarding Incremental Progress
b) Addressing Root Causes for Non-adoption of EHR Technology
c) Questioning Health Information Exchanges (HIEs) as Building Blocks for the Nationwide Health Information Network (NHIN)
d) Catalyzing Movement Toward Modular EHR Technology
e) Focusing Incentives on High Leverage Physicians
f) Recalibrating Expectations for EHR Technology Adoption
g) Getting Bang-for-the-Buck in Achieving Meaningful Use Objectives
h) Comprehensively Revamping Privacy/Security Laws vs. Tweaking HIPAA
i) Maximizing Sync Between HITECH and PPACA
j) Leveraging Potential for Patient-Driven Disruptive Innovation
k) Promoting EHR Adoption Beyond Hospitals and Physicians, e.g., long-term care, home health, behavioral health, etc.
l) Dumping Certification Continue reading “Is HITECH Working? #7: Where’s Plan B? Congress and ONC need to address major flaws in HITECH”

By DAVID C. KIBBE, MD

An article in the April 10, 2010 New York Times entitled “Doctors and Patients, Lost in Paperwork,” brought attention to what may be, in the near term, the Achilles heel of the plan to incentivize doctors for the “meaningful use of EHR technology.” The article cited a study published in the Archives of Internal Medicine this past February, which asked a large cohort of physicians in internal medicine training programs about the time they were spending on clerical work, most of which is documentation in patient charts, both paper and electronic. A stunningly large 67.9% of the respondents reported that they were spending “in excess of 4 hours daily” on documentation, while only 38.9% reported spending an equal amount of time in direct patient care.

Now, I am fully aware that practice in the inpatient, hospital setting is not the same as practice in the office, clinic, or ambulatory care environment. Patients tend to be sicker and require more consistent attention while in the hospital, which often means more documentation is necessary. However, the study and the NYT article point to a real world problem that crosses all medical care settings and impacts physicians and other professional providers of all kinds: the enormous burden of documentation, clerical work, and administrative forms completion that impedes real care giving and makes health care less and less efficient even as we add more and more technology.

Continue reading “Meaningful Use in the Real World — Is the Additional Administrative Burden Worth the Bonus for Small Practices?”

By DAVID C. KIBBE, MD

It’s time to revive the discussion of electronic health record software in light of the new federal regulations that define criteria for meaningful use and also set criteria for the EHR technologies that must be implemented by doctors and hospitals in order for them to become, and be paid for being, “meaningful users of certified EHR technology.”

While most of the public commentary so far has been directed to the NPRM on meaningful use, the real news here relates to the de-construction of EHRs that is described in the interim final rule covering EHR standards and implementation specifications. Of course, the NPRM and IFR are by design tightly linked. But the NPRM on meaningful use is primarily a set of instructions for doctors and hospitals about how to participate in the incentive payment programs established statutorily under ARRA/HITECH. The rule on EHR technology certification criteria, on the other hand, is a playbook intended for vendors and developers who want to qualify their products to meet the expected demand by meaningful users in those programs. Continue reading “EHR Redux”

By Brian Klepper and David C. Kibbe

Massachusett’s voters’ stunning rejection of Democrat Martha Coakley, in favor of a not-very-impressive Scott Brown, should be exactly the splash of cold water that the Democratic party – and Congress as a whole – needed. The defeat can be understood in two ways: one large and one fairly small.

First, the large one. This will probably send reform back to the drawing board. Health care is too much in crisis and too pressing to be pushed completely off the table until certain issues – including both access AND cost – are addressed.

Second, this election marks the loss of a single critical Senate seat, but it is also very loud warning shot. The mandate received at the end of 2008 was a resounding call to throw out the Republicans who for more than a decade had ridden roughshod over American values. Yesterday, the Democrats, in one of their most secure strongholds, received the same message. Whatever people in DC think, rank-and-file Americans – not those on the right or left, but the swing voters in the middle who actually determine election results – are very unhappy with the gaming that’s been vividly displayed over the last year under the guise of health care reform.

