Let’s Reboot America’s Health IT Conversation Part 2: Beyond EHRs

Yesterday we tried to put EHRs into perspective. They’re important, and
we can’t effectively move health care forward without them. But they’re
only one of many important health IT functions. EHRs and health IT
alone won’t fix health care. So developing a comprehensive but
effective national health IT plan is a huge undertaking that requires
broad, non-ideological thinking.

As we’ve learned so painfully elsewhere in the economy, the danger we
face now in developing health care solutions is throwing good money
after bad. We don’t merely need a readjustment of how health IT dollars
are spent. We need to reboot the entire conversation about how health
IT relates to health, health care, and health care reform. To get
there, we need to take a deep breath and start from well-established
and agreed-upon principles.

Most of us want a health system that, whenever possible, bases care on
knowledge of what does and doesn’t work – i.e., evidence. We want care
that is coordinated, not fragmented, across the continuum of settings,
visits and events. And we want care that is personal, affordable and
increasingly convenient.

Most of us also agree that, so far, we have not achieved these ideals.
In fact, health care continues to become costlier, quality is spotty,
and the gap between the health care we believe possible and the current
system is widening.

We believe that most health care professionals are acutely aware that
more health IT alone cannot resolve these problems. Despite billions of
dollars in health IT investments by health care professionals and
organizations, the gap persists and is widening. Many physician
practices have expanded their health IT functions, moving beyond
electronic billing systems – a necessary asset to be paid by Medicare –
toward EMRs and from paper to software systems.  About a quarter of US
physicians use EHRs from commercial vendors. Hospitals and health plans
– larger, corporate organizations with more dedicated capital resources
– have implemented health IT more quickly. Even so, the tools
implemented have typically been focused on record-keeping and
transactional processing, not decision-support. Health care clinical
and administrative decisions have not yet become more rational, less
tolerant of waste and duplication, or more congruent with evidence.

don’t need simply more health health IT; instead, we need an array of
specific health IT functions and capabilities that can facilitate
better care at lower cost, and the adherence to evidence-based rules.

What would those empowering health IT products look like, and what would they do?Focusing on Decision Support
Most important, new health IT would help patients, clinicians, managers
and purchasers make the best possible clinical and administrative
decisions. This includes identifying risks and following the best path
to lowering them whenever possible. Health IT should help people stay
healthy and avoid illness through active clinical decision support, and
make sure that the system recognizes value. Which patients, according
to past data, have acute or chronic conditions that need care? Which,
do the data show, are the most effective (or high value) doctors,
hospital services, treatments and interventions – so that the market
can work to drive efficiency.  Given a particular set of signs or
symptoms, lab test results, or genetic test, what is the best next step in care?

Technology and information engineering is readily available to do this.
Car technologies now help drivers understand when a problem is
occurring, or is likely to occur, monitoring and communicating fluid
levels, tire pressure, maintenance appointments, and location in case
of emergency. Banking technologies can flag suspicious credit card
purchases and can instantly invalidate charge cards. Recently, Google
trended flu searches to help estimate regional flu activity; their
estimates have been consistent with the CDC’s weekly provider
surveillance network reports.

By comparison, most health IT is relatively unsophisticated. In
general, the prevailing front line tools do not yet help clinicians
identify individual- or population-level health risks. They do not yet
provide guidance with evidence-based approaches that can best mitigate
those risks, create alerts and reminders, or help monitor adherence to
care plans, even though the data are now clear that most Americans die
and we pay the most money due to easily preventable and managed

In short, we monitor our cars and bank accounts better than we do our health. We can change this.

Untethering Patients with Easily Accessible Personal Health Information
High value health IT would improve care by making summary personal
health information available to providers and patients, increasingly
independent of location and time. Most health records are still tied to
a health care organization’s data center, supporting an outdated
business model in which the patient must come to a centralized,
expensive location for even the most routine tasks, like history-taking
or lab testing. Most current EHRs don’t change this, in large part
because they aren’t connected to the Internet yet. Web-enabled patient
information would untether the patient, and make increasingly
standardized care more readily available anywhere. De-coupling health
information from health care providers is the first step in the
development of new business models that will offer team-based care
services wherever one is located, saving money and increasing

Empowering Patients Through Online Linkages with Clinicians and Other PatientsHigh
value health IT will link patients with clinicians, will match problems
with the most appropriate solutions, and will use social networking to
increase access to patient- and condition-specific information,
knowledge, and guidance. This class of health IT applications and
services will be particularly useful with chronic illness, shifting
more of the condition’s monitoring and management to the patient and
his/her family and peers, with diminished reliance on the office-based
physician and the single visit model of care. Bringing advances like
these to fruition will require much broader implementation and access
to broadband and mobile technologies, as well as standardized health
record formats that use XML, like the Continuity of Care Record (CCR).

