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Health IT: The Year In Review

This is a summary of the HIT Trends Report for December 2010 (The Year in Review).  You can get the current issue or subscribe here.

Out of 325 stories we covered in 2010, and a few new ones, we picked about 30 that best tell the story of the past year.

Tracking HITECH in 2010:  The Year’s Top Stories

    1. The biggest story in HIT this year is the elegance of the federal ARRA HITECH strategy combining provider incentives and disincentives with state health information exchanges and regional extension centers for support.  While this plan is off to a slow start, it seems to be working.

    2. In July the federal rules for meaningful use were unveiled; a core set of 15 required elements and a menu set of 10 optional elements among which 5 are selected.  Providers will attest to meeting these measures.  In the next stage in 2013, all measures will be mandatory and providers must demonstrate real meaningful use for most patients.

    3. There are now 5 companies designated as authorized to certify EHR technology.  The federal government is keeping an updated list of products that have been certified.  At the end of 2010 the count of different certified product versions was over 200.

    4. NHIN Direct is a concept that grew out of a blog by Wes Rishel, at Gartner.  It’s meant for simple communications between parties who know each other. Its focus is on meaningful use, specifically, summary care records, referrals, discharge summaries and others.  It’s also being used as the foundation for the clinical messaging service recently announced by Surescripts.

    5. The federal government also began work on comparative effectiveness research (CER), which it now refers to as “patient-centered outcomes research.”  $435 million has been awarded by AHRQ across dozens of companies and projects focused on developing patient registries, clinical data networks, and other forms of electronic health data systems in order to generate data about treatment outcomes and options that can be compared by patients.

    6. Todd Park, CTO at HHS, summed up the federal strategy as “incentives plus information equals transformation.”  He connects the dots between the provider incentives in HITECH, provider payment reform in the Affordable Care Act, and Data Liberación, making federal data available for innovation.

Focus on E-prescribing in 2010: The Year’s Top Stories

    1.E-prescribing has been growing dramatically, largely within EMR systems.  Surescripts announced in the fall that 200,000 prescribers, 1/3 of office-based providers, were active on its network.

    2. The DEA approved a security approach, effective in June, to allow electronic prescribing of controlled substances.  It requires two-factor authentication for a prescriber to get a credential and e-prescribe.  One factor is something you know, like a password.  The other is something you have, like a token or a specific device, or something you are, like a biometric signature.

    3.The HITECH incentives require EHRs, so virtually all the standalone e-prescribing solutions found new strategies or exits.  CVS Caremark retiring its iScribe solution is a typical announcement of this trend.  ZixCorp and eHealth Solutions also exited.  Other e-script companies, such as DrFirst and RxNT have become light EHRs, while Prematics got acquired by NaviNet.

    4.Using e-script data from ZixCorp for Massachusetts, researchers at Brigham & Women’s compared prescription orders with payer claims data to document adherence rates by drug class.  Overall 72% of e-scripts for new medication were filled, which the researchers call, “primary adherence.”

    4.And finally, in a study by the Center for the Study of Health System Change, utilization of e-prescribing functions is the real challenge.  While 42% of physicians in the study report having e-prescribing capability, only 23% of these use electronic transmission, drug interactions and formulary checking regularly.  That’s fewer than 10% of all prescribers.

Focus on EHR in 2010: The Year’s Top Stories

    1. The CDC released its annual update for EHR adoption in US physician practices in December. 25% of physicians have a basic solution.  And only 10% have one CDC considers fully functional.  Utilization of available functions is a key issue.

    2. KLAS reported that a few firms are emerging as winners in the EHR wars.  Allscripts, NextGen and eClinicalWorks are considered most often in smaller practices.  Epic is a leader in very large practices.  Other companies of note include athenahealth, Greenway, e-MDs, McKesson and Sage.  Epic and Cerner are reported to win 70% of the over 200 bed hospital deals, and MEDITECH leads in smaller deals, although only Epic customers say it’s worth it.

    3. McKinsey & Co. reported that HITECH incentives of $17,500 per bed won’t cover the $80,000-$100,000 in costs for a hospital EHR project, but an ROI is possible.

