Let me concede from the outset that, in this blog post, I lean toward the negative—dire predictions, worst-case scenarios, a bit of doom and gloom, etc.
But I ask you, oh gentle, patient reader, how could I not?
Let’s go to the satellite. You can see warm air from a low-pressure system (Meaningful Use Stage 2, not changed dramatically by the one-year extension) collide with cool, dry air from a high-pressure area (the turmoil of Obamacare) and tropical hurricane moisture (ICD-10). Tell me you don’t see the Perfect Storm yourself.
And here we sit in our little fishing boat, waiting for the mighty ocean to consume us.
Overly dramatic? Certainly, but still not wholly inappropriate, I will argue.
Consider a recent report on the HIMSS/WEDI ICD-10 National Pilot Program collaborative that was created to, “…minimize the guess work related to ICD-10 testing and to learn best practices from early adopter organizations.”
Designed to ascertain the realities of the entire healthcare system adopting and using ICD-10, this pilot included an education and adoption program for all participants, followed by a set of “waves” in which diagnoses for the 100-200 most common medical conditions were actually coded and submitted using ICD-10.
The end-to-end testing approach …
…would encompass a number of medical test cases that mirror actual processing, including situations with multiple “hops” or “steps” between providers, clearinghouses, and health plans; the identification of high-risk medical test cases to help prioritize testing; the identification of available testing partners; and key reporting and sharing of test results. The test environment must mirror production.
And how did this pilot testing go? (Cue dark, foreboding music here …)
The average accuracy was in the 60 percent range with low scores around 30 percent. Yes, some medical scenarios had nearly 100 percent accuracy, which is great. But very low accuracy accompanied a number of very common conditions. Not so great.
Continue reading “Does ICD-10 Pilot Forecast a Perfect Storm for Healthcare?”
Filed Under: Tech, THCB
Tagged: Edmund Billings, HIT, ICD-10, Meaningful Use Stage 2
Dec 17, 2013
Remember the Ford Pinto and the AMC Pacer, aka the Pregnant Pinto?
Both serve as reminders of an in era in which the American auto industry lost its way and assumed drivers would buy whatever they put on the lot. Foreign competition, primarily from Japan, filled the void created by American apathy for quality and design, and the industry has never been the same.
Admittedly, the comparison of cars and EHRs is less than apt, but health IT also assumes healthcare will buy what we’re selling because the feds are paying them to. And, like the Pinto, what we’re selling inspires something less than awe. In short, we are failing our clinical users.
Why? Because we’re cramming for the exam, not trying to actually learn anything.
Myopic efforts to meet certification and compliance requirements have added functionality and effort tangential to the care of the patient. Clinicians feel like they are working for the system instead of it working for them. The best EHRs are focused on helping physicians take care of patients, with Meaningful Use and ICD-10 derivative of patient care and documentation.
I recently had dinner with a medical school colleague who gave me insight into what it’s like to practice in the new healthcare era. A urologist in a very busy Massachusetts private practice, he is privileged to use what most consider “the best EHR.”
Arriving from his office for a 7 PM dinner, he looked exhausted, explaining that he changed EHRs last year and it’s killing him. His day starts at 7 AM and he’s in surgery till noon. Often double or triple booked, he sees 24 patients in the afternoon, scribbling notes on paper throughout as he has no time for the EHR. After dinner he spends 1.5 to 2 hours going over patient charts, dictating and entering charges. What used to take 1 hour now requires much more with the need to enter Meaningful Use data and ICD coding into the EHR. He says he is “on a treadmill,” that it should be called “Meaningless Use,” and he can’t imagine what it will be like “when ICD-10 hits.”
My friend’s experience is representative, not anecdotal. A recent survey by the American College of Physicians and American EHR Partners provides insight into perceptions of Meaningful Use among clinicians.
According to the survey, between 2010 and 2012, general user satisfaction fell 12 percent and very dissatisfied users increased by 10 percent.
Continue reading “Darwinian Health IT: Only Well-Designed EHRs Will Survive”
Filed Under: Tech
Tagged: Design, Edmund Billings, EHR, HIT, ICD-10, Meaningful Use
Oct 23, 2013
Secretary of Defense Chuck Hagel’s long-awaited (in health IT circles, anyway) decision on the Department of Defense’s core health IT system has been made. The VA’s VistA system is out as the preferred DoD. Unless it’s not.
