A health care Marshall Plan — $50 Billion stimulus to get electronic health records (EHRs) in every doctor’s hands or $50,000 to each physician -– what an incredible marketing job.
Detroit, are you listening? Stop whining to Congress that you need a bailout. Tell them you want to be the new alternative energy Manhattan Project, get the money, and then keep building SUVs and flying around in corporate jets.
To Congress, Daschle, and Obama, please don’t do this. Our industry, health care, combines the worst of the Big Three automakers with the worst of the hubris, dishonesty, and failure of the public trust of Wall Street. Please do not bail us out.
The health care information technology (IT) industry is a close analog
of the auto industry circa the 1970s. A few large players who build
big, expensive systems on outdated technology platforms dominate the
industry. There are some Toyotas, Hondas, VWs, and BMWs in the mix, but
the big players dominate the industry forums, standards organizations,
and mindshare of the institutions – our academic medical centers and
large health care organizations. They sell the institutions Cadillacs
and Lincolns with big fins that wallow and weave as you drive down the
road and they offer the rest of us Pintos and Vegas – smaller versions
of the big systems that unpredictably catch on fire.
Unlike other industries, however, (again, listen up Detroit) there is a peculiarity to health care IT relative to government regulation. The large health care IT companies love regulation and they love government mandated standards. You might wonder, no other industry has government setting standards, why health care?
It’s simply because HITSP and ONCHIT, the organizations set up by industry and the government to mandate standards, are controlled by the large archaic systems vendors. Standards selected and set by these organizations are unnecessarily complicated, expensive to implement, and protective of the big players. They stifle innovation and like the Big Three automakers, keep health care IT completely out of step with the general computer industry. Health care IT and HITSP standards are at least a decade behind the open data standards and open-source progressivism of the general computer industry.
In a nutshell, do not pour more money into this industry without completely rethinking how we drive innovation. Currently available EHRs from the major, CCHIT certified vendors will not save us money. Any assumptions about improvements in quality or patient safety will be offset by an across the board loss of clinical efficiency, a loss of productivity and a counterintuitive increase in the number of personnel, and increased clinical and administrative errors due to system and user interface complexity.
Across the board the decisions by CCHIT have narrowly defined the criteria that constitute a ‘certified’ EHR. They have made the hurdle artificially high and they have made the process as well as the required standards expensive for smaller innovative vendors to comply with and time consuming to implement. EHRs are not the solution, and this is very sad for me to say having devoted most of my professional life to them.
Apologies that this is out of left field but please spend our taxpayer dollars on the following:
A) Allocate $25 million and fund five efforts at $5 million each to build a scalable, XML, and cloud-based claims adjudication, public health, and quality reporting system to replace the entire archaic mainframe systems at CMS. Make the winning solution open source, implement it for Medicare and the CDC, and offer it free to every state Medicaid program and all the commercial payors. In addition make public and open source all Medicare and state Medicaid payment adjudication rules and payment edits. If you want to regulate something, make disclosure of adjudication rules and payment edits mandatory for all public and private health plans and PBMs.
B) Allocate $12.5 million (five efforts at $2.5 million each) to build an XML and web-based, completely secure and confidential patient registration, master person index, eligibility management, claims submission, and explanation of benefits/remittance system that interfaces seamlessly with Item A, above. Involve the patient privacy experts integrally in the selection of the winner and make the winning entry open source and free to all physician practices, hospitals, nursing homes, and ancillary facilities.
C) Allocated $10 million (five efforts at $2 million each) to build an XML and web-based, completely secure, confidential, and digital signature-based integrated ePrescribing and order entry (CPOE) system. Make the winner open source and mandate that all physicians, all hospitals, all institutions, all laboratories, all pharmacies, and all ancillary services use this integrated and uniform prescribing and order entry system for all inpatient and outpatient transactions.
D) Allocate $10 million (five efforts at $2 million each) to build an XML, open source PDF, and web-based, completely secure and confidential results reporting system. The winner would be open source, it’s use mandated, and must generate identical report formats for each type of result independent of source – in other words the onscreen and print based display of a urinalysis, culture, and sensitivities; an imaging report; and all other results would be uniform across the country and across practices, labs, radiology groups, and institutions.
E) Allocate $12.5 million (five efforts at $2.5 million each) to build an XML and web-based, completely secure and confidential clinical and administrative decision support engine that operates seamlessly with C and D, above. Make the winner open source and the solution has to provide open source authoring tools so that academic, public health, and institutional sources can publish plug-and-play guidelines, protocols, and recommendations for cost and clinically effect and evidence-based prevention, diagnosis, treatment, and patient safety.
A, B, and E will save a phenomenal amount of money for providers, payors, and the entire health care system, and C, D, and E will do more for patient safety than all the EHRs in the world. That’s for $70 million — not billion — and remember, the ‘experts’ and the established vendors will say this can never be done for this little money. I’ll take that challenge.
