Thursday, May 31, 2007

IT Writer, Familiarize Thyself

Yesterday's New York Times had an op-ed on EHRs by Thomas Goetz, an editor of Wired magazine ("Physician, Upgrade Thyself"). Goetz believes that he's found the silver bullet on EHR adoption -- it's open-source software, namely, WorldVistA. I guess I was hoping for something more compelling from an IT expert, so forgive me for being underwhelmed.

The crux of his argument is that physicians have huge desire for EHRs, but this demand is stifled by the high cost of the software. WorldVistA, the ambulatory version of the VA's VistA system, is his answer -- it's open source, which to Goetz means that it's low-cost and good enough. He notes that WorldVistA may not be as good as its competitors -- it's user interface is clunky, and it's practice management functions are primitive -- but, he says, these are "Cadillac" features that most physicians needn't worry about.

I don't want to dismiss WorldVistA out-of-hand; my mother spent her entire career as a VA physician, and I myself was a Pentagon civil servant for a number of years, so I'm heartened to see the VA finally get recognized for it's great work with VistA and for the entrepreneurial spirit that has taken it to market. I'm also glad to see that Wired magazine is excited about WorldVistA -- they gave it a 2007 Rave Award. I think it's important not to confuse our hopes with our expectations, however. WorldVistA could find a place in the market, but that's a far cry from becoming the magic solution to the "EHR gap".

If physicians have huge desire for EHRs, they must be hiding it really, really well, because EHR penetration is shockingly low and it's not growing very fast. Clearly, there's more than just cost that's holding them back. Health care delivery is the most fragmented sector of our economy, both on the supply-side and on the demand-side, which has created an unbelievably dense thicket of contractual relationships among purchasers, insurers, providers, and patients. The amazing thing is that almost every aspect of this tangled mess militates against higher EHR adoption. It's thus highly unlikely that one single change, such as a lower cost EHR, can tip the scales on EHR adoption.

I'm not convinced that WorldVistA is that much lower cost anyway. Yes, it's license fees are lower, but license fees are only one small part of the total cost of ownership of an EHR. A practice still has to pay for hardware, networking, installation, implementation, training, upgrades, and maintenance, and it's not clear that WorldVistA would have any cost advantage over its competitors in these areas. The fact that it's open-source doesn't solve these problems either. An EHR will never have the dense base of expert contributors that continue to drive Firefox and Linux -- physician offices don't have programmers with expertise and capacity to develop open-source code, and EHR software is too specialized to attract a large base of student and/or corporate developers.

Finally, while Goetz pooh-poohs the deficiencies in WorldVistA's user interface and navigation, as well as it's back-office functionality, I don't think these issues can be so easily dismissed. Back-office functionality affects the revenue-side, and most practices have some type of electronic billing already. Lack of integration with back-office systems is a show-stopper for most practices because billing for health care is so complicated. Yet, creating such functionality is real work -- it takes considerable effort to develop and support a robust PMS application, and it's not the type of project that lends itself to ad hoc contributions from an open-source community.

It is perhaps ironic, but nevertheless true, that only the most sophisticated computer users make use of open-source software. Yet, physician offices represent the least sophisticated stratum of computer users. It's hard for me to see how WorldVistA will be able to change that equation.

Tuesday, May 29, 2007

Clarifying a recent Information Week article

This week's Information Week had a few interesting articles on EHRs and PHRs. The lead article ("Why Progress Toward Electronic Health Records is Worse Than You Think") hits on some of the more well-known cautionary notes, like the demise of the Santa Barbara Care Data Exchange, and the widely-reported issues faced by Kaiser Permanente in it's Epic installation. The article also describes what may be a deeper and more insidious challenge to significant progress, namely, the lack of urgency among the vast majority of physicians to get moving on EHRs and HIE.

The articles also quote me and describe the work of the MAeHC, and while I'm fine with most of the reporting on us, I want to clarify some false impressions that the articles could create about us and our work.

