The focus on design for health IT at the HxRefactored conference on March 31 raised several tough questions about the hazard-strewn path app developers must travel in that field. My sampling of introductory workshops and afternoon sessions (I unfortunately had the chance to attend only the first day of the two-day conference) brought up many fine design principles, but most of the presenters were general-purpose designers having limited experience in health care. Still, some important distinctions to recognize when entering health IT came up.
One factor making design is so difficult in health care is the vast variety of tasks health care professionals perform. If you’re designing an app to reserve a restaurant table or buy a sweater, how many pathways can a user take? Probably at most a dozen or two. Now think of a hospital ward: one patient whose heart has to be monitored constantly, another who needs regular injections, and yet another whose medication has put her in a delirium that leads her to jump out of bed and wander. Truly, the pathways that a doctor or nurse can take through the health care application verges on the infinite.
It’s always interesting to talk with John Halamka, and last week–after athenahealth bought the IP but apparently not the actual code of the Beth Israel Deaconess Medical Center (BIDMC) web-based EHR he’s been shepherding for the past 18 years–I got him on the record for a few minutes. We started on the new deal but given that had already been covered pretty well elsewhere we didn’t really stay there. More fun that way–Matthew Holt
Matthew Holt: The guys across town (Partners) ripped out all the stuff they’ve been building and integrating for the last 30 years and they decided to pay Judy Faulkner over a billion dollars. And you took all the stuff that you’ve been building for the past 15 to 20 years and sold it to Jonathan Bush for money. Does that make you a better businessman than they are?
(Update Note 2/11/15: While I’ve heard from public & private sources that the cost of the Partners project will be between $700m and $1.4 billion, Carl Dvorak at Epic asked me to point out less than 10% of the cost goes to Epic for their fees/license. The rest I assume is external and internal salaries for implementation costs, and of course it’s possible that many of those costs would exist even if Partners kept its previous IT systems).
John Halamka: Well, that is hard to say, but I can tell you that smart people in Boston created all these very early systems back in the 1980s. On one hand, the John Glaser group created a client server front end. I joined Beth Israel Deaconess in 1996 and we created an entirely web-based front end. We have common roots but a different path.
It wasn’t so much that I did this because of a business deal. As I wrote in my blog, there is no benefit to me or to my staff. There are no royalty streams or anything like that. But sure, Beth Israel Deaconess receives a cash payment from Athena. But important to me is that the idea of a cloud-hosted service which is what we’ve been running at Beth Israel Deaconess since the late ’90s hopefully will now spread to more organizations across the country. And what better honor for a Harvard faculty member than to see the work of the team go to more people across the country?
MH: There’s been a lot of debate about the concept of developing for the new world of healthcare using client server technology that has been changed to “sort of” fit the integrated delivery systems over the last 10 years, primarily by Epic but also Cerner and others. In particular how open those systems are and how able they are to migrate to new technology. You’ve obviously seen both sides, you’re obviously been building a different version than that. And a lot of this is obviously about plugging in other tools, other technologies to do things that were never really envisaged back in 1998. You’ve come down pretty strongly on the web-based side of this, but what’s your sense for how likely it is that what has happened over the last five or ten years in most other systems including the one across the street we just mentioned is going to change to something more that looks more like what you had at Beth Israel Deaconess?Continue reading…
Epic regains its top spot in the 2014 Best in KLAS awards, winning in the Overall Physician Practice Vendor and Overall Software Suite categories. Impact Advisors was named the Overall IT Services Firm.
Last year athenahealth beat out Epic by a narrow margin. This year athena still had an excellent showing, taking the top spots for Practice Management in both the 1-10 physician and 11-75 physician categories, as well as second place (after Epic) in the over 75 physician category.
Epic won Best in KLAS or category leader honors for Acute Care EMR, Ambulatory EMR (11-75 physicians and over 75 physicians), HIE, Lab, Patient Account and Patient Management, Patient Portals, Pharmacy, Radiology, and Surgery Management.
Lawmakers re-introduce the Flexibility in Health IT Reporting Act of 2015, which would shorten the 2015 MU reporting period from one year to 90 days. The bi-partisan-supported bill earned quick support from HIMSS, CHIME, the AMA, MGMA, and other professional organizations. The bill was originally introduced in September but it failed to pass.
Given the growing disenchantment with the MU program, look for this bill to pass – and hopefully give a boost to attestation numbers.
Dr. Google Joins DoD EHR Bid
Google teams up with PwC, General Dynamics, and Medsphere in their bid for the Department of Defense’s $11 billion EHR bid.
