CommonWell Is a Shame and a Missed Opportunity

The big news at HIMSS13 was the unveiling of CommonWell (Cerner, McKesson, Allscripts, athenahealth, Greenway and RelayHealth) to “get the ball rolling” on data exchange across disparate technologies. The shame is that another program with opaque governance by the largest incumbents in health IT is being passed off as progress. The missed opportunity is to answer the call for patient engagement and the frustrations of physicians with EHRs and reverse the institutional control over the physician-patient relationship. Physicians take an oath to put their patient’s interest above all others while in reality we are manipulated to participate in massive amounts of unwarranted care.

There’s a link between healthcare costs and health IT. The past months have seen frustration with this manipulation by industry hit the public media like never before. Early this year, National Coordinator for Health Information Technology Farzad Mostashari, MD, called for “moral and right” action on the part of some EHR vendors, particularly when it comes to data lock-in and pricing transparency. On February 19, a front page article in the New York Times exposed the tactics of some of the founding members of CommonWell in grabbing much of the $19 Billion of health IT incentives while consolidating the industry and locking out startups and innovators. That same week, Time magazine’s cover story is a special report on health care costs  and analyzes how the US wastes $750 Billion a year and what that means to patients. To round things out, the March issue of Health Affairs, published a survey  showing that “the average physician would lose $43,743 over five years” as a result of EHR adoption while the financial benefits go to the vendors and the larger institutions.

CommonWell is just IHE 2.0. IHE stands for Integrating the Healthcare Enterprise, a decade-long project of HIMSS designed to preserve a business model where neither physicians nor patients buy anything (the industry represented in HIMSS serves institutions almost exclusively) and interface costs account for some 60% of revenues. 60% interface costs should be compared to pre-IHE medical interfaces such as DICOM and the universal Internet business model where interfaces are free and only services are billed.

IHE is a governance mechanism for interoperability practices that is managed by the largest EHR vendors and has brought us a decade of stagnation, consolidation, vendor lock-in, and physician and patient frustration. CommonWell is a governance mechanism for interoperability that is managed by the same EHR vendors under a friendly new name.

The specifics of CommonWell are still undocumented. From what I can tell at HIMSS13, the focus will continue to be on institutional control of the physician-patient relationship, coercive patient ID practices, information silos defined by institutional concepts of what patients trust, and protocols designed to perpetuate the vendor lock-in business model.

So let me summarize what I see so far at HIMSS13. Take $10 to $20 Billion of taxpayer money (depending on how HHS will handle remaining EHR interface regulations and privacy governance issues), use it to consolidate small practices and entrepreneurs out of business then orchestrate rent-seeking behavior on 20% of the US economy to extract value from our own data that we can’t access ourselves.

It’s not easy to waste $750 Billion a year by overcharging and providing unwarranted care but coordinated efforts such as CommonWell look like they will continue the health IT industry’s contribution. It’s easy for CommonWell to prove me wrong by announcing that the data liquidity they propose means all interfaces from federally subsidized EHRs will be free and under the control of individual physicians and their patients.

Adrian Gropper, MD is Chief Technical Officer of Patient Privacy Rights and participates in Blue Button+, Direct secure messaging governance efforts and the evolution of patient-directed health information exchange.

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  1. We are looking for funding to do the port to open source. Once we get the funds needed, the port will begin as it has to meet all the regularity and open access the environment will have in order to be a true open source project. The app has taken over three years to get it to work as a closed source system but because the system architecture is done and proof of concept works, the move into open source will not be difficult as the database used is a traditional relational database configuration able to be ported to a PostGresSql or equivalent open source db without issue. 6 – 9 month time frame is a realistic estimate for sharing code once funding has been garnered. Initial reaction has been extremely positive to say the least.

  2. We are working on an open source solution to the nightmare known as HC. The software architecture is done and the proof of concept works without question. The next phase it to get sufficient funding to enable the app to scale and meet regulatory concerns while becoming open source as we intend this app to leverage the net in ways that cannot be done using closed, proprietary code that hinders the ability of medical practitioners to do their job with any degree of true efficiency.

