Tech

It’s Doctors versus Hospitals Over Meaningful Use

The Massachusetts Medical Society may be the first to notice that Meaningful Use EHR mandates favor large providers and technology vendors. Control over the Nationwide Health Information Network sets the stage for how physicians refer, receive decision support, report quality, and interact with patients. State health information exchanges and policy makers are caught in the cross-fire over health records interoperability. Are the federal regulations over Stage 2 being manipulated to put physicians and the public at a disadvantage?

On Dec. 7, the Massachusetts Medical Society took what might be the first formal action in the nation. A resolution stating:

“That the Massachusetts Medical Society advocate for a more open, affordable process to meet technology mandates imposed by regulations and mandates; e.g., that all Direct secure email systems, mandated by Meaningful Use stage 2, including health information exchanges and electronic health record systems, allow a licensed physician to designate any specified Direct recipient or sender without interference from any institution, electronic health record vendor, or intermediary transport agent.”

Scott Mace’s column Direct Protocol May Favor Large Providers and Vendors is the first to report on this unusual move by a professional society. Full disclosure: I’m a member of the MMS and the initiator of what became this resolution.

Meaningful Use is intended to support health reform by promoting interoperability and innovation in health service delivery. The Affordable Care Act, Obamacare, is fundamentally a free-enterprise model without single payer or even a public option. Obamacare depends on the market for eventual cost controls and sustainability. Meaningful Use is regulation designed to enable market-driven health reform by reducing interoperability barriers.

Although Meaningful Use regulations have already handed out $17 Billion to drive “voluntary” adoption of interoperable electronic health records, meaningful interoperability is still elusive. Meanwhile, the doctors are chafing about Meaningful Use intrusions and policymakers worry that the regulations will actually increase costs.

Earlier, Farzad Mostashari provided his perspective on the strategic importance of technology in this excellent interview about his new role.

The vendors and their institutional customers are interpreting Meaningful Use in a way that allows them to censor and tax physician-physician and physician-patient communications. Control over the Nationwide Health Information Network sets the stage for manipulating all of the key elements of health reform including quality, cost and population health. This is Net Neutrality on steroids.

The MMS resolution will open an important debate over the Meaningful Use regulations:

  • Are physicians, institutions, and patients all first-class citizens in the Direct-based NwHIN?

  • Can EHR vendors price messages and documents that come in via Direct differently depending on where they come from?

  • Is health care trust governed through civil federations like our credit cards or based on criminal penalties like mail fraud?

The answers to these questions will have huge consequences for all of us, way beyond the money scramble between hospitals, physicians, and global corporations. Medicine can be regulated as a profession or as a branded proprietary device. As medicine is increasingly mediated by EHRs and integrated over the Internet, the choices we make around the governance of “trust” on the NwHIN and EHR regulation will dictate the rate of medical progress itself.

With this resolution, my medical society has come down clearly in favor of physician-based trust on the NwHIN. What should the federal regulators do?

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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Kory RykmanSabatini MonatestiPeter BachmanMatthew KatzDavid Morf Recent comment authors
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Kory Rykman
Guest

This is a great write up and even better discussion. I hear loud and clear how one can think these mandates favor technology vendors. And I’m speaking from a technology vendor perspective, being employed by simplifyMD ehr/pm company. From our standpoint, the same amount of effort and money is put forth keeping our clinical charting software compliant to government regulations. So it is not like we get any sort of favorable treatment. For simplifyMD , we have to differentiate ourselves from large hospital based systems to earn the business of private practices. The drop down heavy, point and click decision… Read more »

Sabatini Monatesti
Guest

Trust begins and ends at the patient-care giver (clinician) encounter. Anything that gets in the way of establishing trust, i.e, destroying patient informed consent, privacy and security of PHI is wrong headed. Any HISP that does not allow conduit, adds complexity, destroys PHI security and integrity, and opens the whole system of PHI transfer to identify theft.

