Why Clinical Groupware May Be the Next Big Thing in Health IT

What would you call health care software that:Kibbe

  • Is Web-based and networkable, therefore highly scalable and inexpensive to purchase and use;
  • Provides a ‘unified view’ of a patient from multiple sources of data and information;
  • Is designed to be used interactively – by providers and patients alike – to coordinate care and create continuity;
  • Offers evidence-based guidance and coaching, personalized by access to a person’s health data as it changes;
  • Collects, for analysis and reporting, quality and performance measures as the routine by-product of its normal daily use;
  • Aims to provide patients and their providers with a collaborative workflow platform for decision support; and
  • Creates a care plan for each individual and then monitors the progress of each patient and provider in meeting the goals of that plan?

I call this Clinical Groupware. The term captures the basic notion that the primary purpose for using these IT systems is to improve clinical care through communications and coordination involving a team of people, the patient included. And in a manner that fosters accountability in terms of quality and cost.

Clinical Groupware is a departure from the client-server and physician-centric EHR technology of the past 25 years, a fixed database technology that never really became popular.  It is a substantially new and disruptive technology that offers lower price of purchase and use, greater convenience, and is capable of being used by less skilled customers across a broader range of settings than the technology it replaces.

As the name indicates, Clinical Groupware is intended for use by groups of people and not just independent practitioners or individuals. It is not the same thing as an electronic health record, but may share a number of features in common with EHRs, such as e-Prescribing, decision support, and charting of individual visits or encounters, both face-to-face and virtual. Neither is Clinical Groupware bloated with extra features and functions that most providers and patients don’t need and, with good reason, don’t want to pay for.

Some Clinical Groupware may look and feel like a web-based “EHR lite.” But Clinical Groupware aims to create a unified view of the patient, assembling health data and information that may be stored in many different places and in several different organizations – including HealthVault or Google Health — which most EHRs cannot do.

Clinical Groupware is an evolutionary approach to a shifting health economy in which doing more is not always equated with better care, and the physician or provider role is transforming from autonomous expert to advisor, partner, and guide.   It is also an organic response to the reality that most health care data in electronic format is dispersed across numerous organizations and companies – e.g. hospitals, labs, pharmacies, and devices – and provides a means of accommodating patient demands for a more participatory practice of medicine.

Let me give a couple of examples of this new and emerging class of health software.  RMDNetworks (Denver, CO) and Shared Health (Chattanooga, TN) both offer early examples of Clinical Groupware, although their origins and feature sets are different. RMDNetworks is a privately owned software company that started life as a web portal through which patients and doctors might securely communicate about care. Shared Health is a claims-based health records and quality improvement system for physicians, and is a wholly owned subsidiary of Blue Cross/Blue Shield of Tennessee.

(Full disclosure: I am a member of the Board of Directors of Shared Health, and have been a consultant to RMDNetworks.  Although I could write about this subject using other companies as examples, my insights would be less accurate and well-informed.  I’ll leave it to readers to determine my bias level, and react accordingly.  Let me also say that several traditional EHR companies and web portal firms are evolving in the direction of Clinical Groupware, among them eClinicalWorks, RelayHealth, MedFusion, and AthenaHealth.)

Shared Health is a free web-based, highly secure application that offers physicians and medical personnel access to summary health information on their patients who are BCBS of Tennessee members, Medicaid beneficiaries, or employees of several corporations in Tennessee who have signed up to allow their doctors access to their health information. Claims data can be quite rich in detail, consisting of coded diagnoses and problems, medication prescribing and fulfillment information, and lab tests. And this is important: Doctors who use Shared Health’s web-app, known as Clinical Xchange, can access information on ALL encounters by a patient with ALL providers, such as emergency room visits or new medications, not just the information in the doctor’s own paper charting system or EMR.

The Shared Health team has over time added features that doctors using the system have requested, such as e-Prescribing, pediatric annual visit charting, and reminders and alerts known as Clinical Opportunities. These preventive health measure and screening reminders are generated algorithmically based on evidence-based guidelines, and can help physicians and practices bring their standard of care up to the levels required for pay-for-performance bonus through BCBS and Medicaid. Examples include lab tests for diabetes and mammograms for women over fifty. Very little data entry is required of the physicians or practices, and a good deal of effort has gone into making the Clincal Xchange application an “always on” and workflow-friendly component of the doctors’ desktops.

RMDNetworks’ application is also web-based and low cost to providers who use it. However, the organizing principle behind RMD is direct communications among providers who are caring for the same patient, and between providers and their patients, with a focus on chronic care management. RMD’s application is oriented towards the physicians and patients in a physical geographic area, a single community, in which care is likely to be based in medical home practices and nearby specialty clinics, imaging or lab facilities, and one or more local hospitals. However, they are also tying into broader state initiatives for health data exchange and care coordination.