Google brings name recognition and a reputation for innovation and data security. While the Epic/IBM team has been looking like the front-runner, Google puts the PwC/Medsphere/GD team back in the hunt. For those keeping score at home, other vendors in the mix include Cerner/Leidos/Accenture Federal and HP/CSC/Allscripts. A June decision is expected.
Earlier this week, we reported on the current rates of influenza-like illness (ILI), based on data from roughly one million patient visits on the athenahealth network. That report showed a steep increase in ILI rates for the week ending Saturday, December 13 (see previous post). It’s not certain that this season will be as severe as that of 2012-2013 (data for pediatrics suggests that is a real possibility); however, providers are testing for flu more consistently than previous years, and prescribing antivirals more often.
Our data shows that the number of flu tests ordered, per patient visit in which ILI is diagnosed, has risen each of the past two years (Figure 1, graph A). This season, providers are ordering flu tests at a rate of 0.53 tests per visit with an ILI diagnosis, compared to 0.37 for last season and 0.34 for 2012-2013. (Note: There can be multiple tests per patient visit, e.g. Type A and B.)
The Ebola crisis in Texas has tested our nation’s health care system in many ways, exposing weaknesses and potential breakdowns. In particular, the incident with the first diagnosed Ebola patient at Texas Health Presbyterian underscores a fundamental issue with information liquidity between providers, their care teams, and across the continuum of care. The ability to share information effectively is critical not just in responding to health care crises like Ebola — but also in delivering great, cost-effective care.
As athenahealth CEO Jonathan Bush said in an interview with CNBC earlier this month:
“The worst supply chain in our society is the health information supply chain. It’s just a wonderfully poignant example, [a] reminder of how disconnected our health care system is. … The hyperbole should not be directed at Epic or those guys at Health Texas. The hyperbole has to be directed at the fact that health care is islands of information trying to separately manage a massively complex network.”
I WAS NOW the CEO of a rising medical data company.We built automated systems to handle the administrative chores for thousands of medical practices. They didn’t buy anything from us. Instead, they subscribed to a service on the Internet.
This was what would later be called a cloud-based service, but in these early days of Internet era, we were still searching for a name for it. My partner Todd used to say in speeches that he would give Polynesian fruit baskets for life to anyone who came up with a single name for the combination of software, knowledge and work that we were selling. We had moved back east and had a new headquarters in a historic brick armory building along the Charles River near Boston.
Our future looked fabulous, except for one problem: My cousin, the 43rd president of the United States, was about to sign a bill that could destroy us.
This bill, like so many governments initiatives, stemmed from the best of intentions. The idea was to encourage the migration of the health care industry from cumbersome binders full of paper to electronic records. How was this to be accomplished? Well, hospitals and doctors were forbidden by so-called anti-kickback laws from exchanging services, information or products of value with each other. (It’s a law that infuriates me, for reasons I’ll go into later.) The bill before Congress in 2004 offered a regulatory safe harbor for hospitals to provide doctors with all the digital technology the bureaucrats could think of: servers, software licences, and training. That was absolutely the right answer . . . for 1982. The long and short was that hospitals could buy all the old stuff from our competitors, but none of the new still-to-be-named services from us. As often happens, the technology was advancing much faster than the law.
I caught the shuttle down to Washington and commenced lobbying with the fervor of a man with a gun to his head. I raced up and down the marble halls Congress, looking for someone, anyone, who would take the time to learn why this bill was so very wrong, so backward, so devastating, so lethal—at least to athenahealth.
But let me tell you, if you walk into Congressional offices sputtering about a clause in a bill that practically no one has read, something that has to do with hardware and software and online services, people tend to hurry away, or point you toward the door. I could find no one to pay attention. And as I grew more frantic, I started talking louder and faster. That didn’t help things.
Some might find my frustration strange, considering that during this drama my cousin was sitting a mile away, in the Oval Office. Wouldn’t a Bush, facing legislative trouble in Washington, contact someone in the White House entourage? The answer is no. Placing a call to him was not even a remote possibility. For starters, it’s unethical. It is also politically foolish. It would place him, me, and my company in scandal and bring shame upon our family. I would be much more willing to climb the steeple of the tallest church and bungee jump naked in the middle of the night than to call my cousin. And even if I were dumb enough to make the call, I trust George would have the good sense to tell me to get lost.
2014 marks the launch of the Affordable Care Act’s (ACA) most important coverage expansion provisions, designed to dramatically reduce the number of uninsured Americans. Between now and the end of 2016, millions of individuals are expected to sign up for subsidized insurance coverage through newly established health care exchanges, or marketplaces.