    4. Health Directions, a hospital consultant, outlined how hospitals can get an ROI from EHR projects through reaching out to community physicians with services and engaging with patients.  CHiME, the association of hospital CIOs, with the American Hospital Association, compiled a detailed guide to EHR implementation with real-world practical advice.  It considers the HITECH incentives, but goes beyond it, focusing on the enterprise.

    5. Consolidation in the EHR segment is taking some shape.  Allscripts and Eclipsys combined inpatient and outpatient assets in line with future accountable care trends.  GE acquired MedPlexus, a web-based EMR, pointing to the future importance of software as a service (SaaS) applications.  Covisint acquired DocSite, adding a patient registry service to its physician portal being piloted by AMA.  NextGen, Ingenix CareTracker, DrFirst’s Rcopia and other solutions are also using the platform.

Focus on HIE in 2010: The Year’s Top Stories

    1. Consolidation has begun in the health information exchange segment also.  Market leaders Axolotl and Medicity were acquired by UnitedHealth’s Ingenix and Aetna, respectively, the latter at $500 million.  Ingenix also acquired Picis, focused on hospital high acuity, and A-Life, focused on natural language.   IBM acquired Initiate, the leading HIE middleware vendor for master patient index.

    2. Marlin & Associates helped explain the HIT consolidation as potentially resolving into a few super-firms who integrate infrastructure, applications and analytics for payers, providers and patients.  They see an analog to financial services and Bloomberg or Thomson Reuters.

    3. eHI surveyed 60 federally funded regional extension centers (RECs) and 234 HIEs and reported both groups off to a slow start.   14 RECs had signed agreements with physicians for services.  Most are presenting a limited set of 3-8 recommended EMRs to physicians.  18 HIEs are sustainable without additional federal funding.  Most common functions are connecting to EHRs, getting lab results and patient summaries.

    4. Health systems are the most mature information exchanges because they have natural business relationships with community physicians.  In fact, Premier announced it has 40 large health systems in a training program to create accountable care organizations.

    5. Surescripts announced that it is opening up its physician, pharmacy and PBM network to carry clinical transactions other than pharmacy, starting with patient summaries.  Any US physician can send patient clinical summaries to any other physician in the US. The service connects networks to outside physicians, mid-sized EHR solutions to its client physicians, and a portal for physicians without automation.

    6. The Epic users group in Minnesota reported that it has a health record database representing 75% of the patients in the state.  Most of the state’s large health organizations use Epic software.

Focus on Care Communications in 2010: The Year’s Top Stories

    1. Insurance regulators agreed to include certain health IT expenses as medical expenses when calculating an insurer’s medical loss ratio under federal PPACA legislation.  These include expenses related to communications of health record information among providers and their patients. This should make payer investments in wellness, care management and HIT easier.

    2. The market is beginning to look beyond the EMR to find better solutions, in one study, for communications outside the practice and in another, to support medical homes.

    3. The California Health Care Foundation released a report showing 15% adoption for personal health records in California, 11% in western states, and 7% for the US.  Kaiser Permanente and Group Health are major drivers.

    4. Kaiser’s EHR physician user interface is shown improve patient compliance with guidelines in two clinical studies. The tool monitors six chronic conditions and preventive measures.  Patient notifications are sent via secure email. Kaiser also reports that members that use email do better than members that don’t.  Ironically, another study reports that US physicians don’t use email.

    5. Home health is emerging as an important area in care communications.  The two segment leaders, Intel and GE, announced a joint venture combining their products and sales and marketing efforts.

    6. Mobile communications is also important.  WellDoc announced its mobile diabetes solution won FDA approval and a distribution deal through AT&T.  Diversinet reported an Army deal to monitor returning vets with brain injuries.

