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TECH: Conversation with Girish Kumar, eClinicalWorks

• 18

I wrote a brief editorial in THCB and also on FierceHealthcare last week, suggesting that the problem with IT in the US wasn’t so much a lack of interoperability as it was a lack of use of IT in the clinical workspace by physicians in small practices. My editorial was in part inspired by a comment emailed onto me from Girish Kumar, who’s President of eClinicalWorks–an EMR vendor aiming at that market. Given that I’m doing some work on the use of ePrescribing by doctors in that market anyway, I thought I’d imitate MrHISTalk and do a CEO interview to go down a layer or two about how that small practice segment of the market is playing out. So here’s my take on my discussion with Girish.

 

 

eClincial Works is based in Westborough Mass , and it’s a private company with no debt and no investors and no plans to go public — working in a similar philosophy to Meditech just down the road. Currently it has around 150 employees with some $20-25m in software revenues on an annualized basis. They are doubling in size each year with 1500+ customers representing 3300 providers (meaning nurse practitioners and doctors). Their business is focused on the small end of the market, which they define as practices with 1-15 physicians, although they have started going into mid (15- 50) and large (50 +) practices. And a couple of even bigger practices have signed on recently, although that’s not been their prime market.

What about the market in general?

Girish believes that EMR adoption in health care is a long term process — and that realistically we are still 5-7 years away from peak adoption rates and some time after that from total penetration. He was (he says somewhat mis)-quoted last week as suggesting that government help was needed to get that market to take off. He does think that the conversation emanating from Washington is creating a catalyst which is helping physicians move towards automating their practices. But this is a numbers problem. While there are only a few thousand hospitals and big practices, there are over 150,000 small practices. Their EMR adoption is low in percentage terms but quite a few have EMRs which makes a large total number. Girish says that as eClinicalWorks continues to see more and more business every quarter, that tells him that the market is moving forward rather than backwards or sideways. But, and this is the key issue, the numbers of doctors needing to make that move are so large that unless the government puts in place bigger incentives the market won’t go from 30% adoption to 80% without a catalyst any time soon.

Is there a distinct set of players for different practice size?

For practices with 50 + doctors there are a now a more or less dominant set of EMR vendors, such as NextGen, Epic, Allscripts & GE Centricity (Logician). When you go to the below 50 doctor market, it’s coming down to 6-8 companies too, but not the same as the larger ones. For example, Epic doesn’t sell into that market. There are many smaller vendors who used to be able to be much cheaper than the better known companies, but the challenge for those companies is that original price point of $15-20,000 per physician is now falling. So the difference between the small vendor and bigger, better-known players has come down. For example eClincalworks’ EMR is $7500 a seat (you need to add $2500 more for the practice management module).

This is being accompanied by some level of market confidence in the vendors. Girish claims that others are telling him that eClinicalWorks is becoming a brand name for EMR. In addition the vast majority of doctors who buy their EMR product are also picking up the practice management application, and are starting to replace the Medical Managers of the world. As in many other parts of the health care IT arena, the value of the pre-integrated product can exceed the reason for keeping a legacy practice management system, and he expects to see that trend continue. Incidentally, some of his competitors, don’t share that view–Allscripts for instance doesn’t have a practice management module and integrates with those legacy systems. But clearly if physician organizations can recognize a distinct set of vendors who will be around for a while, then it will help the market.

So what should the government do?

In Girish’s view government is recommending the standards for building the highway, (interoperability and RHIOs). There’s no question that you need that for nodes (or in his analogy, cars) to be able to able to connect with each other. But we need to focus on the nodes, and we have to build the on-ramp and off-ramp to the highway. The government needs to incentivize both the infrastructure creation and incentivize the plug-in at the doctor’s office. He’s not critiquing building the highway but we must realize that we need the cars too.

What should that look like at the node level?

The government should come up with a subsidy either via Medicare or a pay for performance package directly related to IT adoption. Then the government should mandate that vendors implement interoperability standards at no additional cost — customers shouldn’t be burdened with the extra costs of interoperability. We need to build an incentive to vendors to do that and that incentive for vendors should be a growing market. In other words, create a market so that the vendors make more money but force them to make interoperability part of the products features. In one example Girish cited a vendor who wanted $60K to integrate inpatient and outpatient information together for single practice. That’s not acceptable to him and the path to interoperability ought to be built into vendors’ standard product roadmaps.

Having said that, there is only a small demand from doctors for seeing the inpatient chart in the outpatient environment, although that varies by specialty. For example, no dermatologist cares, but an ObGyn or cardiology practice might care. The big deal in terms of interoperability is access to lab results. However, overall adoption will be easier if physicians know that the products they buy are interoperable and that they are both able to get information from other systems and able to walk with their data if they don’t like the system they have.

