If First You Don’t Succeed
Amidst recent criticism that ACOs are failing to control costs, HHS announces an $840 million initiative designed to improve patient care and lower costs. The Transforming Clinical Practice Initiative will provide 150,000 clinicians with incentives and tools to “encourage doctors to team with their peers and others to move from volume-driven systems to value-based, patient-centered, and coordinated health care services.” Sounds a lot like the goal for ACOs, which HHS hoped would help providers to “work together to provide higher-quality coordinated care to their patients, while helping to slow health care cost growth.”
DeSalvo and Reider exit the ONC
Karen DeSalvo, MD, the national coordinator for health information technology for HHS, steps down from her post just 10 months into her job to assume the role of Acting Assistant Secretary of Health to address “pressing public health issues,” including the Ebola outbreak. The same day Deputy National Coordinator Jacob Reider, MD announced that he would also leave the ONC at the end of November. The ONC’s COO Lisa Lewis will serve as Acting National Coordinator. The changes comes at a time when critics are asking tough questions about the government’s Meaningful Use program and providers’ lackluster progress qualifying for Stage 2.
Epic, Ebola, and (legal) Payola
Epic President Carl Dvorak stands behind his company’s EMR and blames Texas Health Presbyterian clinicians for the mishandling of the country’s first Ebola patient. Meanwhile, the health system’s Chief Clinical Officer Daniel Varga, MD tells a Congressional committee that his organization is “deeply sorry” for “mistakes.” In unrelated Epic news, the company discloses it spent $24,000 over the last two months lobbying Congress. Epic is in the running for the Pentagon’s $11 billion EMR contract and fighting criticisms that its platform lacks interoperability.
It’s time to think carefully and look at the large systems (human and technical), institutions, and individuals that contributed to Mr. Duncan’s death. Systems should be designed to protect people and prevent human errors. Certainly we rely on the healthcare system to improve our health and to protect our privacy, especially our rights to health information privacy.
Looking at the death of Mr. Duncan, the poorly designed Epic EHR was a critical part of the problem: the lack of clarity, poor usability, hard to find critical information, and no meaningful quality testing to ensure the system prevents critical errors contributed to his death and endangered many others. Why wasn’t the discharge of a patient with a temperature of 103 from the ER flagged?
EHRs are one of several critical systemic problems.
Current US EHRs were not designed or tested to ensure patient safety or privacy (patient control over the use of PHI for TPO). The Meaningful Use requirements for EHRs don’t address patient safety or ensure patients’ legal rights to control use of PHI. Let’s face it, the MU requirements were set up by the Health IT industry, not by a federal agency charged with protecting the public, such as NIST or the FDA. Industry lobbying resulted in industry ‘self-regulation’, which has failed to protect the public in every other sector of industry. Industry lobbying is another critical systemic problem.
Our public discourse also is a critical systemic problem. The 24/7 US media drives us to play the ‘blame game’—and look at what happens: it’s a sham. A massive public and social media exercise substitutes for a crucial scientific and ethical oversight process by government and industry to face or examine the systemic causes and key actors—both people and institutions. We end up with no responsibility being assigned or addressed. Or the media hoopla and confused thinking leads to the opposite conclusion: everyone and everything is responsible and blamed, which has the same effect: it lets everyone and everything off the hook. Either way, no one and no institutions are to blame.
Two thousand hackers from 50 universities around the world came to the University of Pennsylvania last weekend, where they were fed, housed, given toothbrushes, Red Bull drinks, and proceeded to create the most innovative and creative software and hardware hacks to date. The event was PennApps, the nation’s largest and longest-running collegiate hackathon. In 48 sleepless hours, people built new ways to interact with iPhones, smart watches, and flying drones. Microsoft and Google were recruiting engineers. Intel even released a new electronics board for the event.