    Excellent site, I like what’s being said here.

    • @Robert RE “We are working on an open source solution” < can you please tell us what your expectation is WRT the timeline for sharing access to the code repository to enable independent review, comment and contributions?

  3. Hayward and John make excellent points that I mostly agree with but my concern with CommonWell is tactical and immediate. Clinical software is no different from any other form of medical publishing such as textbooks. A lot of our profession depends on dissemination and processing of information and the physician’s dedication to science, peer review and teaching at all levels of the craft. All of medicine is open source except for our clinical software and, as Hayward and John point out, we are all the worse for it.

    Proprietary clinical software makes no more sense than secret surgeries or magic potions. Open source software would not create these outlandish expectations or require $20 Billion of “incentives” that have primarily increased software cost and vendor lock-in. Imagine where we would be today if the federal government had spent $20 B on open source software instead?

    It’s not too late for all of us to insist on open source software in healthcare.

  4. While I have the utmost respect for Adrian’s ken and his understanding of the healthcare system and the HIT world, I have a slightly different take on the implications and promise of HIT.

    I am a practicing physician and a self-proclaimed health IT geek. I wrote my own electronic medical record program (ComChart EMR) starting back in 1991 and has been selling it since the late 1990s. No one can accuse me of being “anti-technology.”

    I used to believe more health information technology would solve the healthcare crisis, ie, reduce the cost of healthcare or improve the quality of healthcare. I am now reasonably certain that is a pipe dream. This pipe dream is being promoted by politicians, computer software engineers, and others who don’t really understand how healthcare works and all of whom have a vested interest. Politicians are responsive to the large electronic medical record companies who support their candidacy. They also desperately hope that health information technology will “fix” healthcare crisis so they are not required to “vote” on legislation that the public will despise. Computer software engineers obviously see this as an employment opportunity.

    A widely publicized RAND study (Health Affairs, 32, no.1 (2013):63-68) looked at this topic. While the article is replete with the author’s bias in favor of the use of health information technology, the authors’ finally conclusion is that health information technology has not yet had a beneficial impact on healthcare crisis

    Kaiser Permanente, a very large healthcare company, has literally invested billions of dollars in health information technology in the hope that it was going to solve the healthcare crisis. On March 20, 2013 George Halvorson, the CEO and chairman of Kaiser Permanente was quoted in the New York Times is saying “We think the future of health care is going to be rationing or re-engineering.” Clearly, he has concluded that, despite an immense investment in HIT, information technology is not going to solve the cost/quality problem. That is not to say that health information technology does not have a role in healthcare, only that is not going to solve the healthcare cost/quality problem.

    Although many believe that healthcare industry should respond to market conditions and information technology, as have all other industry, there are reasons to believe otherwise. The United States’ health care system has always been a free market system, initially it was the barter system, then cash, then there were some commercial insurances, then the HMOs, and now Accountable Care Organizations. While the specifics have changed, it has always been an essentially free market industry. One would think that the free market would drive down costs and improve quality, but that has not been the case. In most advanced industrial societies, healthcare costs are controlled by their federal government, and many have a single payer. In these Federally controlled single payor healthcare system, it can be objectively demonstrated that their quality of health care is better than the United States and the healthcare costs are substantially less. Although this is counterintuitive to a “capitalist’s” world view, this is the reality of healthcare system.

    Why this happens is a bit unclear. My opinion is that most US patients and physicians sincerely believe that they will be “healthier” if more money is spent on their health care. While there are numerous studies to demonstrate that this is not the case, this illusion persists and, as a result, it is very difficult to drive down the costs or improve the quality of health care using the free market system.

    • I also believe single-payer is the only real long-term solution. There are way, way, WAY too many players in our capitalist version of healthcare, and health is not something that lends itself to capitalist management — there are too many human behaviors, genetic dumb-luck outcomes, profit motives, corporations, education levels, and people and organizations mixed together to make sense of it all.

