Confusing ‘Standards’ With ‘Interoperability’–Lessons For The 111th Congress From HIPAA

As we debate whether or not the Obama Administration and the 111th Congress should work towards directly funding EHRs, one of the key questions seems to be whether or not EHRs and interoperability standards are mature enough.

My colleague, John Halamka, Chair of the Healthcare Information Technology Standards Panel (HITSP), made an rational and impassioned plea last week that we have reached a state of interoperability that is at least good enough not to delay allocating Federal funds for investments in EHRs. Dr. Halamka had earlier in December advocated direct grants from the Federal government of $50,000 per U.S. clinician to states to fund the purchase of CCHIT compliant commercial EHR products.

In the ideal world, I agree with John’s position, but have spent perhaps too much time in the real EHR world and in health care standards to truly believe we are where we think we are.  We have been here before and our best intentions were subverted.

On that note, in December the Healthcare Information and Management Systems Society (HIMSS) published its Recommendations for the Obama Administration and 111th Congress. HIMSS also advocates that the Federal government directly fund the purchase of EHRs. In addition, HIMSS would require that, ‘that federal funding to assist providers and payers within these programs adopt health IT only (my emphasis) be used for the purchase or upgrade of new health IT products that apply Healthcare Information Technology Standards Panel (HITSP) interoperability specifications and have Certification Commission for Health Information Technology (CCHIT) certification.’

John Halamka has always been very open about disclosing his affiliations, his own biases, and any conflicts of interest, but nowhere in the HIMSS document is there any disclosure of HIMSS’s close affiliation with HITSP and CCHIT – the very organizations they advocate be the de facto gatekeepers on what systems qualify for Federal funding.

HIMSS is the lead sponsor of HITSP and Mark Leavitt, the Chairman of CCHIT, is on leave of absence as Chief Medical Officer of HIMSS. HIMSS does not disclose the economic benefit that will directly accrue to Dr. Leavitt, HIMSS, or HIMSS members if Congress follows HIMSS recommendations. HIMSS also does not disclose that they are the
sponsors of the Electronic Health Record Vendor Association (EHRA/EHRVA) whose membership will be the direct recipients of the $25 billion HIMSS recommends to be allocated to purchase commercial EHRs. In addition, the EHRVA holds a seat on the HITSP Board and its members co-chair and effectively control the agenda and work of all the core standards workgroups within HITSP.

I think that not disclosing conflicts of interest is unconscionable and unethical. Regardless of this, the key issue with the HIMSS recommendations, and without the ethical overtones, those of Dr. Halamka, is the question of whether we really are ready to state that the standards HITSP has mandated support ‘adequate’ interoperability between existing EHRs.

As I mentioned, we’ve been here before and the simplest analogy is to review the health care industry’s experience with HIPAA.

Unfortunately, The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is now primarily thought of as a bill passed by Congress to deal with patient privacy rights.  Patient privacy, however, is a nominal part of the original HIPAA legislation. The key legislative aims under HIPAA were insurance portability and administrative simplification.  Insurance portability under HIPAA was to allow individuals to retain their health plan when then went from one employer to another – fabulous idea but completely subverted in practice.

Administrative simplification under HIPAA was intended to decrease the complexity of insurance administrative and claim transactions and therefore decrease overall health care overhead and expenditures.  The legislation called for the definition of standards for each type of health care insurance claim and associated transactions, which all health care insurers as well as Medicare and all Medicaid programs would then be required to comply with. In addition, all claims after a predefined date, with some exceptions, would be required to be electronic, reducing errors, improving efficiency, and speeding up health care payments.

From the insurance industry’s perspective this involved two standards – ASC X12 and NCPDP. ASC X12 was the broader electronic data interchange (EDI) industry’s ANSI accredited standards development organization (SDO). The health care group within ASC X12 had already developed the 837 standard to replace the paper HCFA-1500 and UB-92 claim forms, and the 835 standard to replace paper explanation of benefit (EOB) forms.  NCPDP was the pharmacy and PBM industry trade group, and while at the time not an ANSI accredited SDO, had developed the NCPDP pharmacy claim. It all seemed pretty easy – adopt the 837, 835, and NCPDP pharmacy claim and let’s go.