Other tracking initiatives are closely monitoring the number of individuals that sign up for this coverage as well as those that take advantage of expanding Medicaid coverage in some states.
With ACAView, we will take a different approach. We will focus on the provider perspective; more specifically, how the ACA affects the practice patterns and economics of physicians and other care team members around the country. This is also part of a wider effort, Reform by the Numbers, RWJF’s rich source of timely and unique data about the impact of health reform.
ACAView will monitor the impact of coverage expansion on a monthly basis, mining insights from athenahealth’s cloud-based network of more than 50,000 providers and 50 million patients.
athenahealth is a technology and services provider that delivers physicians the tools and support needed to manage the business and clinical aspects of their medical practices. Our cloud-based, centrally hosted software platform provides us with near real-time visibility into practice patterns of physicians around the country.
Our goal is to inform, exchange ideas, and provide a timely, front-row view of how this landmark legislation affects a robust cross-section of providers across the nation. In subsequent reports, we will examine an evolving set of metrics that address a broad range of topics.
We will also share our analyses on the extent to which our providers represent all providers in the US. For more about our data on practices and patients, as well as our preliminary list of metrics, please read our Methodology report.
No Meaningful Change to Date in New Patient Volumes
Among the many unknown questions surrounding coverage expansion is the number of new patients physicians will accommodate. This is a critical issue because one of the goals of health care reform is to allow individuals to form stable physician relationships, rather than seek care in high-acuity settings or forgo care altogether.
If the ACA is working, we would expect physicians to see a higher percentage of new patients over the course of the year. Over the long term, this number should eventually return to historical levels as these new patients become established.
As Washington remains deadlocked on the implementation of the Affordable Care Act, the US government’s shutdown has resulted in the furlough of nearly 70% of the Centers for Disease Control‘s (CDC’s) workforce. CDC Director Tom Frieden recently shared his thoughts in a tweet. We agree whole-heartedly. Although it’s all too easy to take the CDC staff for granted, they are the frontline sentinels (and the gold standard) for monitoring disease outbreaks. Their ramp-down could have serious public health consequences.
We are particularly concerned about the apparent temporary discontinuation of the CDC’s flu surveillance program, which normally provides weekly reports on flu activity. Although flu season typically begins in late fall, outbreaks have occurred earlier in previous years. In 2009, flu cases started accumulating in late summer/early fall. And given the potential for unique variants, such as the swine or avian flu, every season is unpredictable, making the need for regular CDC flu reports essential. We therefore hope to see the CDC restored to full capacity as soon as possible.
In the meantime, we would like to help by sharing data we have on communicable diseases, starting with the flu.
Because the athenahealth database is built on a single-instance, cloud-based architecture, we have the ability to report data in real time. As we have described in earlier posts, the physicians we serve are dispersed around the country with good statistical representation across practice types and sizes.
To get a read on influenza vaccination rates so far this season, we looked at more than two million patients who visited a primary care provider between August 1 and September 28, 2013 (Figure 1). We did not include data on vaccinations provided at retail clinics, schools or workplaces.
This year’s rates are trending in parallel to rates over the last four years, and slightly below those of the 2012-2013 season. However, immunizations accelerate when the CDC, and consequently the media, announce disease outbreaks and mount public awareness campaigns.
Health care providers and consumers are increasingly using mobile technology to exchange information. Many health IT providers readily acknowledge that some level of oversight is required to ensure patient safety and privacy protections, but many providers question whether the FDA is the right agency for the job and want to see the FDASIA recommendations.
Can the FDA, with its already limited resources and lengthy review cycles, regulate the fast-moving health IT industry? Should it? Health IT is fundamentally different from a medical device in many ways. For oversight purposes, the key differentiator between the two is the opportunity for clinical intervention in the use of health IT. Many medical devices interact directly with the patient (such as an infusion pump or pacemaker). Most health IT, on the other hand, merely provides information to clinicians, who ultimately make independent, experienced care decisions. Physicians are informed, but not controlled, by the information. This leads to a vast difference in the patient risk proposition and rigid regulatory oversight is not appropriate.
Advocates of a broad health IT oversight framework – which encompasses mobile health IT – are urging the FDA to delay release of its final guidance, particularly in light of a July 2012 Congressional mandate for the creation of a comprehensive oversight framework that avoids regulatory duplication.
But some mobile medical application developers are pressing the FDA to move forward immediately, believing its guidance will reduce the regulatory uncertainty that they believe is stifling innovation and investment in some aspects of mHealth.