Let the existing health care IT vendors build charting systems, scheduling systems, and implementation platforms for the above technology. They’ll make plenty of money and unlike the Big Three might actually survive.
Rick Peters is an emergency physician, founder and former CEO of the EHR vendors Oceania (now Cerner) and iTrust (now Medplexus), and the PBM PTRX. He has been integrally involved in health care standards and health care consulting.
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Message sent to my Congressmen and Senators,I cannot believe that this government has reached a conscious to support a bill that gives ILLEGAL ALIENS healthcare. Is the government becoming dumber by each day, secondly the people that made it possible to vote you into congress should have a say in what is provided in the HC Bill, you(government) will ration what medical needs a person has, remember we the people are paying for this not the government, what you first need to do is tort reform, secondly hold a vote to the people to see if they want a HC Bill, just as you provide information during your re-elections also provide information on the HC bill to the people, this is like taxation without representation. Where is the logic to provide healthcare to illegal aliens, for that purpose just open the borders and let them in. This government has become a disgrace to the people it serves, I am embarrassed to call my self a DEMOCRAT any longer. Washington has forgotten the needs of the people. REMEMBER this is a government for the people by the people, not a government for your own interest. Do any of you realize what most citizens are going through currently, have you honestly seen what your communities are living, or have you all become so complacent in your jobs that you do not care. We have senators and Congressmen getting favors for there posts, this is shameful to read in the newspapers, all of you should be voted out of office in the next election. You all promised to do a better job for your communities, ask yourselves deep down if you are truly doing the right thing for the people, this was once a proud country, the nation in the world everyone looked to in a time of need, what are we now, are we better than the Soviets in there time, we critize Cuba for being communist but they at least have one of the best health care systems in the world. I am truly sorry that I voted for any of you.
I believe this whole health care debate has gone on long enough in Washington DC. The last three adminstrations have tried and failed to come up with a bill every POLITICAL PARTY could agree on. I say well now its time to use the demorcratic process to make a decision. If our Congress can’t decide then the people of this country should make the decision. I believe that the major versions of the health care bille should be placed on a national balot. The political parties could then campain for their version and provide the education of their version to the public.
I just don’t understand the logic of those who are advocating socializedl health care! It seems to me that they have the proverbial “Cart-Before-The-Horse.”
In order for the health insurance industry to pay out billions in health care claims each year it has to at least take in billions of dollars in premiums.
What are the percentages and the amount of the health insurance industry’s profits, and through conjecture – who and how many might those profits insure?
Why is not this the debate – instead of the ill-defined and nebulous cries of those who claim to be so well-informed in this blog?
Why aren’t President Obama and Congress focusing on the cost of health care treatment in America? Insurance premiums are always the consequence of the analytical cost of anticipated claims.
It’s hard for me to believe that the cost of health insurance in America is our #1 problem, but more so, merely the symptom of waste, inefficiency, profiteering, greed and largess at the inception and delivery of our medical treatment.
I, for one would like for all this uproar and attention be directed as to why the least expensive stay in a hospital in America is close to $1,500 a day and why a patient is charged $9 for a box of Kleenex on the nightstand. We cannot hold the insurance industry responsible for these shameful charges.
It is apparent though that there is a wide discrepancy in both the quality and the cost of coverage from one insurance company to another. If the government needs to intercede with something similar to the Food and Drug Administration (FDA), or other federal watchdogs, I believe our nation and Congress would stop this entire inflammatory idiom that is dividing our nation.
In all likelihood the only other answers for President Obama and Congress [if there is one] is to legislatively freeze medical costs in America with price controls, or use our tax dollars to pay doctors and hospitals for the medical treatment of those who either claim indigence, or are in fact indigent.
Annihilating the health insurance industry in America and replacing private health insurance with a government plan would temporarily lower premiums and therefore insure more Americans. However, medical claims would soon skyrocket and give America, President Bush and Congress a much, much greater challenge than they are facing today.
If anyone really thinks this health care “INSURANCE” program is anything other then a move to force within 5-10, a GOVERNMENT RUN health care like Canada and Britain then read the document yourself. Obama himslef stated in 2004 “I would think we could see the private insurance disappear within 5-10 years” and the real reason for this “I support a SINGLE-PAYER” healthcare system” He says he doesnt support it now because we are on the cusopice of throwing him abnd everyone who voted on this monstrousity out with the baby water come 2010 election time. The Public Option is merely the first step to force private insruance to end. The next thing you are going to hear is “ALL Private insurance must meet PUBLIC Option criteria or stop sproviding insurance”. Thus ending the private option and leaving only the public option. Canada and Britain BOTH admit they wish they had not ever done this and now we are looking done the same road with the path this governement is taking us. This is the first step to the loss of all you liberty. Why does the governemnet require all access to your private bank accounts with the ability to extract via direct withdrawl? THAT is in the BILL !! If this is not a step toward socialism and total government control of your life. IN Ex-Governor Deans recent statement, “Having a single payer public option is going to be the only viable option for the citizens to have in the future” C-Span2 0945 CST 08/14/2009.
