Let’s Reboot America’s HIT Conversation Part 1: Putting EHRs in Context

Kibbe & Klepper are back with an update to their pre-Christmas piece on EHRs and the forthcoming Obama Administration’s investment policy towards them. Lest you think that this is just a small group here on THCB and fellow traveler blogs shouting to each other, I’d point you towards the Boston Globe article about their previous "Open Letter," which shows that this discussion (and a similar piece on THCB from Rick Peters) appears to be being taken very seriously. As it should–Matthew Holt

On Dec. 19, we published an Open Letter to the Obama Health Team,
cautioning the incoming Administration against limiting its Health
Information Technology (IT) investments to Electronic Health Records
(EHRs). Instead, we recommended that their health IT plan be rethought
to favor a large array of innovative applications that can be easily
adopted to result in more effective, less expensive care.

response to that post was vigorous. We received many comments and
inquiries from the health care vendor, professional and policy
communities – urging us to provide more clarity. One prominent
commentator called to ask whether we, in fact, supported the use of
EHRs. We both have been active EMR and health IT supporters for many
years. Dr. Kibbe was a developer of the Continuity of Care Record
(CCR), a de facto standard format for Electronic Medical Records
(EMRs), and has assisted hundreds of medical practices to adopt EHRs.
Dr. Klepper has been involved in EMR projects for the last 15 years,
and the onsite clinic firm he works with provides every clinician with
a range of health IT tools, including EMRs.

That said, we are realistic about the problems that exist with health
information technologies as they are currently constituted. As we
described in our previous post (and contrary to some recent claims),
most products are NOT interoperable, meaning licensees of different
commercial systems – each using different proprietary formats – often
find it difficult to exchange even basic health care information.

EHRs are bloated with functions that often are turned off by
practitioners, that are promoted politically through the current CCHIT
certification process, and that drive up costs of purchase,
implementation and maintenance. Despite moving toward Web-based
delivery models that have MUCH lower transactional costs than
old-fashioned client/server approaches, most commercial offerings are
still extremely expensive, especially compared to the revenue flows of
the relatively small operations they support. (Dr. John Halamka’s recent recommendation that the Fed invest $50,000 per clinician for rapid implementation of "interoperable CCHIT certified electronic records with built in decision
support, clinical data exchange, and quality reporting
provides an idea of the resource allocations that are on the table.)
The very wide range of choices in the market currently raises the
question of whether the implementation of a national EHR infrastructure
MUST be so costly.

Many health care professionals still think of
health IT as a compartmentalized function within health care
organizations. But health IT has increasingly become the glue between
and across all health care supply chain, care delivery and financing
enterprises. In the past, it was enough for health IT to facilitate
information exchange inside organizations – in which case a proprietary
system would do – but we now expect information to be sent and received
seamlessly, independent of platform, including over the Internet. Most
of the currently dominant EHR technologies don’t even begin to get us

Nor, despite the rampant optimism about its potential,
can a focus on health IT alone – or even more emphatically, EHRs –
resolve health care’s deeper problems. As the noted health care
economist Alain Enthoven wrote in a December 28 New York Times

[President-elect Obama]… has suggested, for example, that electronic medical records could
save Americans nearly $80 billion per year. But information technology
cannot bring meaningful savings if it is used in a health care system
that regularly rewards waste and punishes efficiency, as ours does.

In other words, as the recent reports from the Congressional Budget Office and the Dartmouth Atlas
point out (yet again), real reforms will require an array of
significant changes, many of which will face withering opposition from
entrenched interests. One of those interests is the established health
care information technology sector, which stands to finally win
handsomely from huge Federal investment in their current products.

good news is that this is the position held by Peter Orszag, the
incoming Director of the Office of Management and Budget, the current
Director of the Congressional Budget Office, an astute student of
health care dynamics, and a key member of the Obama health team.  In
July 18, 2008 testimony before the Senate Finance Committee, he said:

bottom line is that research does indicate that, in certain settings,
health IT appears to facilitate reductions in health spending if other
steps in the broader healthcare system are also taken to alter
incentives to promote savings.
By itself, however, the adoption of more health IT is generally not sufficient to produce significant cost savings.

other words, it is fair to be skeptical about how we should proceed
with a national health IT build-out effort. The health IT industry’s
current product/service offerings are analogous to the auto industry’s
obsession with SUVs, as much the problem as the solution. Just as the
auto industry can be re-purposed to build lower-energy, less wasteful
vehicles, so too should the health IT industry be encouraged to offer
smarter products that serve the interests of an affordable, convenient,
and evidence-based health care system.

A smorgasbord of Health
Information Technologies is available to help us build a far better
health system. Part 2 will describe some functions that a national
health IT infrastructure renewal effort might consider.

David C. Kibbe MD MBA
is a Family Physician and Senior Advisor to the American Academy of
Family Physicians who consults on healthcare professional and consumer
technologies. Brian Klepper PhD is a health care market analyst and a Founding Principal of Health 2.0 Advisors, Inc.

