According to Ben Franklin, John Adams, or someone else (I could not find a reliable source), “Every problem is an opportunity in disguise.” This bodes well for clinical care software because the number of complaints about current EHR systems grows louder each day. We know the problems: poor usability, lack of workflow support, reporting difficulties, decreased productivity, to name a few. How can these problems be turned into opportunities?
Obviously, solving these problems by designing better software offers an opportunity for software sales; however, I think there is more to it than that. Current EHR products grew out of a particular mindset and way of thinking about software and sales, and that mindset, I believe, has a lot to do with the problems EHR users voice.
When computers were new, they were sold primarily to businesses. The advent of the PC turned computers into consumer products. However, software and computer sales to businesses continued as they always had, which I think contributes to the issues small independent practices have with selection and implementation. Here is an example of what I mean. I have been buying software since I bought my first computer. This was always a straightforward process: find the software, pay for it, done. I remember my bewilderment while at UAB when I wanted to buy statistical software that had data mining algorithms. Since I was at the university, I was told I had to buy it through the university sales channel. I wanted a single copy. I could never find a salesman who would give me a price or tell me how to buy a single copy. I called the local, regional, and finally the national sales office. After a few weeks, I gave up. I never got the software, or even a price. What I did get were repeated promises that a sales rep would call.
In the wake of the National Coordinator’s announcement that he is departing, there has been a flurry of tweets, blog posts, impromptu online polls, and conjecture about the most likely successor. To date, none of these conversations has resulted in a thoughtful assessment of the set of characteristics that would represent the ideal candidate, nor has there been any thorough review of the most likely candidates in the context of these attributes. The need for a rapid transition to a successor is well understood by all – yet there has been no indication that the Obama administration is in a hurry. Let’s hope that we can evolve them toward a greater sense of urgency. The fragility of ONC – and the importance of its health – can’t be overlooked.
Let’s consider some history:
The first two National Coordinators, David Brailer and Rob Kolodner, were appointed before ARRA. The agency was small, focused largely on certification (through CCHIT), standards (through HITSP) and policy. When ARRA arrived, David Blumenthal, a thoughtful, deliberate, policy-savvy internal medicine physician from Boston was brought in to lead the rapid expansion of health IT that was facilitated by the HITECH Act.
ONC expanded under Blumenthal from a team of ~ 30 people to a team of >100 in the two years that he was at the helm, and the agency published the 2011 certification criteria regulations, and collaborated with CMS to publish the regulations that defined stage 1 of the Meaningful Use incentive program. The policy foundation was that the three-stage program – to be implemented over six years – would evolve the nation’s care delivery system by causing adoption of EHR technology (stage 1) and then exchange of clinical information electronically (stage 2) and finally improved clinical outcomes (stage 3).
Farzad Mostashari, who joined Blumenthal as the Deputy National Coordinator early in Dr Blumenthal’s tenure, was quickly named as Blumenthal’s successor when Blumenthal announced his resignation in the Spring of 2011. Both Mostashari and Blumenthal pushed hard for Mostashari’s appointment – so that the consistency, focus and forward momentum of the organization could be maintained.
And so it was. Under ARRA, adoption of EHRs has skyrocketed. The CMS MU Stage 2 regulations and the ONC 2014 certification regulations were published, and the size of the agency has doubled to over 150 people. Recognizing the need for experienced partners to assist him in leading a larger agency – and growing national reliance on health IT and an essential component of the care delivery ecosystem – Mostashari hired David Muntz as the “Principal Deputy” (essentially the COO of the agency), Jacob Reider as Chief Medical Officer (leading a team of clinicians focused on quality and safety) and Judy Murphy as the Deputy National Coordinator for Programs and Policy (adding internal coordination support for ONC programs).
Hi. It’s me again. No, I’ve been doing fine; my writing slow-down is not due to calamity, catastrophe, apostrophe, or even syndactyly. I’ve been working hard, working like a dog.