I think that the Democrats can’t do a good job of changing the Health Care, because they owe to much to the Lawyers, Insurance Companies ans Unions. But, here is an idea, if the Government Run Insurance is a fact, theb all Federal Employees should be under that one plan, that includes the President, the Congress, The Senate etc. No more cadilac insurace subsidised by the people.
It is very difficult to take the pills, vicodin in this case we are gaining control of our body, we must remain very careful and not fall and hang on to drugs, always remember to look at this couple and for our future. I read findrxonline.com certainly are very addictive and so we need to know control.
Go after the overpriced drug makers who are driving up health care costs. People should not have to go bankrupt because they cannot afford their prescription drugs.
Please visit the free video at Google, “The Solution for brain injuries and bankruptcies” it outlines a self reliant system funded by users, in use in Michigan only for 35 years. This Model provides unlimited medical benefits by using a simple idea, and is the only system with hundreds of millions in annual excess! This Model prevents bankruptcies due to medical bills and assures Hospitals and providers get paid, and will save States billions in Medicaid costs. The Federal Government should not attempt to bail out the Health care industry. Great Post!
I thought you all might be interested in this very relevant article about the bailout and medicine: http://thewip.net/contributors/2009/02/paying_for_the_bailout_how_unn.html#comments.
I am against Washington bailing out the health care industry. I do not see how we can keep bailing out everything and everyone.
Its really a useful info. But the plan is quite affordable..
Well-written and very informative article, Rick. Great ideas and maybe this can be part of the solution for the healthcare issues we are facing. Obama’s initial health care reform could be impressive and we are all waiting as it progresses.
Taxpayer investments in HIT need to be analyzed like any other business investment….and your Post is a critical step in this direction. With a national health expenditure exceeding $2.2 trillion dollars and with over 300,000+ physicians, 5,800+ LTAC/IRF/Acute hospitals, 18,000+ LTC/SNF providers and 300+ million patients the solutions to health care reform will be complex and dramatic.
The HIT solution will be challenged by the fact each service setting has its own assessment instrument ( DRG in Acute-MDS in SNF-PAI in IRF-OASIS in HHA-RAI in LTC). Before meaningful HIT changes can be implemented the payment system needs to be consolidated into a single bundled payment for each episode of illness. Fragmentation leads to unnecessary cost. The logical development of new HIT needs to be based on a uniform assessment tool in all sectors of the health care delivery system. Solutions exist for meaningful reform such as those recently offered by the CBO in their landmark December 2008 report. Technology only supports a rational solution in health care reform….it never represents the solution.
HIT is an intregal part of health care reform but it should be the final step in a restructured and more rational delivery system. Hopefully the rush to stimulate our economy will not overshawdow the thoughtful development of a new model for service delivery.
Bailout dollars for tax dodgers like HIMSS, a so called industry trade association?
When 501c 6 status is claimed we the taxpayers subsidize the operation of money grabbing carnival operators. The question is should bailouts and tax subsidies go to those who violate human rights in the work place and claim to offer guidance to our elected officials. No… this is horse crap. Its one thing to put on a carnival, its another thing to violate human rights and public policy. The voice of these blogs is essential to spreading the truth.
Thank you so much for this post. I’ll be contacting my reps with this. While we all have hopes that Obama will bring real change, his proposals so far are a zero. Does his solution in anyway start with identifying the problem? Isn’t it cost and the unfortunate side effect of bankrupting patients? Obama’s solution proposes another huge boondoggle to benefit his donors. This will greatly expand the Novation monopoly tax on “care” while doing nothing to help us – nothing to help with health care or provide jobs since companies like athenahealth outsource to private pools in India.
All the Obama believers should do some serious research on this before we throw billions of dollars at another non-solution.
There was a time when, if you wanted to become a physician, acquiring the requisite funds required more than the mere velleity of making the choice and having the financing appear, as it does today.
Then in the 1950’s and 1960’s the (then) HEW came up with what seemed a simple solution to the health care conundrum: financial aid to medical schools. They planned to flood the market with new MD’s and so cause increased competition to lower the cost factor attributable to doctors’ incomes.
In the mid 1970’s I was a dinner guest of a brilliant couple of Washington health apparatchiks. He was (among other things) guiding the nascent EPSDT program. And she (the sister of one of the Brookings Institution’s leading economists) was eventually to become the Director of the National Center for Health Statistics. In short, not only were they broadly wired into the beltway health establishment, they had their hands on the steering wheel.
Another guest that evening was the wife of a health economist who had recently been jilted by her co-researcher husband. And she was getting back at him by blabbing about the results of their latest research prior to their publication: financial support of medical education was having the opposite effect on health costs than had been anticipated (and hoped)!
Although the increased support given to Medical Schools had worked to increase the supply of physicians, there hadn’t been the expected depressive influence on doc’s incomes. They had found that wherever there were new MD graduates, they would produce more medical procedures and earn a handsome income while doing it.
