Matthew Holt

More on HITECH , Microsoft mea culpas, Google, et al

I draw your attention to a troika of articles, all of which show how things can be slightly misinterpreted.

First, who knew that Blackford Middleton was either the most influential health policy wonk out there, or single-handedly responsible for the Haliburtonization of health IT? If you read the WaPo article about it, it looks as though there was some kind of terrible conspiracy to impose an evil fraud in terms of unnecessary health IT spending on the taxpayer. And for example MedinfomaticsMD over at Health Care Renewal (who appears to have jumped from the position that some health IT installations have real problems to the less tenable one that all EMRs kill) is just one going loopy about it.

I've known Blackford for a while, and even though I don't necessarily agree with everything he espouses I think two things are clear. One, the studies his team did (and does) at CITL were done honestly and competently, and they in general reflect what most of us have observed–EMRs have the potential to improve care quality and save money, but that most of the money saved flows back to payers. This has been the experience both in integrated systems in the US, and in health systems in Europe. There are those of us who think that much of the $2.4 trillion is wasted and IT might be part of the solution to trim that waste.

So it was not a great stretch for the Obama team to make the logical leap that health IT is a good thing, and and that subsidies will have to be given to physicians to get them to adopt EMRs (or wider uses of clinical IT). Fer chrissakes even many on the right agree with them. This was not Halliburton sticking it to the US taxpayer in order to boost Dick Cheney's stock options. (Insert your favorite conspiracy theory about the reasons for the Iraq war here if you don't like that one)

Second, complaining about the Feds spending money on this is a little late. It was front and center in Obama's campaign, which explicitly stated that he would spend $50 billion on health care IT over 5 years if elected. And this was well before the downturn in the economy, which in the WaPo article appears to be the trigger event.

You don't like it? Then you should have voted for someone else. You don't think that the money should go on CCHIT certified EMRs? Then make your case vigorously (as has been done many times here on THCB). But to paint this as some type of deep conspiracy in which Middleton and HIMSS pulled a fast one, ignores the many volumes of research and practice showing the overall benefits of IT use in health care.

* * *

Second, I'd forgotten about about being interviewed for this piece in CNET News about Microsoft & Google in healthy competition. The competition being referred to of course is between HealthVault and Google Health. but as both the Microsofties and Googlers interviewed point out, they're delighted to have the other around. This is a market that's in its early stages.

The point that I'm attempting to make in my quote is that most of the activity among consumers online is in information seeking and communication–in the absence of personalized data. Healthvault, Google Health, Dossia, WebMD, KP HealthConnect et al are trying to bridge that gap, by putting the data that's strewn across the health care system into the consumers hands–and make it manageable.

As we know, that is not easy. The ePatient Dave 'BIDMC to Google Health' story is yet again brought up and yet again Dave is not exactly thrilled with the portrayal. He comments that blame has been unfairly put on Google, all they did was take the data BIDMC sent them. And many of us were very impressed that Dave, John Halamka at BIDMC, Roni Zeiger at Google and Danny Sands (Dave's doc and also a Cisco exec) got on the phone and figured this out in a sensible open manner. How often does that happen in the case of those millions of medical clerical errors buried in those manila folders?

(To be fair, overall Ina Fried who authored the series–part 1 is here–has done a nice job of catching the issues).

* * *

Third, and least. Someone sent me this piece which I'd missed about how I'd upset Sean Nolan (guru of MS HealthVault). I do want to apologize to Sean and the MS team. I owe them a review of Healthvault comparable to the one I did of Google Health a while back. Truth is part of the reason I'm writing this whole post at midnight rather than joining my wife and dog snoozing is because of said guilt. But I'm also feeling guilt from a bunch of other parts of my life not being as "done" as they should be. You know, wives loved, exercise taken, friends cared for, day job being completed, etc. My reasons for not reviewing or featuring HealthVault are related to those issues and overall incompetence on my part. So just to set the record straight