The distaste expressed yesterday probably has little to do with the specific provisions of the bills, except for the largest generalities: that they expand coverage while avoiding a commitment to changes that could significantly reduce cost. But along the way, voters have witnessed — with an immediacy and transparency that has only been available as a result of the Web — lawmaking in its worst tradition. There was the White House’s deal making with powerful corporate interests like the drug manufacturers even before the proceedings began. And the tremendous lobbying contributions by health care and non-health care special interests in exchange for access to the policy-shaping process. Or the outright bribery of specific Senators and Representatives in exchange for votes. Last week’s White House deal with the unions that exempted them from the tax on “Cadillac” health plans until 2018 must have seemed like a perfectly OK arrangement to the people in the center of all this activity, but to normal people who read the paper, it was emblematic of the current modus operandi: If you have power and support the party in power’s muddled agenda, you get a special deal.

The most tempting mistake now for the Democrats would be to dig in. President Obama’s most appealing characteristic — the one that got him elected — was his embrace, his embodiment even, of approaches that would revise the traditional kinds of politics we’ve seen for the last year throughout the health care reform process. Of late, the most telling complaint about this Presidency so far has been disappointment that, once in office, he seemed to cave in so easily.

Undoubtedly, many Republicans are now rejoicing over the Democrats’ loss and the possible defeat of any health care reform legislation. That’s unfortunate. The health care crisis is real and remains unaddressed. The pressures it creates, particularly for powerful interests like business, will force Congress to return to it and develop meaningful solutions. Hopefully (though probably unlikely), Congress and particularly the Democrats, will be chastened and wiser. There’s a big opportunity here to make lemonade.

There is a new, bipartisan movement in Congress, highlighted on NPR two weeks ago, that would revisit the rules around the relationships between special interests and lawmakers. This is an issue that trumps and is more important than all others, because if every policy is ultimately shaped by those with enough money to buy Congress’ favor, then our democracy will be unable to hold.

The silver lining in yesterday’s election was that it was a mild, if critical, reminder that, whatever DC thinks, America’s center is just as displeased with the current governance as it was with its predecessors. Faced with a much larger rejection in the 1994 elections, President Clinton went on TV, took full responsibility, and then spent his time rebuilding. The good news is that today is a new day, and that, if they’re interested in what’s good for America over the long term rather than simply themselves over the short term, Congress has the ability to start again in ways that could please the American people and actually work to our collective advantage.

Brian Klepper and David C. Kibbe write together about health care technology, market dynamics and reform.

by DAVID C. KIBBE, MD and BRIAN KLEPPER

Right now, American health care information technology is undergoing two enormous leaps. First, it is moving onto Web-based and mobile platforms – which are less expensive and facilitate information exchange – and away from client-server enterprise-centric technologies, which are more expensive and have limited interoperability. In addition, more EHR development activity is headed into the cloud, driven by large consumer-based firms with the technological depth to take it there. Both these trends will facilitate greater openness, lower user cost, improved ease of use, and faster adoption of EHRs.

But they could also impact the shape of EHR technologies in another profoundly important way. What is often lost in our discussions about electronic health record technology in the US is the relationship these tools have to our health and health care problems…globally. We could be designing our health IT in ways that are good for the health of people both here and around the world, not simply to enhance care in the US.

Designing health data and management tools only for the particular operational needs of the current US health system may be doubly wrongheaded: It risks locking us into outdated technology and an expensive, dead-end path, while, at the same time, it could restrict collaborative exchanges of ideas and innovations that could improve health care here and abroad through better designed information technology.

Perhaps we should design EHRs for a small planet.

Rene Dubos (1901-1982) was a microbiologist who produced the first commercially marketed antibiotic. He also wrote widely about the relationship of humans with their environment, notably in So Human an Animal (1968), which won a Pullitzer Prize. In 1972, with economist Barbara Ward, he co-authored Only One Earth: The Care and Maintenance of a Small Planet, which set the issues and tone for the first major international conference on the environment. Dubos also first used the term “think globally, act locally,” advice to consider the widest possible consequences of our behaviors, but to take action in our own communities.

