The MAeHC Blog

Maybe MAeHC can help teach the New York Times a thing or two.....

2011-12-19T10:04:00.015-05:00

Today's New York Times has an article on a recent security incident that we experienced at MAeHC. The reporter, Nicole Perlroth, does a pretty good job of bringing together different pieces of the story. Even tries to give it some Bourne-like suspense -- I guess I'd allow Matt Damon to play me in the film version (though I would have to insist that he get in better shape first).

No story is perfect though, and this one had its share of limitations:

It didn't cite the blog post or the HISTalk Practice website that inspired the story and that accounted for much of the article's content. OK, so I'm not a journalist, but this seems like a pretty shaky practice. The storyline comes from the blog, not from the very short interview that I had with the reporter. Furthermore, if my blog account had been an article in, say, Health Affairs, they would have cited both the article and the journal. [Update Note: I forwarded a link to this post to the New York Times and they have now added a link to my HISTalk blog post in the on-line version of their article. Thank you NY Times for your responsiveness!]

The article notes that electronic breach reports have increased in recent years and while that is true, a closer look at the numbers reveals that that doesn't necessarily mean that there are more breaches. There are 2 important subtleties behind this. First, reporting requirements have increased so people have to report more now than they have in the past. In addition, electronic systems have generally better ability to detect breaches in the first place. This is not only due to technologies such as intrusion detection, user-based activity logging, etc etc, but also because physical devices are easier to track and manage than paper systems -- it may be easy to gloss over a few misplaced paper charts, but you can't hide the fact that you lost a laptop. So, the fact that breach reports are up may just reflect better detection and reporting and not necessarily more breaches.

Second, the article suggests that electronic systems increase the risk of breaches. As I explained to the reporter, I believe that electronic systems are more secure than paper/fax, but there is a trade-off in the type of risk that they introduce. I liken this to the difference between auto accidents and plane accidents. Auto accidents happen very frequently but with fairly contained consequences, whereas plane crashes are rare but can be disastrous. The latest OCR report to Congress on breaches reports something like 25K small breaches (fewer than 500), a very large fraction of which are paper/fax incidents.

Finally, I found it a little ironic, that while the NYT article itself is an important step toward educating the public about the real issues surrounding the loss of electronic patient information, it glossed over the steps we've taken to educate the industry – like writing the post that lead the Times to the story in the first place. I think it was a bit of a missed opportunity to encourage organizations that have similar experiences to follow the path of full disclosure that we did.

Meeting halfway

2010-10-15T15:34:00.004-04:00

Those of us focused on health IT are spending a lot of time and energy on bringing the technology to where the patients are. Interoperability is crucial because patients get care in so many different places, and through Regional Extension Centers and other programs we're trying to get EHRs into the hands of small and independent practices at the far reaches of the health care delivery system, again, because that's where the patients are. Something like 80% of practices are small practices, and 90% of outpatient encounters are in those small practices.

I've been wondering recently about whether we're going through a Copernican revolution where the patients come to the IT rather than having us bring the IT to the patients. My own personal experience started my thinking on this. I used to get my care from a small practice primary care physician in Wellesley MA -- great guy, good doctor, gives 110% every day. But he didn't have an EHR (still doesn't) and it was basically my responsibility to get specialist records back to him to make sure that he had the whole picture of my care. I switched to Harvard Vanguard not only because they have an excellent EHR but because they are multi-specialty as well. When I need a specialist I no longer scour all of Boston for the best specialist -- I only look within the Harvard Vanguard system because I want to make sure that my records are kept on the same EHR. What I might be sacrificing on the quality of an individual specialist I'm more than gaining back in having all of my physicians reading from the same page (literally).

Since my Wellesley doctor couldn't solve the interoperability issue, I solved it myself by eliminating it. My wife gets her care at the Brigham, and I've increasingly seen her focus her decision-making in the same way -- she has eliminated the need for interoperability by limiting her choice of specialists to those who are on the Brigham's EHR.

Maybe this is just a family thing. But I started thinking otherwise after I heard a very interesting story yesterday on NPR and Kaiser Health News on consolidation of the health care delivery market, and in particular, the increasing share of outpatient physicians employed by hospitals. As the story reports, almost 20% of physicians work for hospitals today, but 50% of new physicians are taking jobs with hospitals. The looming prospect of Accountable Care Organizations' becoming the operational unit of health care delivery will put increasing pressure on hospitals and physicians to keep patients within their care delivery network. Changes in health plans that limit patient choice will also drive patients to stay in closed networks. All of these trends will increasingly funnel patients into health care delivery networks that also happen to be connected on IT networks.