RMD has partnered with some innovative programs and projects, such as the Colorado Clinical Guideline Collaborative and their Collaborative Care Network, a demonstration project involving 15 medical home practices in the Denver area that have agreed to implement guideline-level care using RMD’s registry functionality for patients with diabetes, hypertension, hyperlipidemia, and fourteen other conditions. Patient engagement is encouraged through RMD’s web portal, permitting patients to access their health information and see explicit care plans and graphs of their progress, receive reminders regarding medications and exams, and transfer their records anywhere, anytime. Doctors using RMDNetworks have the advantage of seeing a single care plan for each patient, with scheduled labs and tests checked off as they are done by any of the providers.

This may permit teams of providers to avoid duplicating each others’ tests or procedures, a common occurrence for Medicare patients who may see as many as six or seven different doctors each year and whose care is seldom coordinated.

RMDNetworks and Shared Health are imperfect, early examples of Clinical Groupware, and any knowledgeable observer would be able to point to a number of obstacles that stand in the way of their more general use by physicians and groups.

For example, Shared Health’s application does not yet integrate with practice-based or hospital EHRs, an interface that would allow two-way flow between the practice’s clinical data and the claims information stored in Shared Health’s centralized repository.

RMDNetworks has not yet integrated e-Prescribing into its offering, and has a number of interface issues of its own to handle.

 But I predict that this class of software will quickly improve, particularly with respect to data sharing, and that as it does it is likely to grow in adoption especially where cross-organizational and inter-enterprise platforms are seen as a lower cost and more easily implemented solution than adopting a single vendor EHR, or building an expensive RHIO-like centralized repository.

Clinical Groupware may never replace an enterprise EHR like Epic or NextGen, but it may serve the needs of groups of practices, and groups of groups, who seek clinical integration and collaboration without financial integration being a prerequisite.

There is definitely a social networking ambiance to Clinical Groupware that EHRs have totally lacked so far.

The recent passage of the Health Information Technology for Economic and Clinical Health Act, or HITECH, may give Clinical Groupware an unexpected boost in popularity. This is because HITECH defines physician eligibility for direct incentive payments in terms of broad “meaningful uses” of health IT, rather than through prescribed products or features and function sets of particular products.

According to the bill, a physician becomes eligible for significant federal funding by using qualified technology to: 1) perform e-Prescribing; 2) carry out “the electronic exchange of health information to improve quality of care, such as promoting care coordination,” and; 3) report on clinical quality measures in the form and manner specified by the Secretary of HHS.

Furthermore, the bill states that:
”The term ‘qualified electronic health record’ means an electronic record of health-related information on an individual that  (A) includes patient demographic and clinical health information, such as medical history and problem lists; and
 (B) has the capacity to provide clinical decision support; support physician order entry;
 capture and query information relevant to health care quality; and
 to exchange electronic health information with, and integrate such information from other sources.


These requirements open the door to health IT implementation in provider organizations that is less expensive and easier to use than today’s EHRs.

Clinical Groupware like that offered by Shared Health and RMDNetworks both provide “meaningful use” of a “qualified EHR” under
the Bill, at least as I understand it. 

At the same time as this new term comes into fashion, I think that the electronic health record, or EHR, will begin to fade. It is already losing its utility, burdened by several different meanings and definitions that confuse almost everyone.

For example, EHR means to some people a suite of software used by doctors to replace paper records, as in those products that are certified by CCHIT according to features and functions. To others, an EHR is a collection of data about an individual, a digital file or files.

And to some, it means both.

 But the real issue isn’t about confusing old names or catchy new ones.  The real issue is the choices that will be made by the 75 percent of physicians who don’t use EHRs yet.

Clinical GroupWare will appeal to these physicians, medical practices, hospitals, and provider organizations who have hesitated from purchasing the high priced comprehensive EHR database management systems on the market; who don’t require all the features and functions that these systems offer (and don’t want to pay for un-used functionality); and who wish to implement quickly and with as little interruption to clinical workflows as possible.

Because Clinical GroupWare is web-based and can be used with any of the popular browser programs, such as Internet Explorer and Firefox, the viewer interface is already familiar and does not require extensive user orientation or training.

Clinical GroupWare integrates some of the most common features of office software used in work outside of health care and in the home — such as e-mail, scheduling, data/table display, and forms completion — rather than retaining complex multi-click document constructions that are proprietary and customized.

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46 replies »

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  2. I really find this a interesting subject. Never looked at this subject in this manner. If you are going to create more articles about this subject, I will return in the near future!

  3. Clinical Groupware applications can be distributed as software-as-as-service, and are intended to support today’s mobile health care environment by supplying the right information, at the right time and the right place.

