Friday, August 31, 2007
It made me wonder how much of this is a market phenomenon vs an individual company story. If EHR use is substantially growing, supply would have to be increasing through some combination of new entrants and substantial growth for existing companies. Since the EHR market is very fragmented with many more private companies than public (CCHIT certified more than 90 vendors last year), I would expect to see a lot of EHR companies on the Inc list. Well, they may be there, but I couldn't find them. My non-scientific, non-exhaustive searching of the Inc. website found only one other CCHIT-certifed vendor: Greenway, at #1570 with 227% growth. I also found a practice management vendor (AdvancedMD), which came in at #465.
Of course, the larger players such as Allscripts, NextGen, GE, wouldn't appear on the Inc list because they're publicly traded. According to their SEC filings, they've shown healthy -- but not spectacular -- growth (15-20%) over the past year.
In 2004, President Bush set a goal to have the majority of Americans on an "interoperable EHR" by 2014. Robert Kolodner recently projected that the US would reach this objective. Outside of eCW's huge growth, there doesn't seem to be much obvious evidence that the EHR market is on the steep part of the "hockey stick" growth path that would be required to take us from the current situation -- where probably 10% of Americans' records are on an "interoperable EHR" -- to the goal of having 51% seven years from now.
Thursday, August 23, 2007
Founded by the Oregon Business Council, the group seemed to have a lot going for it -- funding, staff, tech-savvy population, and broad-based board. According to the Tribune:
On the face of it, the project seems to have violated a core principle -- make sure the first step has a business case, however small. The first project was for a "Results and Reports Viewing and Retrieval System" that would "make already-computerized information from laboratories, hospitals and imaging centers available for viewing and retrieval by all of a patient’s providers."
[A] year after the group began its work, the project has stalled — a victim of technological issues, and also of some overbearing financial disincentives: Some of the entities being asked to pay for the system can make a lot more money when the system isn’t in place.
The project plan called for them to do this in 12 months -- wildly ambitious for a project of this scope. It took many years to get a more limited results delivery system up and running in Indianapolis, if you count the hard work done in value proposition development and business planning -- and Indiana already had an unparalleled base of technology and expertise to build on.
A second more fascinating aspect of the story is the reluctance of the hospitals to participate in the project, reportedly because a main value driver -- reduction of duplicate tests -- was going to cost them $10M in lost revenue.
In my experience, it's rare to hear someone publicly admit that they're benefiting from waste in the system, and then go on to defend it. Yet, that's what Dick Gibson, CIO of one of the hospital systems, did. He even spun the argument to defend even more economic inefficiency, arguing that redundant tests shouldn't be cut because the revenues are used to cross-subsidize free care. I'm sure that's partly true, but that's a very inefficient way to fund free care. And besides, if redundant tests weren't driving up the cost of care, maybe we'd need less free care to begin with!
I would think that the hospital boards would step in at some point and exercise the strategic judgement that I once heard from a senior executive at a large lab company: Building your business on waste in the system is not a sound long-term strategy, particularly when that waste has been exposed. In Indianapolis and Cincinnati, the hospitals pay a large share of the costs of the HIEs because there's a clear ROI for them in results delivery. The hospital leaders leading those HIEs have made the strategic decision to compete on quality, efficiency, and patient satisfaction, not on who can extract more waste from the system.
Perhaps the biggest surprise here is that those with the greatest interest in wringing out the cost of redundant tests -- namely the health plans, employers, the state of Oregon, and patients -- are standing on the sidelines and allowing the hospitals to block the project. I find it hard to believe that they'll be silent for long......
Wednesday, August 22, 2007
In order to get rapid change in this or any other industry, you need either strong economic incentives, strong regulatory compulsion, or a mix of both. The way US health care delivery (and reimbursement) is currently structured, incentives will probably only get us so far before we have to add in a bit of compulsion (or maybe, a lot of compulsion). The EHR mandate issue has come up before in Massachusetts. Given how broken health care delivery is today, I think a mandate is a good idea, but only if we inject funding and support to help physicians and hospitals to achieve the mandates effectively. Otherwise, we can mandate all we want, but we'll only get as far as the current system will allow us to go (ie, not far).
MAeHC estimates that it will take about $500M to get just the ambulatory side done in Massachusetts -- more if you want to include hospitals like the Minnesota mandate does. I haven't heard that Minnesota has provided much funding for their EHR plan ($14M for rural practices). Maybe Massachusetts' and Indiana's leading positions are safe after all......
Tuesday, August 21, 2007
I don't know if any other Cabinet secretaries have blogs (I doubt it -- imagine what Donald Rumsfeld's would have been like). It's hard for a political appointee to reveal what they're really thinking, and I wonder how much will be ghost-written, what type of editing it'll go through with his own press team, and what type of pre-posting screening the White House staff will impose on it. Remember what happened to Dr. Richard Carmona, the former Surgeon General (see "Ex-Surgeon General Says White House Hushed Him").
Nevertheless, I think it's a laudable effort. Best of luck Mr. Secretary!
Monday, August 20, 2007
Commerical plans have been slowly but surely moving into the so-called P4P era of reimbursement, and Medicare is making its way there as well (David Harlow last week posted an excellent summary of Medicare's programs -- CMS forges ahead with pay-for-performance (P4P) initiatives). Up til now, the P4P conversation hasn't focused much on safety. There's been plenty of attention given to voluntary efforts and reporting on safety at the state and national levels (e.g., in Pennsylvania, Massachusetts, Indiana, and IHI's various campaigns). And, of course, there's Beth Israel Deaconness Medical Center which, under the leadership of Paul Levy, has been taking the lead in this type of reporting. But this focus on reporting and prevention had not really penetrated the conversation on payment and incentives. Until now.