There could certainly be many bad affects from such consolidation, such as higher oligopolistic prices, less customer choice, the demise of solo practices that are an iconic part of the American fabric, etc etc. But from a health information exchange perspective, it's only to the good if we can get more patients to meet us halfway on the road to interoperability.

Provider Directories

2010-09-30T22:40:00.004-04:00

The Information Exchange Working Group of the Health IT Policy Committee had a public hearing today on the topic of Provider Directories. The FACA Blog has some background on the issues that we covered today. We have a lot of information to process regarding some very complex issues and unfortunately on a very compressed timeline. Some of the major themes that came out of today's hearing are:

We've got to get rid of the "yellow pages" and "white pages" analogies to Provider Directories. It's fraught with all of the general flaws of analogies, but more important, as my co-chair David Lansky said, "no one under 30 will know what we're talking about."

That said, it is useful to distinguish directories that support machine-to-machine routing from those that have more of a lookup role that might be focused more on use cases involving person-in-the-loop functions. Arien Malec noted that while the latter might initially be used more by humans, there would be interesting applications for machine-to-machine transactions as well, such as identifying providers involved in "post-exchange" continuity of care. Keith Boone suggested that we use the terms "service discovery directory" and "provider discovery directory" to more appropriately describe how technology works today. Abby Sears described the need for provider directory functions, however defined, to be embedded within EHRs to make them useful to end-users.

There are many well-developed directories out there already, so whatever we recommend needs to provide help to enable approaches that have barriers to moving forward while at the same time not stifling forward progress for approaches that are moving ahead. JP Little noted that a number of national directories already exist today, with some degree of interoperability. Charles Kennedy noted that there are is a lot of administrative infrastructure in the market already today, but very little clinical, so we should be thinking of ways to leverage the administrative infrastructure to lower the cost of developing and maintaining clinical infrastructure. Syd Thornton offered that though InterMountain Healthcare maintains its own directory of external providers, they would be interested consuming it from a higher-level aggregator that might offer better economies of scale. Robb Chapman described how the CDC leverages medical registration data from the Federation of State Medical Boards for its Physician Registry Project, but Martin Laventure noted that public health directories are not dynamically linked with any outside systems so updating them is difficult. Karen Trudel described that there are no "one-and-done" solutions in the market today, and even large, nationwide directories such as the NPI and PECOS have significant limitations with respect to the clinical exchange transactions being contemplated today.

Directories are the means for performing value-generating business functions, they are not the end. Tom Morrison said it most clearly when he stated that "data is a by-product of a business process." Sorin Davis recommended provider accountability for entering and maintaining their data. Anita Sarnoff noted that Axolotl recommended NOT having providers be responsible for maintaining their data and leveraging existing accreditation and credentialing information instead. Linda Syth described that it cost $3M to create the provider registry used by the Wisconsin Medical Society, and about $700K per year to maintain it. Carladenise Edwards recommended mandating the use of specified provider directories to better support their sustainability. Putting all of these together suggests that we need to create or leverage directories that enable services that providers have high interest in consuming so that they themselves will feel the need to assure that their information is timely and complete.

If we do nothing else, creating a framework and taxonomy for key concepts would be helpful in and of itself. Greg Debor noted that though we refer to "provider" directories, there are other health care participants (such as public health and health plans) that would be important to future value. Hunt Blair pointed to the need for a common ontology of terms such as "provider", "practice", "entity", etc.

As states move to implementation of their HIE Strategic and Operational Plans, there is an urgent need for some type of guidance or coordination to capture any possible synergies across these efforts and to ensure future interoperability. Goerge Oestreich noted that the pressing need for immediate solutions limited how much central orchestration could be expected and suggested that the focus should therefore be on developing standard interfaces and data formats to support a federated architecture which would allow states and private actors to continue with their own development but with some level of alignment. Steve Waldren cautioned against "over-designing" too early to remain flexible to the many changes that technology change and health reform might bring. Jeff Barnett recommended the need for standards to be able to uniquely identify individuals and organizations. While there seemed to be a general consensus that "a federated approach" was preferable to any other, we did not have enough time today to define the parameters of federation in this context and what requirements would be needed to make it feasible.

There seemed to be rough consensus that while both were important, the "routing directory" should be a priority. Dan Nigrin noted that they know who they need to send information to, but they often don't know how.

These are just some of the many thoughts that emerged from our hearing today. There are more comments posted on the FACA Blog, and additional comments will be collected through October 4.

What's in a name?

2010-09-29T22:47:00.006-04:00

So what's in a name? The full quote of course is: "What's in a name. That which we call a rose by any other name would smell as sweet."