  4. I think one area that needs to be considered in any IT solution is the inabilty of most clinicians (myself included) to provide patients with the day-to-day support they 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;
    • supporting patients to easily and accurately keep track of their performance
    • 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;
    • 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.
    How will this be done? For me, it means creating longitudincal interventions that are based on theory and research, mimic what master clinicians do and accomplish the above mentioned goals.

  5. David,
    Thank you for crystallizing what I believe many of us are beginning to understand. I am referring to the many people in different roles who work to fulfill the promise of IT as an enabler to the work of delivering care to patients and improving efficiency and quality for the professionals who provide this care.
    The idea of collaboration rings very true as an analogy for the work of seeing a member of a patient’s care team, generating data as a result of that interaction or the tests that follow it, then giving the patient the right handle to securely share any or all of this information with other professionals who care for them, and even family and friends.
    Further reflection of the robustness and flexibility of this model of generating, preserving, and sharing information come from the fact that it still works well when superimposed over existing interaction models of ambulatory care delivery as well as over emerging platforms for storing and accessing longitudinal health data like those from microsoft or google.
    As a technologist, I know a lot remains to be done to allow consumers of health care services to be able to understand and manage their personal health data similarly to how easily people manage their bank or retirement (sic) accounts today, but these improvements can continue to happen in this collaborative model as well.
    It comes back to collaboration at the core because the top-level objective must be to make it easier for patients and their care team members to access and generate health information collaboratively in the delivery of care.
    Thank you David for sparking this discussion.

  6. I feel that Clinical Groupware is indeed a very good concept, which will become really big in the very near future. This technology would be immensely helpful for a globalization of the best medical talents of the world so that emergency medical help does not remain within the restraints of geographical boundaries…

  7. Very informative article about web-based EHR. Here are some advantages of Internet-based vs. Web-based
    More flexible
    Internet-based applications can run on PCs and Macs. Web-based applications will only work on one type of browser, on one operating system.
    More secure
    Internet-based applications can create a secure private platform between you and your data. Web-based applications transmit data across the public, forum of the World Wide Web, leaving you more vulnerable to viruses and hackers.
    Internet-based applications like NueMD – http://www.nuemd.com – perform as though they’re running on your own network. Web-based systems are limited by the browser they run on, and tend to have slower connection times.

  8. David C. Kibbe’s overall philosphy on this most important EHR issue is something every healthcare IT professional/hospital executive should understand. It is a highly complex issue with countless stakeholders and points of view. On his approach, it looks like one that Mitochon Systems may well address in 2009. (www.mitochonsystems.com). Practice Fusion is also making headway in this area (www.practicefusion.com).

  9. Dr. Kibbe;
    Sorry, you misunderstood part of my comment. The “ridiculous” part of which I was speaking had to do with
    precisely the scenario you subsequently cited – someone on the other side of the country accessing the file, but John has refused to create a VUHID.Obviously I would not hesitate to post the result to my own system’s file, since it has a unique identifier with which I am comfortable.
    As far as John not trusting the system, I don’t blame him! Perhaps the onus should be on the industry to improve its security rather than relying on us users to solve it for them.

  10. Dear bev M.D. : Well, I disagree. I don’t think it is ridiculous. If you are a laboratory and you want to post a blood type result to John Smith’s file, you do so. Within your system or systems. Where the VUHID comes into play, I think, is when someone on the other side of the country wants to access YOUR system’s data — the lab results — on behalf of John Smith.
    If John has agreed to create and use a VUHID, then it’s easy to match your system’s ID with John’s VUHID. Where ever, when ever.
    But, suppose John doesn’t want to have a VUHID, because he doesn’t trust laboratories, or health care providers, or whatever reason.
    I just can’t see how we can get around this. The public doesn’t want the government to assign a health identifier to each of us. At least not now. But we need, as you so aptly point out, a way of uniquely identifying individuals on the network.
    I’m really open to your ideas and suggestions for how to do this, and to anyone else’s. Regards, DCK

  11. Dr. Kibbe;
    No, I do not have a solution, and I believe a voluntary identifier solution is ridiculous. If I am a laboratory and I want to post a blood type result to John Smith’s file and John Smith didn’t opt in to the voluntary identifier, I could not, in good conscience or good practice, post that result – which John Smith is it?
    I am not a computer expert so this may sound crazy, but is it possible to have a universal identifier which only works to INPUT data to a patient’s file, but is not valid for read-only or WITHDRAWAL of data from that file? In other words, all entities with data to add to the file have the identifier, but this identifier will not work to read any data or download any data from the file. Just a thought. Computer people can do anything these days, right??!!
    It would certainly relieve my mind as a provider of patient information, to know that I am putting that blood type into the correct person’s file.
    As to how to get any data out of the file, I haven’t gotten that far yet. So far I am only concerned with the integrity and reliability of the data in the file. As you know, this is the reason why many, many laboratory and imaging tests are needlessly repeated on patients – because they are unavailable, inaccessible or the doctor doesn’t trust them from somewhere else. I wonder how much THAT is costing the health care system – plenty, for sure.

