POLICY: The (Very) Odd Couple


This week Hillary Clinton met with Newt Gingrich and together they declared
unity and agreement on America’s health care future —  at least as far as the
role of information technology goes in it. 

The author of "The Great Right Wing Conspiracy" cosying up with the woman who dreamed up "HillaryCare?" 

That surprising sight led to an immediate media
freakout. What could it all mean?  Could some sort of earth-shattering political announcement be about to follow? 

The New York Times sheds some light on things:

"As it turns out, Mr. Gingrich and Mrs. Clinton have a lot more in
common now that they have left behind the politics of the 1990’s, when
she was a symbol of the liberal excesses of the Clinton White House and
he was a fiery spokesman for a resurgent conservative movement in

Both Clinton and Gingrich seem to agree that government should help fund the technological transformation of the healthcare industry.  Historically, the implications of this kind of bipartisanship are big indeed.  Well, sort of.  Providers and payers can expect more legislation impacting information
technology, but realistically probably not much more
money from the feds.   

care veterans may recall the last time significant legislation affecting health
care IT was passed: in 1996, when the Senate voted 100-0 in favor of the
Kennedy-Kassenbaum legislation. That law is better known today as HIPAA. Ten
years later payers and providers are still struggling with the implications.  So cast
a jaundiced eye when you hear that Washington is preparing to intervene. 

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  1. gadfly,
    Thanks. I thought that it might be an electronic medical record. I had heard in a vague way that Kaiser was supposed to be really big on investing in IT, that they could afford to do this, because all of their patients pre-paid, unlike a doctor in private practice who gets paid by the HMO for each service.
    Put the letters M and R together, and my first thought is magnetic resonance. That’s why I had to ask.

  2. Another problem with EMR development is that developers are used to seeing interfaces that rank and file workers don’t usually see. Developers also follow their own professional cutting edge ideas and theories. However, when they implement what seems normal to them in the EMR, they create a learning curve for health care providers – and health care providers don’t have time for a learning curve, especially with a new rollout of someone’s pet project occuring every five minutes. This problem can’t be solved by collecting end user suggestions because often the end user hasn’t yet experienced what they would actually find the most easy and convenient – the knowledge just isn’t in their heads, and no one should expect health care providers to engage in a ghost career as technical experts. A more useful approach would be to stick with analogies of existing interfaces. For instance, for better or worse, people are used to using Microsoft tools. Those tools might not be the “best practices”, but most employees have been using these tools for years. It might be worth paying Microsoft royalties in order to use exact analogies.
    I remember going to a CIS presentation (CIS was the EMR Kaiser tried to develope in-house but ended up writing off – huge waste of millions of dollars). The presenters were talking to a room full of people who actually specialized in technology, but they might as well have been speaking Urdu. I think part of the problem is that they were trying to slip in a proprietary professional language along with the new technology. (this strategy is used for new products on the open market as a way of “branding” the product and cornering the market). I suspect this was also because Kaiser partnered with IBM for CIS, and IBM is also a consulting firm which is well aware of the co-dependent value of a language that their own consultants can offer “expertise” in. Anyway, I couldn’t imagine Kaiser shoving their physicians into that sort of alien environment (it was ugly and cheap-looking to, which means that physicians wouldn’t even get to enjoy the geek factor of learning something cool and futuristic). Fortunately after a few years Kaiser realized this was a bad idea. I suppose that Halvorson’s only choice at that point was to work with a vendor if he still wanted to represent Kaiser as being at the forefront of the EMR. If Kaiser had started over at ground zero, it would have taken years and perhaps just ended up running aground again.

  3. The EMR is in its infancy in terms of usefullness. Only a very, very small % of physicians in this country – in the small % of health systems where EMRs are actually implemented – are using CPOE (computerized practioner order entry), which is big problem. Kaiser employs its docs so it can mandate use. The inmates are running the asylums elsewhere.
    A key technological shortcoming of the EMR in its present state is a lack of sophistication of “point of care” decision support. While I’m sure that these alerts have saved lots of lives from medication interactions and the like, docs don’t use the systems because the alerts are incessant and annoying. They slow them down without providing enough perceived value.
    Other than Kaiser (Group Health and a couple of of others) health systems really don’t care about disease management (perversely, it actually hurts them financially), so I haven’t heard about too many examples of using EMRs in this manner.
    The progress toward digitization to date has been mostly about getting all of the transaction data in one place. There’s tons of opportunity to actually use this information in a useful way if the financial incentives are in place to make it happen…

