As we enter summer, the health reform process is moving into its Newtonian phase: irresistible forces meeting immovable objects. In both health cost and access, the trend is not our friend. There is ample evidence not only of intolerable inequities, but also intolerable waste and inappropriate use of expensive clinical tools. President Obama embodies the need for change. He has assembled a very talented and politically savvy crew of helpers. He confronts the sternest test of any Presidency, fixing a poorly tuned and fragmented health system that is, by itself, larger than either the French or British economy.
The principal issue then was whether the federal government should
enter the public power business by investing taxpayers’ money to build
the Tennessee Valley Authority and to harness the Columbia and other
rivers for electrical energy, or whether the sites should be transferred to the
private sector. A second issue was who should build transmission lines
and set wholesale prices when the Federal government built dams.
The answer to the second question was first enunciated on the Senate
floor in the fight over the Wilson Dam in 1920 by Senator John Sharp
Williams of Tennessee. He said, “The government should have somewhere a
producer of these things that should furnish a productive element to
stop and check private profiteering.” Thus was born the yardstick
federal policy which later found its way into TVA legislation through
the efforts of Nebraska’s Senator George Norris. In a 1932 campaign
speech in Portland, Oregon, Franklin Roosevelt referred to his TVA and
other regional proposals as “yardsticks to prevent extortion against
There is a major bipartisan effort going on in the Senate Finance Committee to reform the health care system.Reportedly, one of the elements of that effort may be a tax on "gold plated" health insurance benefits
above a certain threshold–$17,000 for family coverage is one option
being discussed. The new tax could raise close to $300 billion over ten
years to help pay for a health care bill.
“You never want a serious
crisis to go to waste.”
Timing matters. The health industry has demonstrated steadfast
resistance to reforms, but its recently diminished fortunes offer the Obama
Administration an unprecedented opportunity to achieve meaningful change. The
stakes are high, though. The Administration’s health team must not miscalculate
the industry’s goals, or waver from goals that are in the nation’s interest.
The two are very different.
Aligning the forces of reform will be the first challenge. The White House and Congressional Democrats appear to be
collaborating to develop a unified reform design. Even so,
the effort is hardly pure. Lawmakers have been receptive to industry influence.
The non-partisan Center for Responsive Politics
reports that, in 2009, health care interests have already spent $128 million on
Congressional lobbying contributions, more than any other sector.
The tide now turned, most of that largess has gone to Democrats.
Several blog readers have asked me to take a fresh look at all the
organizations related to ARRA and explain how it all works. Here's my
understanding:Office of the National CoordinatorThe
Obama administration's ONC is different from the Bush administration's
ONC in several ways. It's now funded with $2 billion to accelerate
healthcare IT adoption. Its new leader, Dr. David Blumenthal has a
policy focus, so we'll see broad policy guidance and specific
healthcare outcome goals rather than technology for technology's sake.
It has regulation – ARRA is law and there are several new privacy,
standards, and implementation requirements that were only voluntary or
market-driven previously. You can expect that ONC will have a major
role in coordinating federal agencies' use of healthcare IT as well as
adoption in the private sector. By controlling the definition of
meaningful use of healthcare IT as the gatekeeping function for paying
stimulus dollars to clinicians, ONC has real power.
An Open Letter to the New National Coordinator for Health IT: Part 3 — Certification As The Elephant in Health IT’s Living Room
In the first and second parts of this series we talked about how and why there is no universal definition for the term “EHR.” Instead there is a legitimate, growing debate about the features and functions that “EHR technologies” should offer physicians seeking to qualify for HITECH incentive payments. We explored the layers of network technology, suggesting that federal regulators should “separate the data from the applications.”
We also argued that there is much to learn from development platforms, recently and in the distant past, that have used standards to open the aperture of innovation. The best of these standards have reflected the experience of what works rather than specifying how to make it work. Defining the standards for data, devices, and network technologies too restrictively could choke off innovation, rendering HITECH’s offerings whose expense and complexity are a barrier to, rather than an incentive for, adoption by physicians. Incoming National Coordinator for HIT David Blumenthal, MD seems to have been considering just this concern when he recently wrote:“… [M]any certified EHRs are neither user-friendly nor designed to meet HITECH’s ambitious goal of improving quality and efficiency in the health care system. Tightening the certification process is a critical early challenge for ONCHIT.”
For those of you who weren’t at Health 2.0 Meets Ix to hear from the mouths of the four horsemen (Halamka, Sands, Zeiger & deBronkhart) here is Google’s Roni Zeiger’s version of what went wrong with the “incorrect data from BIDMC to Google Health” story and what they’re going to do to fix it.
An Open Letter to the New National Coordinator for Health IT – Untying HITECH’s Gordian Knot: Part 1
Congratulations to David Blumenthal on being named National Coordinator for Health Information Technology (ONCHIT). Dr. Blumenthal will be the person most responsible for the rules and distribution of the American Recovery and Reinvestment Act’s (ARRA) nearly $20 billion allocation, referred to as HITECH, designated to support physician and hospital adoption of health information technologies that can improve care.
The job is fraught with difficulties, which Dr. Blumenthal has readily acknowledged. His recent New England Journal of Medicine (NEJM) Perspective, “Stimulating the Adoption of Health Information Technology,” is a concise, clear and honest appraisal of two of these challenges, namely how to interpret and act upon the key terms used in the legislation, “meaningful use” and “certified EHR technology.” Dr. Blumenthal gets to the heart of the matter by identifying the tasks on which the National Coordinator’s success will most depend, and which will foster the greatest controversy.
The country needs Dr. Blumenthal to succeed. The issues are complex and, with huge ideological and financial stakes involved, politically charged.
An Open Letter to the New National Coordinator for Health IT: Part 2 – Opening the Aperture of Innovation
One of the important decisions before Dr. Blumenthal and his colleagues at ONC and HHS is whether the national health information network will be one of closed appliances that bundle together proprietary hardware, software, and networking technology, or one of open data exchange and management platforms in which the component parts required to do medical computing can be assembled from different sources. If the former direction is chosen, power and control will be concentrated in the hands of a very few companies. If the latter, we could see an unprecedented burst of disruptive innovation as new products and services are developed to
create the next generation of e-health services in this country.
Separating the data from the devices and applications, and maintaining a certain degree of independence of both from the networks used for transmission, is far more than a technical quibble. It can determine the economics of technology in stunning ways.
We live in a time of such great progress in so many arenas that, too often and without a second thought, we take significant advances for granted. But, now and then, we should catalog the steps forward, and then look backward to appreciate how these steps were made possible. They sprung from grand conceptions of possibilities and, then, the persistent focused toil that is required to bring ideas to useful fruition.
We could see this in a relatively quiet announcement this week at HIMSS 09. Microsoft unveiled its “Amalga Unified Intelligence System (UIS) 2009, the next generation release of the enterprise data aggregation platform that enables hospitals to unlock patient data stored in a wide range of systems and make it easily accessible to every authorized member of the team inside and beyond the hospital – including the patient – to help them drive real-time improvements in the quality, safety and efficiency of care delivery.”