  12. Dear bev M.D.: Thanks for bringing up the patient identifier issue once again. I don’t think it was dismissed earlier, but let’s consider it once again. The problem you raise, and with which you have direct experience as do many health care managers, is the difficulty of identifying an individual when a request is made for his/her information. What if the name is spelled incorrectly? Or perhaps there are more than one “Smith, John” s in the database. So which one is the query for? And each feeder system, e.g. lab or EMR, has its own identifier number(s). How to keep these inventoried and all straight? Social security numbers can be used, but they’re not unique. And so on.
    Enterprise IT systems deal with this by creating master patient indexes, or MPIs, that create a unique identifier for each individual regardless of how many other sub-identifiers there might be. But what happens when a person goes to another large provider organization, which has its own MPI? And, if this is someone who travels a lot, well, it can get completely confusing. Now, Microsoft HealthVault, Google Health and other sponsored health records services appear, and they, too need consideration in terms of matching a person’s identity with disparate sources of data.
    The problem needs solution. Problem is, Americans are very resistant to the idea of a Universal Patient Identifier imposed by the government. A provision for just such a numbering system was included in the HIPAA legislation, but removed permanently due to the outcries from the public that Big Brother would know all of one’s medical history. Not going to happen in these United States anytime soon!
    So, that’s why I mentioned the project called the Voluntary Universal Health Identifier, of VUHID, and provided the link http://gpii.info/ to that web site for anyone interested in the subject. A voluntary identifier removes the perception of coercion from obtaining an identifier. No one needs to have one if they choose not to.
    Perfect solution? No. Do you have others? Thanks.
    Kind regards, DCK

  13. I am addressing the issue of a universal patient identifier, which was queried and seemingly dismissed early in these comments. If I understand these proposed systems correctly, an incontrovertible unique and universal national patient identifier will be critical to ensure that depositors of health information into a patient’s record (hospitals, laboratories, pharmacies, doctors’ offices, etc.) have the correct patient! As a former medical laboratory and blood bank director, I have seen every conceivable(and some inconceivable) way that a patient’s identity can be mistaken and incorrect information entered in a patient record. This is one reason why every blood bank will re-draw a patient’s blood on every admission to confirm their blood type is really the same as what is in their record. And no, one cannot rely on the patient himself to verify the information, for a variety of reasons. Please do not overlook the critical necessity for at least one, preferably two, unique patient identifiers in any type of system that is developed – or you may literally kill someone.

  14. Dear Dr. Segal: Good point. As I mentioned in my blog post, I see Clinical Groupware as being a platform for multiple components, including diagnostic tools and decision support, e-prescribing, connectivity to HIEs, and quality and performance reporting — all of which when assembled provide the “meaningful uses” of health IT that would qualify physicians for incentive payments under either Medicare or Medicaid under HITECH. Government could help immensely by encouraging this innovation. Regards, dCK

  15. One of the ways that government can help is by clarifying the extent to which physicians can use clinical groupware and have that count as maintaining records. Most doctors and hospitals would be uncomfortable relying only on clinical groupware now. Similar issues apply to similar offerings by Microsoft and Google.
    At SimulConsult we think the clinical groupware concept should be interpreted widely as including information resources maintained by the community, as in evidence-based diagnostic systems.

  16. Dear Maurice: I can’t dispute a thing you said. But don’t you think the change in payment is coming? Don’t you think that more and more people will be looking for doctors, and groups, and hospitals, and delivery systems that can deliver lower cost care? Don’t you believe that payments for health services will start to be bundled, and include management of care, and allow provider groups who are efficient to share in the savings?
    I do. I really think that it’s inexorable that provider organizations will start to compete on cost. WHEN it happens is unclear, but that it will happen, is already starting to happen, isn’t in doubt.
    Collaboration is just another word for not wasting resources. When that starts to pay off, the demand will be there and the technology, like Clinical Groupware, will be deployed.
    Very kind regards, DCK

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  18. David,
    Excellent post, and great insightful comments from many. I think some of the comments finally got to the crux of the issue behind lack of collaboration, interoperability, data liquidity, integration, etc… “it’s the MONEY, stupid!”
    I admire and applaud the altruistic goal of so many for wanting to improve quality of care and reduce cost, but at the end of the day, when we talk about collaboration and integration, we’re talking about some stakeholder in this ecosystem potentially losing revenues. Unless this is recognized and addressed, the dream lives on.

