Sunday, September 28, 2008

Coming Up for Air

Well, it’s been a long time since I’ve been able to write. As the MAeHC pilot projects enter a transition phase, so too does the MAeHC organization itself. I’ll give a brief summary below of our main areas of activity and, in the coming weeks, I’ll provide more details on some of these activity areas.

We have been focused on three areas over the past few months.

First, and foremost, continuing the work in our pilot projects in Brockton, Newburyport, and North Adams. Almost all of the 500+ clinicians participating in the pilot project are now live on their electronic health records. We’ve brought them live on four systems (in descending order of number of clinicians): eClinicalWorks, Allscripts Touchworks, NextGen, and GE Centricity. Two communities – North Adams and Newburyport – are now live on their health information exchanges as well. Patient participation in the HIEs has been quite high in both communities so far, with over 90% of patients “opting-in” to the data-sharing networks. Finally, the MAeHC Quality Data Center is now in live testing as well. The QDC – which was created with technical assistance from the Massachusetts Health Quality Partners and CSC Corporation – extracts clinical data from the HIEs and calculates physician-level performance measures which are shared back with the participating physicians via a private website.

The second area that MAeHC has become increasingly active in is fee-based activities. The MAeHC Board of Directors has approved creating a subsidiary to provide fee-based professional services, and we are now in the process of hammering out the details of this new company. We have been engaged by a variety of customers already, consistent with our non-profit mission, but as the scale and scope of these activities expands, we believe that they will be best housed in a separate company dedicated to commercial clients. Among the clients that we are honored to already be serving are Beth Israel Deaconness Medical Center, the New York eHealth Collaborative, and the Massachusetts Coalition for Primary Care Reform.

Our third area of focus has been on preparing for the statewide HIT program that became law in August 2008 with passage the Health Care Cost Control Act (also known as Chapter 305). The state has allocated $25M to an HIT fund that will be administered by the newly created Massachusetts eHealth Institute. We hope to be among the organizations chosen to implement the statewide program once the state has defined the program and finalized its plans for allocating the funds.

As I mentioned earlier, in the coming weeks I will describe in greater detail our pilot project activities and fee-based service plans. I wish there was more detail to report on the Chapter 305 program, but we are among the many other organizations in the Commonwealth waiting for the state to unveil details of its plan for the program.

Wednesday, July 09, 2008

Delayed gratitude

Since last week's Globe editorial, we've received kind words from some other folks who I'd like to acknowledge. One was in the blog entry "eHealth: The Globe Turns it Over", written by Health Care for All, and the other in David Williams' Health Business Blog and was entitled Three Cheers for MAeHC.

Thanks to both -- we greatly appreciate your support and help!

Thursday, July 03, 2008

Thank You, Boston Globe

Today's Boston Globe had an editorial about MAeHC. Among the many things the article says is:

The state budget agreement reached this week includes $25 million to advance the creation of these systems. The budget doesn't specify who should get the money, but based on its success so far, the eHealth Collaborative deserves state support to identify other communities that would be willing to implement a health records system.

We greatly appreciate the Globe's recognition of the efforts of the many many people involved in the MAeHC pilot projects!

The article also had a couple of points that need clarification. First, the article states that we are "just starting" our Brockton pilot project, and it also states that "there will still be much work to be done in the three communities" once the pilot funding ends at the end of this year.

In fact, all three pilot projects began at the same time and Brockton is just taking longer because it is much bigger than the other two communities. Even so, all of the roughly 300 physicians in the Brockton project have their EHRs in place, and we have already started hooking them together, which should be completed well before the end of the summer.

At that point, all three communities will have reached a significant milestone that no other communities in the country will have achieved: they will be wired for healthcare. All of the physicians in the community will have EHRs, and all will be connected in a health information exchange that allows patients to enable medical record sharing among their providers. North Adams and Newburyport are already the only communities in the country that can boast such capability, and by the end of the summer Brockton will have achieved this elite status as well.