Supporting Participatory Medicine: Bridging the Medical Home and Web-Based Care

As Kibbe and Kvedar recently wrote, much of the health IT we’re describing here bridges the divide between two powerful trends: Health 2.0 (or user-generated health care ), and “the medical home.”
It is now clear that, while most health care consumers want to be more
actively engaged in their own care management – e.g., using Web-based
search and joining patient communities – they also want to be connected
to their physicians for questions and care when appropriate. The way
forward here is Participatory Medicine that combines and remixes health
information and knowledge – some from experts and some from the crowd –
in the interest of helping us live healthier lives.  Here is a very
good description from Neal Kaufman, MD, a practicing pediatrician and
the CEO of DPS Health, about how this will work:

…organized medicine needs to provide the day-to-day support
patients need to prevent disease and to self-manage their conditions if
they are ill. In the connected era that means just in time delivery of
the personalized and up-to-date data and information a person needs to
have the knowledge to make wise choices. It means supporting patients
to easily and accurately keep track of their performance. It means
providing tailored messages and experience that speak to each person
based on their unique characteristics, their performance on key
behaviors and their needs at that moment in time. It means helping
patients link directly to family and friends for critical support, and
link to their many providers to help integrate medical care with
everyday life.

Making Data and Accountability the Routine By-Product of the Use of Health ITHealth
IT can help make all health care professionals and organizations –
physicians, hospitals, other providers, health plans, drug firms,
device firms – more accountable stewards for quality, safety and cost
results, and for the engineering required for continuous improvement.
We can learn from our current supply, care delivery and finance
processes in the same ways that Toyota and Wal-Mart monitor their
internal business processes.  But we need to design data aggregation into the products from the start, not as an afterthought.
The problem is not just that we lack some important data elements to
carry out these analyses now. More to the point, we have not committed
nationally to aggregating, analyzing, and reporting the massive amounts
of health data that we already have. Similarly, due to a lack of
incentives and competing interests, most professional and
organizational health care players have resisted using data to improve
the quality, safety and cost of American care.

of various EHRs is absolutely critical to the ability to
cost-effectively collect, manage, and report outcomes data.  All health
IT products used in the care of diabetic patients, for example, ought
to be required to export performance data relevant to care of diabetes
in standardized formats.  All research of any kind depends on this

Removing the Complexity and Cost Associated with Multi-Payer Claims AdministrationHealth
IT ought to make claims payment, eligibility look-up, co-pay
verification, and other administrative processes simpler, easier, and
faster for providers, patients, and family members.  There is no good
reason why we don’t currently have an all-payer clearinghouse for
patient administrative and financial information that is standards- and
web-based. There also is no good reason why, in the era of PayPal,
physicians and hospitals experience Days in Accounts Receivable of 36
and 55, respectively. As Rick Peters has written recently, it is time for us 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 and their fiscal intermediaries. “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 payers
,” he says, and we agree it is time to use updated technology to resolve the inexcusable claims administration mess.
Closing the Collaboration Gap
Finally, a new generation of health IT platforms and services will
close the “collaboration gap” that exists between the system’s many
sequestered players, who as a result perform so much less effectively
and efficiently than they otherwise might. Clinicians, for example,
diagnose disease and set up treatment plans but often are isolated from
helping patients cope, manage, or adhere to these plans. Patients, once
diagnosed, are motivated to manage their illnesses but often have few
tools or methods to assist them. Purchasers and payers want to see
clinicians use the most efficacious resources, but typically do not
have a way to inform and reward evidence-based purchasing processes. In
every case, health IT can facilitate a more collaborative experience
that is tailored to the user’s purpose, no matter what role that user
plays in vast health care space.

