Arguably, the biggest news story coming out of HIMSS last month was the announcement of the CommonWell Health Alliance – a vendor-led initiative to enable query-based, clinical data sharing. So much has been written about CommonWell that there is little need to rehash what has been said before.
What has not been said, or at least has been sensationalized nearly to the point of irrelevance is the whole controversy surrounding Epic and how they were not invited to join the CommonWell Alliance until after the announcement. None other than Epic’s own founder and CEO, Judy Faulkner, has gone on record stating the Epic was unaware of CommonWell prior to the announcement. Faulkner has gone on to question the motives of CommonWell, in an effort to subvert it, in her highly influential role on the Dept of Health & Human Services HIT workgroup committee.
That was the last straw.
It is one thing to moan and groan at the HIT love fest that is HIMSS, where vendors commonly discount the announcements of competitors. But it is quite another thing to be a part of a highly influential body that is defining nationwide HIT policy and make the same claims over again, especially when they are frankly not true.
It’s called Blue Button+ and it works by giving physicians and patients the power to drive change.
The US deficit is driven primarily by healthcare pricing and unwarranted care. Social Security and Medicare cuts contemplated by the Obama administration will hurt the most vulnerable while doing little to address the fundamental issue of excessive institutional pricing and utilization leverage. Bending the cost curve requires both changing physicians incentives and providing them with the tools. This post is about technology that can actually bend the cost curve by letting the doctor refer, and the patient seek care, anywhere.
The bedrock of institutional pricing leverage is institutional control of information technology. Our lack of price and quality transparency and the frustrating lack of interoperability are not an accident. They are the carefully engineered result of a bargain between the highly consolidated electronic health records (EHR) industry and their powerful institutional customers that control regional pricing. Pricing leverage comes from vendor and institutional lock-in. Region by region, decades of institutional consolidation, tax-advantaged, employer-paid insurance and political sophistication have made the costliest providers the most powerful.
It’s not my dumping of the payment system so I can focus on care over codes, my use of technology to connect better with patients, or my vision of the “collaborative record” that is wrong. It’s the fact that I am doing this without my most important resource: my patients.
I realized this while driving in to work this past week. My first patient was a tech-savvy guy I’ve known for a long time. Not only does he know me, and knows more than me about technology, he also is a regular reader of my blog (bless his heart)…and he still chose to switch to my practice! So I was looking forward to running some of my ideas by him to see if my thoughts have strayed to the land of silliness (which they often do) or if I am actually onto something. This line of thought led me to think about collaborating with him to work on my IT vision, since he does work for an IT company. My line of thought then careened into the brick wall of the obvious: why just him? I’ve been getting suggestions and offers for help from many of my patients, who are clearly intrigued by my direction and desirous to lend their expertise on the project. So why not involve any of my patients who want to be part of this project?
Recently I was asked if SaaS/Cloud computing is appropriate for small practice EHR hosting.
I responded: “SaaS in general is good. However, most SaaS is neither private nor secure. Current regulatory and compliance mandates require that you find a cloud hosting firm which will indemnify you against privacy breeches caused by security issues in the SaaS hosting facility. Also, SaaS is only as good as the internet connections of the client sites. We’ve had a great deal of experience with ‘last mile’ issues.”
An important study in the Journal of the American Medical Association finds that misdiagnosis is more common than you might think. According to the study, almost 40% of patients who unexpectedly returned after an initial primary care visit had been misdiagnosed. Almost 80% of the misdiagnoses were tied to problems in doctor-patient communication, and more than half of those problems had to do with things that were missed in the patient’s medical history.
The results of this study shouldn’t be surprising if you’re a regular reader here – they are another example of a system that isn’t working as well as it could for patients, and doctors. Doctors – and the medical professionals who help them in their work – are the best educated and best trained than they have ever been. They have more access to medical information and technology than at any time in our history. And yet, U.S. government data show that the typical doctor visit involves 15 minutes or less with your doctor. Medical records are kept in fragmented, uncoordinated ways.
It’s official. The road sign clearly welcomed me here. I guess all business start-ups have to go through this town (Hell).
What? No bravado? No chest pounding about how my ideas will change health care while making patients smell as springtime fresh? Nope. None of that. It’s hard to get excited about ideas when only money pays the bills.
Having now left the safe confines of my leftover earnings from my old practice, I am now supposed to be self-supporting. Two big things have caused this to not go as smoothly as I have planned:
My construction took twice as long as I expected.
