I am a family physician, but one who doesn’t currently practice and importantly, one who isn’t slogging day after day through health care transformation. I do not want to be presumptuous here because the doctors and other health professionals who are doing this hard work are the heroes. They are caring for patients while at the same time facing tremendous pressure to transform their life’s work. That includes overwhelming pressure to adopt and use new information technology.
This level of change is hard, difficult and confusing—with both forward progress and slips backward. Nevertheless, doctors take heart because you are making progress. It may be slow at times, but it’s substantial—and it’s impressive. Thank you.
The Annals of Internal Medicine today published a study (I was one of the authors) finding that more than 40 percent of U.S. physicians have adopted at least a basic electronic health record (EHR), highlighting continued progress in the rate of national physician adoption of EHRs. The study, also found that a much smaller number, about 9.8 percent of physicians, are ready for meaningful use of this new technology.
Some might say, “Wake up, folks!” Look at those small meaningful use numbers. Change course, now. After all of this time and tax-payer expense, less than 10 percent of doctors are actually ready to use these important tools meaningfully. What’s up with that?
To me, though, this study is good news. All who care about health care transformation should be heartened by the progress—but also impressed by the enormous challenge that our health professionals have undertaken.
A question: What is the opposite of health IT return on investment?
The answer: Unintended financial consequences, or UFCs, for short.
The scenario: A sophisticated medical center health system begins to roll out an expensive proprietary EHR and shortly thereafter sustains an operating loss, leaving no choice but to put the implementation on hold. The operating loss is attributed to “unintended financial consequences” directly related to buying a very expensive EHR system.
… has suffered an operating loss of $13.4 million in the first half of its fiscal year. The rollout of MaineHealth’s estimated $160 million electronic health record system, which has resulted in charge capture issues that are being fixed, was among several reasons Maine Med’s CEO cited for the shortfall.
“Through March (six months of our fiscal year), Maine Medical Center experienced a negative financial position that it has not witnessed in recent memory,” Richard Peterson, president and CEO of the medical center, wrote in the memo to employees.
Peterson’s memo outlines the specific UFCs that explain, in part, MaineHealth’s operating loss:
Declines in patient volume because of efforts to reduce re-admissions and infections
Problems associated with being unable to accurately charge for services provided due to the EHR roll out
An increase in free care and bad debt cases
Continued declining reimbursement from Medicare and MaineCare, the state’s Medicaid program
These challenges are common to just about any medical system in the country, making MaineHealth potentially a harbinger of things to come for those hospitals and health systems that pay multi-millions of dollars for a health IT system.
Those of us who have spent years arguing in favor of standards based health information exchange (HIE) have just had a few good months. The federal government has asked IT vendors and providers what it can do to advance health information sharing across organizations. This has drawn new attention to “interoperable” health IT systems and the quality and economy of care delivered to Medicare and Medicaid beneficiaries.
In late March, the Office of the National Coordinator for Health IT (ONC) awarded cooperative agreement grants to two non-profit trade groups working to certify and credential electronic health records (EHRs) and health exchange service providers whose products are capable of secure data sharing — that is, of “talking to one another.” (Disclosure: I am the President and CEO of one of these alliances, DirectTrust.) The tone of the conversation has definitely changed.
My sense, though, is that most people still don’t have a firm grasp on the issues. They remain uncertain or confused about what interoperable health information exchange really means to providers and patients, how it can be achieved, the barriers that remain to be overcome, and who is making the decisions about these matters. So this seems like a good time for both an update and a refresher of sorts on the nature of health information exchange, and to explain why this is not a good time to reduce spending on health IT in America.
Let’s start with what is probably the most important thing to understand: we are very, very close to national deployment of a relatively simple standard, known as Direct, that enables secure Internet transport of health information between people, organizations, and software. Direct exchange permits users of any EHR to send and receive messages and files from any users ofany other EHRs, regardless of operating system or vendor. In fact, Direct facilitates secure messaging, with attachments, to and from anyone with Internet access. It makes EHRs interoperable with one another, but also facilitates secure communication with providers and patients using Internet devices of almost any kind.