    7. Body networks may be the next phase in fitness and wellness with Zeo, Philips directlife and FitBit.

A Few Final Words. Long term health and technology trends lay a foundation for the current dynamics in health IT.  Federal legislation is the big driver right now.  Through provider incentives it will drive adoption of certified EHR solutions from a rapidly consolidating market.  Hospitals are supporting by helping affiliated practices automate.  Insurers are supporting with P4P programs and new investments allowed by classifying clinical HIT as a medical expense.  Larger hospitals and practices will automate first.  But to get to Stage Three of meaningful use and clinical practice transformation, EHR technology isn’t enough. Innovation is required to create solutions that support more collaborative care among providers and between providers and patients in medical homes and Accountable Care Organizations.  And provider compensation must be reoriented toward a new practice model.

Michael Lake has been a healthcare technology strategist for over 30 years.  He is President of Circle Square Inc., a San Francisco-based strategy, business development and market research firm, focused exclusively on the healthcare information technology market. He publishes the HIT Trends Report monthly.  For more information, please see www.michaellake.com.

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22 replies »

  1. Excellent link, Dr. Silverstein.
    __
    “Is it possible health IT cannot improve patient care in such a suboptimal setting, but in fact make the time-constraint issues worse?”
    __
    One of the core beefs regarding EHRs it that they’re really all about the billing. Unless we find a politically and economically viable path away from the FFS warp speed treadmill medicine model, we will remain in problematic circumstances.

  2. Bobby G writes:
    Most fundamentally, I find the coding/billing-driven absurdly time-constrained patient encounter paradigm egregiously unfair (and counterproductive to outcomes in the aggregate)
    Yet that is what we have in the U.S., and it will not change any time soon.
    Is it possible health IT cannot improve patient care in such a suboptimal setting, but in fact make the time-constraint issues worse?
    Are we trying to treat the wrong problems?
    — SS

  3. BobbyG:
    Thanks for the response, and Happy New Year. I think you and I probably agree on more than we disagree on. I’m just becoming increasingly convinced that our current HIT ventures are really just putting lipstick on a pig. And that lipstick is very expensive, and very labor intensive. And the pig is very dysfunctional, dysfunctions that will not be improved, and very well may be made worse, by the lipstick application. I can think of many better uses in health care for that money and labor.

  4. @pcp –
    I am not an “IT Guru,” I am principally a statistical analyst of long experience, much of it in health care (with stints as well in credit risk modeling, industrial diagnostics, and environmental radiation analysis). To me, IT apps are merely tools for getting the jobs done. Neither am I an unreflective cheerleader for HIT. In fact, my next blog update will delve yet deeper into the widespread “usability” problems of HIT that have gotten woefully insufficient attention (e.g., see the recent better-late-than-never NIST report, NISTIR 7741).
    What you naysayers also overlook is that I am an the side of the physicians and their clinical support staffs. I have a deep appreciation for the difficulties they face, and have studied in detail the salient cognitive and empirical elements of (and problems with) clinical decisionmaking. Most fundamentally, I find the coding/billing-driven absurdly time-constrained patient encounter paradigm egregiously unfair (and counterproductive to outcomes in the aggregate). I wish doctors were paid more like lawyers, with their market-based rates based on their objective records (yeah, and, I know, that analogy ain’t perfect either, and it ain’t gonna happen, I know).
    BTW, to your “”if you’re not using the product, you have no right to an opinion on how usable it is” retort: I frequently sit at my desk with my stopwatch, running through various encounter scenarios using the numerous “sandbox” EHR installs that many vendors provide us, building fictional patient accounts and encounters, the whole ball of wax including Demographics, FH, SH, PMH, CC, HPI, Vitals, Meds, Allergies, Labs, ROS, the SOAPe process (including px orders), etc (and, yes, dropping the bill). I do similar things out in the field as I work onsite with our various REC clients, walking them through the navigation workflows relating to the meaningful use requirements, always sensitive to the reality that any appreciable net workflow FTE burden can complicate their efforts and negate the MU incentive money (and we are fastidious to ask for and document problems they have with their respective systems).
    __
    “I’ve also been a care-giver for acutely and terminally ill relatives, but this is IN NO WAY comparable to what docs and nurses trying to use EMRs to simultaneously care for a dozen patients are experiencing.”
    __
    I understand that, but I’m just telling you that I could not be more sensitive to the difficulties clinicians face in the trenches, and a significant part of that comes from my having had to shlep in and out of hospitals, outpatient clinics, rehab units, and nursing homes etc ongoing since 1996, which simply serves to reinforce my HIT work experience. Again, you and Stenes can indulge in a facile blow-off because I’m not a physician, but I am daily in the company of many IT-savvy physicians who also reject this “perfectionism fallacy” schtick.