By producing more Docs, Washington had increased the supply of industrious medical care providers who continued to command a gratifiying return on the investment the government had made in their education.
There was amused consternation around the dinner table. Medical Economics had not responded to the “Law” of supply and demand. “Well, maybe we’ll do better with this new entity, the HMO.”
Rick- Hooray for your article ! We aren’t lacking technology in Health Care- We’re lacking common sense !
But isn’t this audacious? Bailouts use the tax money of the general public to help industries. Government should be more sensitive about such issues.
“Of course, you mean Billions in A-E, not Millions.”
No the numbers cited are even too high at the multiple tens of millions. $10 to $20 million donated to the Apache Software Foundation or comparable organization to aid the establishment of an EMR/PM top-level project is much more than sufficient to create an outstanding FOSS software product very quickly.
Otherwise Mr. Peters is exactly on target.
I read this a couple a weeks ago and was certainly doing the normal head nodding but then out of left field an unrelated piece of data came along that just blew my mind.
A vendor in another industry pointed me to http://www.programmableweb.com This is a site that writes about 3rd party APIs and how to use them to move your company to the Web 2.0/3.0 world.
Here’s the kicker, there isn’t a single healthcare API listed! Does this not say it all.
How hard would it be for the people who have commented here to simply start specifying the APIs for the health subsystems that are listed in the post.
Why not do it the Net way, rough consensus and working code?
Preferred Health Resources
Well written and represents a refreshing well-thought out veiwpoint! I remember when I first started complaining about CCHIT 2 years ago all over the place, very few were listening (one important fellow being Dr. Silverstein above, BTW).
Now, there are few that agree with CCHIT, although it continues its work simply because of the 3 year government contract which hopefully will end in 2009. We need for more folks to write position papers like this…
Happy New Year to one and all!
Al Borges, MD
“What is Wrong with HIT in the USA?”, downloadable at http://www.msofficeemrproject.com/
We think alike.
Happy new year!
Re: “There are 500+ health plans, but 5000+ rules sets associated with the various benefits plans.”
An interesting way to eliminate this problem would be to ban private insurance for Core Health Services such as “Hospitals, Labs, Physician’s Services, and Medications”. This is what we did in Canada. This system of Universal Health Care depends upon doctors having to make a choice: they must either entirely opt out of the one payor system, or entirely opt in. You cannot bill patients privately and through the public system for insured services.
It’s not complicated.
While on the topic, the President Elect should keep all the money he can to reform the failing US Health Care System first, then tackle EMR. Computerizing an inefficient, archaic, decrepid system won’t solve anything.
I’d be interested how you might compare the ideas presented here with IHE.
Fantastic original post and subsequent commentaries. As a primary care physician who purchased an EMR 6 years ago I recall how challenging the task was. Since then I have watched many of my colleagues purchase expensive systems without having stated goals and an understanding of what they were getting into. The IT industry is not too dissimilar from the pharma industry in that the docs rely too much on what reps say.
How is the average doc supposed to get access to the issues raised in these postings? How are we to be protected from making expensive mistakes? We are hearing about P4P and PCMH and that EMR must be a part of these movements. Then we go out and purchase an expensive system to find out that the costs outweigh the benefits but by then it’s too late.
Many of us are trying to do the right thing by spending our money to improve care. But there are many sharks in the waters and we need unbiased advice…a Medical Letter of EMRs so to speak.
The issues, proposed solutions, and desired results that Rick Peters outlines are worthy. But I expect, based on my long experience, that the people who show-up to do the work will be the very same people who are currently active in standards, HITSP, and CCHIT today. Results are generally determined by who shows up to do the work.
It’s true that large healthcare IT vendors, US government agencies, and a cadre of consultants dominate healthcare IT standards development organizations, HITSP, CCHIT, and NHIN. Yet it’s equally true – and disappointing — that representatives from providers, health plans, consumer groups, healthcare professional organizations, and other stakeholders are in the minority despite many calls for participation.
The creation of standards and their implementations does not create adoption. Free and open technology has a cost for acquisition of operating hardware, staffing, documentation, training, ongoing operations, maintenance, and scaling to handle growth. One key barrier is the lack of capital investment funds. Reimbursement levels barely fund operating costs. A massive migration to a new technology base is unlikely, even by fiat. So what about the transition? How do we get there?
Great post, and many thoughtful comments – to which I have to add.
1. Business Model
Any worthwhile endeavor needs to make a profit. So if the government is to be the financier in creating an Open Source EHR/PHR it needs to have equity and expect a return.
Similarly, every Health care organization should want to have a share of it. It is in their best interests to see a competitive no/low/free cost system to put pressure on Epic/Cerner et al. Funds used to finance this venture would be returned by better terms, and provide a hedge against proprietary dominance.