  19. David,
    With all due respect, I am amazed that you and so many others continue to advocate healthcare IT solutions that have been rejected for years by the people who count most — consumers/patients and physicians. And now that the established providers of these rejected EHR systems smell a honey pot of federal funding, they are promoting their oft-rejected-systems even harder rather than developing systems that really meet the needs of consumers and physicians.
    The dialog on this and other healthcare IT sites generally reflect two distinctly different points of view. One is shared by vendors, consultants and/or observers of EHR systems; the other is shared by physicians and consumers who work with and/or need to have medical records. And the differences in their conclusions are dramatic.
    Most doctors don’t want what they are being told they should adopt — and I suspect they will continue refusing to adopt even if the government offers to subsidize them. Similarly, most consumers, patients and privacy advocates strongly resist and rail at Web-based systems because they aren’t secure or private.
    But are any of the vendors and “observers” listening? No. They continue promoting systems that may bankrupt the physicians who adopt them, and advocating web-based systems that open consumers to very real security risks!
    It seems to me that we have two choices. We can continue advocating more of the same (we can even rename it in an attempt to fool physicians and consumers), or we can give them what they want and need!
    I, for one, think it’s time to stop promoting failed products and start meeting needs. Calling a dog a cat doesn’t make it a cat. Neither does saying a web-based record is “highly secure” make it secure!
    (Full disclosure: I am president of Health Record Corporation, developer of a personal health record that uniquely meets the needs of care providers and consumers.)

  20. Although as a patient I appreciated the summary and discussion of this topic, I felt like I was in the middle of a commercial or paid advertisement.
    Clinical Groupware is the NEW New Thing! It will cut, slice and dice. It’s better than anything else out there! It’s cheaper! It’s more “social”! Forget the old EHRs, those have a tiny place in medical offices, but Clinical Groupware will be Everywhere! Soon!
    I would have valued the article far more had you described the pros and cons of this “new” set of applications, instead of just listing the pros over and over again (many of which apply to any PHR system). I mean, PHRs are also “here and now” for many.
    (And an editor for this article would’ve just been icing on the cake.)

  21. Dear Adam: Thanks for articulating one of the major building blocks or components of Clinical Groupware: automatic updating/syncronizing of a person’s viewable personal medical record (PHR is the current term, but views may vary) based upon sources like the hospital’s ADT, a doctor’s EHR, or a pharmacy. These linkages are only now being built, and they’re being constructed almost one-at-a-time by provider organizations in partnership with vendors like VisionTree.
    I would think that for cancer patients this would be very, very important. But I can see the same principles being useful for a person with hypertension, or after a heart attack while dieting, exercising, and monitoring blood lipids.
    Clinical Groupware is “here and now,” your company and other are making it real. It reminds me of the early days of Netscape and the browser add-ins. Functionality was very low to begin with, but the platform grew in usefulness with each additional plug-in or added feature.
    Kind regards, DCK

  22. Dear David: In regards to the “EMR Vendors”, I mean the large companies like an EPIC, IMPAC, or Cerner, etc.
    What we have done as part of a phased integration, is to pull ADT data (Basic Health/Demographic Information) from an EMR into VisionTree to prevent duplication and reduce initial data input. This ADT data is then stored in VisionTree, but there is a secure (VPN, ODBC) connection to the EMR and we “listen” (via Web services, etc.) for any updates from the EMR system, or from the patient/physician (entering data through VisionTree) and then sync the two.
    As the integration phase moves forward, we deliver an integration system that allows the patient to have a true, sync’d health record that is portable and not tied into an EMR.
    We see the motivation for this integration is government mandates for quality documentation, practice improvement and electronic communication. That coupled with current disparate & confused workflows in multiple systems, which is one of pain points VisionTree addresses, is driving HIT adoption and the demand for “Clinical Groupware” Applications.

  23. A M E N
    As many clinicians are realizing, transactional systems (e.g. EMR) are not geared for transformational challenges in healthcare let alone affordably tackle the “cow path” workflow realities unique to each clinic and/or the nomadic behavior of some clinicians. More than physician-patient collaboration, the clinical groupware idea is the basis to spark physician-patient accountability especially when outcome measurements, using validated survey instruments and risk-adjustment factors are included. This is the vision of BoundaryMedical and what our web-based Outcome Enterprise software does so we naturally applaud Dr. Kibbe for his visionary comments.