On September 28, the Office of the National Coordinator awarded the New Hampshire Regional Extension Center to the Massachusetts eHealth Collaborative. Is it odd that an organization with Massachusetts in our name is running the New Hampshire Regional Extension Center? I suppose so, on the face of it, but the reality is that we provide professional services in many states outside of Massachusetts. For example, we're already doing work with the regional extension centers in New York and Rhode Island, as well as Massachusetts. And we're currently working on a project with New Hampshire stakeholders on their Health Information Exchange Strategic and Operational Plan.

All companies have to be based somewhere, and we happen to based in Massachusetts. Granted, most companies don't have their home state in their name. That is a reflection of our non-profit, collaborative roots. We were founded in 2004 by 34 non-profit Massachusetts-based health care organizations. Our mission then and now is to improve the quality, safety, efficiency, and affordability of care through effective adoption of health information technology. Since our founding we've developed a national reputation for being operationally effective, mission-oriented, and consensus-driven.

We have the name collaborative because we work as partners -- we share what we've learned, and we look to learn more things that we can share. We try to develop deep ties with each new engagement, and we could not have gotten this federal award without the endorsement and backing of the State of New Hampshire -- we're grateful for the confidence they've shown in us.

My father is a family physician and surgeon who has practiced his entire career from his office in Pelham, New Hampshire. We're based in the Massachusetts Medical Society, which reflects our strong affiliation with clinicians -- we have deep ties to the physician community and we make it our business to understand the needs of physician practices.

We feel genuinely privileged to have the opportunity to help the clinicians of New Hampshire achieve their meaningful use objectives, and we look forward to deepening the ties that we already have with health care stakeholders across the Granite State. If you're a priority primary care provider in New Hampshire, we're going to be looking for you!

Guy with a good voice......and A LOT of time on his hands

2009-05-15T05:46:00.006-04:00

For those who haven't seen it, Ross Martin's video "An Interoperetta in in Three Acts" is amusing (see below). Though I've got to say, if I had that kind of musical talent, I definitely would not be singing about health IT.....

NCVHS Meaningful Use

2009-05-09T06:19:00.002-04:00

Thanks to John Halamka for featuring my NCVHS testimony on his blog! For those who aren't tracking this closely, all of the testimony is now posted on the NCVHS website. The transcript of the first day's testimony is also posted, which is long but a little easier to follow and also includes Q&A from the panel. There's a wide array of perspectives here, and who knows how it's going to be used to shape the definition of "meaningful use". As I describe in my testimony, I don't think there are as many degrees of freedom here than we might think, because there's not enough money or infrastructure to support a very high bar on meaningful use. I hope I'm wrong.

MAeHC launches subsidiary

2009-02-19T07:08:00.004-05:00

Today we're announcing the launching of MAeHC Professional Services Corporation (PSC), a for-profit, wholly owned subsidiary of the Massachusetts eHealth Collaborative. Our press release is here. PSC will provide a broad range of fee-based consulting services related to EHR deployment, health information exchange, and quality data warehousing. PSC will provide these services—including strategic planning, project management, and project execution services—to both nonprofit and for-profit clients throughout the United States who are involved in a variety of health IT activities.

Today's Boston Globe gave our launch some nice coverage (New eHealth subsidiary will fund expansion), and we greatly appreciate their interest in the story. One thing from the story that I'd like to clear up is that it suggests that we don't work with so-called "web-based" applications such as athenahealth. In fact, both MAeHC and MAeHC-PSC are vendor- and platform-agnostic, and we ourselves have deployed both web-based and client/server-based applications. And, of course, we're happy to work with athenahealth.....

Darn, I'm a breach victim......

2009-02-14T08:31:00.006-05:00

I just got the following email.

Important Message from Pentagon Federal Credit Union
Ref. Card Number
Ending In: XXXX

Dear Member,
Visa Fraud Control has recently notified us that your Pentagon Federal Credit Union Visa credit card account number, name, expiration date, and CVV (a three-digit verification value on the magnetic stripe of the plastic) may have been compromised in a processor level breach at Heartland Payment Systems, Inc. Heartland Payment Systems, Inc. is one of the nation's largest payment processors delivering credit/debit/prepaid card processing, payroll, check management and payments solutions. Heartland has dedicated a website, www.2008breach.com to provide additional information on the breach.

Information pertaining to your other Pentagon Federal Credit Union account(s) has not been associated with this event or compromised in any way. The compromise did not occur at Pentagon Federal Credit Union nor did it involve any of our systems. All of your Pentagon Federal Credit Union account information remains absolutely secure.

We continue to take all necessary precautions to safeguard and monitor your Pentagon Federal Credit Union accounts to protect against unauthorized activity. We have provided a series of frequently asked questions below that provide additional details and tips.
Please review them and if you would like to receive a new card with a new account number, please use the instructions provided below. You may reach us toll free at 800-247-5626 or online at PenFed.org.