Not so easy. HIPAA stated that the standards had to come from an accredited SDO.  The NCPDP pharmacy claim had been built by industry and NCPDP was not an accredited SDO so HL7, an accredited SDO that had their own pharmacy claim standard, cried foul. The problem was that 98% of pharmacies and over 99% of pharmacy claims were already standardized under NCPDP, already 100% electronic, and extremely efficient and cheap. Pharmacy claims adjudication costs, then and now, are insignificant in the overall cost of prescriptions drugs – between $0.05 and $0.20 per claim. Medicare (CMS) and the Federal government, which at that time did not pay for prescription drugs, were unaware of this and HL7 lobbied for NCPDP to be excluded from consideration.

Fortunately reason prevailed, NCPDP applied for and was granted ANSI accreditation, and the NCPDP pharmacy claim was defined as the HIPAA standard for pharmacy claims.

The X12 837 and 835 also had some opposition from HL7 which had also developed a health care claims standard, but that was short lived due to strong support for ASC X12 within the payor community. Electronic claims submission in 1996 was not yet widely deployed, and the problem with the 837 was that where it had been implemented, it had been
modified to meet each specific payor’s needs. This meant that two 837s defined by two different payors were not the same, even if the claim information was identical. If this were the case under HIPAA each physician practice or hospital needing to support electronic claims would have to support hundreds of different ‘standardized’ formats just to get their claims out.

The health care insurance industry lobbied for a single, standardized implementation guide for the X12 837 standard under HIPAA (as well as the 835). Under electronic data interchange (EDI) in health care, both the providers (physician practices and hospitals) and the payors were beholden to the claims clearinghouses who ran proprietary closed EDI networks and charged a transaction fee on every claim. The feeling at the time (1997-1998) was that secure transactions over the Internet would be the ideal way to manage health care claims, eliminating the clearinghouses, decreasing costs, and improving efficiency.

Enter AFEC/AFEHCT, the Association For Electronic Health Care Transactions, which is the trade and lobbying association for all of the EDI claims clearinghouses. AFEHCT and its members, particularly the market leading clearinghouse, Envoy-NEIC, knew that if a uniform 837 implementation guide were established and secure Internet transactions approved under HIPAA the clearinghouses would be out of business. Tom Gilligan, contract Washington DC lobbyist and Executive Direct of AFEHCT and Kepa Zubeldia MD, AFEHCT Board Member and VP of Technology for Envoy-NEIC, lead the charge. Exerting relentless pressure, AFECHT and the EDI vendors established two principles that prevailed. First, AFECHT established that clearinghouses played a critical role in making health care transactions efficient – claiming they saved the practices, hospitals, and insurers from managing the incompatible standards formats and from connecting to each other directly. The primary ploy was that they would be more cost effective than everyone having to implement a ‘new’ standard – despite the fact that there was limited electronic claim submission at that time anyway. Second, AFECHT claimed that Internet security standards, particularly digital signatures, were too expensive and complicated to implement so that private secure, read ‘EDI,’ networks were a safer way to transmit ‘sensitive’ patient information, i.e. claims (www.ncvhs.hhs.gov/970805tb.htm).

In the end when the HIPAA administrative simplification regulations were released, pharmacy claims already standardized under NCPDP were sanctioned, and while physician and hospital claims standards was specified (X12 837 and 835), a uniform implementation guide and standards for secure claims transactions were explicitly not defined. This preserved the status quo of the clearinghouses and their proprietary EDI networks for claims. In addition, the insurers, including each Medicare third party intermediary, were free to implement the 837 and 835 in any way they saw fit. To this day, each payor and third party intermediary uses a different variation on the 837-claim format and the vast majority of physicians, hospitals, and payors pay fees for their claims to flow through the clearinghouses.

Not a red cent was saved and the various players made out like bandits. Envoy consolidated with the clearinghouse NEIC then sold to Healtheon/WebMD in January 2000 for $2.1 billion (eventually $439 million after the dot com crash); Dr. Zubeldia founded Claredy, a company that made money certifying X12 claims compliance with HIPAA, which was sold to UnitedHealthcare/Ingenix in 2005 for an undisclosed sum; and AFECHT merged with, you guessed it, HIMSS, in 2006. All in all this is a pretty darn good outcome for an industry that under Congress’ original intent under HIPAA would have gone the way of the dinosaurs. In a nutshell what happened under HIPAA is as follows:

1. Congress passed with its best intentions a comprehensive bill (HIPAA) to support insurance portability, decrease the overall cost of health care by targeting administrative overhead, and provide protections for patient privacy.

