If one were writing about the improvement of gastronomy in America, one would probably not celebrate “over 300 billion hamburgers served.” But that’s very much the type of success Dr. Ashish Jha is celebrating in last week’s piece on recent US healthcare IT sales. Unfortunately, the proliferation of Big Macs does not reflect superior cuisine, and healthcare IT (HIT) sales do not equate with better healthcare or with better health. Quantity does not equal quality of care.
To be sure, Dr. Jha acknowledges the challenges of rolling out HIT throughout US hospitals. And he should be strongly commended for his admission that HIT doesn’t capture care by many specialists and doesn’t save money. In addition, Dr. Jha points to the general inability of hospitals, outpatient physicians and laboratories to transfer data among themselves as a reason for HIT’s meager results.
But this is a circular argument and not an excuse. It is the vendors’ insistence on isolated proprietary systems (and the government’s acquiescence to the vendors) that created this lack of communication (non-interoperability) which so limits one of HIT’s most valuable benefits.
In our opinion, the major concern is that the blog post fails to answer the question we ask our PhD students:
So what? What is the outcome?
This entire effort is fueled by $29 billion in government subsidies and incentives, and by trillions of dollars spent and to be spent by hospitals, doctors and others .
So where is the evidence to back up the government’s and industry’s promises of lower mortality, improved health and lower health care costs?
Single studies tell us little. Sadly, as many as 90% of health IT studies fail the minimal criteria of the respected international literature syntheses conducted by the Cochrane Collaboration.
In other words, studies with weak methodology or sweetheart evaluation arrangements just don’t count as evidence.
Last week I had the opportunity to test Google Glass.
It’s basically an Android smartphone (without the cellular transmitter) capable of running Android apps, built into a pair of glasses. The small prism “screen” displays video at half HD resolution. The sound features use bone conduction, so only the wearer can hear audio output. It has a motion sensitive accelerometer for gestural commands. It has a microphone to support voice commands. The right temple is a touch pad. It has WiFi and Bluetooth. Battery power lasts about a day per charge.
Of course, there have been parodies of the user experience but I believe that clinicians can successfully use Google Glass to improve quality, safety, and efficiency in a manner that is less bothersome to the patients than a clinician staring at a keyboard.
Here are few examples:
1. Meaningful Use Stage 2 for Hospitals – Electronic Medication Admission Records must include the use of “assistive technology” to ensure the right dose of the right medication is given via the right route to the right patient at the right time. Today, many hospitals unit dose bar code every medication – a painful process. Imagine instead that a nurse puts on a pair of glasses, walks in the room and wi-fi geolocation shows the nurse a picture of the patient in the room who should be receiving medications. Then, pictures of the medications will be shown one at a time. The temple touch user interface could be used to scroll through medication pictures and even indicate that they were administered.
2. Clinical documentation – All of us are trying hard to document the clinical encounter using templates, macros, voice recognition, natural language processing and clinical documentation improvement tools. However, our documentation models may misalign with the ways patients communicate and doctors conceptualize medical information per Ross Koppel’s excellent JAMIA article. Maybe the best clinical documentation is real time video of the patient encounter, captured from the vantage point of the clinician’s Google Glass. Every audio/visual cue that the clinician sees and hears will be faithfully recorded.
Just a little over four years ago, President Obama, in his inaugural address, challenged us as a nation to “wield technology’s wonders to raise health care’s quality and lower its costs.” This was an awe-inspiring, “we will go to the moon” moment for the healthcare delivery system. But the next thought that ran through the minds of so many of us who work on health IT issues was this: how were we going to get there?
We were essentially starting from scratch. Less than 1 in 10 hospitals had an electronic health record, and for ambulatory care physicians, the numbers weren’t much better – about 1 in 6 had an EHR. Hospitals and physicians reported an array of challenges that were holding them back. No nation our size with a healthcare system as complex as ours had even come close to universal EHR use. Yet, the President was calling for this by just 2014.
And it was clear why. The promise of EHRs was enormous and we knew that paper-based records were a disaster. They lead to lots of errors and a lot of waste. I have cared for patients using paper-based records and using electronic records – and I’m a much better clinician when I’m using an EHR. In the weeks that followed Obama’s inaugural address, the U.S. Congress passed, and the President signed the Health Information Technology for Economic and Clinical Health Act, which contained a series of incentives and tools to drive adoption and “meaningful use” of EHRs. None of us knew whether the policy tools just handed to the Obama administration were going to be enough to climb the mountain to universal EHR use. We were starting at sea level and had a long climb ahead.