What would our EHR technology design efforts in the US look like if we incorporated Dubos’ more expansive framework? What principles might shift our thinking about EHRs away from America’s failing health system paradigm — with its illusion of unlimited resources, delivered by a fixed and ritualized set of professionals and institutions, and costs that double with each passing decade — towards a vision in which EHRs promote sustainable efforts in disease prevention, health improvement, social responsibility, and environmental protection? How might we think about EHRs globally while acting locally?

Principle 1: Define success with local health and health care problems in mind.

Defining EHR success is important, partly because US federal policy for EHR adoption is currently so dynamic. It would be easy to simply define success in terms of physicians’ short term acquisition of today’s EHRs, and the economic boost that might result from new government IT spending (e.g., IT jobs and EHR vendor profits). But Dubos might argue that successful EHR adoption should require measurable social and ecological benefits in the communities where the technologies are deployed, after consideration of the ‘big picture’ in which health spending is one among many societal priorities competing for limited societal resources, and therefore ought to be conservative.

The US’ current EHR adoption strategy channels money directly to doctors and hospitals, among the most privileged professional groups in any community. It could, instead, send those funds directly into the communities served, focusing on the local circumstances that result in fragmented, disorganized, and inconsistent health care delivery within driving distances of its citizens. EHR technologies could address communities’ continuity and access-to-care problems, and relate these to major preventative and chronic illness management challenges, e.g. vaccinations, obesity, and risks of heart disease. More and more people in adjoining communities could be reached by building on successes. Lowering health costs nationally is an important goal, to be sure. Maybe the best way to get there is to stimulate uses of health IT to improve individual and community health through local action. (It goes without saying that the system’s financial incentives would also have to be re-aligned.)

Thinking globally and acting locally would require us to study and plan how EHRs might benefit different communities, as unique populations with particular health risks, public health problems, and care delivery challenges. We would have to study those risks and challenges in each community, or in groups of neighboring communities. This is not easy, and it can be time consuming.

But the alternative, which seems to be to spend huge amounts of state, federal, and local dollars on one-size-fits-all health IT projects, top-down EHR systems that work for the VA or DOD but probably nowhere else, or data exchange efforts that may not be capable of solving, or even suitable to, the problems most at hand in that locale, could be simply disastrously wasteful by comparison. What works in central Indiana, quite honestly, may not be the right thing for Green Bay, Wisconsin, Helena, Montana, or Pamlico County, North Carolina.

Principle 2: Make the best possible use of existing IT resources before building or installing expensive new EHR systems.

Rather than ask “What could we do if everyone had computer systems like the most advanced large groups, e.g. Kaiser or the VA, let’s ask “What could we accomplish if we utilize the computers everyone already has?”

Experience has shown that it is not wise to expect big and complicated things to somehow become small and simple. For one thing, costs don’t necessarily scale. In contrast, though, the evidence is now overwhelming that with browser-based software running on personal computers and cell phones, and small applications running on hand-held devices, like the iPhone, consumer use can grow at extremely rapid rates and lead to complex social networks, rapid communications and feedback loops, and massive search and data analysis capability.

Examples abound of the kinds of resources available through inexpensive personal computers connected to the Internet, cell phones, and the newer smart phone technologies. Skype, the Internet-based voice communications company, has over 500 million registered users world-wide, which would make it the largest telecom carrier, if it were one. The top 25 wireless providers globally already service over 3 billion registered customers. The iPhone, introduced in 2008, has more than 57 million users, the fastest user growth in consumer technology in history, many times faster than the earlier rapid growth in PCs or the Apple iPod. Facebook – the social network platform where people send email, chat, share photos, and share interests – now has 350 million users and is growing at 660,000 per day! Lest we forget, these ubiquitous technologies are not just used for fun and games: massive amounts of data are being exchanged as well. And they are getting cheaper to own and operate all the time.

And yet they are for the most part useful only at the margins of health care, an industry that has somehow walled itself off from IT modernity. We certainly have not yet capitalized on the health and medical uses of the extraordinary networked computing resources available now in almost every home and work site in this country. EHRs for a small planet need not cost $54,000 per physician, which is the current estimate used by ONC and HHS.