2. The concept would have worked but at the expense of the EDI claims clearinghouses.

3. The status quo, the clearinghouses, prevailed by changing the argument and claiming that they were actually the solution and that effective security technologies over the Internet were too expensive to

4. The blowback was that a uniform set of claims standards, except in pharmacy, was subverted and effective security, confidentiality, and privacy standards were blocked.

5. In the end, HIPAA did not really result in insurance portability (another story), it did not simplify or decrease administrative overhead in claims (the clearinghouses prevailed), and it requires compliance with patient privacy but without mandating effective technologies to protect confidentiality (there is no reason we do not have strong authentication, full transaction auditing, and digital signatures across all health care IT systems – no, yes there is, it would cost the vendors money and time).

In the end Congress’ best intentions were subverted by the health care information technology (HIT) industry.  Now we are about to repeat that all over again with EHRs.

What are the issues and lessons?

A) In all of our discussions and decisions we have to be very careful and diligent about safeguarding the public, patients’, and our health care system from the economic self-interest of the health care industry itself and its vendors and providers.  If we haven’t learned this in spades in every aspect of health care by now it’s hopeless to consider real reforms. Conflicts of interest need to be spelled out right under the author or organization’s name on the first page of any document of any kind in health care – period.

B) Congressional legislation needs to avoid mandates, such as requiring standards come only from accredited SDOs, that standards be established by fiat or government or vendor dominated entities like
HITSP, and that only ‘certified’ products be eligible for funding – such as the CCHIT certification requirement for EHRs.

C) Federal funding should go to fund research and innovation in health care IT along the lines of the NIH, NSF, and DARPA, not the status quo.  Direct purchase of products and their subsidy should be avoided.  There is a market (finally) for EHRs after all these years and the market should figure itself out without artificial influence.

D) If vendors or institutions seek funding from the Federal government they should have to compete openly with academic institutions, independent contractors, start-ups, and all their competitors, without unfair and anti-competitive artificial constraints.

E) My own opinion is that watching what has happened in every other industry, in particular supply chain and financial services, we would be much farther along in health care EDI using the Internet, with markedly lower transaction costs, and with better patient data security, confidentiality, and privacy without HIPAA.  I was a strong supporter of HIPAA and I think Congress had excellent intentions; it’s just that special interests prevailed.

I also believe that regardless of the excellent work that has been done by HITSP that the current health care standards on the table are not adequate or ready for prime time.  The core issue revolves around what health care data interoperability really means.  Under HITSP to date it has essentially meant messaging – sending a block of data from one system or entity to another. Data interoperability has to be defined in a much broader sense if we are going to truly coordinate patient care, provide for real clinical decision support, and lower overall health care costs. Microsoft HealthVault and Google Health are two key drivers in this. The issue, to paraphrase Peter Neupert from Microsoft, is ‘data liquidity’ – movement of data between patients and providers not just between systems. Microsoft HealthVault and Google Health are not CCHIT certified, but you could build an EHR on top of them using their APIs. Would that type of solution be excluded from Federal funding?

Let’s not confuse standards with interoperability or artificially bias or influence a technology sector that is already in the midst of a transformation. HIPAA preserved the status quo in direct opposition to Congressional intent. Transformations and innovation in technology involve innovators that tilt against and then topple the status quo – that is where government, research, and investor funding ought to go. And, yes I’m biased…

Rick Peters, who has blogged on health care information technology issues, is the also the former CEO of the pharmacy benefit management company PTRX.

12 replies »

  1. Wealthy investors with a high Financial IQ, understand to be truly diversified you need to invest across all four primary Asset Classes which are:

    Real Estate,

    Paper Assets (stocks bonds and mutual funds)


    And Businesses by way of Joint Ventures or owning preferred shares.

    Investing in the four primary asset classes is the secret of accumulating enormous Wealth..