  • I am massively impressed by the commitment Microsoft has shown to health care.
  • I have no pre-conceived bias towards either company. I think it's clear that Microsoft has spent more resources in health care overall (and I think Google would admit that) but Google is clearly  the more dominant of the two companies on the web overall (and in delivery of SaaS products). My only bias is in favor of better (and more) use of technology for people to better manage their health.
  • To be transparent, while THCB has had no funding from either Microsoft or Google, Health 2.0 (which I co-run & co-own) has received sponsorship money from Microsoft, but not Google. However, in terms of presentations Health 2.0 has featured Microsoft and Google (I think) absolutely equally.
  • ….and yes Sean (and Tracey and colleagues) I will get to that review…honest

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  1. I’m getting worried about the articles and discussions that you’ve been having about Health Care IT. There is a simple IT process-solution that meets and exceeds the President’s goals but I have not seen it written about anywhere. Or a discussion of issues that we as a society need to discuss before an IT system can actually reduce costs and medical errors.
    I want to keep this letter at the concept level and not get into a technology whitepaper, but rest assured everything I’m about to suggest is at the cell-phone level of cost for physicians, a little more at the hospital level because of different needs but most importantly the technology already exists.
    There are currently three basic types of medical records, paper medical records, the folder we all know so well, the electronic medical record used mostly at hospitals, think of a printout from a computer system and the Electronic Medical Records (EMR) which are XML-based records that have the ability to reduce costs and errors because they are programmable and can be validated (checked for accuracy and completeness.)
    The first discussion we need to have is who should hold these records. If the goal is to fight disease, find new cures, to identify epidemics and to use these records as a basis for an unparalleled growth of healthcare knowledge over the next ten to fifteen years, we need the records easily and securely accessible. There are two groups that I think have the ability to deal with the billions of pages of medical records. The first is the Federal Government but due to the boom and bust of the budgetary process I prefer the telecoms because they are big enough, have the redundancy, the geographical reach, the competition, the bandwidth and their business model is based on providing reliable services at a low cost.
    Next we need to look at what is the correct paradigm to use for our medical records. This is simple it’s an electronic loose-leaf notebook that mimics a paper folder but has pages that can be forms or entire computer systems like an MRI system. A simple example would be using the Kindle II to access medical records. Because most physicians medical records are in paper form we need to get them scanned into electronic form and sent to the telecoms. This is labor intensive but requires little training; we could use the workers already being assembled for the 2010 census, providing a very quick stimulus effect across the country. This is not make-work because the unfiltered raw data is the most valuable form of information to researchers if searchable. The census worker leaves behind a scanner, a printer driver (to write to the telecoms) and an electronic certificate of use that allows secure and audited, reading and writing to the medical record. The electronic certificate of use controls the type of information the holder can view or update. For instance, a state worker that monitors lead levels may be able to add a report to the book but never read any information and the same would be true of a Department of Children and Family welfare worker. This information could have a direct impact on treatment choices. The census worker also performs an audit of what software systems that are currently in use at the office, for later when we convert to XML.
    At the hospital level we could use the same type of system as at the physician’s office but here since money is available we want to make use of it for future efficiencies. So the first step is to think of each computer system, medical device and medical personnel’s duties as steps in a workbook. The goal is not to run out and replace every computer system you have but rather to identify workflows and steps so that you can layer with an enterprise software service on top of whatever systems and procedures you are currently using. This is the best way to keep integration and training costs to a minimum. This first step sets the basis for measuring metrics across the hospital and after careful analysis selected systems could be replaced. The idea is that the use of EMR records can be implemented outside or on top of your current systems. Disk space is cheap and redundancy of information is not always a sin.
    At this point we’ve minimized the risk of movement to XML. The physician’s office has had time to adapt their workflow to electronic records, has probably replaced the paper folder racks with another examination room and may have had some cost savings. And they no longer have to worry about marrying an IT person to practice medicine. The telecoms are trying to sell all sorts of services like billing, automated reminder calls, electronic prescriptions the list is endless. The hospitals have identified its different workflows, decided where XML would benefit them and possibly received bids from different software vendors to wrap the individual systems either wholly or partially to take advantage of XML. Now it’s time to move to XML.