If you have recently closed the referenced card, please disregard this correspondence. We apologize for any inconvenience this may cause. We appreciate the continued trust you have placed in Pentagon Federal Credit Union. Thank you for remaining a valued member.

Sincerely,
Vincent Gay
Director, Security
Pentagon Federal Credit Union

In this simple email we see the complexity of breach notification. Let me say for the record that I love PFCU -- I've been a member of PFCU for many years and will continue to be for many more.

On the negative side of this notification is the ambiguity. My information "may have been compromised" -- not sure if it actually was, so I'm not sure what the actual risk is. They're fulfilling a legal and/or ethical obligation to tell me the nature of the breach, but are they really helping me by telling me that it's a "processor level breach", without further explanation? And how am I as a consumer supposed to assess my level of exposure? Does this mean that there was an actual intrusion of Heartland's environment, or that they discovered a security hole that could have been entered without their knowledge but they really have no idea whether it was.

On the positive side, I'm alerted, so I myself can keep my eyes open for suspicious activity.

This notification was for a relatively simple incident in a disciplined corporate setting, and it still raises more questions than it answers. Makes me wonder about how we're going to strike the right balance as we move to stricter breach notification regimes in health care.....

Grassroots

2009-02-11T18:34:00.003-05:00

Farzad Mostashari and I wrote a short white paper urging a more direct link between Federal HIT incentive funds and regional HIT extension centers (Farzad deserves the lion's share of credit for taking this idea and running with it). Pretty straight-forward idea, really -- rather than just handing out $18 billion in cash to providers, funnel those funds through an infrastructure that will protect the government's investment by ensuring that adoption happens efficiently, effectively, and with public benefit in mind. You'd think this would be a no-brainer after our recent experience with the $350 billion bank give-away, but so far, the concept hasn't made it's way into the stimulus package.

The letter has gotten almost 60 signatures from individuals and groups across 26 states, including some prominent national organizations such as the eHealth Initiative, NCQA, National Partnership for Women & Families, and Pacific Business Group on Health. It's also gotten a fair amount of attention. It was featured on iHealthBeat, John Halamka wrote about it in his blog, and it was also picked up by the New York Times. Thanks to everyone who co-signed it......hopefully somebody up there is listening!

How the other half lives

2009-01-25T22:43:00.008-05:00

It's good every once in awhile to rise above the surface of the health care market and see how the real economy does things. Today the Times had an article about the barriers to adoption of near field communication (NFC) technology, which would allow you to swipe your phone over a reader to make credit card transactions. The technology is already in use today in Japan and in the UK, but it's facing many obstacles in the US market.

As described in the article, the issue is not technology. By 2012, most phones are expected to have the technology built-in, yet the availability of the "wave-and-pay" function could take much longer. As an industry expert explained:

For that to happen, all the players will have to work together to define standards, determine revenue-sharing, expand the network of electronic readers and think through the other parts of what he calls "this 2,000-piece puzzle."

The expectation is that a trade association, the NFC Forum, which represents 150 stakeholders in this field, will forge the way to a solution. Yet, the same industry expert warns:

...it is completely possible that nothing will happen in mobile phones in the next five years if everybody keeps thinking only about their own piece of puzzle.

I have no doubt that they're going to figure this out and we'll be waving our phones all over the place relatively soon. Reflecting on the somewhat similar dilemma we face with respect to healthcare IT, I'm struck by two big differences that make health care harder.

First, we'd be lucky if we had only 150 stakeholders. Part of our dilemma in healthcare IT is that the demand- and supply-sides of the industry aren't just fragmented, they're atomized. On the demand-side, there are over 1000 health insurers in the US, and on the supply-side, almost 8,000 hospitals and 170,000 office-based physician practices. HITSP and CCHIT have done a nice job bringing together the technology suppliers (in the latter case, probably too good a job....), but they're only addressing the technical side of this issue. NeHC is supposed to be a forum to forge consensus on market-blocking issues, but they're a top-down creation of the federal government, not the result of the burgeoning demands of underlying grassroots contituencies.

Second, the benefits of health IT aren't as crisp and clear as easier credit card transactions, so our customers (ie, patients) aren't exactly clamboring for what health IT has to offer. Most of us use credit cards very often (all right, probably too often), so little tiny convenience benefits accrue in an obvious way. Most of us don't use the health care system that often, however, so the convenience factor isn't all that meaningful to a lot of us, and so the appeal has to be on less immediate benefits (safety, quality, etc) that are harder to grasp (and believe).