    This is why Investing in a Syndicate Mortgage should be a key component of your wealth creation strategy.

    The fundamental investment principles of Banks and Pension funds are Security, good returns and cash flow.

    A Syndicate Mortgage allows you to invest like a Bank or Pension Fund.

    Everyone knows the vast majority of wealth created since the beginning of time, was created through Real Estate, not flipping homes, but acting like a Bank and being a lender to large scale development projects.

    Let’s take a look at some of the reasons you want to invest in a Syndicate Mortgage.. but before we do….. let me explain in simple terms what a syndicate mortgage is.

    A Syndicate Mortgage is when several investors collectively fund one single mortgage instrument

    There a re no shares or units that fluctuate in value..( such as mutual funds or segregated funds )

    Every investor has their full face amount registered in their favour at the land registry office with a lien as their collateral.

    A Syndicate Mortgage allows you to use your registered funds or cash to invest like a bank or pension fund and be the lender.

    A Syndicate Mortgage allows you to truly diversity your portfolio.

    A Syndicate Mortgage offers the following superior advantages.

    ➢ Your Investment Is 100% Secured By Prime Real Estate

    ➢ You get a 8% Guaranteed Rate Of Return annually

    Ø Your Interest is paid quarterly

    ➢Profit Sharing of 12% to 14% upon completing of project, over and above the 8% guaranteed return.

    ➢ The Face Amount Of Your Investment Is Fully Registered &Secured Via A Lien against the Property

    ➢ Your investment term is typically18 to 36 months

    ➢ A Syndicate Mortgage is RRSP,RRIF, LIRA, TFSA, RESP Eligible

    ➢ You Become a Private Lender with Your Registered Funds

    ➢ Allows you to Invest In Projects Typically Reserved Only For Large Financial Institutions

    ➢ A Syndicate Mortgage offers 100% Transparency.

    Unlike the 97% who are following an outdated approach to investing, a Syndicate Mortgage allow you to invest like the 3% who understand that true diversification includes investing in Real Estate, not just Stock, Bonds and Mutual Funds.

    Contact me privately for details on current offerings.

    Tyrone Phipps



  2. Rick who or how do you feel this should be paid for? As a payor, and a small one at that, I’ll admit to being bitter about all the cost dictated down on us and never once a check to pay for any of it. With EDI, which in theory had great promise but ended up costing us far more then it saved, we where told you accept them by X date or we fine you out of existence.
    When I hear providers cry they can’t afford to implement any of this or that without subsidies and support I’m short on compassion, never once in 29 years of being a TPA have we had help complying with the politicians latest solution to all the system’s problems.
    Most years it feels like congress is specifically targeting us to put us out of business, the new Medicare SSN reporting requirement being a great example. We are lucky to make $20 PEPM or $240 a year per employee, less if you equate it to a PMPM. If we miss one person in CMS’s new convoluted reporting process we get fined $1000 PER DAY.
    With what money and what time are we going to achieve interoperability with providers when they refuse to pay, from my reading and experience, and the heavy foot of regulation is one step away from wiping out the family business altogether?
    HIPAA had some incremental improvements but from my side the responsibility fell to heavy on the payors. Why weren’t providers required to bill us electronically at the same time we where required to accept bills? Under the old system a provider paid $0.41 to mail me a bill and I paid $0.41 to mail them a check, now I pay $0.40 for them to send me a bill and $0.41 to mail them a check. How did we end up where I pay the providers EDI cost? Why aren’t providers required to bill under their legal name so the IRS stops fining me $50 for bad 1099s? Electronic verification of eligibility, which is meaningless anyways, and benefits should also be required. Why shouldn’t providers be required to do these as part of being in business? I can’t afford to invest tens of thousands for software to receive EDI if only a handful of providers use it. Same for eligibility and remittance, I know it’s only a matter of time before I have to pay for the capability out of my pocket the least everyone else can do is assure it will be used.

