OP-ED

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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outletanlgf
Guest

f^Kj% g.*M, /z]%P QA^5> Go,$Z

Robert Moran
Guest

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… Read more »

Robert Moran
Guest

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.

Thomas Lukasik
Guest

@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?

Adrian Gropper MD
Guest

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… Read more »

Hayward Zwerling, M.D., FACP. FACE
Guest

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.… Read more »

John Proffitt
Guest

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… Read more »

kiranreddy
Guest

Health is important for all people in world…. this is useful for all people

Health

vps
Guest

I really love this site. You write about very interesting things. Thanks for all your tips and information.

Adrian Gropper
Guest

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… Read more »

Peter Bachman
Guest

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… Read more »

Adrian Gropper
Guest

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… Read more »

Peter Bachman
Guest

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.

Hayward Zwerling, M.D., FACP. FACE
Guest

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… Read more »

John Proffitt
Guest

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… Read more »

Brian Too
Guest
Brian Too

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… Read more »

Whatsen Williams
Guest
Whatsen Williams

Did you mean to say sham rather than shame? What these vendors do is perpetuate the false sense tha they are trying to improve safety and efficiency rather than ring their own cash registers.

Simple google does more for quality than HIT vendors: http://www.nytimes.com/2013/03/07/science/unreported-side-effects-of-drugs-found-using-internet-data-study-finds.html?ref=science#comments

Adrian Gropper
Guest

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.

John Proffitt
Guest

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… Read more »

Adrian Gropper
Guest

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.

steven j sattler
Guest

EXACTLY — i’m biased but Informedika has such a platform and is in use today.

Peter Bernhardt
Guest
Peter Bernhardt

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

Whatsen Williams
Guest
Whatsen Williams

HIT vendors and the courts http://www.medscape.com/viewarticle/779721 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.… Read more »

southern doc
Guest
southern doc

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

Dr. Rick Lippin
Guest
Dr. Rick Lippin

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

Vince Kuraitis
Guest

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.

Adrian Gropper
Guest

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… Read more »

Vince Kuraitis
Guest

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… Read more »

Adrian Gropper
Guest

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.

Adrian Gropper
Guest

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… Read more »

Thomas Lukasik
Guest

@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.

TJL

Margalit Gur-Arie
Guest

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… Read more »

Adrian Gropper
Guest

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… Read more »

Margalit Gur-Arie
Guest

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)… Read more »

Adrian Gropper
Guest

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… Read more »

southern doc
Guest
southern doc

“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.