      In terms of Health IT, what I would say is this… IT cannot solve the systemic problems we have and IT is not a panacea for our problems. Our problems transcend information gathering, processing, and analysis. Health IT is a set of tools that do not make you well, nor do they make you sick; they don’t make healthcare profitable, nor do they make good healthcare affordable. That said, a total lack of digitized health information can only prolong our problems, because we can’t “see” our healthcare system in quantifiable data. We can’t assess the scope of our problems without semi-standardized technology.

      I see only two paths forward for the industry and our nation: Either:

      [1] We double-down on the capitalist version of healthcare, and bring customer and vendor together (patient and health provider), while pushing third parties to the side (insurance companies), creating a real market of competition, price transparency, and customer responsibility, or

      [2] We follow the example of every other nation and centralize our healthcare and separate profit motive from human health outcomes for good. Companies that profit from disease cannot be trusted to help us build a healthier population — they have a vested interest in sickness.

      But in either path, we need information. We need digitized health so patients can see / access / utilize / extend their health information. We need health data to be portable between all the players. We’re not going back to paper. So let’s buckle in and start building a better healthcare future with selective application of Health IT.

  5. Here’s my comment to Forbes thread on Epic vs. CommonWell:

    Epic and CommonWell are two sides of the same coin. Both depend on picking and choosing the open standards that favor a vendor lock-in business model.

    CommonWell is built on a devilishly clever concept of “profiles” that was pioneered by the HIMSS vendors under the name Integrating the Healthcare Enterprise (IHE) some 10 years ago. The vendors use a closed process to pick inadequate standards (or standards they can manipulate to make them inadequate, like HL7) and then use a large-vendor-managed process called IHE to develop profiles and very expensive certification requirements on top of the standards. All together, this ensures that innovators are excluded and startups are driven broke. The founders of CommonWell have been honing this method for years in IHE and all they did was invent a friendly new name for IHE.

    For its part, Epic is openly closed but what people don’t know is how much it charges for its messaging from Epic to any other vendor. I’ve heard it’s more than $2 / message but this is unconfirmed.

    The coin of CommonWell / Epic stands in sharp contrast to Internet and Web practices where interfaces are always free, large vendors like Google spend massive amounts of money making it easier for small innovators and developers to interoperate, and the standards, although also manipulated by large vendors to some extent, are done in an open process that also ensures that open source software is not at a disadvantage.

    Vendor lock-in in US healthcare IT is a major impediment to reducing the $750 B in unwarranted care.

    • As I mentioned at Direct Scalable Trust, I’ve been meeting with VCs to get their feedback on achieving some balance, (or at least a hedge), in terms of the lock in problem as described by Adrian. Generally many people realize the problem of the lock in, but the short is the most common approach to deal with this.

      Consider it equivalent to what Michael Lewis described happened in the “The Big Short” I will convince them that the HIT bubble is slowly leaking air, by consuming far in excess of what it could and should do to get the real job done, and point out where that money is really going. However it’s still in a consensual model because that’s the only way to get anything done, it has to be a shared realization of where it is going anyway in terms of the economy.

      I’m quite willing to be public about this strategy because it is a strategy where all the actors have to play their best strategy, i.e. a nash equilibrium.

      Thus in terms of the ad hominem or it’s counterpart Ipse Dixit that’s largely irrelevant.

      Certainly with the kind of money that was thrown at the defined problem with ARRA one of the actual effects was to solidify the business layer model that Adrian and Margalit described in which organizations use EHR both in a MU but also a dual-use sense that disadvantage the PCP and long term relationships to shift affinity to organizations.

      People see the image of the Norman Rockwell painting of the office visit, or a specialist, but they are really confronting a system in which they have no personal level of meaningful control over the relationship.

      The major cost savings will also be in the form of personal control over large systemic forces, which first means being realistic about what those forces are.

      So, Epic is in effect right, its a distraction towards solving the real problems, but then clearly says it could be a business layer “dual use” weapon against them. Oddly everyone is right, for different reasons.

      • Peter, are you sure it’s leaking air as slowly as you imply? Do you really think the feds are going to risk heaping more MU3 regulation on an already unpopular and politically challenging program and then patiently wait for MU3 to become effective in 2117 or whatever century the incumbents would have it?