  3. John Kelly – I appreciate your perspective and apologize that you think I am some crazy nut ranting about health care. You and I have different definitions of disintermediation. You work with Harvard Pilgrim Health Care (HPHC), the most progressive payor in the country. I sincerely congratulate HPHC on being selected (for the 4th year in a row) as the #1 commercial health plan by U.S. News & World Report/NCQA – it reflects the quality of work all of you do. HPHC has taken the lead at disintermediation, but there are still lingering questions. 1) What year did your web services portal go live? 1998? If I remember correctly it wasn’t until 2004-2005. 2) I assume all of your internal uses of 270, 271, 837, and 835 are 100% standardized, but are you 100% standardized with BCBS of Massachusetts, United Healthcare, Anthem, BCBS of Rhode Island, etc.? 3) What percentage of overall national eligibility and claims transactions does HPHC represent? What percentage of any providers overall claim volume within your catchment areas?
    Payors I have worked with during the time HIPAA regulations were being defined and subsequently do not feel that HIPAA really served its purpose. Most hospitals, practice management vendors, and provider groups feel the same. I think we can all understand that each has its own spin on that, but overall the intent of Congress was pretty clear and I strongly believe we did not fulfill our mandate in health care. Aside from claims standards we really punted on patient privacy protection and are still in a bit of a quagmire over that. As you know from your work in Massachusetts. secure transactions can be done and complete protection provided through real policy, but we did not step up to the plate as an industry under HIPAA and address that. It would have cost us money and a fair amount of reengineering, but we did no do it, and for all practical purposes a decade later still haven’t.
    Being from Boston you also live within a very progressive HIT and data exchange world. John Halamka’s blog Electronic Medical Records and Obama’s Health Plan from 12/12/08 does a very nice job of itemizing the successes in Massachusetts (https://thehealthcareblog.com/the_health_care_blog/obama_administration/index.html), the painful thing is how unique Massachusetts is versus the rest of us. Even out here in progressive California and even within other progressive health plans we have not been able to replicate what you have all done.
    I also am not a conspiracy theorist, far from it – we each have to take explicit responsibility for our own fortune and misfortune and not pass off the blame. HIMSS, HITSP, CCHIT, and the EHRVA do not represent a cabal. There are great people, companies, and organizations involved in all of these. I respectfully request, however, that if there is a conflict of interest or undo self-interest that all players be honest and completely open about this. As physicians practicing medicine we are not immune as the excellent work of Senator Charles Grassley, ranking Republican on the Senate Finance Committee on ties between physicians and pharmaceutical companies has shown. If you want to read something very sad, please read Dr. Marcia Angell’s review in the most recent issue of The New York Review of Books on the corruption of doctors. What has happened to professional ethics?
    We’re crazy to think as providers, vendors, payors, professional societies, and even as government that we are immune to less than enlightened self interest in healthcare information technology (HIT). I use HIPAA as an example of how we shot ourselves in the foot. If you disagree and think we were successful, I respect that. I would be so bold as to assume, however, that you might agree that we are not yet running – rather we are still limping.
    If I have an ax to grind it is that I am tired of our own hypocrisy in health care about technology. We use the best technology possible in our practice of medicine and we change it out as fast as something better comes along. In HIT we do anything but that. The systems that run our institutions are archaic and completely under serve our patients and with the exception of a few leading EHR, PHR, payor, and Health 2.0 vendors I do believe that the major players are unfairly trying to constrain the market. I am not immune. I have been deeply involved in the EHR business and on the payor side. I understand why protection of your market and market share is logical and rational, but I’m at a point where I am going to speak out if I think such actions are unfairly constraining the innovation we critically need.
    Finally, on the revenue cycle side of things, I agree with you that we are further ahead there, but we still need greater standardization, more universal adoption of electronic remittance transactions, and we need an entire overhaul on the member/patient EOB front. My heart goes out to plan members who get our bills and the HR departments who are taxed to deal with our ambiguity.
    Thank you for your comments and for beating on me! It keeps us honest.