On the face of it, the issue seems pretty straightforward. I pay you to do something, and if you screw up along the way, you should pay to fix the screw-up that you created. In practice, of course, it's much more complicated. A couple of issues that come to mind are:
Measurement. Are there clear ways to distinguish preventable from non-preventable errors? The issue is both with respect to categories (e.g., central line infections but not other types of infections) and threshholds (e.g., zero tolerance vs deviations from a baseline). If it's like most measurement, the majority of cases will be relatively easy to categorize, but some won't, and this minority of cases will constitute 90% of the measurement effort and 100% of the pushback.
Payment. Who's going to pay for the treatment of preventable errors? While we'd like to think of these as potentially zero-incident events, we live in a messy world, and statistically it's never going to be zero. So, let's say I suffer a "preventable error" in the hospital, and my insurance carrier tells the hospital that they're not paying for my treatment. Well, who does pay at that point? Supposedly the Medicare rules are going to say that the hospitals can't pass this cost to the patient. Is the hospital on the hook for the payment? What if the error was caused by a physician who isn't a hospital employee -- is s/he responsible for the payment? Will hospitals and physicians have to take out more or a different type of insurance to cover such payments? Will their malpractice liability exposure go up if Medicare determines that a particular patient suffered from a preventable error? Will their malpractice insurance premiums be affected if Medicare determines that they caused preventable errors, even if no litigation arises from the incident?
I don't think these complexities are show-stoppers -- after all, health care reimbursement addresses very complex issues every day (the new 2008 rules on inpatient prospective payments are over 2000 pages long -- and that's just this year's changes). I think this is a watershed moment in health care financing because it constitutes a real step away from the current "cost-plus" paradigm of reimbursement. I don't count current P4P efforts as real change because there's much more smoke there than fire owing to weak measures, dubious connections between those measures and actual quality, and correspondingly, shallow financial incentives.
Not paying for preventable errors seems different than current P4P efforts because it's something that patients/consumers (and the media) understand, it deals with reimbursement at the individual case level rather than the patient panel level and, finally, there's real money on the table. The fact that Medicare is taking this step is perhaps the biggest news of all. Medicare is the biggest player in the health care market, and commercial plans are generally loathe to make fundamental changes in reimbursement approaches without Medicare's participation because they don't want to "go it alone" against physicians and hospitals, and because their efforts are ineffectual anyway if they are diluted or contradicted by Medicare policies. Medicare's making these changes gives commercial plans the cover and the incentive to make more far-reaching changes in their own reimbursement approaches than they've been willing or able to make for a very long-time.
Tuesday, August 14, 2007
Many Americans are under the delusion that we have “the best health care system in the world,” as President Bush sees it, or provide the “best medical care in the world,” as Rudolph Giuliani declared last week. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.Most health care professionals already know this to be true. It's also true that we lag behind most of those same countries in the use of health IT. The connection between health IT and quality is pure correlation at this point -- no one has proven causation. Health IT won't be a panacea anyway -- most "wired" physicians I've worked with point out that the technology has only revealed for them how much the technology can't fix and how deep our problems really are.
Looking across countries, I'll bet that greater IT use is not a cause of greater quality, but rather, it's an indicator of a better health care system. Those systems have aligned incentives in a way that encourages not only IT tools but a whole host of processes and behaviors and tools to improve quality, safety, and efficiency -- exactly the opposite of the incentives in the U.S. system. Doesn't mean that adding health IT won't improve the U.S. -- I think it will. But we shouldn't kid ourselves about the fact that we're sub-optimizing -- until we have a health care system that is fundamentally oriented toward improving the quality, safety, and efficiency of care, we'll continue to be outperformed by our peers, regardless of how much technology we put in place.
Monday, August 13, 2007
The Dossia project has taken some interesting turns in the last couple of months. First was Marianne McGee's initial report in Information Week ("Major E-health Records Project Unravels Into Legal Battle"). More recently, Modern Healthcare reports that Dossia has asked a court to seal the records of its dispute with its vendor over the project ("Dossia wants PHR deal kept under wraps").
Though I have been fairly critical of the Dossia project since it's origins ("Hi, I'm from WalMart and I'm here to help" and "You can't get blood (or data) out of a stone"), I don't take a whole lot of pleasure in seeing a high-profile health IT failure, especially at a time when we in the field have very few successes to speak of. That said, it's probably good that it's falling apart now on relatively straightforward corporate contract issues (money, deliverables, etc), because it shows that they're probably not yet ready to tackle the hard stuff anyway -- like privacy, security, access, control, secondary uses, etc etc etc.
One fascinating aspect of the issue is the David and Goliath angle. Dossia (ie, WalMart, Pitney Bowes, British Petroleum, Intel, etc) is throwing legal weight around in court trying to prevent public access to court records about some pretty mundane contract issues -- relatively small amounts of money ($6 million or so), associated contract deliverables, and conflicting claims of breach of contract. And they're turning the screws on the Omnimedix Institute, a 15-person non-profit organization. Don't get me wrong -- Omnimedix may very well be in the wrong, and unsuited and unqualified to take this on besides, but they are, in the end, a 15-person non-profit organization.
If this display of bare knuckle tactics and secrecy about details is any indication, Dossia's leadership seems like it might be a little behind the times with regard to patient privacy, consumer empowerment, and transparency. Let's just hope that they get up to speed by the time that there's real patient data on the line.....