In his May 21 memo, Hagel directed the DoD to initiate a competitive process for a commercially available electronic health record (EHR) solution. Understandably, the secretary has to create a level playing field, a competitive process, so he can tell Congress with certainty that due diligence was done. Hate it a lot or hate it a little, this is the nature of our political process.
Already, many are spinning Hagel’s decision as a huge win for proprietary solutions; popular blogger Mr. HIStalk has already established Epic as the frontrunner in the upcoming DoD derby.
But before we simply anoint Judy Faulkner the queen of American health IT, I want, as the Brits say, to throw a spanner in the works.
Commercial ≠ Proprietary
A careful review of the Hagel memo and other recent statements from his top lieutenants reveal a more progressive vision and clear requirements for an open architecture and service model.
From the Hagel memo:
I am convinced that a competitive process is the optimal way to ensure we select the best value solution for DoD … A competitive process will allow DoD to consider commercial alternatives that may offer reduced cost, reduced schedule and technical risk, and access to increased current capability and future growth in capability by leveraging ongoing advances in the commercial marketplace … Also, based on DoD’s market research, a VistA-based solution will likely be part of one or more competitive offerings that DoD receives.
To sum up, the secretary has directed the DoD to go commercial instead of developing and maintaining their own VistA-based solution, but commercialized VistA-based solutions will be included in the competitive process.
Continue reading “Defense Probably Goes Commercial, Not Necessarily Proprietary”
Filed Under: Uncategorized
Tagged: Department of Defense, Department of Veterans Affairs, Edmund Billings, Interoperability, Open platform, VistA
Jun 13, 2013
A question: What is the opposite of health IT return on investment?
The answer: Unintended financial consequences, or UFCs, for short.
The scenario: A sophisticated medical center health system begins to roll out an expensive proprietary EHR and shortly thereafter sustains an operating loss, leaving no choice but to put the implementation on hold. The operating loss is attributed to “unintended financial consequences” directly related to buying a very expensive EHR system.
This is exactly the situation at MaineHealth, who selected Epic. As recently reported, a little while ago Maine Medical Center President and CEO Richard Peterson sent a memo to all employees saying the hospital …
… has suffered an operating loss of $13.4 million in the first half of its fiscal year. The rollout of MaineHealth’s estimated $160 million electronic health record system, which has resulted in charge capture issues that are being fixed, was among several reasons Maine Med’s CEO cited for the shortfall.
“Through March (six months of our fiscal year), Maine Medical Center experienced a negative financial position that it has not witnessed in recent memory,” Richard Peterson, president and CEO of the medical center, wrote in the memo to employees.
Peterson’s memo outlines the specific UFCs that explain, in part, MaineHealth’s operating loss:
- Declines in patient volume because of efforts to reduce re-admissions and infections
- Problems associated with being unable to accurately charge for services provided due to the EHR roll out
- An increase in free care and bad debt cases
- Continued declining reimbursement from Medicare and MaineCare, the state’s Medicaid program
These challenges are common to just about any medical system in the country, making MaineHealth potentially a harbinger of things to come for those hospitals and health systems that pay multi-millions of dollars for a health IT system.
Continue reading “Unintended Financial Consequences”
Filed Under: Tech, THCB
Tagged: Costs, Edmund Billings, EHR, Epic, HIT, Hospitals, MaineHealth, return on investment (ROI)
Jun 3, 2013
“No aspect of health IT entails as much uncertainty as the magnitude of its potential benefits.”
A few years into the Meaningful Use program, it seems this quote from a 2008 Congressional Budget Office report entitled “Evidence on the Costs and Benefits of Health Information Technology” may have been written with the assistance of a crystal ball.
Fast forward to 2013.
“Just from reading a week’s worth of news, it’s obvious that we don’t really know whether healthcare IT is better or worse off than before [Meaningful Use incentives],” popular blogger and health IT observer Mr. HIStalk wrote earlier this year.
So, perhaps RAND was hypnotized by Cerner funding when they created their rosy prognosis (hearken back, if you will, to 2005 and the projected $81 billion in annual healthcare savings). Maybe they were just plain wrong and the most recent RAND report stands as a tacit mea culpa.
Either way, we’re left with hypotheses that, while not incontrovertible, are gaining traction:
- Health IT benefits will manifest gradually over an extended timeframe.
- Those benefits will not quickly morph into reduced costs, if they ever do.
- Because of 1 and 2, investing in a hugely expensive electronic health record system is potentially risky.
How risky? Without question, massive health IT expense and the predominant proprietary IT model are threats to a hospital or health system’s financial viability, to its solvency.
We’re seeing some examples even now.