  4. I’m sorry but this is the biggest crock of reinvented history I’ve ever seen on a serious health care blog. The standards mandated under HIPAA have significantly disintermediated the clearinghouses in this country and saved billions of dollars in transaction fees that have been avoided by the direct submission of claims, claims status and eligibility transactions by providers to payers. In addition, the successful disintermediation of clearinghouses on the revenue cycle side has prepared the market for the exchange of clinical information using the same network channels established to exchange HIPAA transactions. In addition, the fact that many of the people with expertise in electronic health information technology happen to engage activities related to HIMSS, HITSP, CCHIT etc. doesn’t necessarily indicate the existence of a selfinterested techno cabal. The fact that Rick Peters’ rants continue to get picked up in the press and that his perspective gets proliferated as valid commentary on a system that can benefit significantly by the adoption of technology demonstrates a real problem in the level of HIT awareness possesed by the main stream media. I can’t imagine what axe Mr Peters has to grind but anyone who takes his blogs seriously needs to do some serious fact checking.

  5. Wow, this is a fascinating history. I am a software developer working
    directly on HIPAA implementations (mainly 270/271 eligibility
    transactions but I see the 835/837 mess too). I came to this from
    outside healthcare (from a more high tech company, in fact) and I am
    absolutely appalled at the lack of regard for interoperability.

  6. Are providers really paying for EDI? Most clearing houses we come across admit they give it to providers for free and then rip off us payors. We are finally seeing cost come down but for years we didn’t imbrace EDI becuase at $0.40 cents a claim and being liable for Dups and claims that aren’t ours it wasn’t economical, we could key it in cheaper.
    Oddly the worst rip off was Medicare Secondary payor. I beleive it started at $1.00 and when we stopped had only dropped to $0.75 per claim. Complete rip off but the market wouldn’t accept a Medicare Supplement that required being billed. CMS and the intermediares had us by the balls and knew it.
    There is such a simple solution to this but I have never seen a politician mention it or a policy paper analyis it;
    The Fed has been cheaply and efficiently clearing banking transactions for decades. Each bank has their own interface and captures extra data for themselves but the file passing through the fed is standardised. The cost is pennies per tranaction, I think .07 at most.
    The same framework should be used, each provider and payor gets a routing number and everything passes through some healthcare Fed. In addition to costing a fraction of what the clearinghouses are killing us for;
    1. For public health and research there will be a central repository of all care being rendered almost real time, imagine the possibilities…
    2. Fraud can be monitored on a macro basis and date minimg possible for suspected cases
    3. We are hoping to move to an electronic payment in the near future, this seems to require intergration with the Feds current ACH system anyways
    4. Get the IRS off payors ass for 1099s, they will have real time and complete payment records without fining me for not knowing a provider billed me under a wrong name(yes very bitter about this)
    5. They have been succesfully doing this for decades, 837 is just a longer NOCHA file, it souldn’t take years and billions to implement.
    Cheap quick and logical solution, guaranteed to never happen

  7. Wow, this is a fantastic history and presenting it is a great service.
    I do have confusion on one point (or is it that I disagree?) and I hope Rick or someone else can clear up or confirm my difficulty.
    I was with you entirely, mostly getting schooled, until your recommendation (B) to avoid mandates. I know that your point is that these will be subverted by industry to oppose the very goals they were intended by politicians to achieve. However, I still don’t see how we can escape mandates, or quasi-mandates in the form of financial penalties for non-compliance (which is what the Medicare eRx incentive program is going to turn out to be, and that’s fine with me).
    Healthcare does not operate according to the same incentives as does the banking industry. If it did, we would have already seen highly efficient internet-based transactions. As you yourself wrote:
    In the end when the HIPAA administrative simplification regulations were released, pharmacy claims already standardized under NCPDP were sanctioned, and while physician and hospital claims standards was specified (X12 837 and 835), a uniform implementation guide and standards for secure claims transactions were explicitly not defined. This preserved the status quo of the clearinghouses and their proprietary EDI networks for claims. In addition, the insurers, including each Medicare third party intermediary, were free to implement the 837 and 835 in any way they saw fit. To this day, each payor and third party intermediary uses a different variation on the 837-claim format and the vast majority of physicians, hospitals, and payors pay fees for their claims to flow through the clearinghouses.
    Payers were “free” to implement the 837 and 835 differently, but that doesn’t mean they had to. Why did they, when it meant they would have to pay more? Similarly, providers have been “free” to purchase EMR systems that can talk to each other, but that obviously has not been a priority. If it were, like the banks, they would have insisted that the vendors comply and would have set up the systems to communicate electronically and share data long ago.
    So something must be different, and I think part of what is different is that the healthcare industry actually tends to reward inefficiency, or at least not penalize it as much as in other industries so that inertia plays a larger role. There are several reasons this phenomenon exists which many of us know and I won’t go into here. The upshot is that I don’t agree that you can just point to how efficiency and operational standardization evolves in the marketplace elsewhere and assume it will also for healthcare if we only put more government funding into non-profit research and development.
    Any reformer is going to have to embrace your principle (A) and fight to change incentives and business models in the industry that have been taken for granted for decades for payers, providers and suppliers (my catch-all for pharma, DME manufacturers and information systems companies). But if that’s what we need to do, and we are conscious that the industry segments will try to subvert reforms that harm their financial interests, then why not mandate standards with this in mind, rather than throw more money at various institutions to do more research and development in the nebulous hope that something emerges and then grabs hold and becomes the de facto standard?

