Matthew Holt

Cats & dogs: Can we find unity on health care IT change?

Those of you paying attention for the past few days might have noticed on the one hand a sense of optimism and unity as Barrack H. Obama, somewhat somberly, began his presidency.

Meanwhile, over the past few weeks the fur has been flying among the electrons on THCB while some very knowledgeable and opinionated health care wonks and geeks have been battling it out about what exactly we should be doing in terms of federal health care IT spending.

Given that even among you smart THCB readers this may be all a little perplexing, I’m going to try to try to make what I hope are some elucidating comments to put this argument in context. I’m doing this partly because I’m perplexed too, but also because I think that there is some hope for a middle road.

First the basics: As sometime THCB contributor & uber-CIO John Halamka makes clear in this excellent post about The Greatest Healthcare IT Generation, some $20 billion of the soon to be passed “spend it as fast as you can” stimulus package is going to be targeted towards health care IT. Now, that’s by no means the biggest part of the $800 billion or so package, and it’s not even the biggest part of the health care spending in the bill. Nearly $87 billion or so is going to support Medicaid, although that will mostly will be replacing cuts being forced on states.

Let’s be clear, the stimulus package’s main role is to stop the patient from bleeding out and will probably need to be joined by a bank restructuring the likes of which we’ve never seen. Health care is a sideshow, but $20 billion is still $20 billion, and given that the current health IT market is only between $20 and $30 billion annually, it’s a huge potential increase for the industry.

This spending is separate from any larger health care reform proposed by Obama, even though it appears that such a reform package is fairly likely to appear in Congress as soon as Daschle, Baucus and Kennedy get their ducks in a row. And of course, most of the issues that divide THCB’s various commentators on health IT are rooted in problems that only a major reform can solve. And realistically even those most optimistic about the prospects for reform don’t believe that the Obama/Daschle/Baucus plan will get at the core problems of the U.S. health care system any time soon.

The underlying problems: American health care has two linked and intertwined problems. First, (and it is first) due to America’s unique political history, most of the pain of dealing with increasing health costs is deposited on a poor (or soon to be poor) and relatively powerless minority of the population—the sick who are uninsured and underinsured. No one is really responsible for their financial well being, nor is any entity forced to make their cost of care equal to that of the rest of society. So the health care system has reacted rationally over the years by increasing what it charges the majority, and not worrying too much about that minority even as it grows. Every other rational country instead distributes that cost evenly by putting (more or less) everyone in the same financial pool, and puts someone (usually the government) in charge of the total cost of the system to society. The US is different, as it’s the only place where for the players in the system doing more means getting more absolutely. Everywhere else, the rest of society stops the health care system arbitrarily grabbing more resources.

The process whereby the health care system grabs more and more in the US comes mainly via an incredibly strong supplier community that has political control over the large share of spending that is government funded, and economic control over the main providers of private spending—employers. Of course it may not feel that way to the suppliers in the system but the numbers (share of GDP going to health care more than doubling over 30 years) don’t lie.

This leads to the second problem: The mechanism of that provider control is a payment system that encourages piece work, acute care, fixing rather than prevention, specialization over primary care, and—not least—big hospitals over community based clinics. Now as Atul Gawande points out in the New Yorker this week, it’s not as if every other country does exactly the opposite, but the scale by which we’ve tipped over here is unprecedented. And multitudes of articles on THCB over the years prove it out, and show that it’s very hard to change that status quo.

This starts to get us back to IT. The first significant use of IT in health care in the US was in large hospitals primarily aimed at accounting (and billing) for piece work. Eventually most large and many smaller hospitals began to extend their IT capabilities to automate other aspects of their activity, but even among the most sophisticated, the role of IT supported rather than transformed the way they delivered care. The goal of the hospital is after all for the hospital to thrive and prosper, not for the community to improve the care it gets at a lower cost. This has continued as IT investment has picked up, especially since 2003, and of course it’s been reflected in the stock price and profitability of the winners in health IT, notably Cerner and Epic.