It would be a critical mistake to waste our resources, time, and effort building new specialized state or regional data centers requiring complex and proprietary identity management technology for access, and to train a generation of IT professionals how to manage these expensive centers and the technology deployed there, when better design and efficiency could be obtained by use of the existing “off the shelf” general- and multi-purpose data highways, application platforms, and end-user computing capacity now available for health data exchange.

Principle 3: Design EHRs for the smallest unit of care delivery, with a focus on connectivity and communications.

Connectable EHRs can be designed for small medical practices and clinics in primary care, where the great majority of care is delivered, and for patients’ themselves — in their homes and places of work. Designed from the local, grassroots perspective, EHR technologies would also focus on affordability, ease-of-use, and especially on connectivity and continuity of information across those units in a given community, using existing computers, cell phones, the Internet, and yes, even fax machines.

Our current approach to health care IT, in contrast, is biased towards the needs of a handfull of professionals working in a relatively small number of large enterprises, such as hospital systems, and in large multi-specialty practices. These large units typically represent the most complex “use cases” for EHRs, based on the needs of the most complicated and sickest patients, requiring the most intensive usage of drugs and pharmaceuticals, and at the far end of the spectrum in terms of complicated ancillary medical devices, such as MRIs, medicated stents and proton accelerators.

These large health care units are often fiercely competitive and have little use for data exchange with competitors, and even less interest in using computing resources to reach across the communities they serve. As a result, they may be among the least appropriate and least competent stewards of community-based health IT resources. And yet their representatives dominate the steering committees and governance boards for the nation’s health information exchanges (HIEs) and regional health information organizations (RHIOs), where a big chunk of the federal funding is now going.

If waste is the failure of design, then designing EHRs for a small planet would avoid lengthy and disruptive installations and long training cycles involving expert consultants. Instead, they would favor modular, browser-based EHR software that are familiar to physicians, their staffs, and their patients, and that can be navigated simply.

Implicit in this design priniciple is a requirement for minimal training that focuses on how to use the software to best improve care, rather than on which buttons to push in which sequence to optimize fee-for-service reimbursement. EHR software that looks more like Facebook and less like a database manager’s tool kit, that can work through web browsers and mobile devices, and that can be incrementally expanded as new uses arise, is not only likely to be more adoptable than today’s EHRs, but also less expensive to own and operate.

Principle 4: Recognize that what sustains most information technologies is people’s desire to connect with one another.

Email is the “killer app” of the Internet. Facebook and Twitter have become the amazingly fast growing online social networks. Human beings seek connection at nearly every opportunity. Technologies that facilitate that connectedness and then provide key utilities are most likely to succeed.

Maintaining and restoring health, preventing disease, and the act of caring for others who are in need due to problems of the body and mind: these are among the most basic social activities of human beings, our communities, and our cultures. And yet, for complex reasons associated with money and power, our health system and the care it delivers is too often fragmented, dis-connected, and isolated. And its technological disconnection is both a symptom and a substrate of this phenomenon. Physicians and nurses face many barriers in communicating amongst themselves, with their patients and with their patients’ caregivers. The current crop of EHR products do virtually nothing to address this problem. In fact, EHRs in the US may have exacerbated our health care dis-connectedness.

EHRs that can share data, information, and connect the experience of patients, caregivers and doctors more directly are much more likely to be utilized at the community level than EHRs that in essence capture and remove data, isolating them and their potential social uses in faraway databases that no one can get into.

The huge success of health-related social websites – like PatientsLikeMe.com, DiabeticConnect,com and Sermo.com – are testament to the desire that many people have to close what Adam Bosworth has called the “collaboration gap” that stands between the limitations of the legacy health care system and the almost infinite benefits that arise from participating in self-help and online socializing activities. People who share their experiences – and data about themselves – know that this is helping them close the collaboration gap. But this gap is being perpetuated by EHRs that are organization- and enterprise-centered, and can only be substantially closed if physicians and medical groups in communities around the country use EHR technology to leapfrog over the communications and socialization barriers inherent in their older technologies. This will require new forms of EHR technology capable of socialization, which we have described elsewhere as Clinical Groupware.