Don't get me wrong, there will still be more work to do in these three communities, but where is that not true?. In 1942 Joseph Schumpeter made popular the term creative destruction, which accurately describes every part of our economy except health care delivery. And even though information technology was embraced by other parts of economy many years ago, they're still discovering ways in which IT can improve the quality and efficiency of the products and services that they provide.

When the US military launched the first Global Positioning Satellite in 1978, it's goals were limited and clear: Improve the ability of the military to coordinate the movement of weapons, troops, equipment, and supplies. Now, thirty years later, GPS is being used in military and commercial ways that it's designers could never have imagined, and each year seems to bring even more uses. Similarly, when the first commercial cellular telephone was launched in Japan in 1978, they probably had only the smallest inkling of the kinds of innovation that would still be taking place thirty years later. If anything, even after three decades of use, the pace of change wrought by these technologies is not slowing, it's getting ever-faster. In 1978, the year that GPS and commercial cellphones were born, Microsoft was 3 years old and had 2 now famous employees, and the founders of Google and Yahoo were barely in elementary school.

Like GPS and cell phones thirty years ago, connecting up an entire health care community is a clear, discrete, "step-up" that provides tools that didn't exist before to change the way things are done. And like those technologies, providing the tools is only the first step, because they're only tools -- the creative energies of the people who use those tools will spur innovations in these three communities over the next 10, 20, and 30 years that we can't even hope to understand through the foggy lenses of today. That type of "creative destruction" isn't something that any of us can or should want to architect in a year or two or three.

The vision for a state funded program should be to get all communities in Massachusetts to the place that Brockton, Newburyport, and North Adams will be by the end of this summer. The goal should be to use state funds judiciously to do just enough to get this important part of our economy over the technological hurdle that is absolutely stifling innovation in health care delivery today. After that, step aside as fast as possible and let the market harness technology and human creativity in ways that only the market can do.

I can guarentee that thirty years from now the patients and medical professionals in Brockton, Newburyport, and North Adams will still be improving on the systems that were put in place by MAeHC in 2008. But they'll be able to look back and say that 2008 was when they got the tools to think about health care delivery in ways that they couldn't before. If you ask me, that will be the true measure of our success......

Thursday, June 26, 2008

Of HIEs and PHRs......

Yesterday we announced the launch of our second HIE, this one in greater Newburyport. My blog energy on that launch went to my entry on WBUR's Commonhealth site: Realizing the Dream of 21st Century Health Care.

David Harlow wonders aloud in HealthBlawg whether the GoogleHealth and Microsoft HealthVault PHRs may obviate the need for the type of HIE infrastructure that we're putting in place in our pilot communities. The answer, I think, is, maybe, someday, but it's going to be a long time before there's enough electronic information for patients to reap, and therein lies the biggest obstacle to PHR's getting a greater foothold among consumers.

For example, in Massachusetts today, if a patient gets all of their care at Beth Israel Deaconness Medical Center, and their insurance from Blue Cross, all of their clinical and claims information will be easily uploaded into a GoogleHealth account -- that's pretty cool. Most patients are like me, however. I don't get my care at BIDMC, nor am I member of Blue Cross, so at the moment I'm plumb out of luck -- I would have to gather, scan, and upload all of my medical records and claims into my GoogleHealth account, and then keep it current myself any time I get more care. Which means I won't do it.

There's certainly hope, and GoogleHealth and HealthVault are solid, well thought-out products that deserve to be taken seriously. Indeed, MAeHC is likely to be working with one or both of them in the near future. But considering that real EHR use is somewhere between 4-13% in the US according to the best study to date on the topic (published in last month's New England Journal of Medicine), I don't see how a PHR-driven strategy will get us there any faster than an HIE-driven one.

Wednesday, June 11, 2008

Vermont Flying Under the Radar

I don't know why this hasn't gotten much press in the health IT press, but on May 12 the Vermont Legislature approved a program to create a health IT fund that would pay for EHRs and health information exchange across the state. The program will be implemented by Vermont Information Technology Leaders (VITL), the statewide "RHIO". (The press release is here, and the actual legislation is here). The program will be financed by a claims assessment on health insurers (and self-insured employers), who will pay a quarterly fee of 0.199% claims paid (or 19.9 basis points or one-fifth of a penny per claim dollar). The assessment is expected to raise about $32M over the next seven years. The funds will be used to subsidize EHRs for primary care physicians, who will receive a 75% subsidy on an EHR purchase (up to $45K). Physicians will have to pony up the remaining 25% themselves. The fund will also pay for connecting these physicians on a statewide health information exchange.