Some other countries were introducing more clinically-based IT into their health care systems over the 1990s, and they tended to place it where their systems were focused—which tended to mean in primary care. The three Ns (Norway, Netherlands, New Zealand) along with the Danes & the Brits were close to 100% EMR use in office based primary care by the early 2000s. The UK was able to use this to actually track what its primary care docs were doing, and started paying them bonuses for doing the “right thing” in terms of prevention and evidence based medicine. But note that the IT was shoe-horned into a system which was by and large doing that already. It did not change the core way care was delivered. In fact in the UK the links between primary care (GPs) and specialty care (hospitals) are still by and large absent—despite a huge budgeted (and not fully spent) investment in Healthcare IT that exceeds what’s in the current US stimulus package for a country 1/5th the population! The astute observer will also notice that several countries that don’t have EMRs in universal use among physicians, notably France and Germany, also have pretty well regarded health care systems.

So it’s a pretty fair assumption that IT use in health care will reflect the system it’s put into, rather than transform it to something completely different.

So why all the aggro? Since the Obama win and the recession made the stimulus a certainty and health care IT’s inclusion in it a reality, THCB has been the venue for a series of articles in the form of Open Letters to the Obama Administration by David Kibbe & Brian Klepper, a defense of the proposed spending by John Halamka, an analysis of the perversion of administrative simplification under HIPAA by interested parties (clearinghouses) from Rick Peters, all culminating in a declaration that Health IT is in fact ready, just add $20 billion, by Mark Leavitt yesterday. This argument has by no means been confined to THCB, and in fact this latest discussion was started mostly in a series in Health Affairs, in which Carol Diamond and Clay Shirky accused the current health IT establishment of “magical thinking”, while somewhat surprisingly Microsoft—which sells a lot more in copies of Windows and Office to hospitals than health care tools to consumers or small practices—in the person of its health care leader Peter Neupert suggested that we should take a pause before hitting the “buy” key, and spend money on outcomes not on technology for its own sake. And enfant terrible Jonathan Bush is warning anyone who’ll listen that we’ll be locking in place outmoded technology.

Essentially the argument comes down to two things (Warning—gross generalizations ahead!). I liken this to the common truism that dogs attach themselves to people while cats attach themselves to places

Outcomes vs. technology: The Kibbe/Klepper/Peters/Neupert/Bush faction (the dogs)assumes that we need to change the incentives in the system, and then IT will naturally follow—and the current embryonic decision support systems will flourish quickly. But that current clinical systems aren’t good enough to invest in mostly because current results from EMR installations are very disappointing.

Although they discuss incentives (and most of the $20 billion will probably be aligned with some P4P measures), the cats’ (Leavitt/Halamka/Kolodner) view is closer to the thought that if you get the appropriate clinical technology (essentially in-patient and outpatient EMRs) into the hands of clinicians, then they’ll figure out what to do with it, and eventually the government can pay them according to how well they do it. (Halamka is a bit more open about this also being an IT public works scheme).

Patients vs. facilities: There’s also a more philosophical bias which harkens back to the difference between American and European health care systems, but not in the way you might think. The dog faction is in general primarily in favor of light-weight tools (and standards) that allow for innovation and service of the consumer patient by primary care teams (that’s the European part). The recent emergence of Web-based tools and patient communities that allow patients to apply self-service techniques and easy communication with teams of providers (yes, yes, that’s Health 2.0) are for them the keys to enabling better care. These tools are relatively cheap (and flexible) and mirror the SaaS trends in the rest of technology. (Think Gmail vs Outlook).

The cats’ view is closer to the opinion that the real work in American health care happens in big hospital systems, and that the key is to get everyone connected to their core clinical systems. Hence the concern with standardizing on products and private networks (RHIOs) rather than allowing a mass of anarchic applications out on the Internet which are more likely to “mash-up” together.