Continue reading “For Hospitals On the Edge, HIT Is the Tipping Point”
Filed Under: Tech, THCB
Tagged: bitter pill, Costs, Edmund Billings, Henry Ford Health System, HIT, Hospitals, Meaningful Use, RAND study, The States
May 1, 2013
In these politically polarized times, Americans expect Republicans and Democrats to disagree on every detail right down to what day of the week it is. This is especially true in the posturing hurly-burly of the House, where members can appeal to the few select priorities of a gerrymandered district to win re-election.
So it’s remarkable and unexpected when any legislation exits a House committee with unanimous bipartisan support. It’s even more surprising when the legislation potentially threatens the status quo for established corporate interests—in this case information technology companies.
The Federal Information Technology Acquisition Reform Act (FITAR)—sponsored by California Republican Darrell Issa along with Virginia Democrat Gerry Connolly, and supported by every member of the House Oversight and Government Reform Committee—threatens to put open-source software on par with proprietary by labeling it a “commercial item” in federal procurement policies. The proposal wouldn’t give open source a privileged position, just an equal one.
Continue reading “Washington’s New Open Source IT Law Could Change Everything. Let’s Count the Ways …”
Filed Under: OP-ED, Tech, THCB
Tagged: commoditization, Department of Defense, Department of Veterans Affairs, Edmund Billings, federal budget deficit, FITAR, HIT, IT acquisition, Open Source, software
Apr 9, 2013
I want to begin by sharing well-known information for the sake of comparison. Both the Apple and Google Android platforms welcome the introduction of new and (sometimes) highly valuable functionality through plug-n-play applications built by completely different companies.
You know that already.
Healthcare IT companies welcome you to pay them great sums of money for enhancements to their closed systems. This is on top of substantial maintenance fees that may or may not lead to hoped-for updates in a timely fashion. (With all due respect to the just-announced CommonWell Health Alliance, Meaningful Use does mandate interoperability. The participants are, in effect, marketing what they have to do anyway to try to differentiate themselves from Epic.)
The respective results of these two divergent approaches are probably also familiar to you.
Consumer technology has taken over the planet and altered almost every aspect of our lives. These companies and industries have flourished by knowing what customers will want before those same customers feel even a faint whiff of desire. We are both witnesses to and beneficiaries of dazzling speed-to-solution successes.
Back on planet health IT, the American College of Physicians reports that the percentage of doctors who are “very dissatisfied” with their EHRs has risen by 15 percent since 2010; in a poll, 39 percent said they would not recommend their EHR to colleagues and 38 percent said they would not buy the same system again.
I will argue that the difference between health IT and every other progressive, mature industry is the application of open source, open standards and, most importantly, open platforms. These platforms supporting interoperability and substitutability have enabled Apple and Google—and NOAA weather data, the Facebook Developer Platform, Amazon Web Services, Salesforce, Twitter, eBay, etc.—to drive innovation and competition instead of stifling it. They have created markets where everyone wins—the client, the application developer and the platform company.
The keys to open platforms are application programming interfaces (APIs) through which a platform-building company (i.e., Apple, Google) welcomes the contributions of clients and other companies. The more elegant the API, the more it can support true interoperability.
Continue reading “Beyond HIT Operability: Open Platforms Are Key”
Filed Under: Tech, THCB
Tagged: API, Apple, application programming interfaces, consumer technology, Edmund Billings, EHR, Google, HIT, open platforms
Mar 14, 2013
Anyone who understands the importance of continuity of care knows that health information exchange is essential. How are we supposed to cut waste and duplication from the healthcare system and truly focus on patient welfare if doctor B has no idea what tests doctor A conducted, or what the results were?
The predominant proprietary HIT vendors know this, yet have engaged in prolonged foot-dragging on interoperability and even basic data interfacing. Yes healthcare IT is their business, but interoperability is not in their nature.
As we’ve seen before, the problem is with the business model.
The proprietary business model makes the vendor the single source of HIT for hospital clients. Complexity and dependence are baked into both solutions and client relationships, creating a “vendor lock” scenario in which changing systems seems almost inconceivable.
In the proprietary world, interfacing with third-party products is a revenue generation strategy and technical challenge; the latter, though unnecessary, justifies the former. When we go looking for the reasons that healthcare is a laggard compared with other industries, this single-source model—the obstacle to much-needed competition and innovation—is a primary culprit.