Thursday, May 22, 2008

Google Health

I've finally found my competitive niche. I am the only health care blogger in the world who has not written about the launch of Google Health.

Wednesday, May 21, 2008

Thank You North Adams

MAeHC announced today that we have had 25,000 patients consent to having their data exchanged over the health information exchange in North Adams. This is a terrific achievement as it represents a high opt-in rate (94% of those asked) and a large fraction of the entire North Adams community (in the one year since go-live, we've reached over half of the roughly 40,000 people who live in the North Adams cachement area).

As I said in the press release, this is really a testament to the many individuals who have worked with us in that community to deploy a system that offers clinical benefit while at the same time engendering the trust of patients and providers alike. Administrative information for patients, including privacy and security policies, are available on the Northern Berkshire eHealth Collaborative website.

We're not done though -- far from it. In the next couple of months we'll be launching a patient portal in the community that will allow patients visibility into the eHX so that they can view certain parts of their records from all of the participating physicians and the hospital. We'll also launch electronic ordering as well, to complement the automated lab and radiology results delivery that is already in place across the community.

Adoption of these systems takes time because it takes a lot of effort to work out all the kinks in the systems and because it takes time for physicians to incorporate this new information into their workflows. That said, the Emergency Department is reporting a roughly 50% "hit rate" on queries to the eHX, meaning that roughly one-half of all of the encounters in the ED are now informed by clinical information that would probably not have been available before. It will take some time to quantify the benefits of this, but there should be no doubt that the quality and safety of care has improved in North Adams, even if we don't yet have the data to show it.

Sunday, March 30, 2008

"Time waits for no one, and he won't wait for me"

The market won't stand still. While a bunch of us are futzing around with patient portals, PHRs, patient kiosks, and other tools to add convenience to health care delivery, along comes ZocDoc ( which allows online scheduling of physician and dentist appointments for participating providers. Physicians pay for the service and it's free to patients.

Online scheduling has been around on the web for awhile. Booking tickets, for example, for everything from movies to airplanes. And allows free restaurant reservation booking in a number of cities. Like opentable, Zocdoc also allows patients to review their physicians on the site.

Physician offices are trickier than other businesses, however, because health care operates so much like a cottage industry. The workflow issues are always full of gotchas. Unless Zocdoc is interfaced with the physician's scheduling system, it seems like the only way to make it work will be to use it as the primary scheduling system in a practice, which could be problematic since there's no billing function. I'm also not sure how they've tackled the security issues, particularly with respect to the HIPAA security rule. With no in-person authentication, there seems to be something here that won't pass the basic HIPAA sniff test.

I think this is a cool idea though, and any innnovation pushes us all forward, even if the innovating company itself doesn't survive. My guess is that this type of service is highly unlikely to survive on its own, as a stand-alone. I could see EHRs or health information exchanges (HIEs) interfacing to the service or licensing the technology to build into their own suite of services. Zocdoc's best hope, and I'm sure what they're banking on, is to be acquired by Microsoft or Google who are looking to add to the service bundle offered in their PHRs.

Sunday, March 02, 2008

Battle Royale in PHRs

A lot of buzz lately around Google's and Microsoft's PHRs. John Halamka's blog (and Paul Levy's cross-linked entry) talk about Google's PHR -- these two guys get so many hits on their blogs that whatever they talk about is buzz, by definition.

Meanwhile, at HIMSS Microsoft announced the creation of a fund (the Be Well Fund) to spur ideas for integrating information into their HealthVault PHR. They plan on funding about 20 initiatives ("new and innovative scenarios") at about $150K apiece. A pretty clever way of getting the juices flowing on this issue if you ask me, especially since the biggest obstacle to getting real market traction is cracking the nut on connecting gazillions of disparate hospital and physician office legacy systems. HealthVault also had a full-page ad for the fund on the back page of Saturday's Wall Street Journal (you can only see the ad in the print edition).