First, I'm not nearly as arrogant as I sound in the article (not nearly!). When asked if I felt that there was a lot of pressure on us to deliver, I responded that we certainly feel that there is a spotlight on us. That got turned into a quote that has me suggesting that THE national spotlight is on us, as if there aren't other important activities going on around the country. There are over 150 HIE efforts around the country according to the last eHealth Initiative Annual Survey, and concrete, replicable successes among any of them will be important guideposts for the rest of us and for the national effort at large.

A second clarification I need to make regards a sidebar article on PHRs ("Doctors Debate Giving Patients' Online Access To Health Data"). The article suggests that an MAeHC-funded practice won't give patients access to records because "patients aren't ready and doctors aren't ready." This does not accurately reflect either MAeHC's PHR plans or our views on the "readiness" of physicians or patients for this technology.

MAeHC expects to launch patient portals in all three of our communities, including the one referred to in the article. These portals will have the benefit of being "untethered" from any specific provider, so that patients will be able to access summarized clinical data from all of their community providers, not just any one provider. Not only do we believe that physicians and patients are ready for such technology, we believe that such patient-centered applications should be one of the principal goals of community EHR/HIE programs.

We're honored to have Information Week devote space to describing our project, and I think that their reporting on the lack of urgency for EHRs and PHRs among physicians and patients is spot on. I look forward to following their future coverage of these important issues.

Friday, May 25, 2007

Pennsylvania maps out an EHR strategy

The Pennsylvania eHealth Initiative ( has released a report detailing an EHR/HIE roadmap for the state. Seems like an excellent first step. There are already a number of innovative initiatives in Pennsylvania, like the Pennsylvania Health Care Cost Containment Council and the Pittsburgh Regional Health Initiative. I was recently at the National Business Coalition on Health conference on Advancing Value-Driven Health Care at which I heard Governor Rendell describe his Prescription for Pennsylvania program, which would base the state's approach to health care on Ed Wagner's well-known Chronic Care Model, shown below (you can see the Governor's plan here and a story about it here).

I don't know of any other state that's focused it's entire strategy around a specific model like this. It's ambitious and somewhat risky politically because the urgency for such reform stems from a need for cost control, but a comprehensive chronic care approach like the Wagner approach will probably pay dividends over the long-run but may very well cost more in the short-run.

The PAEHI report maps out an EHR/HIE strategy to support the Governor's strategy. This strikes me as the right approach -- first, get state leadership to articulate a vision and strategy for health care, and then articulate an IT roadmap to support the vision. Unfortunately, what's missing from the PAEHI roadmap is the same thing that's missing from most other such plans around the country: $$$.

Thursday, May 24, 2007

National (I mean, Nationwide) Health Information Network, Round 2

The next round of Nationwide Health Information Network projects is set to launch. For those who missed Round 1, the Office of the National Coordinator (ONC) let 4 contracts a couple of years ago to consortia led by large IT-type companies to develop prototypes for a Nationwide Health Information Network (which was, at the time, called the National Health Information Network). Those companies were: Accenture, Computer Sciences Corporation, IBM, and Northrop Grumman.

The contracts were originally let under David Brailer, the past head of ONC, but he left while the contracts were underway. Looking at the work undertaken by these groups and the ensuing "deliverables" resulting from those contracts, many of us are left scratching our heads about what the NHIN prototypes were supposed to accomplish in the first place. You can judge for yourself by looking at the results of the 3rd NHIN Forum held earlier this year.

So, fast forward to the present. Late last week a "pre-solicitation notice" appeared quietly on the FedBizOpps website. The synopsis reads as follows:

As part of advancing the President's Health Information Technology agenda, the Office of the National Coordinator for Health Information Technology (ONC) of the U.S. Department of Health and Human Services (HHS), will be soliciting proposals to establish Nationwide Health Information Network Trial Implementations. The purpose of this project is for state, regional and non-geographic health information exchange consortia to become components of the "network of networks" that is the nationwide Health Information Network (NHIN). These consortia should combine inclusive organizational governance and trust relationships, provider organizations and healthcare markets, consumer applications and participating consumers, existing health exchange activities and technical expertise. Each Contractor shall work cooperatively with the other contractors to develop specifications for, and trial implementations of, the NHIN, and test these trial implementations with each other to ensure that they can all work together to implement an interoperable "network of networks" - built on top of the Internet. The trial implementations shall demonstrate core services, exchange summary patient records and support the capabilities outlined in several AHIC use cases based on shared NHIN standards and specifications. The trial implementations shall demonstrate the represented information exchanges with provider organizations, personal health records, specialty networks, and the other NHIN contractors. This is a partial small business set-aside with up to a third of the contracts awarded to small businesses. We anticipate the award of up to 10 contracts. The period of performance shall be for a period of 1 year, with two 1-year options. Options will be evaluated with the base period. Options may or may not be exercised based on performance of the contractor and the needs of the Government.