So why should the government subsidize the EMR?

Putting aside the fact that the government subsidizes lots of parts of the health care system already, I pushed him a little on the idea of subsidies. After all if adopting technology gives the physician efficiency (and several vendors show that in their studies) and it’s saving them money, why should there be an incentive from the taxpayer? Girish felt that the improvement in care EMRs would create would save Medicare and the government money in terms or reduced hospital admission, better drug compliance, etc — so in his view it would be an investment. But he was happy enough with a proposal that any subsidy should be budget neutral overall for physicians, but that Medicare or the government would essentially be paying them to adopt the EMR while they were paying them less for other activities in their practice.

While I agree and I think that the P4P movement is pushing this way, I can imagine the AMA might not agree quite so readily! Still, I’m with Girish in believing that the adoption of EMR tools in small practices is the most crucial aspect of IT in health care, and it’s good to hear that there is some activity in that arena. And that at least one vendor is talking a good game about how that market can be grown at benefit to all of us.

HEALTH PLANS: The Gadfly seems to have caused Kaiser real trouble

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So the Gadfly has really had an effect, and in some ways so has THCB. But I’m not sure it’s a good one. Yesterday for the breach of patient confidentiality that was fairly exhaustively documented on THCB and elsewhere, the California Department of Managed Healthcare (DMHC) fined Kaiser $200,000.

Just to remind you, some contractor left some database schemas of Kaiser’s Health Connect project on an open web site some time between 2002 and 2004. Somewhere in those charts, which I looked at (not knowing what was in them) were patient records for 150 real live patients (although I never saw one and the Gadfly said that she only ever saw three and never knew they were real). The Gadfly linked to the site from her website, and after she wrote to me, I put it in a story here last August. Within a few days, that website had been taken down, and I assumed that that was that.

But apparently not. The Gadfly, who was involved in a nasty if unrelated dispute about her firing, had mirrored and copied the site to prove (at least to her satisfaction) that Kaiser was doing something wrong. Kaiser apparently is being fined for not reporting its breach of confidentiality. "DMHC officials were concerned that Kaiser allowed the site to languish on the Web in an accessible format and did not act to remove it until its existence was brought to the attention of federal civil rights authorities in January 2005. In addition, Kaiser authorities chose not to inform state regulators until after the site had been reported to the media in March. However, Kaiser has since informed all of the approximately 150 members who may have been affected." So playing out the time-line, Kaiser knew (we can assume) in August 2004, started going after the Gadfly in March 2005 when the story broke in the SJ Mercury News, but apparently had been told by the Civil Rights Commission in January that there its data had been (or still was) online, but didn’t inform the DMHC until March.

However, given that they had taken down the offending site the previous August, really Kaiser is being punished for not informing DMHC when it knew, rather than keeping it quiet and pretending (or at least insinuating pretty heavily) that it was the Gadfly who’d allowed public access to the site. But then again the Gadfly was allowing access to the data from August 2004 until March 2005, although it was a mirror of the site that had been up for over two years.

In some ways there is some karmic justice to all this. Kaiser didn’t treat the Gadfly at all well as an employee. She went after them rather too aggressively, even if she didn’t know that she was showing real patient data. Kaiser in turn responded in a more than proportionally aggressive response, and never tried to work it out with the Gadly to see if some reasonable accomodation to her problems could be reached. And they failed to do the CYA necessary to stop themselves getting in trouble with DMHC. But if $200,000 is a fair fine, then it’s more than $1200 per person, and probably more than a few thousand dollars per actual viewing by anyone on the web. So to my mind that’s a more than proportional punishment.  And I’m not sure that it’s not just DMHC grandstanding–I mean I know it was against the law, and Kaiser was slow, but I can’t see that that much harm was done to any of those patients.

Now Kaiser is a very wealthy organization and had a very good year last year ($481m profit in Q1 2005 alone), so $200,000 is not exactly that much to it. But on the other hand, it’s real money that could be used to provide health care to many needy people, and I suspect that had just a little been spent on better health insurance for the Gadfly, all of this could have been avoided. Of course the DMHC can now try to go after the Gadfly, but it appears that HIPAA privacy requirements do not apply to individuals.

So the lesson for health care organizations is mind your data and mind your employees, and treat both with common sense.

POLICY/INTERNATIONAL: More rubbish being talked about single payer and Canada by major newspaper columnist

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I had hoped that when the Boston Globe gave Jeff Jacoby a chance to rant about Canada and single payer, and THCB was able to call bullshit, that I wouldn’t have to repeat myself quite so soon. But to no avail. The Chicago Tribune gives a columnist called Steve Chapman, who incredibly enough worked for the liberal  New Republic (although aside of that has a long list of writing for libertarian and conservative newspapers), a chance to spread way more disinformation.