        I think MU2 is it. There’s enough in MU2, VA / DoD, and state HIE procurement to drive the singularity I described here a last year: https://thehealthcareblog.com/blog/2012/09/17/the-coming-health-care-singularity/

        I take CommonWell as evidence that it’s already too late for the institutions. They waited too long to start paying attention to the value they’re not adding.

        If the doctors on the frontlines don’t step up and start paying attention to their IT tools instead of MU, the patients will do it for them.

        • No I’m not sure.

          The rate of economic descent may have more risk than I anticipate for the late adopters as the model shifts and they continue to use the same strategies, and I do include Zittrain’s “generativity” regarding the distribution of intelligence and networks as a significant factor leading towards that singularity. The motivation to crush the innovators is bad for the country, but rational since the current approach is not sustainable and while individual innovations may in fact be welcomed, the real game changing systemic effects have yet to be felt.

  6. I agree with Adrian’s blog. Physicians have been relegated to vendor status in a massive medical-pharmaceutical-insurance-health information technology complex. This complex will eventually dwarf the military-industrial complex that President Eisenhower has so presciently warned us about.

    I am fed-up with the whole “meaningful use” world. I do not believe “meaningful use” has improved the quality of medical care I deliver to my patients and it is impeding my ability to take care of my patients. I knowledge that some of the things “meaningful use” demands is “good,” but that is not a justification for the entire HIT world or of the many mandated “meaningful use” hoops I must jump through every day.

    Until there is data to prove otherwise, I will not believe a fully interconnected medical community is going to significantly improve the quality of care or reduce the cost of medical care in the US; as the vast majority of medical care does not require the physician to have access to every last bit of their patient’s medical data.

    I believe we, physicians, have been sold a bill of goods from the medical-pharmaceutical-insurance-health information technology complex, that the HIT world will solve everything that is wrong with US healthcare. I also believe the HIT spokespersons will denigrate anybody who speaks out against the HIT world as a luddite or anti-healthcare. (I was publicly accused of violating my Hippocratic oath, by a prior CMS director, when I publish a letter arguing that CCHIT had too much influence in HIT.)

    I think it is far past time that the CIT formally discussed this topic. With all due respect to Joe Heyman’s comments, I do not believe that our last meeting addressed this issue, we were simply responding to questions provided to us.

    It is my opinion that the committee should issue a formal statement arguing that the whole health IT agenda needs to be put “on-hold” until there is objective data showing that Meaningful Use and an interconnected medical community actually results in a reduction in the cost of health care and/or an increase in the quality care, which is sufficient to justify the HIT expense and societal disruption. I also think that CIT should issue a formal statement mandating that all HIE technology and EMRs be open source or fully transparent, and the Federal Government (or Comm of MA) show “favor” this type of technology. Should MMS CIT publicly issue such a statement, it will have great weight in many venues.

    If we fail to stand-up for the practicing physician, we will only have ourselves to blame when the medical-pharmaceutical-insurance-health information technology complex steamrolls every practice in the US.

    Hayward Zwerling, M.D., FACE, FACP
    President, ComChart Medical Software, http://www.ComChart.com
    The Lowell Diabetes & Endocrine Center, http://www.DiabetesEndocrine.com

    • I’m definitely sympathetic to the physician’s plight, but I can’t let one of your notions pass without comment.

      You claim we should stop all HIT investments and stop the meaningful use march until we have proof these technologies are making an impact on cost and/or quality. But that’s not possible. You can’t prove HIT works (or fails) without, (a) fully deploying it, and (b) collecting data on its efficacy. Put another way, you’re saying we shouldn’t hatch any eggs until we’ve proven there are chickens to lay them. Or something. 😉

      The only way to prove HIT’s value is to deploy it, integrate it, and gather data on its use — meaningful or otherwise. We’re just not there yet. Lots of practices still don’t have EHRs deployed. And most EHRs are, so far, not very well integrated with practices, partially because the developers don’t understand medical practices, and partially because lots of doctors and practices prefer to behave idiosyncratically rather than systematically. The ‘country doctor’ lives in the hearts of many physicians today, and data-driven medicine is anathema to that self-image.