7 replies »

    The intense discussion about the correct formula for producing and integrating truly beneficial and compatible EHRs has as much to do with the belief of some that EHRs may benefit the practice and delivery of healthcare and beneficially influence patient outcomes as much as it has to do with who wins pots-of-gold from the government.
    I think THCB, among others, is performing a useful platform for the voices of those genuinely interested in finding workable and effective solutions to our healthcare systems and delivery problems, but there is a problem.
    I have been following with interest the EHR thread initiated by Drs. Kibbe & Klepper and posted one comment to their original excellent letter.
    However, this, and other, blogs have a serious flaw that should be corrected immediately and that is the unstated interests, conflicts, and affiliations of authors and commenters that could possibly influence the content of their postings.
    Many unstated potential conflicts exist in that thread and they should be clarified.
    If authors and posters have positions or arrangements with organizations or associations that bias their argument these should be stated under their name.
    I propose that each author and commenter state the following every time a posting or comment is made:
    1. Poster’s or commenter’s full name, not just their email name or website
    2. Names of all organizations that employ them or financially support them and their positions in those organizations
    3. The product and/or mission of those organizations or association and how they relate to the subject or purpose of the posting and subsequent comments.
    4. All Boards and Consulting arrangements in areas related to the pertinent subject matter.
    5. Any possible other bias arising out of a commercial or political interest, directly or indirectly.
    As for the subject matter of the Kibbe and Klepper original postings and subsequent comments, there are significant financial benefits that could possibly, either directly or indirectly, accrue to posters and commenters if conflicting associations or afilliations exist.
    If they exist, and are not declared, the blog thread has no credibility.
    I believe complete transparency is required.
    The readers and writers of all blogs deserve no less.
    Louis Siegel, M.D.
    I an not employed.
    I am on no corporate, association, or organization Boards
    I receive no compensation from anyone related to any of my postings or comments.
    I publish a website, http://www.LikeADoctorInTheFamily.com, at my own expense, on Strategies for Surviving Healthcare
    I am currently not an adviser or consultant to any healthcare-related organization.
    As regards EHRs, I have no conflicting arrangements.

  2. I think the EHR/EMRs are good things and are necessisties. The trouble is that its benefits are misplaced.
    My business partner has a very great simple to use and manage software for personal health management by self and by clinicians.
    We did a full article on healthcare solution and we belive only way the crisis can be solved sustainably is to look at it at system level. The article is at http://blogs.biproinc.com/healthcare/?p=485
    Our experience has been that any software implementation is successful if the implementation and preimplementation has been done properly.
    More often than not, we see that at the end business cases are not realized mostly due to good implementation and partly due to the fact that many of these softwares are in bits and pieces.

  3. Ravi, would you consider that portable information (carried by, or with access controlled by patients) might answer the need for a new “operating system?”
    I assume you don’t literally mean a new software platform, but are speaking metaphorically.
    I strongly believe what we need to exchange is weakly structured, not strongly structured data. The problem with the Continuity of Care Record and HL7 is that it’s too heavily rooted in the flawed EHR programming morass.

  4. David, Brian
    Healthcare needs a new operating system. Let’s not simply reboot the same flawed system. We have a legal, financial and policy framework in the U.S. that hamstrings nearly every reform effort. It drives our healthcare stake holders to cross purpose goals, giving them a vested interest in keeping our current system.
    Though technology will be an important driver in healthcare reform it will happen only after we adopt a “shared priority” philosophy. We must place patients/consumers at the center of the medical data hub. Public and private healthcare organizations will need to be transparent. Healthcare professionals will need to collaborate and exchange information locally and globally.
    This new healthcare operating system will let us become owners. When we take ownership, we’ll drive change that healthcare needs. And the right sets of tools will be built around our needs. Maybe that will include EHR/EMRs or web services tying all of these together.

  5. Michael nailed it. EHRs/PHRs are bottomless pits of useless information from which only trained professionals can extract the truth. GIGO. Unless you’ve got an AI capable of passing a medical Turing test, you’re not going to be able to avoid human expertise.
    I’d just go a step further and suggest doing this expert abstraction more than once, and for more patients than just the sickest 5%. Anybody with more than one provider would benefit. Obviously if you only have 2 providers the benefit would be lower…but so would the costs.
    In terms of updating the document, here’s where EHRs are helpful. A nearly-live feed would be best. EHR interoperability would be a necessary–though not sufficient–precondition for live updates.

  6. The problem with investing in more EHRs is that they contain the wrong content.
    EHRs are basically real-time utilities for managing provider work product. They can have tremendous local value if properly configured and used. But they are exactly the wrong platform for data interchange no matter how they are connected, because the raw data they contain is incomplete, inaccurate, distorted (“coding for dollars”), volatile, stale, unfiltered and far too voluminous.
    Gathering what is basically landfill into giant repositories is silly (are you listening, Microsoft and Google?) Making all the inaccurate, stale data “interoperable” is also silly (are you listening, RHIOs?)
    What is not silly is abstracting, filtering and reconciling the raw data on the sickest patients into concise summaries that professionals can quickly absorb, and patients can transport between points of care in the lowest common document format.
    The fantasy of Personal Health Records is a good one — except they don’t exist. Patients can’t build them themselves (Are you listening, over 100 vendors of empty templates?) Nor can you build them out of cash register tape (Are you listening, Aetna?) And, there is no A.I. system in the world that can automatically read, parse and rationalize EHR content without human intervention.
    The investment we need now is to support human, expert abstraction and analysis of a few million records that already exist on the sickest 5% of patients. Once.

  7. There is also a disconnect between where the investments are made (provider settings like clinics, labs and hospitals) and where the financial benefits accrue (insurance companies and government).
    One classic example in Oregon where a number of hospitals were going to implement a lab HIE (health information exchange) was canceled when they realized they would lose money as a result of not being able to duplicate tests.
    Another RWJ funded example in Whatcom County, WA where patients with chronic conditions actually helped design the HIT software (available for free now) resulted in such dramatic savings ($3000 a year) that local specialists complained that they were losing money and no one was willing to fund it once the grant ran out. (note the key to this was the use of nurse case managers not just software). http://www.patientpowered.org/
    Incremental change is the best way to improve quality and outcomes. One area that is promising would be to streamline the payment system. In France in many private practices there are NO non medical staff at all. http://www.boston.com/news/globe/editorial_opinion/oped/articles/2007/08/11/frances_model_healthcare_system/
    Sherry Reynolds

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