Peter Bachman
Guest
Peter Bachman

Obscuring the advantages of Direct encrypted end to end communications between people, and now doctor to doctor, and patient to doctor, has been a strategy of the NSA since 1994 when people rejected key escrow and the LEAF. The misinformation is deliberate and people are beginning to connect the dots following Snowden. However the key management for PKI is hard work, but a lot less work than exchanging private keys, and a lot more scaleable because you can look up public key certificates in a directory and import that into your mail client, thus setting up a Direct connection. This… Read more »

Adrian Gropper, MD
Guest

Many of the excellent points Peter makes are covered in the Federal Health Architecture Request for Comment at http://www.connectopensource.org/fha-directed-exchange-workgroup-survey

The deadline for comments is January 14 and there’s a great deal of very detailed and thoughtful discussion in the four documents they posted.

Although the FHA does not speak for HHS, it has the power of the purse and can do a great deal of good by implementing Blue Button Plus Push (Direct) and Pull (REST) in a way that allows end user accountability for secure messaging.

David Morf
Guest

AG’s last comment above gets to the center of things. A vendor-centric health care model is not pt-centric, not financially centric, not population-centric, not community centric, not-employer centric—however, it is sustainable until the music stops. The last time we had a systemic crunch like this only began to end with the partial success of the trust-busting era a century ago. Today’s bank-centric money hustle has not been halted, and won’t end until globally leveraged derivatives are uncoupled from banks. This will help pull some of the energy out of the financing now flooding the health system vendor space and multi-regional… Read more »

Adrian Gropper, MD
Guest

Hospitals used to be run by professional doctors. They are now run by professional managers, a few of which might be doctors too. Their success at making money is undeniable. Their success at PR and politics is unchallenged. Their success at manipulating the software industry to serve their business is apparent. Their success at improving outcomes is modest at best.

I’m eager to see the first institution to adopt Blue Button Plus as a pure patient-centered and transparency move. Any takers? Any leaders?

Matthew Katz
Guest

Currently the trend is toward hospital employment for doctors. That shifts the dynamics of how much influence doctors may have. I agree that clinicians and patients need to make sure that the process works to enhance the therapeutic relationship and outcomes rather than enhancing market share or reimbursement.

David Morf
Guest

The HIT complexity is a vendor shell game. The HIT challenge is the legacy software built around the coding structure for single-morbidity FFS billing control, rather than built around the multi-morbidity pt. The clear center is the pt. All functional data including docs, labs, vitals, morbidities and care sites across walk-in centers, primary, specialist, hospital, recovery, home care all logically connect to the pt. Call up the pt, get cross-section or longitudinal data. Call up the provider or the facility, get the pt data array. Therefore look at VistA with the largest single online repository of pt data in the… Read more »

Peter Bachman
Guest
Peter Bachman

David M, I’m glad that you see the provider and patient id directory with PKI for the potential it has to work off the same unique data set for the entire US. It’s just that simple. Medical data on the other hand is hard and work has to be done to fix that. Even matching between different code sets is possible given low cost engines to do so, and semantically moving in the right direction, converging rather than attempting to do the big thing in a waterfall approach. I think that is all happening, but then it gets held back… Read more »

Adrian Gropper, MD
Guest

Peter, Thank you for your thoughtful contribution. Your point around the provider directory should not be underestimated. Direct secure messaging need not and should not be hijacked to _prevent_ end-to-end security. This is why DirectTrust needs to be just an option rather than the basis for Directed Exchange. Not only can trust be established at the directory level for professionals but, in the case of patients, it can be based on in-person authentication. This preserves the primacy of the physician-patient relationship while allowing the convenience and power of on-line secure messaging. It’s 2014, and being able to send and receive… Read more »