Health IT presents enormous, unprecedented opportunities to improve the
quality of care, to dramatically reduce the waste and cost inherent in
our current approach, and to culturally transform physicians and
patients so both become more actively engaged in improving health and
health care. Bringing the fluidity of health information and knowledge
that is just starting to fruition will allow us to leverage the true
power of information engineering, and that can take many forms.  We
think the name “clinical groupware” is more appropriate to this new
class of health IT products and services than is the term “EHRs.”  In
any case,  the real health IT challenge to the Obama health care team
is to step back, take stock of the kinds of applications that are
emerging in the domain of health IT, including EHRs, and create an
expansive, open policy structure that can leap beyond the status quo
and really change the way American health care, in all its facets,

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

9 replies »

  1. David Kibbe says:
    > While all the experts were debating the causes of the
    > infection and what to do about it, Dr. Snow had the
    > simplest and most direct answer of all: remove access
    > to the offending source of the calamity.
    Well, he’s hinting at this, but according to a terrific book I’ve read about the episode, The Ghost Map, the consensus was that the offending source of the calamity was the foul air of London, not the perfectly clear, good-tasting water that made the Broad Street well popular. Dr. Snow’s removal of the pump handle was an inexpensive experiment.
    About the 17 ways to capture charges: there is no “best way” and that’s the point of the system providing several. If the owners of this practice can tell the implementation team how they want to capture charges, and they’re willing to preclude the possibility of doing it another way, then he could have it his one single way, presumably “best” for him. Of he could ask an experienced consultant about the pros and cons of two or three approaches, pick one and then train his staff (including all the practice partners) to do it that way. Either approach will increase the cost of implementation somewhat: maybe the EHR with the “best way” to do billing implemented would cost $1.4M instead of $1.2M. There is no such thing as turn-key business process automation software. Sorry.
    And back `round to the top: there is no agreement about what the basics of an EHR are, and evaluators buy “features” not “quality”. Therefore EHRs offer lots of features of dubious quality or utility.

  2. As I talk to doctors, they confirm what you have said in the past: IT vendors are selling clinicians systems that are needlessly complex–and expensive.
    This is yet another example of money (and the desire to make money) driving decisions in our healthcare system.
    As one doctor told me: my practice spent $1.2 million on our EMR system–and I’d like to throw it out the window. I offers 17 ways to capture charges. We don’t need 17 ways. We need the best way.” And, he says, the system they have is generally considerd the best of the 3 best-known oncology specific systems.

  3. One area of focus for patient centered HIT is in chronic disease management. Beyond the basic PHR concept (accessing lab results and requesting prescriptions) is an interactive tool that clinicans can have patients with chronic diseases or on self administered drug regimens use to monitor their behaviors between visits. These can include diet, blood sugar, BP, exercise and drug regimen adherence. This diary concept supercharges the patient’s participation in their care, making every patient part of an ongoing (although uncontrolled) real world trial. Making greater use of medical devices that seamlessly interface with the patient record and PHR will allow patients to more factually assess their adherence to protocols and allow clinicians greater insight into patient behaviors that significantly impact outcomes.

  4. It is great that you are bringing attention to this topic. I also have written some recent articles and blog entries on advanced health IT beyond EHRs. I hope that others will join the effort in bringing awareness to the benefits of these technologies in the health care environment.
    As a previous blogger noted, more IT in and of itself is not the solution — but using it as a tool to facilitate evidence-based practices can not only improve patient care, but also reduce costs and minimize risks from the individual level to the federal government level.
    Let’s hope that HHS catches on…

  5. Web Calls – Sign of the Times?
    No man is an island, entire of itself.
    John Donne
    American Well, a Web service that puts patients face-to-face with doctors online will in introduced in Hawaii on January 15.
    Claire Miller, New York Times, January 5
    Face-face? Maybe click-to-click, byte-to-byte, or even island-to-island, or in the future, Skype-to-Skype, might be more descriptive.
    In any event, the new Hawaii online service is a boldly innovative thing to do. The distant from your doctor and time away from your home or work, or even the cost of care, will no longer be barriers from your doctor.
    The Hawaii Medical Service Association, the BCBS licensee, will make the online service available to everybody on the island, all 1.275 million of them, not just 700,000 BCBS members.
    The idea is to make access easy for the uninsured and insured alike, and for those who have to travel long distances, which don’t have a personal doctor, who simply want a prescription refilled, or who need a convenient post-surgery follow-up.
    Patients can use the service by logging into health plan websites. The cost for members is $10 for a 10 minute online appointment (more for visits over 10 minutes) and $45 for the uninsured for a 10 minute gig. You can get your prescription refilled, your problem diagnosed and treated, and your anxiety relieved.
    The system just might be the ticket in Hawaii, where travel between islands is slow, distants are great, and rural doctors are rare. Besides Hawaii is a healthy place with great demographics. Cigarette and alcohol consumption rank low (48th in the U.S.), the obesity rate is also low (47th), the number of uninsured is the U.S. best (9%), the unemployment rate of 3.2%, rising but still great, and it is has a low population ranking among states (it has 1.275 citizens, 42nd among all states).
    Online care has its critics. Online care is impersonal. Doctors might miss visual cues, signs, and symptoms; you can’t test for everything online, e.g. strept throat; there’s always the danger of unwittingly supplying drugs to addicts; and the uninsured might not have broad band access (though 2/3s of the uninsured do, according to the California Healthcare Foundation). And in the future the lack of visual contact could be overcome with a Skype connection.
    The technology surf is higher in Hawaii than on the mainland. The Skype’s the limit.