What about the biases? There have been plenty of accusations of bias and self-interest on these pages, and it’s worth quickly looking at it. For example, Jonathan Bush believes he’s riding a wave towards a SaaS future, whereas most of his competitors are still MUMPS-based client sever technologies—he fears the $20bn will be used to subsidize SUVs in a world where AthenaHealth is selling the Prius. Mark Leavitt, while on loan to the Chairman of CCHIT is the former CEO of MedicaLogic (now the core of GE’s Centricity EMR product) and a former HIMSS official. Most people in health care think of HIMSS as a vendor promotion association. Halamka of course is part of a very large AMC and the chair of the HITSP standards organization which tends to favor larger systems, whereas Kibbe is well know for his work promoting the lighter weight CCR standard and his involvement in the American Academy of Family Physicians—long the orphans of our specialty dominated medical culture. I also suspect that Kibbe’s recent criticisms of the EMR haven’t exactly helped his chance of receiving consulting dollars from the major HIT vendors, but he is also involved in consulting with smaller companies that stand to benefit from the emergence of new models of care. And of course Brian Klepper and I are involved in Health 2.0 (together in a consulting venture and me as co-founder of a conference).

However, I perhaps naively choose to believe that everyone involved is motivated more by their cultural takes on what’s important for health care, than their desire to put a hand-out for the $20 billion. I think that these same positions would have been taken by the same people 6 months ago when the bailout was yet a twinkle in Obama’s eye.

So in change, can we find unity? So despite the fierce words and the grave differences of opinion, can cats and dogs live together in harmony? I think that in the spirit of Obama’s first days in power we can find some unity. At the same time we need to be realistic about what comes next.

First, we need to get rid of the notion that IT is going to transform our health care system. To transform healthcare we need to get real health reform right. Obama is not doing IT any favors by imposing that pressure on its use—the dogs are correct here.

Second, we are not immediately going to move away from an acute care, large system-focused health care environment. Any change towards overall more consumer-focused health management will continue to be slower than some of us might like. So getting those acute care facilities that are not at BIDMC or InterMountain levels of technology readiness in better shape can’t hurt.

Third, despite all the harsh words, as the bill now stands, most of the $20 billion will reward actions with some form of P4P. If the folks at HHS & CMS who will be responsible for crafting the incentive structures hear a more unified voice from the assorted commentators, geeks, cats & dogs arguing over here, we’ll likely get more incentives rewarding better process and less direction on particular technologies—which will be a good thing.

Fourth, there’s an underlying concern among the dogs that in the cat view (which is more clearly the “establishment view”) the patient is lost. Yet I still see Leavitt and the others from the establishment keen to bridge the gap to patients with connectivity tools and to give them control over their data in PHRs. And I don’t believe anyone is suggesting that we halt the rapid development in the ability of patients to manage themselves, and communicate with each other and clinicians, which is at the heart of Health 2.0.

So I have hope that, while the health IT part of the bailout will not be the ultimate cure for our health care system, it will help in many ways all over the system. I also hope that while there won’t be complete consensus both cats and dogs will agree that it should fit some core basic principles so that in years to come we’ll judge that this money was wisely spent.

Of course I’ll be reserving judgment at least till the bill makes it out of committee, and probably until we see exactly how CMS wants to spend the money!

7 replies »