This event was also the debut of PennApps Health, which will hopefully be a part of this event from now on. The turnout was impressive. Epic Systems, Independence Blue Cross, and Mainline Health each presented specific healthcare challenges and rewards. Their presence motivated at least 35 teams to compete in health challenges. Here are the main takeaways from this event:
1. Healthcare hacking is less sexy than device hacking
At open-ended hackathons, the “popular” crowd usually pursues high tech hacks e.g. virtual reality and other cutting edge devices. One group, for example, wired up a motorized skateboard so it could be controlled wirelessly with gestures. Another group created a Google Glass app for the blind that recognized, and spoke aloud, the names of objects in front of the wearer.
Matthew Holt interviewed Jacob Reider, Deputy National Coordinator for Health Information Technology and Chief Medical Officer at the ONC, ahead of his appearance at the 8th Annual Health 2.0 Fall Conference. Jacob will be participating in several panels at Health 2.0, beginning with the Monday main stage panel “Smarter Care Delivery: Amplifying the Patient Voice”.
In this interview, Jacob gives an overview of the HITECH program, the question of interoperability, and the broad adoption of technology in health care as an industry.
Matthew Holt: So, let’s touch base on a couple of things. You’ve been in ONC some time now. Let’s talk about how the general HITECH program has gone and is going. If you were to get to rate it, the spread of EMRs and the usefulness of them, their usability, how would you say we’re doing so far?
Jacob Reider: I think we’re doing very well. Some of your readers know I went to college at a place that had no grades. So I’ll give you the narrative score.
The narrative score is that the program has been very successful achieving the goals that were defined at the outset. So the first iteration of the program, stage one, was all about getting organizations to adopt Health Information Technology, and I think all of the metrics that we’ve seen have validated that the program has been quite successful in accelerating the adoption of Health Information Technology, in both hospitals and practices. That doesn’t mean that we’re finished, but the vast majority of these organizations have now adopted Health Information Technology. Are there additional goals that we’d like to be able to meet? Absolutely, we’d like to see interoperability working better. As you mentioned, we would like the products to be more usable, and therefore, safer.
We’d like to see patients even more engaged than they currently are, so they have more access to the information in their records. We’d like to solve a problem that we’re starting to see in the industry, which I started to call hyperportalosis, which is that in any given community, there may be many portals that patients are expected to log in to. So we’re trying to think about how those problems can be solved in the next iteration of the HITECH program.
European health care systems are already awash in “big data.” The United States is rushing to catch up, although clumsily thanks to the need to corral a century’s worth of heterogeneity. To avoid confounding the chaos further, the United States is postponing the adoption of the ICD-10 classification system. Hence, it will be some time before American “big data” can be put to the task of defining accuracy, costs and effectiveness of individual tests and treatments with the exquisite analytics that are already being employed in Europe. From my perspective as a clinician and clinical educator, of all the many failings of the American “health care” system, the ability to massage “big data” in this fashion is least pressing. I am no Luddite – but I am cautious if not skeptical when “big data” intrudes into the patient-doctor relationship.
The driver for all this is the notion that “health care” can be brought to heel with a “systems approach.”
This was first advocated by Lucien Leape in the context of patient safety and reiterated in “To Err is Human,” the influential document published by the National Academies Press in 2000. This is an approach that borrows heavily from the work of W. Edwards Deming and later Bill Smith. Deming (1900-1993) was an engineer who earned a PhD in physics at Yale. The aftermath of World War II found him on General Douglas MacArthur’s staff offering lessons in statistical process control to Japanese business leaders. He continued to do so as a consultant for much of his later life and is considered the genius behind the Japanese industrial resurgence. The principal underlying Deming’s approach is that focusing on quality increases productivity and thereby reduces cost; focusing on cost does the opposite. Bill Smith was also an engineer who honed this approach for Motorola Corporation with a methodology he introduced in 1987. The principal of Smith’s “six sigma” approach is that all aspects of production, even output, could be reduced to quantifiable data allowing the manufacturer to have complete control of the process. Such control allows for collective effort and teamwork to achieve the quality goals. These landmark achievements in industrial engineering have been widely adopted in industry having been championed by giants such as Jack Welch of GE. No doubt they can result in improvement in the quality and profitability of myriad products from jet engines to cell phones. Every product is the same, every product well designed and built, and every product profitable.