      I could go on. But the reality is that we need more data, not less, and the only way to deal with data is with technology. I’m not a fan of all the regulations out there and I think the giant money dumps from ARRA and HITECH and so on have done just as much harm as good. But there’s no question health data is the future, and technology is right there along with it.

      • You sir, get a thumbs up for this post.

        When medicine wants to document quality improvements, cost improvements, outcome improvements, I’m all for that. When medicine says “proof of such improvement is a prerequisite for investment in the improvement program”, I call BS.

        I have been in IT for a long time now. The thing is that IT has been used successfully in every industry, every sector, every type of organization. Personally, I’m fascinated in IT failures and how, despite those failures, organizations continue to try. They see the successes and the draw of those successes spurs action.

        There’s no particularly compelling reason to believe that medicine is an island in society, immune or somehow apart from the forces that change everything else. Medicine has gone a long way as a craft, structured somewhat like the guilds of old. Their professional organizations are unusually strong, and it helps that there is a stress on education, publishing, and evidence.

        Nonetheless there are substantial areas of medicine that simply need some modern process control. Practices and outcomes can be greatly improved just by introducing these.

        There is no longer any justification why proven best medical practices, fully published and peer reviewed, takes an average of 17 years to become the universal standard of delivery. That statistic is not one to be proud of.

        As for CommonWell, I simply don’t know. Sometimes these ad-hoc groups can do real good and produce a de-facto standard that works. There’s already a good base with HL7 v3 and hopefully they will leverage that. MU comes in for lots of criticism, but who else is there? Data sharing can and must occur. I’m for whatever structure or organization will spur the changes needed to make that happen.

    • They both apply. With 10 years of experience in manipulating a market, they have developed a very sophisticated and almost organic capacity for sham and the good people involved may not even realize how they are contributing to unwarranted care.

      Thanks for the link! Innovators need access to our data in ways that we can hardly imagine. As the story notes, this access has major privacy implications and requires both open discussion and appropriate technology. CommonWell missed an opportunity to do this.

  7. Thanks for this piece. When I saw the news out of HIMSS and saw the list of vendors, I rolled my eyes. As noted in prior comments, this is a defensive move against Epic and an attempt to give the impression of forward movement without direct government intervention by regulation.

    I’m sure the individuals cited above mean well, but in companies of thousands of people, thousands of customers, hundreds of strategies and millions of lines of code, the notion that interoperability will go to the top of the list and stay there is not credible. Even well-funded HIE-focused developers can’t do this well or easily yet. Moreover, customers are not screaming about interoperability yet — first they want EHRs that make patient care easier, faster, better. Money talks, especially from customers.

    Personally, I’d rather see this data model turned on its head, as it’s likely to be in the years to come anyway, where patient data is standardized and the “users” are both patients and doctors. Think the GEDCOM model from genealogy, in which lots of client software can read and create the files. Or DICOM. Or even Excel documents. The future looks to me like standards centered on patient-owned patient data, not doctors, and not institutions.

    • Exactly!

      I love that you bring up Excel. Almost all of us still use Excel format to work with each other but Google Docs and Windows / Mac users use very different systems to do it. Some users add Dropbox and others Sharepoint to the workflow. Very few people complain about their spreadsheet tolls or the interoperability.

      This kind of interoperability did not evolve because Microsoft and Google and some kids at MIT hacking Python (Dropbox) went into a back room and decided on a clever name to introduce at the industry’s major annual meeting.

    • John, this may be a naive question to ask, but doesn’t CDA address the problem of standardizing patient data?

  8. HIT vendors and the courts


    On Monday, March 4, a group of doctors who are suing their electronic health record (EHR) manufacturer for selling them a “buggy” product and then discontinuing it learned that the defendant’s motion to block the lawsuit and compel them to accept binding arbitration was overruled by a judge in Miami, the first step in getting a court date in what is believed to be a first-of-its-kind case.

    At issue is the quality of the product the doctors were sold and the defendant’s subsequent failure to support or improve it as promised. Anesthesiologist Robert J. Joseph, MD, of the Pain Clinic of Northwest Florida in Panama City, a plaintiff in the suit, makes no bones about it. “Our EHR is a piece of crap,” he states.