To make money the organization would have to add value to its open source. One way would be to host the software as an ASP (Salesforce.com) for the benefit of smaller providers who do not want to run their own IT organization. For larger providers, there is a consulting business for customization and integration with their legacy systems.
Another model might be to become a worldwide distributed, interoperable, health care social network – with any service provider being able to attach themselves and extract revenue in any form they can – advertising.
Existing Health care providers should want this because they have the potential to become the best networks – paying patients as customers, qualified, knowledgeable providers, no need to take advertising. However they lack technical expertise which Open Source software can provide them with.
Consumer information providers (Google, Yahoo, Microsoft…) should want it. They have – technical expertise, fleeting customers, no sustainable revenue stream. With Open Source they could leverage their ability to operate at huge scale to work cooperatively with the Health care providers.
Health care is a federated, distributed system. The domain has thousands of concepts, the data sets are huge and need to be maintained in time series. Every technology that has tried to meet these demands has failed.
Rick and others have identified some requirements of a system, namely:
The software system has to be able to directly represent the concepts we deal in, which means it needs to digest information models and turn them into executable code. The conceptual formalism needs to be simple and extensible and not tied to UML.
There are several HC models (HL7, OpenEHR, DICOM …) – the system needs to be able to digest every one of them – (and any more we come up with) and ensure they are semantically reduced to the same concepts, so they can inter-operate at a primitive level.
There will always be legacy systems (as will this become) that will need interfacing. Proprietary Health care software offers no such thing as a standard interface, therefore any new system has to have creative ways of reaching in to whatever is offered – SOAP/WebServices, HL7, ODBMS … by any means possible (pub/sub. polling …).
Ability to expose every Health care conceptual “object” on the Internet as a uniquely addressable URL, which can be mashed up in a social network. So that I could for example paste the URL of the Ultrasound image of my son in the womb, where the image is being hosted by my Health care provider, on my FaceBook page. Or, I could put the URL of my PHR in the address book of my mobile phone, so that a first responder could locate it in an emergency and better treat me.
Every Healthcare URL that referred to me, secured and controlled and owned by me. So that I could decide whom I wanted to share it with. Logging of all access to these URL’s, with access to the logs, which in turn identified the accessor by a similar URL.
f. Massively Scalable
The sort of cloud file and database storage techniques used by Google, Amazon, Yahoo et al. will be needed to run it. Take a look at “Hadoop.”
g. Coded in Java
To attract the largest number of developers in the Open Source community.
The ability to morph and apply changes to the system as it is running so that as a new concept that is realized or any new interface needs to be added – this can be done without taking the system down.
Meet all these requirements and we have the killer Health care app.
The issue is not EMR’s, the issue is integrated health care.
Buried in your article was the answer to why the healthcare delivery system is having such difficulty in adopting IT the way it has been adopted in virtually every other industry. Mayo and Geisinger have made EMR work because they are integrated systems. Contrast this with the norm in healthcare delivery – independent, small practices focusing on acute rather than chronic care. This model has given us higher costs and poorer outcomes than in any other developed nation, and many less developed countries.
Imposing EMR on the current system, whether government funded or by fiat, will only exacerbate already dysfunctional practices. If the Obama administration is serious about reforming healthcare it will have to focus on rethinking the delivery system at the same time it sets out to provide greater access to the system. One without the other is not sustainable. A truly integrated healthcare system will demand IT and it will be made to work. That is the place to start.
I agree with your ideas – the current crop of large vendors are doing nothing to improve the health system where ever they are deployed in the world.
My concern is that open source by itself is NOT a panacea for this problem. The current lack of interoperability and computability of data is the largest issue to be solved. Open source apps such as Vista are excellent applications, however they still use ‘proprietary’ and non standard data formats and are not interoperable with anything else. Open source does promise cheaper software, but many health services are still very nervous about using open source software (usually for all the wrong reasons).
Simple XML schemas just don’t cut it in the clinical space which is THE most complex information domain.
We need a platform that enables interoperability so that we can develop SOA type applications. Imagine a hospital that has an EHR service, with a whole lot of other services such as clinician and patient indexes. Imagine software that just plugs into these services because they are based on open standards which are independent of vendor and technology. No integration costs, with data that can be used for third party decision support etc etc. Imagine software produced by relatively small vendors for specific niches in the health system that fit perfectly into a more complex whole. Imagine primary care physicians who have software that can understand data at a semantic level that comes from other clinicians and health services.
All this is possible now…
openEHR is one such standard which is now gaining a large mindshare in the UK, Europe (especially Denmark and Sweden), South America, Japan, Australia and New Zealand with increasing interest in Canada and the US.
Lets not replace a proprietary EMR based on non standard and non interoperable data with an open source one that is also based on non interoperable data.
Hats off to a deliberately provocative approach to historic talk in the “let’s get physicians to adopt EMRs more” world. As described, traditional EMRs have been very expensive systems designed to be installed in physician’s offices, thus requiring the implementation of extensive infrastructure (networks, servers, IT support) in order to function. Small wonder that adoption rates have been low, especially in smaller practices. And, even in larger clinics or subsidized settings where the traditional “EMR 1.0” systems have been put in place, interoperability – data sharing between physicians, between patients, with hospitals, and with insurers – has remained very problematic.