I don't really know what all of the above means -- there was a public conference call yesterday which I wasn't able to attend, and the full solicitation won't be released for another 2 weeks. We're still struggling nationally, regionally, and locally with the question of how to get this "health IT thing" done within a political-economic system that: 1) professes to be market-driven, 2) is timid about admitting how much is actually government-driven, and 3) thus has a hard time figuring out how to respond when the market fails. Perhaps the NHIN Round 2 program will provide some answers.

Monday, May 21, 2007

IT advances that are changing the rules

The exciting thing about information technology is that as it gets more sophisticated, it grows in ways that were hard to imagine at the outset. Collaborative technologies that exploit the connectivity of the internet are completely remaking the way that people work with their peers, interact with their customers and, ultimately, how they derive meaning from their craft. I have three computer-savvy kids who teach me this everyday. A few stories I've come across provide better documented evidence.

An article in last week's New York Times magazine (please see "Sex, Drugs and Updating your Blog") describes a musician who decided to write and publish a song a week, which led to a devoted fan following and a connectedness between him and his audience that is redrawing the lines of how he creates, markets and sells his music. Being directly connected to his fans allows him to target live performances to places where he knows he'll have a sell-out, and it also allows him to get immediate feedback on his music. On the downside, it's created an enormous responsibility to maintain direct connections with an ever-growing fan base who have come to expect a direct relationship with the artist.

Second, yesterday's Boston Globe had an article on "crowdsourcing" (please see "Crowdsourcing: Mining the masses for the next big thing"), defined as "throwing your arms open to the Internet community and inviting them to help create content or software." Music, software, video -- you name it, all sorts of products and services that are based on intellectual capital are being collaboratively developed by groups of otherwise unaffiliated contributors.

A specific example of this was described on National Public Radio a little while ago (please see "Musicians Collaborate from Afar on the Web" ). This was a story about websites that allow completely collaborative creation of music. Someone starts with a seed, like a bass line or a melody, and anyone else can upload overlays of instruments and vocals or anything else they can think of. "Songs" arise organically from the combinations of these layers, and indeed, one can imagine many "songs" being "created" from a single seed by mixing and matching these overlay tracks. Perhaps most fascinating, a listener can mix and match these tracks to generate a song that suits his or her tastes.

The web has expanded our current notions of "product" and "creator" and "consumer" to the point that these definitions start to merge into each other. I wonder how long it will be before these types of technologies start reshaping health care delivery -- longer than in the music industry, to be sure, but faster than most people appreciate at present. Collaborative input to diagnosis and treatment of individual complex cases, for example, which of course happens today, but is mostly limited to circles of colleagues who know each other. Or building rich libraries of treatment pathways, developed by mixing and matching layers of sub-pathways (pathlets?) from a wide variety of contributors. And this is all "b2b" or "physician2physician" collaboration -- what about "b2c" or "physician2patient"? The ability to have rich, 2-way, ongoing conversations with many patients presents many opportunities and, of course, many burdens and responsibilities as well. There are obviously many, many other examples, but I'm limited by my imagination (and the time-pressure to post this blog!).

One wonders whether the widespread use of such technologies will first require fundamental changes in the way medicine is organized today, or whether such technologies in the hands of younger physicians will fundamentally alter the structure of medicine. We have a tendency in the field of medicine and informatics to focus on how different health care is than everything else. As information technology becomes more useable and more sophisticated, it starts to look more similar.

Thursday, May 17, 2007

An EMR Mandate -- Let's Go!!