Like the "wave and pay" issue, the obstacle in health care IT is decidedly not the technology. If we can't get "wave and pay" into the market by 2012, what hope do we have of achieving the President's goal of universal EHR adoption by 2014? It's clearly going to take a much larger "forcing function" than the health care market will be able to muster on its own. The Congress' watered down version of the President's health IT vision clearly isn't going to provide that "forcing function", however, so it looks like we're going to have to place our hopes on health care reform.

Piety in the House of Representatives

2009-01-22T20:32:00.007-05:00

The House versions of the economic stimulus related to health IT are working their way through the Ways & Means and Energy and Commerce Committees. Then, it's on to the Senate. The House bills delay release of 90% of HIT funds until 2011, ostensibly on the grounds that the technology isn't ready for immediate investment. Paradoxically, the House approach works only if physicians start investing in systems right away, and it completely ignores the reality that the problem isn't the technology, it's the lack of a business imperative. The very same technology that they criticize is now expected to solve the mind-numbing flaws that currently plague our health care delivery system.

The House approach takes $20B and gives $2B to a government agency now, and $18B to physicians in the form of phased incentives starting in 2011. However, in order to get these incentives, physicians have to be already using these EHRs and HIE in "meaningful" ways (ie, electronical clinical quality reporting and care coordination) by 2011. Which would mean that for most physicians, they would need to start implementing within the next 18 months, because it takes that long to get up and running on these systems.

In taking this approach, the legislation assumes that each physician will make a roughly $50K investment now on the promise of being repaid for this by Medicare over a period of 5 years beginning in 2011. Assuming, of course, that they can pass Medicare's test on "meaningful" use, even though that hasn't been defined and at present there's little to no infrastructure to allow such meaningful use anyway.

Seems like a tough sell to me. There are very very few places in the country that have regional health information networks, and there are no places that have real infrastructure for electronic reporting of clinical quality data, so Medicare will have a hard time defining what meaningful use is, let alone certifying that physicians have successfully done it. They already tried to launch electronic quality reporting a few years ago in the DOQ-IT program, and it was an unmitigated disaster.

Then there's the problem of implementation. According to Medicare, 30-40% of EHR implementations fail. And the vast majority of the ones that don't fail aren't implemented to inter-operate with other systems or generate good clinical quality data.

The House approach glosses all of this over, however. It underinvests in a technological and organizational infrastructure to guide this massive makeover of 15% of our economy, and overinvests in a misplaced faith that IOUs to physicians will drive individual purchases of EHRs, and this, in turn, will induce demand for the network and implementation infrastructure needed for success. And according to success criteria that we're unable to define at present. And in time to meet the President's goal of ubiquitious adoption by 2014.

It reveals an almost religious belief in the power of incentives, however diffuse, and technology, however complicated, and markets, however dysfunctional, to solve the problems that have left 96% of physicians without a fully functional EHR up until now. Almost touching, really, this kind of faith, misplaced though it may be.

I'm speechless...

2009-01-21T00:47:00.014-05:00

"In reaffirming the greatness of our nation,
we understand that greatness is never a given.
It must be earned."

Message to Congress: It takes a village to implement an EHR

2009-01-19T06:33:00.004-05:00

Well, the health IT legislation is starting to take shape, and it's a little more sobering than the initial speculations of tens of billions of HIT dollars being unleashed on state governments in the next few months. In many ways the recent turn of events is an about-face from the early speculations. The House Appropriations and House Ways & Means Committees approaches have the following policy underpinnings:

Separates HIT spending from the economic stimulus
Focuses first on creating a framework for how to handle billions of dollars of HIT funding
Drives the vast majority of money (90%) through Medicare/Medicaid reimbursement channels
Focuses the role of state governments on areas that require local coordination, tailoring, and governance
Moves ONC beyond "coordinator" to actual owner of administrative infrastructure, with all of the programmatic and fiduciary responsibilities that such functions imply
Makes the Federal government the decision-maker on issues such as technical standards, with input from advisory committees on policy and HIT

I'll admit that I was among those who was getting a little dreamy and even woozy at the thought of billions of dollars flowing into health IT over the next year. Compared to that somewhat heady vision, the House language is surely a disappointment. Yet, like most compromises, it represents progress in certain key areas.