    The largest cost savings and reduction of medical errors comes not from the EMR record but from the workbooks. This type of workbook is really a best medical practice workflow, in it’s infancy it’s just an electronic record of symptoms, treatment and justification, sent to a third-party like a telecom. The purpose is to prevent a remake of the “Verdict” with Paul Newman except on the History Channel. But to do that the workbooks need to be created and maintained not by an individual software vendors or physicians but by a consortium of interested parties like the medical manufacturers, pharmaceuticals, medical associations, physicians groups and finally the Federal Government for an effectively rating. This allows for the creation and refinement of many backend programs that can check on the validity of treatments in so far as medical errors and options are concerned
    Next up are the healthcare insurance providers. Because the medical community has its own very precise terminology, what’s covered, partially, wholly or not at all by an insurer can be conducted in an XML contract in a matter of seconds. It should also allow the insurers to provide an alternative treatment to the patient. This provides the patient a cost with an effectively rating and maybe a couple of different optional treatments so the patient in consultation with their physician makes the judgment.
    We left the medical records as electronic medical records earlier we need to get them into EMR but I’m of three minds here. The first is that we could have done the conversion when the records were scanned in and using software and our census workers create the EMR, this provides the greatest stimulus to the most people. Or we could scan them in and have the conversion done in places like Elkhart, Indiana or other areas hard hit by this recession, because most people that have worked in a factory or assembly line already have the skills needed for XML. But we could also write software programs to parse, categorize, and convert the data to EMR which would produce valuable programs that could be used outside of our medical records, to XML and Artificial Intelligence programs in general. The programs are re-executable whereas using the census workers is more of one shot deal. The other thought is that when designing the XML processing procedures it should never be pigeon-holed into what we expect to collect for information. A notebook can have anything in it but a page or maybe even a chapter could be validated but it needs to be remembered this is a data collection system that must change frequently with the pathogens and treatments out in the field. Layered from the unknown but collected (notebook) to the known (page) outside in.
    Now the medical office worker, physician and patient all check the accuracy of the EMR. From the physician’s point of view, forms can now be filled out on the hand-held device, new features or workbooks appear tailored to their specialty and particular treatments. Perhaps a table of relatives allows access or just querying the patients relative’s books for pertinent information, but of course this is up for discussion. The hand-devices could now have barcode readers, GPS units and biometric fingerprint readers for drug auditing, security and for access auditing. Deceased people’s books are constantly being sent to the National Archives or CDC for storage and research, a little like donating your body to science without the yuck factor.
    Hospitals have spent there monies wisely, have color-coded hand-held devices so they don’t bring the wrong one into the operating room. But most importantly, they’ve changed from, a who can pay and who can’t, to true cost accounting and I don’t mean in the IRS sense. But we as a society need to actually advance not to just pay as you go. So therefore, charging ten dollars for an aspirin from an IT perspective, I can’t help you. However, if the reason you’re charging ten dollars is to offset the fact that you have a separate DBA for each database or you need 24/7 support there I can reduce your costs significantly.
    Finally, we’ve created a series of checks and balances in our healthcare engine that should help it stop leaking oil. We’ve given everyone a haircut to one degree or another but we’ve refocused on the fact that the goal of our healthcare engine should be on providing better healthcare for ALL Americans and that profits should be earned though innovation and hard work not just by exploiting leaks in the system or clever accounting.

  2. I think the issue has been the amount of money being spent on IT. I for one am not challenging the need for IT. IT is much needed. Though I am not sold on the benefits.
    Here is the problem…and it was well articulated by the folks at Oklahama Medical School. If you do not have a working process on paper, and you go and digitize it. You just get a faster process producing lots of crap.
    Our current IT products are not necessarily based on sound process design ( sadly the case even of so much money has been spent on developing them”). Why is the case is another topic. So pouring money on IT has little impact on healthcare cost. The energy must be spent on making the fundamentals of healthcare work..first one paper. And for that, there is less need for money and more for desire, vision, goal, and leadership.
    Once that is done..then IT will be useful. I am speaking from years of experience….trust me!
    rgds
    ravi
    blogs.biproinc.com/healthcare
    http://www.biproinc.com

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