The solution is not simply to throw money at dinosaurs. Granted, the highly capitalized companies that have built and sold their products would love for that to happen – that is not where solutions are to be found. As you point out, where moneys and resources need to be applied is in the development of new technologies: web-based, hosted EMR systems (“EMR 2.0”) that are very-low-cost (or free) to physician end-users where clinical data can be easily (but securely) shared among practitioners. Sophisticated reporting, and evidence-based decision support can be deployed much more easily across the spectrum with this model.
I have been working with Practice Fusion, a startup free EMR 2.0 effort built with this vision. My hopes are that the new administration will realize that new solutions need to come from new technologies, and that old, expensive and cumbersome EMR 1.0 behemoths are simply not where solutions to the adoption question will be found.
I am really intrigued to learn more about your history and experience in the health care industry. Can you please contact me @ email@example.com I would love to discuss the issues you address in your blog.
Yes indeed. The VA system actually works. Expand it to work everywhere, but don’t farm it out to Google or Microsoft or you’ll just get another proprietary system.
But this undertaking has to be subsidized by the feds. The MAJOR beneficiaries of these systems are insurance companies and hopefully patients, not providers.
If I have to spend $50000 on it, it’s not going to happen.
Sherry: VistA is a beautifully designed system that was developed exclusively for the VA. It is in many ways an electronic replica of their old paper charts. It works well for them, but it would need a significant amount of modification to work in other settings. The VA is self contained, so their software doesn’t need to communicate with outside providers, outside pharmacies, outside hospitals, or perform billing functions. Also, if you aren’t familiar with the VA’s system, it’s a significant learning curve just like any other EMR.
I just posted my latest blog, which pretty much echoes your sentiments and observations.
HIT vendors are salivating at 50 billion dollars, just as they did when ONCHIT was announced, and went nowhere.
A bailout for healthcare IT will enable investment in immature software and lock in systems that are inadequate for what we really need to have.
We need a lot more input from providers, nurses, and public health officials familar with epidemiology, measures of outcomes (if there really are any). P4P measures and rewards need to be analyzed further to see if this is real or just P4 reporting.
The VA system is already in use at 1300 facilities, CCHIT certified and open source and being integrated with the DOD and is the largest EMR in the country.
The current head of the Office of the National Coordinator is from the VA as is the acting director of the new public private non-profit that will follow the AHIC. Why not at least roll that out to public health facilities across the country?
One other idea from John Amato’s blog. “For a relatively small amount of money, we can provide primary health care to every American in need of it through an expansion of the successful Federally Qualified Health Center program. On a budget of only $2 billion a year, this program, which has enjoyed widespread bipartisan support, now provides primary health care, dental care, mental health counseling, and low-cost prescription drugs to 17 million people through 1,100 health center organizations in every region of the country for an average cost of $125 per patient per year. The doors of these centers are open to all, including patients with Medicaid, Medicare, private insurance, or no insurance at all, with sliding-scale fees.
… for a total of $8.3 billion a year, we could have 4,800 centers caring for 56 million people in every medically-underserved region of the country.
This upfront investment – which constitutes less than 0.5 percent of overall U.S. spending on health care – would more than pay for itself. The centers are among the most cost efficient federal programs in existence today. On average, medical expenses at health centers are 41 percent lower than in other health care settings.”
I like your emphasis on open source. I forgot to bring my iPod the other night while walking my dogs and I got to thinking about what the perfect EMR would be. My favorite operating system was my inspiration. As a business model, there would still be plenty of money to be made on customization, installation, training, and support.
It’s hard for small practices to afford expensive EMR/EHR software while at the same time they derive very little practice improvement from the investment. EMR/EHR at the large, multi-specialty group level, may OTOH, justify its expense and productivity loss by improved communication within the group.
I currently work in a medium sized (~80 provider) primary care practice. To date replacing our first proto-EMR (“paperless” scanned handwritten files) with a new big name EMR has been a step backwards for us. However, if we could have purchased an EMR with open source, we could have more easily customized it to suit our practice needs (we see a large percentage of HMO patients, but have a kludged and unwieldy referral system grafted on to the current mess). At the same time we could have said to our specialists, many of whom are private practice or very small groups, “Here is the open source communication software that you will use to communicate with us.” That spreads the intercommunication part (the important part!) of the EMR virally. We’re not huge, but we are large enough that we have the clout to provide the leadership that is needed to begin to establish EMR in the community.
Oh well, that was just blue-skying. The EMRs that are available commercially stink. Their entire emphasis is on generating better billing data; providers and patients be damned.