Things I like about the approach are:

Balance of state-led and federally-led approaches. I like the idea of a network of regional HIT Extension Centers that work directly with ONC rather than through states. State governments have a role as well, but mostly in the areas of coordination, galvanizing health information exchange, promoting quality improvement and public health, and making sure that under-served communities don't get left behind. I like this approach because EHR adoption is not nearly as state- or local-specific as is HIE, which really does need to be tailored to local markets and conditions. Thus, it makes sense to let the Feds drive EHR adoption through regional organizations, and have states focus on state- and local-level HIE concerns.
Incentives for doing stuff, not just for buying stuff. Focus on incentives that require participants to use the technology, rather than just having systems that are "certified". I like that the incentives are tied to quality reporting and health information exchange because I don't believe that inter-operability standards are enforceable without having activing monitoring by certified HIEs, public health entities, and quality data aggregation entities.
Resources and authority to ONC to get on with it. Gives the clear message that the federal government has to take a stand on key policy decisions in order for us to move forward. This is not ideal, particularly for standards in a fast-moving, decentralized technology space, but it's not clear to me that other approaches are obviously better. The Federal government needs to set standards for Medicare and Medicaid, so that much makes sense regardless of how standards get determined generally.

Things that I think would improve the House language are:

Develop a programmatic overlay to the EHR implementations. Inter-operability and robust reporting don't just happen, they get done. And they won't get done if there isn't an implementation program behind the effort, because the systems are too complicated for individual physicians to do this on their own. There's also too much coordination required with other entities, which can only be coordinated by a formalized program. Therefore, we should cement the link between EHR incentives and the HIT Extension Centers. EHR implementations should be executed through or certified by the HIT Extension Centers, otherwise we'll end up with a lot of really bad retail implementations, just like we have today, because we'll only find out about them ex post (ie, after they've failed and can't deliver on their quality and HIE requirements).
More HIT funding should be made available before 2011. Not necessarily the whole $18B, but there are some parts of the country that are ready to meet the new requirements right away, and we should make funds available to them to build on their momentum while the overall program catches up.
We should try to go "wholesale" rather than "retail". The current approach to the incentives is to go "retail", meaning physician-by-physician, but there's much more value to be had by going "wholesale", meaning market-by-market. Retail implementations will only mimic, or worse, amplify, the existing entropy of care delivery. Putting a programmatic overlay to "communities" or "markets", such as New York and Massachusetts are doing, creates more effective and efficient vehicles for getting providers to work together, which they do too little of today, and ease the path for them to focus on how to best use technology to improve care across the system, not just in their individual offices.

So, concrete ways to accomplish these goals might be:

Designate a couple of HIT Extension Centers right away
Formalize the role of HIT Extension Centers so we get more proactive interventions in government-funded EHR implementations to get better assurance that they get done right the first time, rather than trying to rescue them after they've failed
Provide additional funding to these HIT Extension Centers for them to provide implementation services to physicians up-front
Accelerate Medicare and Medicaid incentives to the markets that these HIT Extension Centers cover
Allow aggregation of incentives by community according to a formula that allows providers who share the same patients to implement in a coordinated way, and perhaps provide a "sweetener" to those who organize themselves this way

One thing we should recognize is that by putting most of this into Medicare/Medicaid incentives, and by delaying most of the money until 2011, HIT could be on a collision course with health care reform. In some ways that's good, because we shouldn't be using technology to try to solve the intractable problems of the current system, we should use technology to enable and enhance a better system. Yet, the reality is that we could get to a point where we push off the 2011 date to align it with health care reform. That would get us even further away from the President-elect's goal of ubiquitious EHRs by 2014.

The National eHealth Collaborative

2009-01-09T00:46:00.005-05:00

The AHIC successor organization is now the National eHealth Collaborative. As a friend reminded me, imitation is the sincerest form of flattery. We at the Massachusetts eHealth Collaborative thus couldn't be more flattered. And we'll get over the name thing. Really. We will.

In all seriousness, congratulations to NeHC -- we wish you every success!

Ready for prime-time

2009-01-06T06:46:00.006-05:00

The New Year’s Day issue of the Boston Globe had an article discussing some objections by people concerned that HIT systems aren’t ready for the large-scale investments being advanced as part of the economic stimulus package (“Letter highlights hurdles in digitizing health records”). The critics advocate investing at a slower pace and focusing investments not on purchasing current technologies but on creating new technologies to fix perceived shortcomings in current systems.

I understand the concerns – after all, we’re talking about spending billions of hard-earned taxpayer dollars, and as a citizen and former federal government employee, I see that as a sacred trust. From what I’ve seen though, these concerns are either misplaced or readily addressable and therefore don’t warrant delaying large-scale investment.

It is certainly true that current EHR systems are complicated, cumbersome, and barely inter-operable. They are that way for a reason: US health care delivery is complicated, cumbersome, and barely inter-operable.