Principle 5: Separate data from the applications and from the transport layer.

It is a stunningly simple yet powerful feature of the most familiar and widely-used information technologies that data – the message – is deliverable regardless of the sending or receiving applications, and independent of the network or transport layer that carries it. Email messages can be sent and received via many hundreds of client applications (what you and your computer use to compose the email or to display a received email.) Email and messaging services can carry many dozens of different kinds of attachments, e.g. pdf documents, across both open and secure networks, and networks with different kinds and levels of security protection in place.

This is a small planet idea that is the direct consequence of the openness of Internet protocols, but one that has not yet become incorporated in US health care, where data messages, applications, and network transport protocols remain unendingly, even stupifyingly, proprietary. Not only do these approaches perpetuate “walled gardens” – hospitals using one EHR system can’t send a simple electronic medical summary to another hospital using another EHR system across the street — but it also is a barrier to the innovators who would design, build and implement new, low cost applications like modular EHRs.

Clay Shirky makes this point in a blog post recently:

Thus the question for broad participation… is not: “What will the most complete system look like for the richest and most technically adept institutions?” Rather, it is: “What’s the simplest and most low cost way for a small vendor or new market entrant to get a small practice tied in?”

…Here’s what a workable set of transport standards will not do: It will not assume to know what kind of applications any given network participant is running locally. Once the data are delivered, it should be usable by everything from the simplest to the most complex application, since the recipient of the data will have the best understanding of what works in their local context.

This ability to separate data from transport and applications from data is the essential pre-condition for innovation — a group that has a valuable new idea for presentation of data for clinical use should not also be forced to think about the data encoding or the way the data are transported. Groups working on new data encodings should not be tied to a pre-existing suite of potential applications, nor should they have to change anything in the transport layer to send the new data out, and so on.

Patients and doctors in offices, homes, laboratories and pharmacies most often need information, and most often they need it in the form of small amounts of summary data such as a medication or problem/diagnosis list, a specific allergy, a limited number of recent or historically important lab tests or images. Where there is continuity of care and information flow, especially, there is rarely the need to access the complete or comprehensive medical record or its full contents.

For most ambulatory and outpatient clinical care needs, simple dashboard and summary health “EHR light” products may be sufficient, and there is a logical progression towards more complex health IT as the acuity of care increases. Modular design of EHR technologies may help to bridge this gap without creating large discontinuities of user interfaces and may also keep prices for health IT in the community setting at a lower point than otherwise.

*****

In the U.S., many of our health problems result from the growing burden of chronic diseases occasioned both by an aging population and our sedentary lifestyles. In much of the developing world, by contrast, the local health problems – pandemics like HIV/AIDs, malaria, and drug-resistant tuberculosis – result from poverty and a lack of basic public health resources. However, similar EHR technology in each of these settings can provide efficient health data exchange and information management. Both individual and population health status could be improved with medical records that are inexpensive, simple to use, and capable of network exchange

To this point, each of the above principles for small planet health IT is already being put in place effectively in many developing countries, where cell phones are used to remind patients of their medication regimens and are the vehicle for relaying laboratory test results and vaccination information from provider to provider in sparsely populated and very resource-limited communities. As part of the Millenium Villages Project in Ghana, for example, cell phones are part of a program that is dramatically improving the chances of survival for pregnant women and their newborns.

Our brethren in other countries, developed and developing, face many of the same challenges obtaining good quality health care that we do here in the United States, including realizing the promise and hope offered by health IT. If we persist in federal EHR policies that “over-serve” local US communities’ needs by developing complex and expensive systems of health IT, we may not only be missing the mark at home. We might also be missing the opportunity of helping the other inhabitants of this small planet.

David C. Kibbe MD, MBA and Brian Klepper, PhD write together about health care technology, market dynamics and reform. Their collected writings can be found here.