Meanwhile, not much has been heard from RevolutionHealth, Steve Case's much ballyhooed entry into health care. I've got to think that they don't stand a chance now that Microsoft and Google are on the scene. From what I've seen of RevolutionHealth, it's more patient education than a PHR, and that segment is pretty crowded already.

It's been about 6 months since Aetna's Ron Williams called Microsoft's and Google's entrees "vaporware", and despite more concrete offerings now, there's still a fair amount of grousing that Google, in particular, should "just launch it already!"

I'm actually sympathetic with their instinct to move slowly. The health care sector is tougher than any market either Microsoft or Google has faced to date -- highly complicated subject area, fragmented supply- and demand-side, unsophisticated users (on both the supply- and demand-side), and potential for high liability exposure (privacy, misrepresentation of medical information, etc) with not much tolerance for error.

Neither Google nor Microsoft lacks for hubris, though, and in the end, that could be their undoing. At every conference I've seen them at they've both presented themselves as the white knights who are going to "change the paradigm" and "use disruptive technology" to unleash "demand-side pull-through" -- so much jingoism that it would make any 1st year business school student blush. Yet, their value proposition to patients is very tenuous, at best, because so little clinical data is electronically accessible at present. Couple that with the lofty, self-generated expectations they've created, and you've got the potential for one or both suffering a large public failure.

I hope not. I want health IT to mature to a point where they and other leading edge consumer-oriented companies like Apple and Sony and Panasonic can enter the space with customer-facing applications that just work -- no fuss, no muss. I just worry that they may be ahead of their time and if they fail now, it might be years before they're willing to come back.....

Tuesday, February 26, 2008

In the interest of science

This month's Nutrition Action Health Letter from the Center for Science in the Public Interest has an article about caffeine -- "The Good, the Bad, and the Maybe". They describe one study on how caffeine affects driver alertness as follows:
French researchers accompanied young males as they drove 125 miles on a highway between 2 a.m. and 3 a.m. When the young men were given coffee with 200 mg of caffeine before getting behind the wheel, they inadvertently crossed into another lane an average of two times during their drive. When they were given decaf, they crossed over an average of six times.

I'm guessing that there was no IRB review of this study protocol.......

Monday, February 25, 2008

Spreading our wings

We are proud to be chosen by Beth Israel Deaconness Medical Center to provide project management and practice consulting services to their EHR deployment project. We're working closely with BIDMC's excellent staff and with eClinicalWorks and Concordant, who were also chosen for the project and who we know very well from the MAeHC project.

This is the first commercial project undertaken by MAeHC. As we near the end of our seed funding from Blue Cross Blue Shield of Massachusetts, we are pursuing a 'public service' strategy and a 'commercial' strategy. The public service strategy is to get collaboratively provided resources to build on the successess and lessons of the pilot projects and launch Phase 1 of a statewide rollout. The 'commercial' strategy is to pursue paying customers inside and outside of the Commonwealth who have needs that we have the skills and interest to address. These strategies are complementary -- the lessons we learn from clinical leaders such as BIDMC will make us even more seasoned for the challenges of a statewide rollout. In return, if we can get any organization to avoid our mistakes and replicate our successes, our mission will be forwarded.

Wednesday, February 20, 2008

News flash: Higher Quality Care May Actually Cost More Money

There was a Dutch study published last week showing that providing better quality care, in this case to smokers and obese patients, raises the cost of health care because it prolongs the lives of patients (here's the Boston Globe article and here's the actual study). Prolonging lives means they need care for longer periods of time and they die of diseases that are more expensive to treat -- unlike lung cancer, for example, for which there is no treatment, which makes it a relatively cost-effective way to die; better still, using this calculus, would be getting hit by a Mack truck. But I digress....