    • What patient would want to see a doctor who is so stupid as to voluntarily buy a “piece of crap” EHR?

  9. Adrian-You got it

    “Increasingly, physicians are losing whatever influence they may have had in this matter, and it wasn’t much, as they are forced by government policy to become employed by these institutions. And unfortunately, those who supposedly advocate for patients are blinded by misinformation and are relentlessly tilting at the windmills of “paternalistic” doctors and “computable data”, while corporations are robbing everybody blind of both cash and freedom of meaningful choices”

    Dr. Rick Lippin
    Southampton, Pa

  10. The EHR vendor business model of the past two decades has been non-interoperable technology, proprietary business models, high switching costs, and customer lock-in.

    There are many details to work through and much of the intent is yet to be discerned, but CommonWell is exactly what we’ve asking the EHR vendors to do.

    Shame on you, Adrian, for not noticing that CommonWell is at least a glass half full.

    • Vince,

      I’m not sure if you’re being serious. It has been said that “systems are perfectly engineered to achieve the results that they actually produce” and my point about the similarity of governance between IHE and CommonWell is just that.

      From my first hand conversations, the overall secrecy, and the lack of specifics, I can only infer that their plan is to streamline some aspects of classical HIE practice while disregarding some issues of privacy and, like the Epic everywhere silo, disregarding the fact that patients should not have to choose services based on vendor and institutional strategy.

      Can you point to any information that suggests otherwise?


      • Adrian, I’m perfectly serious that your knee-jerk, pessimism toward CommonWell is premature and unjustified.

        This project was spearheaded by Arien Malec of McKesson and Dr. David McCallie of Cerner. We know both of these people and we know they have integrity.

        I – and many others – see CommonWell primarily as a competitive strategy toward Epic. Epic sorely needs competition. I trust neither you nor I want Epic to dominate the EHR markets (hospital and ambulatory).

        As to not solving the problem of institutional control over the physician-patient relationship, I’ll grant you CommonWell in its current form doesn’t address this problem. CommonWell also doesn’t address world hunger. Is that a reason to reject it?

        Similarity of governance between IHE and CommonWell? We’d both agree that IHE has been very weak. But times are different now and EHR vendors have economic incentives to move toward more collaborative, open platforms. Why are you assuming the worst here?

        Much of your ideology about free interfaces and physician control has appeal, but that’s no reason to reject the good while waiting for the perfect.

        Again, shame on you Adrian for not noticing that CommonWell is at least a glass half full.

        • I know and have deep respect for all of the people you mention and many others in the EHR business. I am, a career vendor myself. What’s at stake here has nothing to do with the fact that the architects themselves are great people. Please see my reply to Margalit for my perspective and why this is not a glass half-full.

          As far as the glass half full vision you have, many in the e-patient and privacy community say “nothing about me without me” and I doubt that they would see this as a positive step.

          • Please allow me to try one more line of argument about the glass…

            I’ve worked with the folks in standards, IHE, and the architects of CommonWell for many, many years. To a one, their integrity is unmatched. By the same token, I do not doubt the integrity of the physicians I work with either.

            My thesis is simply that both architects and physicians are being manipulated as part of a system that results in an incredible amount of unwarranted care and that CommonWell shows no evidence of changing that system.

            For me to see the glass half-full, I would need to see how CommonWell is different from IHE, or a tip-of-the-hat toward e-patient and privacy perspectives, or, indeed, actual results.

        • @Vince RE “I – and many others – see CommonWell primarily as a competitive strategy toward Epic.”

          The problem is that CommonWell seems ashamed to simply admit this. Instead they cast it as some groundbreaking and noble gesture.

          That’s more than a little annoying for folks who’ve been involved in sincere efforts to improve Healthcare integration for decades.


  11. Adrian,
    You seem to acknowledge the real problem which is “consolidate small practices and entrepreneurs out of business” and “institutional control over the physician-patient relationship”, but then you seem to expect that the vendors who sell tools to these consolidated institution, should somehow solve the problem by not charging these institutions for some of the tools.