  6. The essence of complexity is simplicity…simply stated, if all of HIT tried to mimic what a master clinician does with her or his patients we would make major strides. Whenever in doubt about what should be done always go back to that simple rule.
    Put another way…all we need is F*R*I*E*N*D*S*. I used this approach when deciding what I should do. I hope you find it helpful.
    Friendships: Create positive relationships between individuals and between members of organizations.
    Results: Distribute rewards based on results.
    Information: Assure the free flow of timely and accurate data, information, knowledge, and wisdom.
    Emergence: Encourage new and innovative ideas and practices through the creative energies of individuals.
    Nurturing: Assure everyone is loved, nurtured, safe, and intellectually stimulated.
    Dollars: Provide easy access to adequate resources for everyone.
    Strong Communities: Strengthen every community and all families.
    These simple rules, if practiced by everyone, would lead to healthier individuals, families and communities. If practiced by all healthcare providers supported by master-clinician mimicking HIT could lead to the transformation of healthcare we all need and deserve.

  7. We need to revolutionize medical care using IT, not the other way around. IT is a aggregating and reporting tool, not a result.
    Back in the days of Lotus Notes, I rode technical herd on a global project to “promote collaboration” among brokers. I learned a great deal then.
    Thing is, brokers don’t collaborate. They compete. No amount of IT was going to change that. The executive suite insisted this would change everything. It did. No one used the system, and no one trusted the IT department ever again, even though it wasn’t their idea. Blame ensued. Millions of dollars wasted.
    Same thing. Different decade, different century. Any endeavor is about people and their activities, not the IT analog. A great percentage of people will not submit to computer control and the attendant loss of autonomy. Period.
    The resentment doesn’t come from technology, it comes from cross-purpose motivations. Make money or be fired. Diagnose to a billing code. Avoid liability. Computers are seen as a calcification of that dissonance, rightfully so.
    Fix medical care so it’s about healing people. The money will follow where there’s value. And maybe we can stop treating people like things.
    Hey. I can dream.

  8. Dear Docanon: Having thoughtful physicians like yourself enter the debate and discussion is one of the primary reasons that Brian Klepper and I are doing these blogs on re-thinking health IT! Thanks for your input, which I think is brilliant. We need to start from scratch in thinking about how health IT relates to health, to health care, and to health care reform. Let’s not forget the story of John Snow and the removal of the Broad Street pump handle, during the deadly cholera outbreak in London in 1854. While all the experts were debating the causes of the infection and what to do about it, Dr. Snow had the simplest and most direct answer of all: remove access to the offending source of the calamity.
    Your suggestion approaches that kind of directness and simplicity: turn off the hype over health IT and get back to basics.
    Your suggestion about re-thinking “exactly where electronic systems are necessary,” and, by extension, where they are not, may well be the subject of our next blog post. DCK

  9. This is all very interesting. But I have to wonder: do we really need a national health IT revolution? Or do we need a national health information revolution? I think it is the latter.
    Thinking about the difference between IT and health information more generally, it’s important to realize that the low-hanging fruit (the interventions that will yield the largest population health benefits for the least cost) may not involve electronic, computerized records at all. As some of us mentioned yesterday, creating clean, complete, and accurate summarized medical records is not an IT function. It is a human expert function. Similarly, when a patient of mine sees a specialist, a phone call to me during that visit (using 19th-century technology) is likely to be more beneficial for clarifying the reason for the referral and overall goals for the patient than an interoperable EHR.
    A clarified system of communication rules, a few universal checklists, and a few tweaks in payment policy may trump billions spent on IT.
    A more thoughtful approach to the exact benefits that IT–and only IT–can provide is needed. Here are the things I think are particular advantages to IT:
    1. Legibility
    2. Durability
    3. Remote accessibility
    Here are the particular disadvantages:
    1. Information overload (low signal-to-noise ratio) [ironically, Dr. Halemka’s piece on renewal highlights the fatal flaw of every EHR I’ve ever worked with]
    2. Cost
    If Drs. Kibbe and Klepper could provide their thoughts on exactly where electronic systems are necessary, this would be very helpful.