Trends in US healthcare expenditures are financially unsustainable (1). I would like to propose two tweaks of the healthcare delivery process that may, in a small way, help rectify this problem.
Although there is a widespread impression that health information technology (HIT) will eventually “bend” the cost curve and put healthcare spending on a sustainable course, there is, as of yet, little data that convincingly supports this hypothesis (2).
Kaiser Permanente is a large, integrated healthcare delivery system which has invested heavily in HIT. George C. Halvorson, the chairman and CEO of Kaiser Permanente appears to have concluded that this investment will not solve the healthcare cost issue, when he was quoted in the New York Times (3/20/13) as stating “We think the future of health care is going to be rationing or re-engineering.”
Because HIT, as currently implemented, will probably not solve the healthcare cost problem, I would like to suggest a minor “re-engineering” of the electronic health record user interface which may help bend the cost curve.
At every office visit, the physician must make a myriad of decisions which incrementally effect the nation’s total healthcare expenditures. For example, the physician will have to decide which medicine to prescribe, and which radiology study or laboratory test to order.
In many situations, there is more than one acceptable choice. The physician’s ultimate decision will integrate their understanding of the disease process, the treatment’s side effect profile, their familiarity with the treatment options, patient preferences and many other variables.
I would suggest that every time a physician is about to order a test or a prescription, the cost of the test or prescription should be displayed to the physician. In the same vein, whenever a computer displays a test result, the cost of the test is immediately available to the reader. This information could then become an additional factor that the physician may choose to integrate (or ignore) at the moment when he/she is about to commit the patient and society (which is now paying >50% of all healthcare bills) to another healthcare expenditure. In terms of a risk/benefit analysis, I can see little downside to providing this cost information to physicians.
Uwe Reinhardt said it perfectly in a Tuesday plenary but I can only paraphrase his point: “health information is a public good that brings more wealth the more people use it.” Or, as Doc Searls puts it: personal data is worth more the more it is used. Datapalooza is certainly the largest meeting of the year focused on health data, and our Health and Human Services data liberation army was in full regalia. My assessment is: so far, so good but, as always, each data liberation maneuver also reveals the next fortified position just ahead. This post will highlight reciprocity as a new challenge to the data economy.
The economic value of health data is immense. Without our data it’s simply impossible to independently measure quality, get independent second opinions or control family health expenses. The US is wasting $750 Billion per year on health care which boils down to $3,000 per year that each man, woman and child is flushing down the drain.
Data liberation is a battle in the cloud and on the ground. In the cloud, we have waves of data releases from massive federal data arsenals. These are the essential roadmap or graph to guide our health policy decisions. I will say no more about this because I expect Fred Trotter (who is doing an amazing job of leading in this space) will cover the anonymous and statistical aspects of the data economy. Data in the cloud provides the basis for clinical decision support.
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.
An unfathomably complex entity such as a health system grows over time like a city. Right now, communications and data usage in the US healthcare system is a bit like a medieval town, with new streets and squares popping up in unpredictable places and no clear paths between them. Growth in health information has accelerated tremendously over the past few years with the popularity of big data generally, and we are still erecting structures wherever seems convenient, without building codes.
In some cities, as growth reaches the breaking point, commissioners step in. Neighborhoods are razed, conduits are laid in the ground for electricity and plumbing, and magnificent new palaces take the place of the old slums. But our health infomation system lacks its Baron Haussmann. The only force that could seize that role–the Office ofthe National Coordinator–has been slow to impose order, even as it funds the creation of open standards. Today, however, we celebrate growth and imagine a future of ordered data.
The health data forum that started today (Health Datapalooza IV) celebrated all the achievements across government and industry in creating, using, and sharing health data.
Useful data, but not always usable
I came here asking two essential questions of people I met: “What data sources do you find most useful now?” and “What data is missing that you wish you had?” The answer to first can be found at a wonderful Health Data All-Stars site maintained by the Health Data Consortium,which is running the palooza.
The choices on this site include a lot of data from the Department of Health and Human Services, also available on their ground-breaking HealthData.gov site, but also a number of data sets from other places. The advantage of the All-Stars site is that it features just a few (fifty) sites that got high marks from a survey conducted among a wide range of data users, including government agencies, research facilities, and health care advocates. 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.
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.
But here’s a teaser…