Health care for veterans has been all over the news. At the same time, the DoD is moving to procure a replacement EHR system. So it seems there is no time like the present to review a recent RAND case studies report entitled “Redirecting Innovation in U.S. Health Care: Options to Decrease Spending and Increase Value.”
The case studies include a chapter comparing America’s two most broadly deployed EHRs: The VA’s VistA and Epic. The tale RAND tells is not one of different EHR technologies, as both VistA and Epic both employ the MUMPS programming language and file-based database. Rather, it is about how different origins, business models and practices have dramatically influenced the respective systems. As the report itself says, the contrast offers “useful insights into the development, diffusion, and potential future of EHRs.”
VistA, “the archetype of an enterprise-wide EHR solution,” supports the Veterans Health Administration, “the largest integrated delivery system in the United States.” Initial VistA development was a collaborative, distributed, grass-roots effort where individual VA medical centers built out new clinical functionality on a common platform.
In the mid 90’s, VistA became the instrument of change at the VA.
The pace and scope of EHR adoption increased dramatically under the leadership of Dr. Kenneth W. Kizer, who served as the VA’s Undersecretary for Health from 1994 through 1999. Dr. Kizer considered installation of a major system upgrade to be a core element in his effort to transform the organization …Continue reading…
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.
This is exactly the situation at MaineHealth, who selected Epic. As recently reported, a little while ago Maine Medical Center President and CEO Richard Peterson sent a memo to all employees saying the hospital …
… 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.
Several months ago, I wrote a blog post comparing customers’ experience with Epic with the Stockholm Syndrome.
I reminded people of the syndrome:
Stockholm syndrome, or capture-bonding, is a psychological phenomenon in which hostages express empathy and have positive feelings towards their captors, sometimes to the point of defending them. These feelings are generally considered irrational in light of the danger or risk endured by the victims, who essentially mistake a lack of abuse from their captors for an act of kindness.
Then, I noted:
What is striking about this company is the degree to which the CEO has made it clear that she is not interested in providing the capability for her system to be integrated into other medical record systems. The company also “owns” its clients in that it determines when system upgrades are necessary and when changes in functionality will be introduced. And yet, large hospitals sign up for the system, rationalizing that it is the best.
I quoted an article by Kenneth Mandl and Zak Kohane in the New England Journal of Medicine:
We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants. In reality, diverse functionality needn’t reside within single EHR systems, and there’s a clear path toward better, safer, cheaper, and nimbler tools for managing health care’s complex tasks.
A year ago, Forbes noted, “By next year 40% of the U.S. population–127 million patients–will have their medical information stored in an Epic digital record.”
It is this last point that we must now address, as I hear from my colleagues in the EHR world—no, not Epic’s competitors– that Epic engages in practices that well help cement that market share for years to come.
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.
Almost 20 years ago close to 4,000 people from 200 companies gathered in San Diego for a conference to discuss the future of health-care information technology. This was before the Web. This was back when computers in physicians’ offices, to the extent they were present at all, were used only for scheduling and billing patients. Paper charts bulged out of huge filing cabinets.
It was one of the first big conferences held by the Healthcare Information and Management Systems Society (HIMSS). I was among a grab bag of physicians, technologists, visionaries, engineers and entrepreneurs who shared one idealistic goal: to use information systems and technology to fundamentally change health care.
We didn’t just want to upgrade those old systems. We imagined a future that looked a lot like what we were being promised throughout the economy as it sped into the Internet era. Computers would enable improvements in the practice of medicine—and make it safer, higher quality, more affordable and more efficient—all at the same time. We wanted people to be healthier.