  24. Dear Adam: VisionTree has been at this for some time, and I’m sure readers would like to hear a little more about what you’re doing (without it being a commercial!). What does it mean, for example, for “EMR vendors” to “integrate into VisionTree” ? Regards, DCK

  25. Thanks for the great executive summary and vision David. There is so much room for growth in this space and your examples coupled with a few other firms who are taking this challenge head on will drive the collaboration the health care system needs.
    I believe the integration challenge (as mentioned in the comments) will be solved by the end customers at champion/high profile sites demanding integration with their PMS systems and their EMR/EMR lite.
    At VisionTree, which is leading the way on the integration with EMR’s in oncology with our Groupware solution, our clients have demanded from the EMR vendors the integration into VisionTree.
    It is fascinating what a multi-million/billion will do with an outcry/demand from a large client. This will be the way to have these integrations succeed in my view. Once you start to hit the $$$ side, people pay attention.

  26. B R A V O.
    Reliable elimination of paper is enough incentive on its own for MD’s to adopt. So long as there are no productivity losses that have crippled EMR installations.
    I absolutely love the thoughts posted here. Very refreshing from a tired industry of same old mouse clicks but different place on the screen.
    Hoorah Dr. Kibbe!

  27. This is all very exciting, but will only be adopted to the extent that there is always about 10-20% of a given user population willing to try collaboration over a networked system.
    But collaborative healthcare won’t come first from computers. It will come from people.
    Long as it takes me 4 weeks just to get my records released from one doctor to another, while both offices throw as many obstacles in the way as possible, nothing will change. And it’s not the manual elements of that system, it’s that the process is designed to protect files, not people.
    You can’t program people to collaborate. They all have to see the advantage. Computing doesn’t cause collaboration. Sense does.

  28. Because of the ubiquity of network problems and Internet access problems the user would need to be able to create a local backup copy of his patient database, and a set of virtual patient records, that could be accessed without having access to the web based software.
    Security would be a major issue. Patients, hospitals, and physicians would need to be confident in such a system. One will also need to carefully consider the role of insurance companies. They are often legally entitled to access to a portion, but only a portion, of a patient’s records. They may have a great deal of interest in the type of powerful access to information that this would make available, but this software would need to make sure that the legal restrictions were built into the program to protect patients, and not jeopardize the physician users.
    It is not difficult to imagine a way to allow Clinical Groupware to tie into practice management software that was either already installed in the private physician practice or perhaps a web-based practice management option for those who were not already linked tightly to a system that they liked. There is already electronic medical record software that will interface with multiple practice management software packages.
    This is the type of interesting and stimulating idea that keeps me coming back to this blog.
    Thank you, Steven Zeitzew

  29. Dear Dr. Pandey: I agree with you wholeheartedly that Clinical Groupware needs to focus not only on helping people who are already sick, but finding ways to help people stay healthy, practice wellness in their lives, and avoid risky behaviors. This is the ideal therapeutic conversation, no?
    James: Medicaid programs are certain to experiment with Clinical Groupware as part of the solution of lowering cost of care and improving access. North Carolina and Tennessee Medicaid programs are both actively involved. Perhaps we’ll hear from others in these comments.
    Regards, DCK

  30. I think this all can be done for far less than 2 billions…I would think in the order of 2-5 hundred millions. What we also need in the system is SECURITY.
    In the end, however, I have fundamental issue. We are doing all this to manage sickness…why can we not focus on WELLNESS. And have tools and reports and wares to improve on wellness.
    It is a fundamentally different philosophy.

  31. Dear Dr. Sucher: Thanks again for bringing up an issue that needs to be addressed if Clinical Groupware is going to be successful and catch on: billing systems integration.
    There’s really no short answer here, except to suggest that where fee-for-service dominates as a business model, Clinical Groupware will catch on more slowly than where quality of outcomes or value purchasing prevails.
    I don’t think that Clinical Groupware can simply “build in” a fee-for-service billing component, as that is contrary to the model in which coordination and collaboration are being purchased as part of the business model. Billing systems count services, equating them with “health care.” It’s a failed business model that inflates costs, but does not deliver good care consistently.
    My sense is that the next generation of pay-for-performance programs, both with Medicare and the commercial health plans, will involve meaningful management payments on a PMPM basis — or, almost the same thing, calculated bonuses and rewards for populations of patients — that change the business model enough for Clinical Groupware to become a necessity, not just a good idea. If care management is going to meaningfully return to the field of the doctor and patient, and if self-management is going to be rewarded both financially and by improved personal outcomes, then we have to start paying doctors who help their patients stay well and improve their health, and giving consumers incentives to participate actively. It’s just that simple: although it’s actually going to be very hard to turn this corner as a nation.
    So…don’t give up the faith! The whole Health 2.0 movement can be seen as societal groupware for health and wellness, and it’s going to have its effect on how physicians and hospitals behave, sooner or later. Changing the payment mechanisms will hasten the change, but it’s going to occur regardless, in my opinion.
    With kind regards, DCK