  1. This chain has been interesting and it’s not surprising that a $20 B stimulus would be fiercely debated. It’s the largest infusion of funds that has ever appeared on the HIT horizon and it makes the venture capital that was briefly available in the later part of the 1990’s seem like small change. Let’s only hope that we’ve grown wiser in the interim years and invest these new funds in areas that will pay real dividends – not just to technology companies but to consumers in the form of better quality health care that is accessible and affordable.
    Perhaps it is worth resurrecting a question that remains unanswered from the remnants of those failed efforts of the past decade, namely who will benefit from these new investments and who should pay the largest measure of the costs. As with so much else in health care – the payer is usually not the beneficiary. Aligning incentives has always been difficult and HIT offers no exceptions.
    Back in the early days we discussed what it would take to jump-start adoption of HIT – carrots or sticks? That still is a key question in which the “dogs” and “cats” are well engaged. The stick people are probably most closely aligned with the dogs – wanting the 800 pound gorilla that is the federal government to clearly advance health care reform by mandating standards, compliance and tying funds to improvements in overall health status that is measured in quantifiable outcomes.
    The carrot people, more closely related to the cats, believe that if you get the technology in place by handing out big incentives, the transformation will evolve and even if some entities do not participate, all boats will eventually rise. From the point of view of providing economic stimulus, this approach will probably have a much more immediate impact if only in terms of the jobs that will be created.
    In the late 1990’s I was a carrot and stick person – trying to be an honest broker among vendors, providers, government and private sector interests that included employers and health plans. I did this by asking what would really help consumers – especially what would help them live healthier, more productive lives? I believe this question is still very apropos. If the stimulus can offer the right mix of carrots and sticks and consumers end up with accessible, affordable and better quality health care – everyone wins because we are all consumers.
    As consumers we will score the biggest wins if investments are made in technologies that are seamless, interoperable and engaging. Focus should be on making it easier to stay healthy and preventing disease. If we can infuse a consumer point of view in this debate we might come out with real reform – the kind that will come when Americans are fully engaged in their health and well being.

  2. President Obama will offer some form of universal health care coverage. However, we need to fix the health care system as well.
    As a patient and a former employee (I used to work at a famous hospital on
    Long Island) of the health care system – I have first-hand knowledge on how
    the care system works in America. Close to 100,000 people die each year in hospitals due to medical errors. The hospital I worked at had too much administrative waste. There was endless paperwork in processing patient information. Many of the positions, especially in the non-medical areas, were filled through nepotism. Many of the supervisors and mid-level managers at this hospital were concerned about how they looked to top administrators, rather then perform their jobs effectively. (CYA was the major activity).
    A question I would like to ask the general public, particularly doctors – How come doctors never challenge other doctors?
    Right after I graduated college I was “confused,” doing drugs, and getting into trouble; so my parents sent me to psychiatrist. The psychiatrist said I was “mentally ill” and he sent me to neurologist for my tests. (Our family doctor stated at first I did not need any tests, and then he changed his mind.) The neurologist examined my brain and said I was fine. I just needed to “grow up.”

  3. Great discussion. Just a bit of a musical spin on this
    One of the biggest issues that impacts the entire healthcare industry is the challenges in defining and adopting true interoperability data standards. Their is tremendous resistance related to impacts on “proprietary positions” and “creativity” let alone the inertia of change for existing systems. To address some of these concerns in lectures that I have given I use the music analogy. At some time in the past a defined set of standards at a very precise level was established and adopted for music notation. These standards do not try to force anyone into using a specific instrument, language or style of music, but were very precise about about notes, timing, scales and other canonical functions. Because of this we can pick up any instrument and play music written by someone that wrote it hundreds of years ago in a foreign country. We can play it with others that we have never met using a wide variety of instruments. We can use the same standard for jazz, rock, classical, country or any other varieties of music.
    To date this standard has enabled and enhanced both prorietary efforts and creative and has definitely enhanced the world experience. Until we can get to that interoperability standard we will have a real problem playing great healthcare music together in an envronment that supports creativity and proprietary interests.
    This dosen’t take a large investment in money, but it does take a large investment into the fortitude and commitment to drive and enforce these standards in an industry the is resistant.