It’s good to know that a serious newspaper can allow a leading columnist to write about Canadian health care using numbers about the length of Canadian waiting lists from hopelessly biased organizations like Fraser and Cato, but ignore the official statistics which indicate that Fraser is wrong on waiting lists by a factor of 4. And for that matter the average waiting lists quoted by Fraser of around 4 months for elective surgery aren’t that bad–yet somehow Chapman starts talking about two year waiting list because one orthopedic surgeon said so.

Chapman then goes on to cherry-pick different outcomes on cancer to show that American care is better. Of course he doesn’t bother looking at overall care in different countries. This article in Health Affairs did just that (and is one in a series). The result, as again commented on in THCB, is that overall there is no real advantage to being in America. We do worse on somethings and better on others, but the suggestion by the Canada bashers that we get what we pay for is well off-base. And we clearly pay a lot more than anyone else and the share of those costs borne directly by poorer Americans is much, much greater than that borne by poor Canadians (or poorer people in other nations).

And if you look at the Health Affairs study a little more carefully you come to the authors’ conclusions.  Remember this is a real academic peer reviewed study, not some rubbish that Fraser Institute made up to suit its political agenda.  Here are the conclusions:

Across multiple dimensions of care, the United States stands out for its relatively poor performance. With the exception of preventive measures, the U.S. primary care system ranked either last or significantly lower than the leaders on almost all dimensions of patient-centered care: access, coordination, and physician-patient experiences. These findings stand in stark contrast to U.S. spending rates that outstrip those of the rest of the world. The performance in other countries indicates that it is possible to do better.

There’s plenty wrong with Canadian health care–something I looked at in depth in my "Oh Canada" piece. I’m also pretty sure that it’s not a good model for America, whereas Germany, Holland, France or Japan might well be.  But I really wish that if right-wing know-nothing columnists are going to write about this subject, that they’d either learn something about it themselves, or try to abstain from feeding at the research trough of totally biased organizations like Cato and Fraser. I suspect though that I’ll be wishing in vain for a while, but shouldn’t the Chicago Tribune hold itself to a higher standard?

INTERNATIONAL: The Future of Europe, Seen from a Sickbed

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Timothy Garton Ash is a veteran British journalist, sort of from the Blairite "Third Way" school. He has lectured Bush on foreign policy and has been an influential writer about the collapse of communism in Eastern Europe. So his thoughts about how the health service in the UK is a microcosm of the future of Europe, which is called The Future of Europe, Seen from a Sickbed, is a great read.

It’s also very relevant in the US, where an aging white population is going to have proportionately more Hispanic youngsters looking after it in the coming decades.

TECH: Interoperability/schminteroperability

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This week the Clinton/Frist (or should it be Frist/Clinton) legislation got on breakfast time TV, and Brailer’s office announced that it was going to be starting the first few pilots towards interoperability with some $60m available. A more ambitious $4bn bill was introduced too, although that won’t go anywhere unless someone adds the words "Terror" or "Iraq" to the title. But while all the fuss is about interoperability of data transfer, there is a whole set of players who need data to become electronic before it can be made "interoperable". While the larger medical groups and hospitals are rapidly getting on the EMR adoption curve, it’s a much slower process among the small practices that account for 75% of America’s doctors and patients — most of their information is stuck in paper. Other countries solved this problem the old fashioned way — the government paid for doctors to get EMRs in their offices.  Before we get too worked up about interoperability and RHIOs, a bigger national push to get smaller practices using clinical information technology might be a better idea.

POLICY: Now let’s remember a few basic things about Medicare, single payer, vouchers et al, with brief UPDATE

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Well either the doppelgangers are firing off or a few people have been reading this blog or the Jungian collective unconscious is working. In any event several of the issues about single payer versus vouchers that have been raised here have been echoed elsewhere.  First Fuch’s co-author Zeke Emmanuel in a guest spot over at Washington Monthly in response to Kevin Drum (the host there) spends some time explaining how insurance organizations (plan sponsors, an intermediary layer, call it what you will) could actually provide some innovation and be allowed to compete over that, rather than risk selection.

May be so, but there are two obvious points. First, there’s no reason why competition amongst that intermediary layer need not be controlled by a single payer system — something like that is starting out in the UK now.  My major point is that a quick Medicare-for-all legislative rush which puts us in one big risk pool is much more politically likely than an attempt to create a formula that gets us to perfect risk adjustment which Congress will pick to death while it’s legislated.  Second, Emmanuel reckons that we won’t get to single payer without a national crisis (and I agree) but then he thinks that the voucher system is palatable enough to somehow sneak past the special interests in the absence of said crisis. I don’t think so. Significant universal insurance reform will be so difficult to do that it’ll need a national crisis.  But then I’d call, say, 80m uninsured Americans a national crisis — or at least one that may show up politically if enough of the uninsured are male Republicans in the south –and we may well get there if current cost trends continue.