The supply-side of health care is unbelievably fragmented. According to the AMA, there are about 670K practicing physicians in the US. Roughly 150K of them are hospital-based and practice in 7500 hospitals, two-thirds of which are community hospitals. The other 520K physicians work on the ambulatory side and, according to the CDC, they are spread across 170K office-based practices nationwide, 80% of which are solo or 2-physician practices. This is a cottage industry where the individual businesses face little market pressure to standardize around anything except billing codes. Not surprisingly, when they purchase technology, they don’t demand standardization either, and indeed, they demand the opposite, namely, that the technology be able to adapt to their non-standardized and idiosyncratic workflows and clinical decision-making processes.

This fragmentation among so many small and independent providers has three negative effects on health care delivery that federal HIT funding can help resolve. First, care is difficult to coordinate. Second, basic reporting for public health and performance measurement does not exist. And third, clinical documentation and data standards are impossible to promulgate and enforce. Federal HIT funding can help overcome these obstacles by giving all users the tools to document and communicate key information according to national standards, and requiring that they do so as a standard of care.

Getting back to the main point then, the critics have it all wrong. We shouldn’t be waiting for better technology, because technology is an ever-moving target driven by technical and scientific improvement and user demand. If we had insisted that Tim Berners-Lee anticipate live streaming of HD video from the likes of YouTube and Netflix, we’d still be waiting for the World Wide Web. Nor should we be spending a lot on “innovation” or “simpler, easier” technologies, because we’ll almost assuredly get that wrong. Governmentally-directed innovation spending would never have come up with Google, Twitter, Facebook, YouTube, Hulu, Yelp, Sermo, and craigslist, and we’d be much worse off for it.

So, government funding is needed, but spent the wrong way it can stifle innovation and just plain waste a lot of money. What we need to do is first recognize that this will take a long time to get right, it’s wrong to try to architect it perfectly in advance, and it will only become mature when more users engage in using technology to accomplish real business needs. With such a decentralized user base, fast-moving technology, and a dynamic, complicated field such as medicine, we should specify as little as we can get away with technologically but create a flexible architecture that can efficiently accommodate changes into the future. New York is working on just such a model.

EHR technology has gotten as far as it can in a thin market – what’s needed now is more bottom-up pressure from more users, and more top-down pressure from policy-makers and businesses to align these users. Federal dollars can facilitate this by creating a large user base and imposing a policy and programmatic overlay to what would otherwise be a funding free-for-all.

My personal recommendations for an economic stimulus funding program would be:

Establish goals focused not on technology, but on what we want people to do with technology, such as coordination of care, adherance to guidelines, reduction of medical errors, and improvement of population health
Each state should designate an HIE entity (or entities) to broker and enforce statewide health data exchange, and make Medicare and Medicaid data available to authorized users through this HIE infrastructure
Require that all clinical entities use the state-designated HIEs to provide patient-specific post-visit reports to each other
Require that all clinical entities use the state-designated HIEs to regularly report public health and quality/safety data to state-designated public health and quality data entities
Require that all clinical entities use the state-designated HIEs to populate patient health records (PHRs)
90% of funding be earmarked for EHRs, and 10% for state-designated HIEs, quality data warehouses, and public health reporting infrastructure
Require that state-designated HIE, public health, and quality data entities monitor and enforce health data exchange according to existing HITSP standards for data exchange and existing quality and safety measurement standards established by AQA, NQF, HITSP, and others, and penalize states that don’t do this

Is it scary to spend so much taxpayer money so fast? You betcha. But that’s true for every part of the economic stimulus package, not just health care. The need is great, however, so we need to roll up our sleeves and put in place the right vision, leadership, and management. The health IT infrastructure and experience base is perfectly poised to make excellent use of such funds to accomplish the goals of immediate economic stimulus and improvement in health care. By outfitting physicians with modern tools, and requiring that they use them to achieve societal goals, our federal stimulus dollars will provide returns to the country for years to come.

Coming Up for Air

2008-09-28T22:52:00.004-04:00

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.

Delayed gratitude

2008-07-09T00:02:00.005-04:00

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!

Thank You, Boston Globe

2008-07-03T05:21:00.005-04:00

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......

Of HIEs and PHRs......

2008-06-26T23:57:00.002-04:00

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.

Vermont Flying Under the Radar

2008-06-11T06:30:00.001-04:00

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.

Google Health

2008-05-22T06:29:00.004-04:00

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.

Thank You North Adams

2008-05-21T14:43:00.003-04:00

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.

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

2008-03-30T22:57:00.004-04:00

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 (http://www.zocdoc.com/) 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 www.opentable.com 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.

Battle Royale in PHRs

2008-03-02T15:28:00.015-05:00

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.....

In the interest of science

2008-02-26T23:56:00.003-05:00

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.......

Spreading our wings

2008-02-25T22:43:00.003-05:00

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.

News flash: Higher Quality Care May Actually Cost More Money

2008-02-20T16:42:00.004-05:00

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.