  32. Dr. Rowley (and Dr. Kibbe),
    There is one huge oversight that I had when commenting on barriers (mainly because I was thinking about my particular environment). I missed asking about the biggest barrier of them all…. The Business of Medicine… In a former life of mine, I created EMR software and ran a business on the client-server model. I knew from the day I created the software that it already had one foot in the grave because the web-model would be the future. But the most obvious problem was integration with the Practice Management software. This is the most predominant issue facing every practice, large or small, specialty or primary care. They need to run a business.
    Well, the Practice Management business is built mainly on local service markets. In 1997 (that’s when I was “in the business”) there were 1400 practice management companies in the U.S.. Talk about fragmentation! You can’t write EMR software to deal with that level of integration. Oh, you might talk about HL7…. but we all know that if you have implemented one HL7 solution, then you’ve implemented only one HL7 solution. It really doesn’t get you to the nirvana of a BableFish.
    So, this long winded diatribe is meant to ask… How does/will the groupware model handle dealing with the business of medicine? You can’t simply say that your groupware software has a practice management component built in (at least not now), because the practices have entrenched PM software that they actually like. Additionally their hardware is usually supported by the PM software company (hence the reason why it remains a local provider service market).
    Anyhow, I am not a nay-sayer for what you both are talking about. Quite the contrary. I am a true believer. I just don’t seem to be sharp enough to figure out how to break through these obstacles… and breaking down the obstacle of integration with the PM component is one that I would like to hear your ideas on.
    Thank you,

  33. I personally have a strong belief in the long term prospects of the web based business model for delivery of EMR and clinical groupware.
    My question to the learned audience is what is the actual adoption of web based solutions in the US?
    Are physicians and others actively swapping client-server software or using the simplicity of the web based model to finally move from paper based records to electronic storage and access?
    The following take-up is claimed for various web based applications:
    * Practice Fusion – 1,300 physicians (august 08)
    * AdvancedMD – 8,500 physicians (july 08)
    * Athenahealth – 17,300 physicians (sept 08)
    Any insight greatly appreciated.

  34. David: I commend you for outlining a vision for the direction toward which healthcare IT should evolve. It is strikingly consistent with the vision I also have, and around which our own efforts at Practice Fusion are focused. I believe that a patient-centered clinical record which transcends historic boundaries (ambulatory-care across multiple practices, including hospital integration), is hosted and free (or nearly free) to the physicians, has a portal by which patients participate in their own record, and can push wellness as well as disease-management prompts both to the physicians but also to the patients – such a technological capacity is clearly foreseeable. It does mean breaking the boundaries of traditional EMRs, which, while helpful to individual practices, still keep data in silos within practices or local networks.
    One of the presumptions of Groupware, as described, is that healthcare can be more participatory and interactive. The way in which healthcare has been traditionally organized is challenged by this notion. In order to move toward the participatory and interactive nature of healthcare delivery facilitated by such an e-tool requires structural changes in healthcare. The Patient Centered Medical Home is an example of a new type of organizational basis – one which values primary care as its core, as the “orchestra conductor” of a coordinated and rational delivery system. I suppose my concern is a bit chicken-and-egg: does implementation of electronic tools, or implementation of structural and compensation changes come first? They will probably evolve simultaneously. By itself, e-tools are just that: tools. How they are used depends on how medicine is organized. Tools that facilitate coordinated, participatory care will help the changes that need to take place – however, the tools by themselves won’t accomplish the changes needed.
    Great work in articulating a vision for us all.
    Robert Rowley, MD

  35. I agree with Dr. Kibbe’s “clinical groupware” concept, and I applaud it. “Groupware” jibes with my biases:
    1) that clinically useful electronic health records will be market-based, not government-based;
    2) that web-based clinical records will outpace, out-hustle, and eventually submerge propriety records;
    3) that for every complex problem, there is a complex understandable solution;
    4) that health record systems that do not allow multiple parties to communicate are basically useless.
    Kibbe’s “clinical groupware” solution reminds me of the principles enunciated in the book Edgeware: Insights from Complexity Science for Health Care Leaders (VHA, Inc, 1998).
    These insights include,
    • Good-enough vision – build a good-enough vision and provide minimal standards rather than trying to work out every detail.
    • Tune to the Edge – Tune your place to the edge by fostering the “right degree” of information flow, diversity and difference, connections inside and outside the organization, power differential and anxiety.
    • Multiple actions – Go for multiple actions ar the fringes, let direction arise rather than believe you must be sure before proceeding with anything.
    • Chunking – Grow complex systems by chunking by allowing complex systems to emerge out of the links among simple systems that work well and are capable of operating independently.
    For every complex situation, there is a complex solution requiring collaboration and cooperation, and it is usually right.
    P.S. – By the way, as this is posted, I read in the WSJ re: the Senate’s stimulus bill,”The deal jettisons or pares back a number of items Obama wanted. Funding to computerize health records is all but gone, as is a national study on the comparative effectivenss of health treatments.”
    Posted by: Richard L. Reece, MD, medinnovationblog.blogspot.com | Feb 8, 2009 8:29:23 AM

