Thursday, November 30, 2006

Hi, I'm from WalMart and I'm here to help.....

Yesterday’s WSJ reported on a WalMart/Intel collaboration in digital health records. I don’t have a well-formed opinion yet on whether this is good news or bad news for the HIT adoption effort that many of us are engaged in, partly because the article didn’t provide a whole of detail on what this collaboration is actually doing. So let me proceed, but with caution. John McDonough asks whether this might be a “disruptive technology”. I don’t think so. He also asks whether this will complement the work of MAeHC and others involved in promoting HIT adoption. I do think so.

On the technology question, it’s not obvious what’s meant by “digital records for employees” and “portable electronic records.” Patients don’t document medical care, physicians do. And only 10-15% of physicians have EHRs, and most of the country’s 7600 hospitals don’t have accessible data either, so unless this is really a program giving digital records to physicians – and then giving patients access to those records – I don’t see how patients will benefit much.

Perhaps the WalMart model will be based on models that are already out there for the two types of data that are already electronic: claims and prescriptions. Health insurers are well down the road toward providing claims-based PHRs for patients, and AHIP has even brokered a deal for portability of the data across health plans. Revolution Health is going to build a portal that allows patient access to health financial information and health education information. KatrinaHealth is a patient-centric digital record of prescription information. None of these incorporate any hospital or physician information (ie, what we typically think of as our medical records) for the same reason noted earlier, namely, the data isn’t accessible electronically.

So, I don’t think this is a “disruptive technology” from a technical or innovation perspective – I personally don’t believe that there’s a technology magic bullet out there (though we all keep wishing for one!). The main obstacles, as always, are structural (our health care delivery and financing system is broken) and cultural (providers are notoriously independent and resistant to change, and patients think they get the best care in the world, even though there’s tons of evidence that they don’t).

I also don’t think it’s a “shift left” a la Andy Grove. You can’t get data out until someone puts it in, so I don’t think there are any good shortcuts here. It also has to be good data -- you can’t aggregate data that isn’t structured, so having physicians use word processors rather than real EHRs won’t facilitate data warehouses and will actually set them back 10-15 years. I agree that we don’t want to have complex technology be a barrier to adoption, but it needs to be sophisticated enough to deliver value.

That said, I do think this WalMart effort might exert “disruptive pressure” which could push the agenda forward and be very helpful to efforts such as MAeHC. The problem in HIT is that there’s no compelling reason for physicians to adopt EHRs or for providers to link up their systems once they have them. Most efforts to date have focused on the supply-side (ie, providers) because there’s been no real pressure from the demand-side (patients and employers, and their proxies, the insurers). Pay-for-performance may be an indirect means of forcing technological transformation, but it’s indirect. By contrast, when working with their other supply chains, WalMart, GM, Intel, and others insist that their vendors set up electronic data interchange systems that allow real-time inventory management, order management, delivery tracking, etc. If employers start thinking of their health care supply chain in the same way – and require that providers have EHRs and interoperability – they will fundamentally alter the pace of change by creating urgency, where none really exists today. Patients will be the main beneficiaries in the end.

I think it’s fair for all of us to be concerned about anything related to healthcare that WalMart is involved in, because their business success is based on cost-reduction, not on maintaining high quality products or service, and they apply this approach to their suppliers and to their employees alike.

I also worry that there could be an element of coercion in their model as described. Will they derive revenue from selling the de-identified data from the warehouse? Will they ask patient permission to sell this data (HIPAA doesn’t require it)? Will they share the revenues with their employees? My fear is that the answers to these questions aren’t on the side of their employees. WalMart of course would argue that the data is theirs since they’re holding it, paying for it, and de-identifying it (I guess possession is 9/10 of the law, or something like that). Yet another reason that we should move away from our system of employer-sponsored health benefits, but I’ll wait for John McDonough to open up that can of worms……

1 comment:

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