To be fair, provider organizations, with little if any incentive to exchange patient data before the advent of Meaningful Use, haven’t shown much collaborative spirit either. In the fee-for-service model, why would a healthcare organization let patients slip from their grasp? Health reform is finally mandating needed change, but when will proprietary vendors actually enable the interoperability hospitals and practices soon have to demonstrate?
Recent rumblings from Washington, DC, suggest the feds are losing patience.
Continue reading “Is Interoperability Possible in HIT? And if it Is, Do We Even Want it?”
Filed Under: Tech, Uncategorized
Tagged: Cerner, continuity of care, Edmund Billings, Epic, Farzad Mostashari, health information exchange, Interoperability, McKesson, Meaningful Use, Neil Patterson
Feb 15, 2013
We should have seen it coming, really. It was entirely predictable, and the most recent RAND report proves it.
We incentivized comprehensive IT adoption, making it easier to bill for every procedure, examination, aspirin, tongue depressor, kind word and gentle (or not) touch without first flipping the American healthcare paradigm on its head, if such a thing is even possible.
According to analysis by the New York Times, hospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier. Overall, the Times says, “hospitals that received government incentives to adopt electronic records showed a 47 percent rise in Medicare payments at higher levels from 2006 to 2010 … compared with a 32 percent rise in hospitals that have not received any government incentives …”
To paraphrase the mantra of Bill Clinton’s successful 1992 presidential campaign: It’s the system, stupid. More specifically, it’s the business model, stupid, the fee-for-service system in which electronic health records are enabling tools.
It’s also the law of unintended consequences. You know … you take action, planning on this but instead you get that.
Like the introduction of cane toads in Australia to kill beetles (they couldn’t jump high enough). Like letting mongooses loose in Hawaii to manage the rat population (they preferred native bird eggs). Like Kudzu, the insatiable vine that’s devouring the South.
According to the authors of the RAND report, the problem is with the incentive structure that encourages more tests and procedures. Well, of course it is. Doctors and administrators have a clinic or hospital to run. They have expensive invoices from Epic and Cerner to pay. They can now track and bill for all this stuff they used to not get paid for. Are we surprised?
And meanwhile, fee-for-service leads us down a contradictory rat hole of massive healthcare costs and lousy public health. Continue reading “It’s the System, Stupid: Reversing the Law of Unintended Consequences”
Filed Under: Uncategorized
Tagged: ACOs, Cerner, Commonwealth Fund, Costs, Department of Veteran Affairs, Edmund Billings, EHR, Epic, Fee-for-service, Hospitals, Incentives, Intermountain Healthcare, Kaiser Permanente, RAND study
Feb 5, 2013
What a week last week! First the disgraced cyclist confession and later the baffling college-football-player-and-his nonexistent-(dead)-girlfriend story, with the RAND report sandwiched somewhere in between. It’s positively a scandal-palooza.
What’s that? You don’t feel like the recent RAND report, which basically says that a 2005 RAND study financed by GE and Cerner was wildly optimistic in predicting about $81 billion in potential health care cost savings through widespread adoption of electronic health records, qualifies as a genuine hoax, controversy, scandal?
But it does neatly frame what is arguably a unique characteristic of the healthcare industry—a trait that extends to peripheral industries as well. Basically, healthcare is an interconnected environment. Call it the systems theory of healthcare, co-dependency … or just regular dependency. Call it what you want, but there is an interconnectedness in healthcare that we ignore at the expense of national wellness.
Witness key data points provided by the RAND report:
- Modern health IT systems are not interconnected and interoperable, functioning “less as ‘ATM cards,’ allowing a patient or provider to access needed health information anywhere at any time, than as ‘frequent flier cards’ intended to enforce brand loyalty…”
- Neither are they widely adopted, with an estimated 27 percent of hospitals utilizing a basic electronic record. Without broad adoption, interoperability is far less relevant.
- Improvements in quality of care / patient safety and reductions in healthcare costs (which have grown by $800 billion since 2005) are not manifesting with EHR adoption, in part because hospitals and clinics are rushing to adopt mediocre solutions and garner federal funds.
- The provision of care is the same as it ever was, even though EHRs are frequently promoted as the optimal tool for a different kind of care.
The reasons for these disappointing stats are readily apparent and unalterably interconnected.
Continue reading “Are Healthcare and Health IT in a Dysfunctional Relationship?”
Filed Under: THCB
Tagged: Cerner, Costs, Edmund Billings, EHR, EHR incentives, Fee-for-service, General Electric, HIT, Hospitals, Interoperability, IT vendors, Meaningful Use, Patients, Physicians, Quality, RAND study
Jan 23, 2013