Anyway, the study has been actively blogged on the WSJ health blog already, but one angle I haven't seen discussed is the impact of this on health insurance dynamics. A not uncommon refrain among commercial health insurers is that their investments in quality improvement are reaped mostly by Medicare, because the benefits of healthier enrollees don't really pay off until those enrollees are older and mostly off commercial insurance. The Dutch study suggests that for certain conditions the opposite is true -- higher quality care may increase costs to Medicare (and Social Security) by increasing the fraction of people who live to draw on Medicare (and Social Security) benefits.

States like Pennsylvania and Vermont have adopted the chronic care model as state policy, not only to promote better quality lives for their citizens, but also on the assumption that there are cost savings down the road. The National Quality Measures Clearinghouse has literally thousands of quality measures, and the drumbeat of quality improvement is beating louder and louder every day. Yet, the Dutch study and work by the Partnership for Prevention suggest that the economics for universally applied quality improvement just aren't there.

A real moral dilemma for our society could come with the realization that the Dutch findings may be more generally true -- it may actually cost more to get higher quality care. David Cutler has argued that we should spend more on health care because the marginal returns are so high, and measured in lives saved and pain avoided, that is certainly true. But we live in a reimbursement system where costs are vigorously monetized but benefits aren't, and literally no one has an incentive to put in more money for anything. Funding longer lives and less pain for all will be much easier said than done.

Monday, February 18, 2008

More woes for NHS

When I was younger, I took an immersion Russian course at Norwich University in Vermont. On the first day, our teacher, who was himself a gifted, fluent non-native Russian speaker, asked each of us why we wanted to learn Russian. One of the students said "I've always dreamed of reading War and Peace in the original." The teacher responded in a joking tone that revealed the hard truth: "Yes, and I too hope to be able to do that someday." We all realized in that moment that we had a hard slog ahead.

I was reminded of that moment when I read an article in this week's Economist magazine about the UK National Health Services's much troubled "Choose and Book" system (see Notional Health Server). The goal of the system is to "allow patients in the National Health Service (NHS), advised by their doctors, to choose the treatment they want, and book an appointment when they want it." Unfortunately, after 3 years of hard work, it still hasn't worked out that way. Over 50% of physicians have a negative view of the system according to the British Medical Association. One of the physicians interviewed said that in her experience the system is so slow that it takes about 2 minutes for each visit request, and even then, it functions properly only 10% of the time.

Those familiar with health IT will immediately recognize how ambitious Choose & Book goals are and, I suspect, feel sympathy for their plight. As the article put it, the system will only perform as designed if everything goes right, meaning that the hospital, physician, and health trust systems that it needs to interact with fit together perfectly, and that the physicians and administrators who use those systems fit together perfectly as well. You would think that this could be accomplished in a government-owned health system...........and you'd be wrong. Which leaves those of us living in a highly decentralized system wondering just how ambitious we should be.

Unfortunately, users, and especially physician users, assume that they'll immediately be able to do the kinds of things that Choose & Book is supposed to, and it's often hard to ratchet expectations back to reality. In the MAeHC pilot projects, we're launching health information exchanges in three pilot communities and we're constantly in the struggle of trying to prevent the perfect from being the enemy of the good by reminding physicians that the first version is "Version 1.0" which will be improved over time. It's fantastic that our users are engaged and they want to get value out of the system; it won't be fantastic if "Version 1.0" isn't good enough to want them to stick around for Versions 2, 3, and 4.

I find managing this tension -- between designing the perfect architecture vs launching something good and attainable -- to be one of the biggest challenges in the health IT space. The most difficult part of the challenge is that the culprit isn't the technology, it's the lack of alignment of the technology and processes used by the most important data sources, hospitals and physician offices. It's the same problem faced by Dossia and Microsoft's Health Vault and Google Health -- will our users be willing to wait for the system to catch up with the technology?

Wednesday, February 13, 2008

"Strap on the feed bag"

In the constant battle to control health care costs, there has been lots of experimentation with controlling the supply-side (eg, certificates of need, cutting back reimbursement levels to providers, etc) and the demand-side (eg, coverage limits, tiering, co-pays, co-insurance, etc). Health care costs continue to rise rapidly, but that doesn't mean that these methods have failed -- we don't know what cost growth would have been like without them.