  5. ‘Oh, OK, there you go, the classic “if you’re not a doctor, you have no right to an opinion in these matters.”
    Mr. Stenes, I have been an acute cases next-of-kin caregiver since 1996, my work in IT and data analytics aside. So, spare me the tired condescension.’
    No, what he’s saying is “if you’re not using the product, you have no right to an opinion on how usable it is.” And that is true.
    Your posting is very typical of the attitude on the part of HIT gurus that causes so much trouble. The experience of the USERS (not the designers and the marketeers) of the product has to be the primary consideration. As we’re seeing, if the experience stinks, the product doesn’t sell.
    I’ve also been a care-giver for acutely and terminally ill relatives, but this is IN NO WAY comparable to what docs and nurses trying to use EMRs to simultaneously care for a dozen patients are experiencing.

  6. BobbyG
    “you simply think deployment of digital HIT is a net waste of effort and resources? That medical information contained on paper is less complicated and less difficult to manage, and thusly better facilitates care?”
    Based on studies published so far and personal experience, yes.
    I’m not the one making ridiculous claims for the imagined benefits of EMRs/CPOE, so I’m not going to waste my time devising studies to prove them. If the EMR cult cannot provide, and has no expectations of ever providing, evidence to support their claims, isn’t it about time to admit it?
    Honestly, the real problem isn’t EMRs. It’s that our medical system has been so totally corrupted by ICD/CPT/CYA that EMRs are only making things worse. It’s like trying to repair a ruptured aorta with a one-inch BandAid: it’s distracting, time-consuming, and it just clutters up the work area. By obsessing over EMRs, we’re ignoring the real problems.

  7. @Samuel Stenes, MD-
    Oh, OK, there you go, the classic “if you’re not a doctor, you have no right to an opinion in these matters.”
    Mr. Stenes, I have been an acute cases next-of-kin caregiver since 1996, my work in IT and data analytics aside. So, spare me the tired condescension.
    Sir, there are LOTS of other DOCTORS who would emphatically disagree with you, so, while you can enjoy your summary ad hominem dismissal of me, it’s not gonna wash. Moreover, the technology choices are increasingly NOT your weak false dichotomy of a paper folder vs computer terminals.
    That was rich.

  8. Bobby G has no idea about patient care when stating: “That medical information contained on paper is less complicated and less difficult to manage, and thusly better facilitates care?”
    Booby G, when did you last take care of a hospitalized patient?
    There are huge advantages of having hundreds of data points, clinical responses, and test and exam finding right there in your hands, only accomplished with paper.
    A terminal for today’s results may be of help, but only minimally…
    Unless, you have the luxury of at least 5 computer screens available at your desk to accomplish the same thing…but many clinicians and nurses can find information quicker on the paper chart than by silo-searching…omg, these devices do not even have a search function!

  9. @pcp –
    So, given that you sidestepped the question regarding how you would operationalize a RCT of HIT to dispositively prove or refute its value, can we then assume you simply think deployment of digital HIT is a net waste of effort and resources? That medical information contained on paper is less complicated and less difficult to manage, and thusly better facilitates care?

  10. propensity (& co) is outraged at the very idea anyone would propose, much less attempt to implement, incentives for application/use of technologies to monitor/measure what clinicians are doing.
    It should be obvious that when doctors say they are doing something safe & effective for patients, we should just take their word for it. After all, that approach has always worked so well in the past, in medicine as in other endeavors.
    stick a leech in it, p

  11. BobbyG:
    ‘Is the broad a priori assumption that better aggregate access to clinical information (e.g., more timely and comprehensive and accurate, net) is “better” for everyone involved unwarranted in principle?’
    So far, it seems that access to information is not “better”, but more complicated and difficult to manage, so I think your question is specious. I don’t see any evidence that “everyone involved” is benefitting.
    I do think your comparison of the adoption of EMRs and the invasion of Iraq (both based on wishful thinking and lies) is quite apt!