  4. //so clinicians havne’t yet figured out how to maximize cost containment/quality//
    Clinician adoption was a problem (i.e., spending more time dealing with computer input and learning curve than on encounter with patients). I want to underscore, all my impressions are from the time when I worked for Kaiser, so I don’t know much about what happened after around June 2003. What I do know is that at that time there was a lot of smoke and mirrors in regard to the EMR. The first thing that was going to be implemented was the billing system for “point of sale” billing. There was massive speculation that Kaiser was only interested in the billing system. The computer programmers complained that the system that was purchased was based on old 80s technology (MUMPS), and Kaiser would be held hostage to the vendor for any flexibility in that respect. The EMR roll out was based on integration with existing systems, with maximum propaganda to make the whole thing look new, unified, and simple – i.e. “packaged” for sale. Millions of dollars was being spent on “transitional” systems in Northern California alone, with just a partial EMR roll out being projected five years into the future.
    From the patient’s perspective the EMR initiative created new difficulties. For instance, I participated in the roll out of a transition-to-EMR system for doctor email. The result was that I was that Kaiser felt they were able to refuse me that part of my medical records. Even thought their are laws in CA which specify that I have a legal right to my medical records, Kaiser was able to stall and delay and pretend that these were just inaccessible. The Dept. of Managed Health Care told me that they weren’t obliged to help me in this regard. Kaiser did eventually provide them many months later, but by then they were useless to me.
    One of the problems is that patients see the convenience of automation, but by the time they realize the problems, it’s too late to do anything. The infernal machines are already in place.

  5. I’m embarrassed to say I know very little about Kaiser, but have a very positive impression of them.
    So I’m curious–when it comes to EMRs, are they really maximizing them, using ’em to integrate care and start doing some really sophisticated disease management? Have they figured out how to integrate billing and clinical functions? Or is it just smoke and mirrors? Or is it somewhere in between–the adoption curve is just beginning, so clinicians havne’t yet figured out how to maximize cost containment/quality, but Kaiser is doing a good job teaching their practitioners so it’s just a matter of time…

  6. EMR = Electronic Medical Record
    You might also see AMR = Automated Medical Record.
    Kaiser was originally developing their own EMR, but they decided to speed up the process by buying components from Epic. Kaiser’s EMR is actually cobbles together a lot of systems – existing systems are being integrated with the Epic components. Kaiser then named the whole thing HealthConnect to a) make it sound like a simple “solution”, and b) give the vendor components a Kaiser brand. I actually have a Halvorson quote somewhere that confirms the motive for renaming the EMR HealthConnect was so the idea of a cutting edge EMR would be associated specifically with Kaiser. Several months later Kaiser testified before the Ways & Means Committee to argue for federal EMR funding.
    As mentioned above, I was in a meeting where Kaiser physicians and project managers discussed how much money could be made once the EPIC components were combined with Kaiser’s own population management data.

  7. gadfly,
    I’m still just learning about the history of healthcare policy. Could you please explain what EMR stands for?

  8. Interestingly, a few hours earlier, the Secretary of HHS had released a report on the need for more health IT investment at the Business Roundtable’s big Health shindig–it could have been a nice little story for the administration on public/private partnerships and HIT.
    I would LOVE to know the tick-tock on who was going to unveil first–were Clinton/Newt stepping on the new Secretary’s message, or was it vice-versa with the administration playing “me too” defense, hoping for a second graph mention on their efforts in healthcare IT? Anyone got insight? A late-day media advisory, maybe?

  9. I still think Kaiser’s approach to me has something to do with how they’ve been positioning themselves as the recipients of federal Health Technology largess. As I’ve mentioned before, I was in the room when high level physicians and project managers discussed strategies for repackaging and reselling Kaiser’s EMR.
    Did anyone else see the Eli Lilly settlement with the FTC: http://www.ftc.gov/opa/2002/01/elililly.htm
    Hmmm, perhaps I should have filed my complaint with the FTC instead of the OCR?
    By the way, Kaiser is filing more papers today. I’ve been mystified as to why they are keeping this up in light of the bad PR. I’m now thinking that they are trying to kick up a lot of sand to complicate matters in case someone files a suit like the Eli Lilly one.

  10. Newt is in Iowa, I wonder why, and is being quoted in the press as saying that he may run for President. He says that if the crowds in Iowa get really large, fat chance, and they beg him to run he will consider it. Newt goes on to say that all this talk about him running for President is really helping book sales.
    In other news in Iowa today, Democrat Gov Vilsack signs sweeping Medicaid reform. Now poor Medicaid Iowa folks will get the HSA option in Medicaid and is the first state in the nation to do so. So that is nice and Vilsack can run for President as the extreme moderate with a health care lagacy.
    We have been advertising the MSA and HSA in Iowa since 1997 on WHO radio during Rush. Iowa Senator Neil Schuerer contacted me and asked for HSA information and I complied. I hope that info made some difference. Really, Iowa Republicans pressured Vilsack into signing this unprecedented reform. Next it’s on to Medicare for the HSA.

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