  4. I’m a catdog.
    When a situation is as dire and as complex as the one our healthcare system finds itself in today, there usually is a need for multiple venues of intervention.
    It is true that the beneficiaries of whatever we do, must be the patients. The problem is very simple to define: healthcare in the US is too expensive. The solutions, or the various possible interventions are mostly loaded with social/ideological implications.
    I believe there are four major categories of possible actions that should be taken in paralell.
    1) Reform the payor model – I believe the private insurance companies are a financial drain on the system. The billions of dollars in profits funneled out of the system every year by those giant corporations and their shareholders could be saved, if we moved to a universal payer model, even if that payer proves to be as inefficient and bureaucracy heavy as the commercial payers. Of course, we could realize significantly more savings if we create an efficient universal payer.
    2) Reform the care model – I think everybody agrees that the state of Primary Care in this country is very troubling. There is both a shortage of primary care docs and a documented willingness of these physicians to abandon practice. There are multiple initiatives out there to support patient centric medical homes. Coordination of care, preventive care, disease management and high availability of the care giver are things that will increase the quality of care and reduce the overall cost by reducing the need for acute care and by keeping patients healthier and happier.
    3) Reform the reimbursement model – This goes hand in hand with the item above. The procedure driven reimbursement model is forcing primary care physicians to concentrate on volume instead of quality. There should be reimbursement for coordination of care. There should be incentives based on outcomes. The current P4P initiatives are too low and not really measuring outcomes objectively.
    4) Increased HIT utilization – Healthcare IT (EHR, PMS, PHR…) is in a support role for all of the above initiatives. The software should be the toolbox that a provider/patient/payer uses to implement these initiatives. Basically, EHRs should support the real time communication needed by a medical home; it should provide guidelines and decision support in the workflow; it should facilitate proactive Health Management; it should allow communications with patients and other providers; it should simplify every workflow and every process for providers and patients alike and of course, it should replace the paper chart. This sort of software should not be cost prohibitive for the physician and should be simple to learn and easy to use. In order for this to happen, government agencies, like CMS, need to refrain from stifling progress and competition in the software market, by promoting and mandating use of old products chock full of questionable features with astronomic price tags. Let innovation take its course. Lobbyists are out of favor in DC nowadays; they should be out of favor with CMS as well.

  5. Matthew,
    Great post and as always, right on the money. As you well know and probably Lone Consumer Voice does not, all of us cats and dogs -you, John Halamka, David Kibbe, Brian Klepper, Jonathan Bush, Mark Leavitt, Peter Neupert, Rob Kolodner, Carol Diamond, Clay Shirky, and lead management in government and at the EHR and Health 2.0 players all know each other and respect each other completely. Passion and our different experiences and analyses drive our differences of opinion.
    We will all work integrally together to solve this and I want to personally thank TheHealthCareBlog for being a key forum on this issue. As you and John Halamka (in his Greatest Generation blog) so aptly point out it is now time to go to the next level and talk about disparate yet compatible strategies to solve our core problems. I also agree that we are all focused on the patient and as we resolve our differences or use them to foster change we need to keep that focus.
    I look forward to a deepening dialogue.

  6. In every other industry, IT spending is based on ROI to the purchaser. If we don’t have IT in healthcare, it’s because it doesn’t help the potential IT purchaser enough to provide a positive ROI. If health care participants have an economic reason to purchase IT, they will. Until then, extra funds will purchase things that don’t have a positive ROI and will be money wasted. As most people in IT know, computerizing something that doesn’t work only makes it go bad faster.

  7. Matthew, three cheers to you on your call for unity. I want to quickly correct a factual misstatement – as I stated in my post, I am the full-time chair of CCHIT, not on loan nor a HIMSS employee – but having done that, let’s get to the ‘meat’ of this dog/cat melee.
    As health IT ascended to become a topic of national policy in the past few years, it simultaneously became politicized. Now there have always been vigorous debates in health IT — best-of-breed vs single vendor, client-server vs web, Health 2.0 vs provider EHRs — and these should go on. What is new, though, is the metamorphosis of health IT experts into charismatic national figures. For many of us whose main political experience was becoming president of the high school physics club, it’s an ego rush to testify to Congress at a televised meeting or appear on a list of healthcare’s 100 most powerful people. But media interest thrives on controversies, not reasoned agreements. It makes the news more exciting, but does it benefit our shared cause of improving health and health care? Is it possible some dogs and cats have been sucked into intentionally provoked interspecies fights to boost their visibility profile?
    We have a common foe -– a dysfunctional healthcare system -– and a shared tool to help in its solution -– information technology in many forms, forever evolving and improving. Our common ground far exceeds our differences, so let’s not be baited into staged fights. Peace, and here’s a biscuit – good boy!
    Mark Leavitt