So, what’s been so all-consuming that I can’t sit down and write? My computer system. I know it may sound nerdy and lame, but I’ve been putting every ounce of my creative energy into building a system. It’s driven by two main things: trying to give the best care I can, and doing so while avoiding personal bankruptcy. Fear of the latter is strong motivation. So I’ve been pouring myself into this task like nothing I’ve done before. My goal is to build a system that will:
1. Organize information. My care will only be as good as the information I have. It should be presented in a way that gives me just the right amount of information, with the ability to get more when I need it.
2. Cope with the flood of incoming information. Take the piles of communications coming in and route it to the proper storage place, use the information to make decisions, communicate it with the patients, and decide on follow-up. This is an enormously difficult task.
3. Integrate with every communication tool possible. Most doctors don’t do this because they rely on office visits for income, and that hinders the care they give. Communication is care, and I want to have good communication that is enlightened by good information.
4. Create a shared medical record with my patients. I am convinced that my patients will get the best care if they have access to their information. But this needs to be done in a way that is both simple and secure. I want “one stop shopping” for people to communicate or look at their records.
5. Keep my books. I don’t want to go bankrupt and don’t want to go to jail for keeping disorganized books. It’s possible to get freed from the fear of Medicare audits, but not from IRS audits.
6. Organize the future. There are far too many missed opportunities for care. Integrated task-management (shared between patient and their care team) is my goal.
7. Grow with me. If I accomplish 1-6, my practice will grow. I don’t want that growth to outpace my system.
So far I’ve been focusing on 1, 2, and 5, with eyes on the rest. I’ve made great progress, but there’s much more needing to be done. My ultimate goal of this is to build working prototypes of both this practice model and the software that will enable it to be more than just a side-show, an alternative for doctors who want to escape. I believe that this is truly better care. It is focused on what the patient wants: to be healthy and to spend as little time thinking about their health care as possible. It’s working so far, but it can be much more than it is now.
In these politically polarized times, Americans expect Republicans and Democrats to disagree on every detail right down to what day of the week it is. This is especially true in the posturing hurly-burly of the House, where members can appeal to the few select priorities of a gerrymandered district to win re-election.
So it’s remarkable and unexpected when any legislation exits a House committee with unanimous bipartisan support. It’s even more surprising when the legislation potentially threatens the status quo for established corporate interests—in this case information technology companies.
The Federal Information Technology Acquisition Reform Act (FITAR)—sponsored by California Republican Darrell Issa along with Virginia Democrat Gerry Connolly, and supported by every member of the House Oversight and Government Reform Committee—threatens to put open-source software on par with proprietary by labeling it a “commercial item” in federal procurement policies. The proposal wouldn’t give open source a privileged position, just an equal one.
In a few days, I will be releasing the most controversial healthcare project I have ever worked on. But you do not need to take my word for it. I will be releasing a completely new healthcare data set. That data set, which will remain a “Mystery Data Set” until its release to the healthcare data scientists attending Strata RX, should completely revolutionize the way we think about healthcare delivery in the United States.
This mystery data set is the first real outcome of the Patient Skunkworks project. Patient Skunkworks is a new way for me to try and create high-impact but low-profit software projects. This is part of a new Not Only For Profit software development model that I have been working on. The new company forming to do this work will be called Not Only Development.
I will be releasing this data during the last keynote on the first morning (Oct 16) of the 2012 Strata RX conference. There is simply no way, in a single keynote, to even begin understanding all of the ways that this data set will be leveraged to improve healthcare. More importantly, there is really no way to adequately explain why I would choose to give away such a valuable and dangerous data set.
To help people digest the implications of this data set, I will be writing two articles about the data set. This one, before the release which helps to explain the underlying motivation behind the release, and another one after the release explaining what the data set is, and how I think it can be leveraged.