Great ideas and they will work if the new administration will give them a try. This really isn’t brain surgery but this is only part of the solution. We all know that there is a lot more to the medical inflation problem then getting payors to improve their processes, e-prescribing, and EHR’s. Doctors, hospitals, PBM’s, DME providers heal thy selves. Using evidence based and expert medical systems to assist in diagnoses, stopping the unnecessary testing, allowing transparency in pricing, and making continuity of care the hall mark of medicine in America must run concurrent a HIT revolution. We can produce the best medical care system on the planet but we must all take up our part to make it happen.
While it is agreed that EMRs are needed but the value being given to it is completely erroneous and misplaced. I have seen the ERP systems…they rarely promise what they deliver. Most of the time the roll out sucks, the promises are not met and by the time you get done you need newer version.
Most of the blame of ERP failures are not on the system itself though. It is shared between the quality of the software, the preplanning and robustness of the process. And the quality of team implementing- this one is a big deal.
Great post. Thank you for showing that corporate interests, whether they be large HIT organizations or health insurance companies, are not necessarily aligned with patient interests nor with provider interests.
Deron, I hope that my motivations for submitting this post are pure, but we all have our agendas and our biases. I also hope people who know me in health care feel that I am at least open, honest, and ethical about my biases. Over the years my agenda relative to health care IT has fundamentally changed. I have been an incredibly strong advocate of EHRs and structured and reportable data – driven by structured data entry, but I have had to face a reality check. First, none of the leading systems in use, including the one I use, do structured data entry – we’re collecting a lot of data but it is mostly free text and disparately coded. Second, most EHRs really hit us hard in terms of provider clinical productivity, particularly the ones where we have to type – we cannot lose 10-20% of physician and nursing productivity. Physician loses are bad enough, but none of these systems are designed to assist nurses in their workflow. We cannot forget that nurses do 80% of the actual patient care. Meanwhile 80-90% of the decisions affecting care, cost, and outcomes/patient safety are made by physicians. Unless an EHR fundamentally addresses workflow and efficiency all other desired outcomes go out the window. Physicians and nurses are already too overwhelmed and it is only getting worse, but this is a whole blog post in its own right. My focus of this post and my agenda is to fix the mess we have collectively made on the administrative, lab, order entry, and prescription/fulfillment side of things.
Can we address the fragmentation issues? Yes, I think we can. You ask about assigning access to a chart from one physician to another in a referral. If we had a standardized and open source patient registration and eligibility system (Item B in my list) and we truly engaged and worked with the privacy advocates we can build secure systems to protect privacy and promote data exchange.
tcoyote, I agree with your quibble – goes hand-in-hand. If CMS, and every payor, enployer, and state won’t agree to simplify at least having a uniform open source claims system and mandated disclosure of payment rules and claims edits would force transparency onto the system. After watching us all melt down with Wall Street, I’ve become an even bigger fan of transparency. Also if you have access to Jeanne Lambrew and Peter Orszag in the Obama transition team, please let me know. I am DEAD SERIOUS about these proposals.
Jean – you are right on! Wall Street just took half of our retirement; let’s not let health care squander the other half.
David and again tcoyote, thanks – administrative overhead is 50% or greater of our health care dollars if you include what it costs practices and hospitals. Everyone looks at payor overhead, but we do not look at practice overhead enough, not just in terms of the percentage of the dollar, but as you both point out, in what it detracts personnel from, which is direct patient care.
Casey – thanks, at least if we broaden the debate it’s a start.
Facts that are believed to exist regarding the present U.S. Health Care System-
This may be why about 80 percent of U.S. citizens want our health care system overhauled:
The U.S. is ranked number 42 related to life expectancy and infant mortality, which is rather low.
U.S. is ranked number one in the world for spending the most for health care- as well as being number one for those with chronic diseases. About 125 million people have such diseases. This is about 70 percent of the Medicare budget that is spent treating these terrible illnesses. Health Care cost presently is over 2 trillion dollars of our gross domestic product. One third of that amount is nothing more than administrative toxic waste that does not involve the restoration of the health of others. This illustrates how absurd the U.S. Health Care System is presently. Nearly 7000 dollars is spent on every citizen for health care every year, and that, too, is more than anyone else in the world.
We have around 50 million citizens without any health insurance, which causes about 20 thousand deaths per year. This includes millions of children without health care, which is added to the planned or implemented cuts in the government SCHIP program for children that covers about 7 million kids.
Nearly half of the states in the U.S. are planning on or have made cuts to Medicaid, which covers about 60 million people, and those on Medicaid are in need of this coverage largely due to unemployment. With these Medicaid cuts, over a million people will lose their health care coverage and benefits.
About 70 percent of citizens have some form of health insurance, and the premiums for their insurance have increased nearly 90 percent in the past 8 years. About 45 percent of health care is provided by our government- which is predicted to experience a severe financial crisis in the near future with some government health care programs, it has been reported. Most doctors want a single payer health care system, which would save about 400 billion dollars a year- about 20 percent less than what we are paying now. The American College of Physicians, second in size only to the American Medical Association, supports a single payer health care system. The AMA, historically opposed to a single payer health care system, has close to half of its members in favor of this system. Less than a third of all physicians are members of the AMA.