    I just don’t understand the logic. Even if vendors decided to provide interfaces for “free” (although there is a cost with maintaining interfaces), how would this affect the business models of their clients? Are health systems viciously competing for market share, and the right to triple prices, going to suddenly and selflessly begin sharing data with their competitors just because they got a 0.01% cut in HIT expenses? Do you seriously believe that CommonWell or common bad or whatever, can impose their wishes on their multi billion dollar clients’ strategic direction?

    Increasingly, physicians are losing whatever influence they may have had in this matter, and it wasn’t much, as they are forced by government policy to become employed by these institutions. And unfortunately, those who supposedly advocate for patients are blinded by misinformation and are relentlessly tilting at the windmills of “paternalistic” doctors and “computable data”, while corporations are robbing everybody blind of both cash and freedom of meaningful choices.

    • Margalit,

      I should have been clearer that BOTH things are required:
      – free interfaces and
      – physician control (as opposed to institutional control)

      To the extent these things are possible, the patient’s data will move to those EHRs, decision support, care coordination, patient engagement, etc… systems that best serve the physician-patient relationship. In the limit, a physician that doesn’t like her EHR could use a completely different EHR for some or all of her patients.

      Unless we move to this model, physicians will not be able to act as the the patient’s advocate and we will need to create a class of accountants and advocates that mirror our accountants and lawyers in being bound to serve only their client’s interest. This might be inevitable for patients but it will be a loss for the medical profession.

      Under both HIPAA and the principles of the medical profession, the institution has absolutely no standing in this matter. It is only able to control the actions of physicians as a result of policy or contract or convenience. EHR technology that prevents physician action in this illegitimate sense should not be eligible for federal subsidy.


      • Adrian,
        I don’t see how your vision can become reality, unfortunately. Physicians employed by health system are not now, were never, and will not ever be, free to use any EMR they wish. They were not even free to use any paper charts format they wanted before the advent of EMRs.

        The institution may have no standing in this matter from a medical profession point of view, the way medical profession was historically defined, but this definition is being altered as we speak. Institutions decide what your patient load is, where you refer to and what guidelines (clinical and documentation) you must follow in order to remain employed. Patient advocacy is secondary, and subject to corporate rules.

        EHR technology is purchased, implemented and configured to serve corporate rules. EHR vendors have no say in the matter. I agree that they should have the ability to transport information out of corporate walls, but most do (certainly the large ones). Some systems utilize this ability for limited self-serving purposes (e.g. connecting inpatient and ambulatory disparate systems), others do not.

        This is about business, Adrian, not about medicine and not about patients. Remember who was the loudest opponent of making discharge summaries available for patients at short notice during the MU2 debate? It wasn’t the EHR vendors.

        And to Vince’s point, exchanging clinical information does not decrease client lock-in and does not reduce switching costs for EHR vendors. Information exchange, on the other hand, may be detrimental to a health system’s customer retention efforts and, much more important, referral revenue and price setting capabilities.

        • Margalit,

          My main point is that the EHR vendor lock-in business model plays a central role in $750 Billion of unwarranted care.

          The US health care market, where Medicare policy is hamstrung by political influence and private insurance lacks the clout to counteract provider institution consolidation, is unique in the world. Other countries have either more effective cost controls or more effective competition.

          I believe the pendulum you describe has shifted too far in the direction of institutional consolidation at the expense of professional medical ethics. I also believe that technology that empowers patients and professionals will eventually evolve to illuminate the social graph that drives the unwarranted care.

          CommonWell and any other technology that does not treat people as individuals is a missed opportunity. Hopefully, the tide toward citizen empowerment in healthcare is still sweeping in.


    • “those who supposedly advocate for patients are blinded by misinformation and are relentlessly tilting at the windmills of “paternalistic” doctors and “computable data”, while corporations are robbing everybody blind of both cash and freedom of meaningful choices.”

      Great analysis! Those “advocating for patients” are frequently the loudest cheerleaders for big corporation medicine.

    • Actually there are numerous alliances and consortia of this type an many high tech industries. Structured properly, they should have no problems with the feds.

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