Allscripts is one of the biggest companies in Health IT. Glen Tullman built it from almost nowhere and then last year after one bad quarter and a power struggle in the boardroom (which he initially won), he left–and he stresses it was his decision. Along the way there were lots of interesting choices made, and he and Allscripts ended up with a sweep of all the negative awards at this years HISSIES (including his first time as “Industry figure in who’s face you’d most like to throw a pie”).
But despite all the abuse, what Glen did over the past 15 years is pretty remarkable given the stagnant state of the enterprise HIT market. I’ve interviewed him almost every year since THCB started and he was never shy in giving his opinions. Last month I got him for a long retrospective. THCB will be running that in parts over the next week or so, and he dishes on the Allscripts’ record, on Epic, on the future of health IT and more.
It’s a busy time in Washington, DC. June 3 marks the Datapalooza and begins a week of cheering and reflection on the success of federal initiatives designed to improve health while reducing cost. This year, the big claim is “information following patients” – a combination of federal Stage 2 Meaningful Use regulations, federal Health Information Exchange guidelines and federal open pricing data policies. We’re surely beyond 1,000 pages of federal initiatives around health data and the policy fog seems to be getting thicker every day. The Independent Purchase Decision Support Test is my beacon for whether we’re headed in the right direction.
“In effect, HISPs are creating “islands of automation using a common standard.” This will hamper information following patients where they seekcare―including across organizational and vendor boundaries―to support care coordination and Meaningful Use Stage 2 requirements.”
How will “information following patients” improve health while reducing cost?
It all depends on where the patient goes to get what. Not surprisingly, federal Accountable Care Organizations and related accountable quality contracts with private payers are exactly about where the patient goes too. The difference between these health reform innovations and the old managed care approach is supposed to be the patient’s ability to choose where to go for a healthcare service. Will Stage 2 and the new federal health information exchange implementation guidelines actually lead to effective patient engagement or is it time to “reboot” the HITECH incentives as some have suggested?
The Independent Purchase Decision Support Test cuts through the techno-jargon and paternalistic framing and goes straight to the heart of the policies that influence the physician-patient decisions to drive health care quality and cost. This the essence of patient engagement and the place where the money in healthcare is actually spent.
There is growing interest in relying more on outcome measures and less on process measures, since outcome measures better reflect what patients and providers are interested in. Yet establishing valid outcome measures poses substantial challenges—including the need to riskadjust results to account for patients’ baseline health status and risk factors, assure data validity, recognize surveillance bias, and use sufficiently large sample sizes to permit correct inferences about performance. We believe the operational challenges of moving to producing accurate and reliable outcome measures, though daunting, are worth the effort to overcome.
Patients, payers, policy-makers, and providers all care about the end results of care—not the technical approaches that providers may adopt to achieve desired outcomes, and may well vary across different organizations. Public reporting and rewards for outcomes rather than processes of care should cause provider organizations to engage in broader approaches to quality improvement activities, ideally relying on rapid-learning through root cause analysis and teamwork rather than taking on a few conveniently available process measures that are actionable but often explain little of the variation in outcomes that exemplifies U.S. health care.
However, given the inherent limitations of administrative data, which are used primarily for payment purposes, and even clinical information in electronic health records (EHRs), consideration should be given to developing a national, standardized system for outcome reporting . A new outcome reporting system would not be simple or inexpensive, but current data systems may simply be insufficient to support accurate reporting of outcomes. An example is the National Health Care Safety Network system for reporting health care infections .
A recent blog posting calls for a “universal EMR” for the entire healthcare system. The author provides an example and correctly laments how lack of access to the complete data about a patient impedes optimal clinical care. I would add that quality improvement, clinical research, and public health are impeded by this situation as well.
However, I do not agree that a “universal EMR” is the best way to solve this problem. Instead, I would advocate that we need universal access to underlying clinical data, from which many different types of electronic health records (EHRs), personal health records (PHRs), and other applications can emerge.