Adrian Gropper MD
Guest

I think we’re seeing the limits of a mixed regulation and free market system. The economic incentives of the current health IT system customers do not favor interoperability AND, in a third-party paid industry, the physicians and patients are not the customers. HITECH made a valiant effort over the past 4 years to regulate and pay off the vendors and their institutional customers to achieve transparency and interoperability. But $20 Billion of incentives are subject to manipulation and unintended consequences when the institutions are scrambling for market share in a complex $2.8 Trillion market. As the payment reform part of… Read more »

legacyflyer
Guest
legacyflyer

I am not nearly as informed on this topic as some of the above posters but …

It seems to me like “the fix” is still in. Whatever payments the EMR vendors made to be allowed to use proprietary formats have continued to pay dividends for them.

Adrian Gropper, MD
Guest

We are where we are. Most of the MU money has been spent. The interoperability we were promised is both lame and expensive. The EHR vendors that have locked in the institutions are now working to torpedo health information exchanges that they see as competition. We’ve replaced paper silos with vendor silos.

Where do we, the doctors, go from here?

Bobby Gladd
Guest

Opacity + Barriers to Entry = Margin

Some things are simple and clear. Efficient Markets Hypothesis 101: Transparency and profitability are directly inversely proportional.

If maximizing profit is the sine qua non, then opacity must rule.

Bobby Gladd
Guest

As I’ve written on my REC Blog: __ One.Single.Core.Comphrehensive.Data.Dictionary.Standard One. Then stand back and watch the Market Work Its Magic in terms of features, functionality, and usability. Let a Thousand RDBMS Schema and Workflow Logic Paths Bloom. Let a Thousand Certified Health IT Systems compete to survive. You need not specify by federal regulation any additional substantive “regulation” of the “means” for achieving the ends that we all agree are desirable and necessary. There are, after all, only three fundamental data types at issue: text (structured, e.g., ICD9, and unstructured, e,g., open-ended SOAP note narrative), numbers (integer and floating-point decimal),… Read more »

Curly Harrison, MD
Guest
Curly Harrison, MD

Meaningful use is a meaningful ruse, to control and regulate the doctors using devices that themselves have not been vetted for safety. The line by the HIT vendors repeated by the members of Congress like parrots is that regulation will stifle innovation of the HIT vendors. Hello?? What do you think the meaningfully unusable HIT devices and the meaningful ruse 1 and 2 does to doctors’ creativity and their innovation of caring for patients? The HIT programme is a sham…an international scandal that is sucking funds from care and patients and depositing them into the pockets of the vendors and… Read more »

MD as HELL
Guest
MD as HELL

Each stage also molds the patients into the herd.

Bobby Gladd
Guest

“Medicine can be regulated as a profession or as a branded proprietary device. As medicine is increasingly mediated by EHRs and integrated over the Internet, the choices we make around the governance of “trust” on the NwHIN and EHR regulation will dictate the rate of medical progress itself.”
___

IIRC, you pointed out elsewhere that regulation of Health IT was tantamount to regulation of medicine. This post follows up on that nicely.

Great stuff.

Dr. Rick Lippin
Guest
Dr. Rick Lippin

“With this resolution, my medical society has come down clearly in favor of physician-based trust on the NwHIN. What should the federal regulators do?” says Dr Gropper

My answer is “the same”

Congratulations on asking the tough right questions

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

I am concerned that physicians and the general public are not going to understand the importance of the “trust” issue, the control of the NwHIN and the ramifications this will have to the practice of medicine and public health. Because of the technical complexity of the issue, I anticipate (unfortunately) that there will be little/no response to your blog. I remain concerned that the Mass Med Society resolution by itself will not effect any policy changes, either at the state or federal level, for the same reason. I fear that if there is a hint of movement at the policy… Read more »

Adrian Gropper, MD
Guest

Do people want hospital or doctor-centered ACOs? As Farzad makes clear, both are a possibility but the doctors have a ways to catch up.

MD as HELL
Guest
MD as HELL

Neither