Yesterday's Boston Globe had an article describing a draft Massachusetts Senate proposal to "mandate that doctors and hospitals switch to electronic medical records within five years" (please see "Officials say state must curb health cost"). The article describes this proposal as "the most controversial" among a set of proposals focused on cutting the cost of health care in the Commonwealth.

I think that a mandate may be the best solution to the EMR dilemma that we face today. While EMR implementation is obviously occurring today -- and Massachusetts is fortunate to have higher use than most other states -- progress is spotty, slow, and in many ways, ineffectual.

There is a growing digital divide in health care delivery. Large systems like Partners and Harvard Vanguard (sorry, I just can't call them "Atrius" yet) have the organizational fortitude and financial resources to successfully invest in EMRs. However, smaller practices (those with 10 or fewer physicians), and particularly primary care practices, don't.

Nationally, only about 25% of small practices have an EMR; 5 years ago it was about 20%, so we're not getting anywhere fast with this group. Unfortunately for us patients, 90% of our outpatient care happens in small practices, not in the large, well-resourced ones. Thus, at the current pace of EMR growth, it's going to be a looooooong time before most of us get the benefits that EMRs have to offer.

The dilemma is that physicians in small practices don't feel a whole lot of urgency to invest in EMRs at present. That's because it costs a lot to get up and running on a good EMR (almost $40K per doctor), and there aren't strong incentives or mandates compelling them to move faster. Unlike most businesses, physicians can't pass the cost of capital improvements on to their customers. Yet, on the other side of the equation, they can't stop the benefits of those improvements from flowing to their customers either. It's a perfect recipe for under-investment.

A mandate would provide the urgency for EMR implementation that the market can't provide today. However, a mandate needs to be coupled with an approach to assisting physicians get over the hurdles that have prevented widespread EMR investment in the first place. Without such a bulwark, a mandate will be a complete disaster.

I believe that a mandate needs to be coupled with an approach that addresses five key questions:

  1. What is an "EMR"? This is still a nascent technology, and there are a lot of bad systems out there. We need to mandate that physicians implement only qualified EMR systems, and we need a way to facilitate that process.
  2. What does "implement" mean? EMRs are only valuable if they're used in a way that creates value. So a mandate needs to cover not only what they implement, but also how they use it once it's in place.
  3. Who's going to pay for this? An unfunded mandate will create chaos in the near-term, because you can't get blood out of a stone. If we don't create a funding mechanism that forces health insurers and employers to bear their share of the cost, we'll end up with a lot of physicians going out of business or leaving the state.
  4. Who's going to implement this? Retail EMR implementations have a 30-40% failure rate today. EMR implementation is hard, and the practices that need EMRs the most are the same ones who don't have the expertise to get it done effectively. In addition to funding, a mandate needs to be backed by an infrastructure that can assist physicians with rapid, effective implementation.
  5. What about health information exchange? One of the biggest problems with leaving EMR implementation to market forces is that the market doesn't address health information exchange, which is a pure "public good" that benefits society but that no one wants to invest in on their own. If we're going to have a mandate, it should include HIE, because that's where a lot of the value lies.

MAeHC has estimated that universal adoption would require that we outfit 8,000-10,000 physicians with an EMR who wouldn't otherwise get one on their own. We estimate that this would cost roughly $500 million if we include the cost of health information exchanges as well as EMRs (you need HIEs to get the cost reductions that everyone is looking for). This figure also includes the cost of an infrastructure to facilitate rapid and effective implementation. Spread this over 5 years, and it amounts to $100 million per year. Considering that we spend over $50 billion on health care in Massachusetts every year, this is a miniscule investment compared with the value that it will bring.

The universal health law will be merely a facade if we can't dampen health care cost growth. Indeed, current rates of growth threaten not only the universal health law, it affects all of our health care benefits. EMRs aren't a panacea, but they are key to ANY solution. That's why a mandate makes sense.

We are fortunate to live in a state that can actually provide practical solutions to make an EMR mandate effective -- there are few, if any, other states that can make that claim. An appropriately structured mandate that addresses the questions noted above will catapult Massachusetts into the next era of health care delivery and burnish our already well-earned reputation as a national beacon of health care innovation.