I am releasing this dataset because I believe that the only way to solve the problems in healthcare is to embrace a radical openness with health data. Healthcare data, with the exception of patient identity data, belongs in the open, in the sunlight. When used correctly, I believe that healthcare data should make patients feel empowered, and everyone else in the healthcare industry uncomfortable. I believe that patients deserve deep, dangerous and real access to data. I think when we start talking about how data might actually be dangerous for patients, its just a sign that we are “doing it right”. I call this concept Radical Access to Data (and yes, that recursively spells “RAD”).
Venture capitalists like to use the word “traction.” It sounds all glamorous, like an ad showing a Range Rover toughing it out up some impossible incline. But when I hear a company talk about ‘early traction’ in its pitch, I’m always leery of the “First and Worst” effect.
My first customer at my first company was a grandfatherly CIO at a big hospital. Of course I wanted to please him, and was enthusiastic about doing so. But I was also very focused on taking over the world with our software. I told him, “We’ll change anything you want about the product, as long as it’ll be good for all our future [gazillion] customers.”
Of course, The Grandfather wanted lots of one-off customizations that would really only be good for him. I told him that all the time we spent doing custom work for him was going to make us less profitable, and less likely to be able to sell the product to other people. And to survive long enough to do any improvements to the product at all, we needed to be profitable. He seemed to think that made sense, and begrudgingly agreed.
In the end this arrangement was a win for both of us. Our product was a home run for his hospital. We got an evangelical reference customer, and his hospital helped make our product better. The precedent we’d set with The Grandfather gave us the courage to refuse other customers who wanted one-off changes. Sure, we could have done this for one or two hospitals, but by the time we got to hospital 300, it would have been a mess.
For the majority of my career I have been obsessed with creating technologies to modernize our largely dysfunctional U.S. healthcare system. To me, it is very clear that the emergence of cloud computing has finally created the opportunity to truly address this daunting problem. Cloud-based solutions are the only viable option for effectively getting providers, patients and other key stakeholders online so that the necessary efficiencies find their way into the system.
To the rest of healthcare IT, however, it is not so clear, as witnessed by the lack of truly cloud-based companies in the marketplace.
Most of the large, established players in this industry continue to rely on the outdated client/server or older technologies, such as MUMPS. Some of these companies’ products trace their roots as far back as 1969. These companies and their software were built before the world wide web, before Facebook, the iPhone and iPad, salesforce.com – and even email, for God’s sake! There also exists a tremendous amount of confusion related to the morass of small, bootstrapped EMR companies, which number in the hundreds. People do not understand the difference between buying a monolithic single-purpose app to utilizing a robust, cloud-based platform approach.
This lack of understanding has made me realize that we need a better way to explain what the cloud has the power to do, and what true cloud-based technology even is. Easier said than done!
I was recently afforded a breakthrough, though unfortunately at the expense of an ancient treasure. Allow me to explain:
Not a week goes by without seeing some headline about deficits pushing municipalities to desperation or Bill Gates describing state budgets using accounting techniques that would make Enron blush. The common culprit: healthcare costs with Medicaid being the biggest driver.
Recently Carly Fiorina opined on The Health Care Blog about Health Care, Not Coverage. She pointed out the unnecessary administrative burden that could be better spent on delivering healthcare. Fortunately, there is already a proven model, developed and run by physicians, that has shown it can reduce costs 20-40% by removing administrative overhead while improving outcomes (e.g., 40-80% reductions in hospital admissions) and greatly increasing patient satisfaction with Google/Apple level of patient satisfaction.
It can be described as two parts Marcus Welby and one part Steve Jobs. The federal health reform bill included a little-noticed clause allowing for Direct Primary Care (DPC) models to be a part of the state health insurance exchanges. That little-noticed clause (Section 1301 (a)(3) of the Affordable Care Act and proposed HR3315 to expand DPC to Medicare recipients) should have the effect of massively spreading the DPC model throughout the country. In California, the DPC model was introduced in a bill to bring explicit support for the DPC model as has been done in the state of Washington and elsewhere.