There's been a lot of emphasis recently on digging further into the nature of demand -- rather than just cutting back patient choice, why not cut back on patient need by getting patients to be healthier in the first place. Employers pressure health insurers to curb cost growth, but the insurers argue that employers don't do enough to get employees to be healthy in the first place. Physicians and hospitals, pressured to improve quality and efficiency, complain that patient adherance is a large barrier to improved care -- if patients don't take simple measures to be healthy, and/or refuse to follow prescribed treatments, what is a provider to do?

This seems like a win-win-win; people shouldn't need that much encouragement to become healthier, and the results will be beneficial to all. Well, a large employer that is also a very savvy health care business has been experimenting with direct patient incentives to encourage healthier lifestyles, and they're finding that it's not quite as easy as it sounds (see Employers experiment with tough get-healthy regimes).

Clarian Health Partners of Indianapolis is an integrated delivery network that employees 13,000 people. They tried to segment their employee risk pool by setting higher premiums for employees who don't attempt to improve their health in certain ways, such as smoking, obesity, and high cholestorol. We as a society already allow this type of risk segmentation in other areas of insurance, and indeed, it's the very basis of preventing moral hazard incentives that undermine the efficiency gains of insurance to begin with! For example, bad drivers, and those assumed to be bad drivers (like teenagers), pay a lot more for insurance. Seems like a slam dunk, right?

Clarian ran into a buzz-saw and never rolled out the program. Some critics saw it as an intrusion of privacy -- an employer shouldn't be allowed to dictate what employees do outside of work. Others saw it as discrimination -- an employer shouldn't be able to single out certain groups of people based on health history or habits.

One bizarre quote in the article points out how weird this conversation can get. Commenting on why his company doesn't raise premiums for overweight employees, an auto-parts supplier stated that:

"We're a little bit reluctant to go down that path. It's not really the fear of litigation as much as the lack of evidence that it works," he said. "I look at my own reaction and if I were going to be penalized for my weight I'd say, 'If for an extra $15 a month I can strap the feed bag on I'm going to do that and I'm going to make sure I get my money's worth.'"

I can't think of a better summary of the depth of the problems that we face.

P4P may finally be growing up

I've heard anecdotally that health plans are retrenching on so-called pay-for-performance (P4P) reiumbursement programs because they're not getting the return that they hoped to get. There seems to be some evidence of this in the data as well -- projections from 18 months ago suggested gushing growth (see The state of P4P programs), but the trend more recently seems to be on refinement rather than expansion (see It's everywhere but measuring effectiveness of P4P is challenging). There seems to be a trend out there away from pure P4P and toward mixed reimbursement models that blend in capitation with performance-based payment, exemplified by two new approaches.

First is the so-called "medical home" idea, which has been articulated and promoted by a variety of medical specialty socieities (for example, see Medical home could rescusitate primary care and Joint Principles of a Patient-Centered Medical Home Released by Organizations Representing More Than 300,000 Physicians). While a lot of the focus of the medical professionals has been on bolstering primary care, the business community has recently jumped on the bandwagon because of the financial benefits of the approach. Bridges to Excellence estimates that the medical home approach yields savings of $250-$300 per patient per year by reducing unnecessary specialist and emergency room visits and preventing acute medical episodes that result from poor preventative care (see Group Offers Doctors Bonuses for Better Care). Since the average primary care physician cares for roughly 2000 patients, this can add up to real money real fast.

The second approach is in the creation of alternative payment models such as that announced by Blue Cross Blue Shield of Massachusetts earlier this year (see A New and Different Way to Pay for Care). This approach has had some early bumps, but it's still early (see Blue Cross faces uphill climb over flat-sum payments).

The best description I've seen of the benefits of moving back toward some type of capitation model is in Benjamin Brewer's column in yesterday's Wall Street Journal (Finding a Medical Home May Be Just What the Doctor Ordered). Dr. Brewer gives an excellent ground-level view of what it means to pay physicians to manage patients instead of acute episodes, and why such an approach might really offer benefits to patients and physicians alike.