What we really need for optimal use of health information is not an application but a platform. This notion has been advanced by many, perhaps most eloquently by Drs. Kenneth Mandl and Isaac Kohane of Boston Children’s Hospital [1,2]. Their work is being manifested in the SMART platform that is being funded by an ONC SHARP Award.
There has been a lot of controversy in health policy circles recently about hospital market consolidation and its effect on costs. However, less noticed than the quickened pace of industry consolidation is a more puzzling and largely unremarked-upon development: hospitals seem to have hit the wallin technological innovation. One can wonder if the two phenomena are related somehow.
During the last three decades of the twentieth century, health policymakers warned constantly that medical technology was driving up costs inexorably, and that unless we could somehow harness technological change, we’d be forced to ration care. The most prominent statement of this thesis was Henry Aaron and William Schwartz’s Painful Prescription (1984). Advocates of technological change argued that higher prices for care were justified by substantial qualitative improvements in hospitals’ output.
Perhaps policymakers should be careful what they wish for. The care provided in the American hospital of 2013 seems eerily similar to that of the hospital of the year 2000, albeit far more expensive. This is despite some powerful incentives for manufacturers and inventors to innovate (like an aging boomer generation, advances in materials, and a revolution in genetics), and the widespread persistence of fee for service insurance payment that rewards hospitals for offering a more complex product.
Technology junkies should feel free to quarrel with these observations. But the last major new imaging platform in the health system was PET, which was introduced into hospital use in the early 1990’s. Though fusion technologies like PET/CT and PET/MR were introduced later, the last “got to have it” major imaging product was the 64 slice CT Scanner, which was introduced in 1998. Both PET and CT angiography were subjects of fierce controversy over CMS decisions to pay for the services.
There was a hole in the wall of our bathroom that was a painful reminder of a bad encounter with a plumber. Yes, that hole has been there about a year, and it has been on my to-d0 list for the duration, daring me to show if I inherited any of the fix-it genes I got from my father. Why not hire someone to come fix it? I also got (as I mentioned in my last post) dutch genes, which scream at me whenever I reach for my wallet. So this hole was giving me shame in surround-sound.
I attempted to fix it the hole last year, even going to the degree of asking for a router table for my birthday. Since there was previously no way to get to this all-important access to the shower fixture without cutting through the sheetrock, I decided I would take a board, cut it larger than the hole, then use the router to make a rabbet cut so the panel would fit snuggly. Up until then, I thought a rabbet cut was a surgery to keep the family pet population under control, but my vocabulary was suddenly expanded to include words like rabbet, roundover, chamfer, dado and round nose. Unfortunately, my success only came in the realm of vocabulary, as I was not able to successfully master the rabbet cut without making the wood become a classic example of the early american gouge woodworking style.
I am not sure why, but something inside me told me today was the day to give this another shot, and to my shock (and that of my family), I was successful!
This home project is actually a late comer to the DIY party I’ve been holding for the past few months.
Don’t like your practice? Build your own from scratch!
Don’t like the health care system, build a new one!
My latest DIY venture is in an area I swore I’d not go: I’m building my own record system.
You probably saw some of the headlines last week where Box announced that is supporting HIPAA and HITECH compliance, signing Business Associate Agreements, (BAAs) and integrating with several platform app partners such as Doximity, drchrono, TigerText, and Medigram to help seed its new healthcare ecosystem. I also announced that I was formally advising Box on their healthcare strategy.
I was drawn to Box because of all the lessons I learned at Google building a consumer-directed, personal health record (PHR), Google Health. Google Health allowed you to securely store, organize and share all of your medical records online and control where your data went and how it was managed. It was unlike the other PHRs in the industry that were tethered to the provider or payor or part of an Electronic Health Record (EHR) system.
Sound good? Well, it was in theory. The big issue with Google Health was aggregating your data from the disparate sources that stored data on you. We had to create a ton of point-to-point integrations with large health insurance companies, academic medical centers, hospitals, medical practices and retail pharmacy chains. All of these providers and payors were covered entities in the world of HIPAA and were required to verify a patient’s identity before releasing any data to them electronically. It was a very bumpy user experience for even the most super-charged, IT savvy consumer.