Our health care we offer citizens is sort of a hybrid of a national and private health care system that has obviously mutated to a degree that is incapable of being fully functional due to perhaps copious amounts and levels of individual and legal entities.
Half of all patients do not receive proper treatment to restore their health, it has been stated. Medical errors desperately need to be reduced as well, it has been reported. It is estimated that we need about 60 thousand more primary care physicians to satisfy the medical needs of the public health in the United States. And we have some greedy corporations that take advantage of our health care system. Over a billion dollars was recovered for medicare and Medicaid fraud last year through settlements paid to the department of Justice because some organizations ripped off taxpayers. These are the taxpayers in the U.S. who have a fragmented health care system with substantial components and different levels of government- composed of several legal entities and individuals, which has resulted in medical anarchy.
Thanks to various corporations infecting our Health Care System in the United States, the following variables sum up the U.S. Health Care System, which is why the United States National Health Insurance Act (H.R. 676) is the best solution to meet our health care needs as citizens. We would finally have, as with most other countries, a Universal Health Care system that will allow free choice of doctors and hospitals. It should be and likely will be funded by a combination of payroll taxes and general tax revenue:
Access- citizens do not have the right or ability to make use of this system as we should.
Efficiency- this system strives on creating much waste and expense as it possibly can.
Quality- the standard of excellence we deserve as citizens with our health care is missing in action.
Sustainability- We as citizens cannot continue to keep our health care system in existence , or tolerate it as it exists today any longer,
These are all great ideas – getting them off the ground will take a New Deal level of effort and engagement.
The entire health care delivery system has been mired in more and more administrative hoop-jumping as ‘managed care’ has managed to insert itself into every patient/doctor interaction.
I’m not sure what the blockage is here – the creators of the unwieldy proprietary systems that can’t/won’t talk to each other, or systemic exhaustion at looking at one more ‘solution’ that isn’t.
The first step toward meaningful change would be to kick off just one of these suggestions – keep pushing!
Rick: You’ve done us all a favor by bringing up the expense of the current multi-payer claims adjudication and payment system, a situation that wastes huge amounts of money as every medical practice, large and small, and every hospital, rural or suburban, tries to comply with the calcified hairball of rules and system friction. There are 500+ health plans, but 5000+ rules sets associated with the various benefits plans. I estimate that a single web-based source for health plan beneficiary information (your A + B) — eligibility, co-pay, deductible status, and the like — could save from 10-25% of the office overhead in most medical practices in this country in one fell swoop.
As tcoyote points out, this would repurpose the primary care office towards the delivery of care instead of the hassle-prone objective of getting paid by health plans.
Kind regards, dCK
We can only hope that our new president will follow through on his promises of healthcare reform and help us save some money. As a webmaster for a group healthcare and financial products broker in Dade and Broward counties in South Florida, I see just how much the costs of care have risen here due to the heavy population of retirees and their needs for prescription drugs and just plain general health pictures. I am approaching retirement myself and have no desire to have to spend my hard earned annuities or IRA and 401K that I have saved as part of my retirement planning on healthcare insurance! Car pooling can help save a little, but healthcare reform would save me a whole lot more.
This is a really impressive post. Of course, you mean Billions in A-E, not Millions. I agree completely with your core premise: the feds could throw a ton of money at the existing applications, piss everyone off and not get a dime’s worth of societal return from investments, just like the Brits did. You know well from your systems development experience that if this approach were taken, it would become suddenly very important for the major vendors you speak of to create interfaces from their legacy systems to this architecture.
A +B are the key it would enable physicians to repurpose their office staffs to provide clinical support to patients, rather than sit on hold waiting to talk to a robot in the health insurer’s claims dungeon.
One small quibble: simplification of the healthcare payment model goes hand in hand with this approach, since it is a waste of scarce societal dollars simply to automate 30 billion transactions, many of which are unnecessary and create no value for anyone.
You need to send this to Jeanne Lambrew and Peter Orszag in the Obama transition, and follow up until you get a hearing. It isn’t clear yet who the lucky Healthcare IT Czar is going to be, but you need to find that person when he/she is designated and run them to ground. They are still dealing with this at a very high level, and do not understand the level of backlash against the “state of the art” EHR’s in the present clinical marketplace. The Obama people are smart people, and should do their homework before squandering a lot of money on this.
I’m not sure your motivations for the submission were all pure, but I like some of what you’re suggesting. It sounds a lot more interoperable than the IT islands we have now.
“make disclosure of adjudication rules and payment edits mandatory for all public and private health plans and PBMs”
Love it! I like the decision support aspect too.
Do you feel you can adequately address the fragmentation issues out there with a system such as the one you described? In other words, if Physician A refers a patient to Physician B, can B be somehow assigned access to the patient’s chart to see the history, etc. documented by A?