  36. Dear Dr. Sucher: I think you do a great job of summarizing the barriers to the adoption of Clinical Groupware and cloud computing in health care. These are primarily due to the current, status quo business models for medical practice, hospitals, labs, and devices that include no incentives for data sharing except inside a particular business unit or enterprise, and sometimes not even then. This is in large part what makes them inefficient and high cost, but highly remunerative under FFS payment system that pays providers and enterprises on quantity of services, not quality of outcome.
    However, I’m seeing cracks in the walls. Even within some very large health care organizations the high costs of single vendor enterprise EHRs are daunting. The strategy of rolling these out to newly acquired or affiliated medical practices, and even more important, the resistance by physician groups to hassle-prone and workflow interrupting IT, are forcing these organizations to turn to lighter weight, web-based apps for clinical integration strategies to go forward.
    The change isn’t going to occur over night. It’s key that the Obama administration find ways to encourage collaboration by changing the method of paying for Medicare services, through incentives both to the providers and to the patients. This will enhance the value of Clinical Groupware even more.
    Honestly, I’m not sure there is a need for a universal health identifier. I like the idea of a voluntary identifier system, like that developed by Barry Hieb (see http://gpii.info/ ) if we go in that direction. There are people much smarter than I working on the problems of a federated identity process that would allow mulitple sponsors of Clinical Groupware to share a patient’s data with permissions.
    My assumption continues to be that data are “owned” by their creators, but that individual citizens always possess a right to access (copy) data about themselves. The stewardship of health data is terribly important and full of responsibilities, but we should not shy away from them.
    Kind regards, and many thanks for your good comments: DCK

  37. Dear a family doc: I don’t think that Clinical Groupware necessarily changes the ownership and access issues for health data that exist today, although Clinical Groupware will certainly increase access or data liquidity. Consider the “sponsors” or “stewards” of digital health data: these are doctors’ offices, hospitals, clinical labs, pharmacies, health plans, and so on. Federal law (HIPAA) ensures my right as a patient/citizen to access these data. Federal law also permits certain uses/exchanges of these data (health care, payment, and certain operations) by “covered entities” and their business associates without explicit consent, and other uses of these data when consent is solicited and granted, e.g. research or marketing.
    It is hard for me to imagine that certain payers or providers could more zealously cling to their data than they do today, or how the widespread adoption of Clinical Groupware could make that situation worse. On the contrary, I think it will be the adoption and use of Clinical Groupware that will put pressure on more health plans, hospitals, and physicians’ practices to share the data on the behalf of the patients’ better outcomes in appropriate ways.
    Consumers and patients ultimately control their own health data. This is already federal and state law, although it is not generally or universally exercised. Clinical Groupware will make likely make it easier for patients to switch doctors or hospitals and maintain access to and portability of their data.
    Kind regards, and thanks for your comments. dCK

  38. Dr. Kibbe,
    You are uniquely qualified to talk on this subject, and I appreciate reading your thoughts. You have appropriately revealed your conflicts of interest, and that is good enough for me.
    My concern is that there remains many obstacles keeping the dream of collaboration from becoming reality. There are ongoing fiefdoms in the device acquisition industry, pervasive silos of information in the hospitals, and privacy issues of data ownership that are concerning. I, like many people, have had this dream of groupware for two decades, and it appeared even more plausible when the Internet became available to the masses.
    So, I guess my point is that despite the obviousness of what is needed, I continue to see the same obstacles in our path that haven’t changed. How will we address these obstacles? Do you see a chance for a universal patient identifier? Will there be an answer to who owns the data? Is there enough momentum that will allow larger organizations to collaborate?

  39. Who owns and controls access to the Groupware and the data? Can the data easily move from one groupware to another when the patient changes payers or physicians? What happens when to patient data when physicians drop payers or drop hospital affiliations?
    While better sharing of data among EMRs is needed, I could easily see commercial payers, government payers, and large hospital networks using this to exclude competitors and to bind patients to them and their physicians.
    Portability of data is important in preserving some semblance of choice for patients and physicians.

  40. Great post. As a general trend I would say that this is definitely the direction that market is likely to move. Historically, as far as I can tell, everything in Health IT has been viewed through the narrow lens of transactional systems.
    A much broader, less expensive and easier to use approach is required (e.g. what the IOM calls small scale optimization) if the industry is to break be new ground.
    Web 2.o technologies have a critical role to play here and I find it fascinating that important first steps by thought leaders are already getting some traction.

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