I have yet to find a computer system that doesn’t make me want to pound on my desk and wantonly overuse the word “inconceivable.”
Two weeks ago I had the good fortune to be invited back to the South by Southwest Conference (SXSW) to participate as a judge of a digital healthcare start-up competition. SXSW, which takes place in Austin, TX, is historically an indie music gathering that has evolved into a massive mainstream music conference as well as a monumentally huge film festival, like Sundance times twenty. There are literally hundreds of bands and films featured around town. There has now evolved alongside this a conference called Interactive that draws more than 25,000 people and focuses on technology, particular mobile, digital, and Internet.
In other words, SXSW has become one of the world’s largest gatherings of hoodie-sporting, gadget-toting nerd geniuses that are way too square to be hip but no one has bothered to tell them. Imagine you are sitting at a Starbucks in Palo Alto, CA among 25,000 people who cannot possibly imagine that the rest of the world still thinks the Internet is that newfangled thing used mainly for email and porn. SXSW is a cacophonous melting pot of brilliance, creativity, futuristic thinking, arrogance, self-importance, ironic retro rock and roll t-shirts and technology worship. One small example: very hard to get your hands on a charger for anything other than an iPhone 5 because, seriously, who would have anything else?
The EHR vendor lock-in business model is under attack by frustrated physicians and patients and the reality that health care cost and quality are more opaque than ever. Doug Fridsma of ONC politely talks of the need to move from vertical integration of health care services to horizontal integration where patients can choose with their feet. Farzad Mostashari calls for moral behavior and price transparency. The Society for Participatory Medicine says “Gimme My DAM Data” and Patient Privacy Rights asks HHS to allow physicians to prescribe health IT without interference from the institution or the vendor.
The vendors’ response is a charm offensive called CommonWell Health Alliance with a pastel .org website. The website is presumably the official source of information about CommonWell and it lays out the members’ strategy to preserve the vendor lock-in business model for a few $Billion more. Ok, maybe more than a few.
The core of the CommonWell strategy is to avoid giving patients their data in a timely and convenient way.
A recent RAND(1) study has concluded that the implementation of health information technology (HIT) has neither effected a reduction in the cost of healthcare nor an improvement in the quality of healthcare. The RAND authors confidently predicted that the widespread adoption of HIT will eventually achieve these goals if certain “conditions” were implemented. I do not believe that there is sufficient scientific data to support the authors’ conclusion nor validate the Federal Government’s decision to encourage the universal installation of “certified” electronic medical records (EMRs.)
As a “geek” physician who runs a solo, private practice and the creator of one of the older EMRs, I believe that I can provide a somewhat unique perspective on the HIT debate which will resonate with a large fraction of private practitioners.
I want to begin by sharing well-known information for the sake of comparison. Both the Apple and Google Android platforms welcome the introduction of new and (sometimes) highly valuable functionality through plug-n-play applications built by completely different companies.
You know that already.
Healthcare IT companies welcome you to pay them great sums of money for enhancements to their closed systems. This is on top of substantial maintenance fees that may or may not lead to hoped-for updates in a timely fashion. (With all due respect to the just-announced CommonWell Health Alliance, Meaningful Use does mandate interoperability. The participants are, in effect, marketing what they have to do anyway to try to differentiate themselves from Epic.)
The respective results of these two divergent approaches are probably also familiar to you.
Consumer technology has taken over the planet and altered almost every aspect of our lives. These companies and industries have flourished by knowing what customers will want before those same customers feel even a faint whiff of desire. We are both witnesses to and beneficiaries of dazzling speed-to-solution successes.
Back on planet health IT, the American College of Physicians reports that the percentage of doctors who are “very dissatisfied” with their EHRs has risen by 15 percent since 2010; in a poll, 39 percent said they would not recommend their EHR to colleagues and 38 percent said they would not buy the same system again.
I will argue that the difference between health IT and every other progressive, mature industry is the application of open source, open standards and, most importantly, open platforms. These platforms supporting interoperability and substitutability have enabled Apple and Google—and NOAA weather data, the Facebook Developer Platform, Amazon Web Services, Salesforce, Twitter, eBay, etc.—to drive innovation and competition instead of stifling it. They have created markets where everyone wins—the client, the application developer and the platform company.
The keys to open platforms are application programming interfaces (APIs) through which a platform-building company (i.e., Apple, Google) welcomes the contributions of clients and other companies. The more elegant the API, the more it can support true interoperability.