Zeke also reminds us that Medicare isn’t such a great program either, and I completely agree. Medicare is basically a welfare program for hospitals and providers, and soon to become one for drug companies too. It’s the fact that it doubles as a way to stop old people from being unable to afford hospital care and thus from dying in the streets that gives it such popularity.  But that income protection for seniors part of it can be preserved while making the overall program better. First off, the amount of money paid to those provider organizations can be reduced (and will be), but they need to improve their productivity and stop delivering "flat of the curve" medicine (i.e. more money with no comparable output). Some hints in this direction include implementing some of the lessons from the Dartmouth crowd’s work on overuse of resources in ICUs. The other part about Medicare is that it can be used as a force for good and to foster innovation. With all its warts that’s what P4P is all about, and I don’t see why Medicare is worse at doing that than private health insurers, which anyway tend to follow its lead.

Finally, I’d like to remind all parties that the gulf between the universal insurance crowd and the single payer crowd isn’t so big, as they both have everyone covered and everyone in a single big risk pool (called America). And with some variations, the Europeans show us that multi "intermediary" systems such as the ones in the Netherlands, Germany and Switzerland can be very effective.

UPDATE: Jonathan Cohn, who seems to be giving it away over at TMPCafe these days instead of selling it at TNR, has some pretty sensible points to make about the eventual similarity between universal insurance and single payer.  He doesn’t quite get to my logical conclusion — which is that we get to some type of government-funded quasi-competitive regulated market via an extension of Medicare’s single payer model — but I think he’ll be there eventually.  And I think he’s in some agreement with me about the politics of all this. i.e. Life has to be really bad and this has to be done once and quickly…..Gramsci called that Fortuna et Opportunta, or waiting for the time to be right and then giving the right legislation (or revolution in his case) a big shove.

POLICY: Another dribble on the single payer versus voucher issue

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There’s an interesting set of six letters about Krugman’s article in the NY Times.  One of the letters is way off base, suggesting that Medicare limits what doctors can and can’t do.  Well I suppose compared to a cash paying gazillionaire that’s true, but anyone who knows anything about private health plans know that they are much tougher on limiting access to different types of care and different drugs than Medicare (not that it’s done without good reason sometimes, but as my other post this morning shows sometimes there may be no good reason). The writer wonders whether Teddy Kennedy would want to be on Medicare. Unless I don’t understand Senators’ health plans, I assume he already is, and Krugman surely will be if he doesn’t get assassinated by the loony right. It beggars belief how the Times can publish that sort of uninformed tripe which contains not one iota of evidence, but then again it never published my brilliantly argued rebuttal to a letter from AHIP’s President about a previous Krugman column.

But one of the other letters is rather more interesting.  It says"

I find Paul Krugman’s column disturbing. If 72 percent of Americans want a national health insurance program but insurance companies have the power to override that majority, what does that say about the health of our democracy?

Where can we get insurance for such an ailment?

Glenn Alan Cheney, Hanover, Conn.

Basically Mr Cheney is right. People like his namesake the VP have proved time and time again that access to power can be bought by moneyed special interests — after all we still don’t know and probably never will exactly what went on in those meetings about the energy bill, but it’s pretty damn certain that Enron execs were writing US energy policy up until the moment that they just had to be repudiated.

However, I do have to take issue with the numbers quoted.  Essentially Krugman is quoting a number that has stayed relatively constant in various surveys, and crosses party lines.  The number is basically those who would in theory support universal health insurance.  These numbers are though not very important. A much better number is those who answer the three part question Harris has been asking for 20 odd years.  That question adds in the other part to "supporting universal insurance" by asking about the amount of change required in the system.  The three answers are broadly a) very minor change required, b) substantial reforms required, and c) complete rebuilding required.

The important answer is how many people are looking for a complete rebuilding. Because if there isn’t a substantial group in favor of that, none of the reforms required to get to universal insurance can happen. That number tends to hover between 20% and 30% (and by the way it’s way higher here than in any other English speaking country, which gives the lie to those saying that foreigners dislike their systems as much as Americans dislike ours). During the early days of the Clinton Administration, the "completely rebuild" number got up to over 40%.  More recently it also got into the higher 30s.  But for an Administration or Congress to have the will to defeat the special interests on health care, that number needs to be in the 40s or even 50s and stay there for a while. We haven’t seen that, which is why we haven’t seen real reform.

It will come, but the question is, how long will it take for things to be bad enough to drive enough Americans into the "completely rebuild" camp?