  8. With all due respect to my IT friends, they oversell the maturity as well as the usefulness of the product. That is the reason, I hear stories from healthcare providers how their implementation did not deliver the benefit promised.
    Make no mistake. I support EMR/EHR. What I do not want people to do is misrepresent. As of now, the products in general have following oppouritnities
    1) Interfacing with other systems
    2) Standardization of language
    3) Process standardadization
    4) Security
    5) Discreteness in sharing
    6) Patient control (here my business partner has, as I had mentioned in one of my earlier comments, a very robust software called personal healthprofiler. It is simple and easy to use and patient has complete control).
    If one wants to see what pitfalls could happen, please look into the manufacturing world where they have beeing using ERPs for decades and still huge improvment oportunities, standardadization opportunities, etc lie.
    Last but not the least, the final need for success is to create a good preimplementation design and implemention program managment. For this, we need to use people not because they have the experience or knwoledge but those who are capable.
    Healthcare industry need to open up for it to succeed.

  9. Perhaps there is a third model? One that avoids the use of “gate-keepers” and follows the same model that the internet itself followed? The collaborative W3C model http://www.w3.org/Consortium/ where “standards” are vendor neutral and presented as recommendations. A network of networks is already being developed via the NHIN and that is where I expect the bulk of the funds will flow.
    Clearly the federal government is the largest purchaser of health care and has a vested interest in a cost effective system so it makes sense that they would drive this process and ask that everyone has the same standards for data exchange. If we could even get all of the insurance companies to use one standardized online billing process that alone would save millions.
    I expect that the new Administration will build upon existing models and will continue to invest in the myriad of demonstration projects that are part of the growing NHIN network of networks rather then giving every doc in the country a tax rebate for the purchase of an EMR.
    Just as a side comment – Google Health and Health Vault have established key relationships with government and major health care providers but HV is simply the underlying platform and GH so far has only exported existing EMR data and asked consumers to manually enter their own. Neither of them are clinical applications and aren’t in play.
    Both are consumer facing applications that rely or importing data from other systems (or forcing people to manually re-enter data)to really have much value to consumers or clinicians right now. Who on here has used either of them for anything other testing? (Most people who follow the health care sector realize that most consumer app’s have already moved to mobile platform’s like the iPhone. )
    This segment of the population (healthy wealthy) could however finance the underlying framework for the Health Record Banking model that people like Yasnoff advocate for. E-prescribing is the tipping point as it streamlines a process, has a financial incentive to the providers and increases patient safety. Perhaps focusing on the 10% of people with chronic conditions makes the most sense for targeted investments going forward. (one example at GHC – the use of online RX records combined with Pharmacist interventions)
    The goal is higher quality more efficient and humane patient care not standards or job creation. I doubt that the reason that most countries in the EU have this because of their technology.

  10. Rick, this is an excellent post. I applaud your eloquence in providing analysis on a topic to which I have had very little exposure.
    You mention how ‘HIPAA did not really result in insurance portability (another story)’. I am relatively new to the health care field, and I am curious if you or others could point me toward some good reading on this particular topic.
    Thanks in advance.

  11. Rick, I’d be interested connecting with you more concretely on an implementation approach to disintermediate the clearinghouses. We couldn’t agree with you more on this point, and we have a working group right now of major health plans and providers working towards this end. I’d be very interested in speaking with you directly (ewallace@gnyha.org).