  12. @pcp –
    I am not unsympathetic to your point. But, tell me how you would go about operationalizing a RCT of HIT that would illuminate any significant and generalizable difference? Some things in society are problematic. You don’t invade half of Iraq, holding the other half as a control group, and see which half turns out “significantly better.”
    Is the broad a priori assumption that better aggregate access to clinical information (e.g., more timely and comprehensive and accurate, net) is “better” for everyone involved unwarranted in principle? The fact that they’re having to shoehorn this stuff onto the existing unsustainable and unjust reimbursement paradigm is another matter, one that just unhappily serves to cloud the core issue.
    BTW: Citing the study above that Dr. Stenes serves up via which to naysay:
    “… [ONC] has initiated several programs designed to increase the likelihood that the transformative vision of the EHr will finally be realized. Key policies and programs include EHr certification, development of meaningful use criteria, a regional extension program, state health information exchanges, funding of university and community college programs to bolster the health IT workforce, and research support to improve the safety, security, and usefulness of the next generation of EHrs.
    We believe that these programs are well conceived and anticipate that they will lead to more effective use of EHrs, which will in turn lead to improved quality in US hospitals.”
    While I was not exactly born last night, neither am I a fan of “Perfectionism Fallacy” excuses for failing to act. If you take to the trouble to read my REC blog posts, you will see that I am no unreflective Polyanna HIT cheerleader, but I have to come down on the side of HIT in the end.
    Not that I won’t be calling ‘bullshit’ where I see it on that side as well.

  13. No matter how dangerous these CPOE devices are, it is now law that they are to be purchased and “meaningfully” used. That the doctors put up with this is a sad commentary on their professionalism.
    Just think, the government wants you to use medical devices that have no vetting for safety and efficacy, and multiple studies showing no benefit to outcomes or costs.
    The best advice for the doctors who desire to continue to provide safe and effective care of their patients, do not purchase these disruptive devices, despite the pressure and “incentives” from the government. Take the pittance of a penalty. Your patients will thank you.

  14. BobbyG:
    Put the shoe on the other foot. Cite one randomized study with controls that shows any of these “trends” doing anything to improve patient health. It is the responsibility of those who make seemingly outrageous claims to provide supporting evidence.

  15. I do not agree with your term “elegant” strategy of federal legislation. There was nothing elegant about it. Elegance as defined in the dictionary is:
    1. tasteful in dress, style, or design
    2. dignified and graceful in appearance, behaviour, etc.
    3. cleverly simple; ingenious an elegant solution to a problem
    [from Latin ēlegāns tasteful, related to ēligere to select;
    Obama care, for want of a better identifier, was and is a ‘sledgehammer’ approach with a multi-pronged approach to making change with a law that was written, and approved by a congress that did not take the time to read or analyze it’s impact upon health financing and care in the U.S. It is not a health care reform law. It is a health care financing reform law. It has already had a negative impact on the economy, business planning, and counterproductive moves by insurers to guarrantee recouping their losses. Less than 10% of President Obama advisors are from the private sector.

  16. @Samuel Stenes, MD
    “misrepresenting the truth about the adverse outcomes, rip-off costs, and disrupted medical care in hospitals.”
    ___
    And, you, of course, can documentably enlighten us as to the extent and characteristics of these? All of which can be laid at the feet of HIT?
    You cite ONE dated and narrow study reporting mixed and hedged results to summarily dismiss inpatient setting HIT? Would you care to expand on that?

  17. Your failure to report on the RAND study is consistent with your religious beliefs about HIT: http://www.ajmc.com/supplement/managed-care/2010/AJMC_10dec_HIT/AJMC_10decHIT_Jones_SP64to71
    Your report is flawed, misrepresenting the truth about the adverse outcomes, rip-off costs, and disrupted medical care in hospitals.
    The results of the current RAND study were not in keeping with what Cerner paid for (Hillestad et al) from RAND in 2005, so now they propose new research methods to make steak out of bovine waste.

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