More woes for NHS

2008-02-18T23:54:00.005-05:00

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?

"Strap on the feed bag"

2008-02-13T11:24:00.011-05:00

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

2008-02-13T06:20:00.004-05:00

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.

MA Health Policy Forum

2007-12-03T18:34:00.000-05:00

The Massachusetts Health Policy Forum has written a pretty comprehensive brief on the various health IT activities going on in Massachusetts. It was written to support an upcoming conference. To download the brief, go to the link at the bottom of the page.

It takes more than money

2007-11-28T06:10:00.000-05:00

Just about a year ago I wrote about Britain's Connecting for Health program's privacy policy or, more appropriately, their lack thereof. Their approach at the time can best be described as "opt-NOT" -- patients getting care through the NHS would automatically have their data shared on the "Spine" (the national HIE). No fooling around with the niceties of opt-in vs opt-out -- patients could only opt-out by opting out of getting their care from the publicly-funded health service that they pay dearly for.

The NHS has since backed off from this stance and now allows an opt-out policy. That's still a far cry from the opt-in approach taken by MAeHC, and in the context of a burgeoning US movement toward "personally-controlled" health data management, it's downright archaic.

The latest report is that despite this change in policy, physicians themselves are rebelling against the system: 2/3 of NHS family physicians say that they will boycott data-sharing in the system according to a recent poll (see Family doctors to shun national database of patients' records). In a country where individuals have historically deferred to the government on issues of information access, this is a pretty stunning development.

Our policy in the MAeHC project is to allow patient opt-in, meaning that no information will be made available to other entities without the specific permission of patients. Our current opt-in rate is about 93%.

While an opt-in approach clearly has some short-term risks -- such as, slower adoption of systems by physicians, delays in achieving the benefits of clinical data-sharing -- it provides a firmer foundation for the overall enterprise. In the end, we won't be able to reap the benefits of clinical integration unless we build systems that both patients and clinicians can trust.

Wal-Mart's epiphany

2007-11-13T13:58:00.000-05:00

So Wal-Mart is expanding health coverage to more of it's employees -- at least according to a story in today's New York Times. What caught my attention was the description of how they've shifted their view on health benefits -- what were once seen as pure costs are now seen as investments in the work force to improve "presenteeism" and absenteeism and thereby increase overall productivity.

Personally, I'd like to see us get rid of employer-sponsored health insurance, but I recognize that one positive aspect of it is that employers can instill market principles into health care delivery by acting as "smart buyers" of health care services on behalf of their employees. The fact that it's taken Wal-Mart, of all companies, this long to come to the realization that investing in one of their key factors of production just might improve productivity suggests that this "smart buyer" role may not be as compelling as we'd like to think. Maybe Wal-Mart's epiphany will accelerate this type of thinking among other employers.

Now, if we could just get Wal-Mart to invest in technology upgrades for their health care delivery supply chain, we might make better progress on the health IT front.....

Uh-oh....

2007-11-07T17:08:00.000-05:00

I hope my Board doesn't read Computerworld:
"Whole Foods to restrict online postings by execs after CEO brouhaha"

Yet another plug I should have made.....

2007-11-05T05:39:00.000-05:00

OK, so I'm still catching up. There's another shout-out that I keep meaning to make. The Partnership for Healthcare Excellence launched their website a couple of weeks ago. If you live in Massachusetts and haven't heard of them yet, you will soon.

Every Health Economics 101 class begins with a description of the basic tenets of competitive markets (many suppliers and demanders, homogeneity of products and services, full information, yada yada yada). The class then goes on to show how the health care delivery sector violates every tenet.

Health care markets deviate from the theoretical definition in a few ways. For example, consumers don't have enough incentive to worry about value-for-money (because insurance shields them from transaction prices), and they depend on their suppliers (ie, medical professionals) to tell them what services they need. Some of this deviation is structural -- the health care market is never going to operate like the auto or cereal industries because the stakes are too high and the services are too complex.

There is now a push for more tranparency in health care, which is edging the entire industry toward performance measurement and public reporting. The Massachusetts Health Quality Partners is one of the country's leading efforts in this area, the Massachusetts Quality and Cost Council is gearing up for more public reporting, and a bunch of states are already publishing reports on quality measures, hospital infection rates, costs, and medical errors (among them are Vermont, Pennsylvania, Florida, Missouri, Indiana, New Hampshire, and Massachusetts).

The real question, though, is whether consumers will make use of this information. Some believe that consumers will never act on such information, so it's a waste of time and effort. Others agree that consumers will never act on such information, but if their medical professionals will or their employers will, it's still worthwhile. Regardless, the hope is that public reporting will affect consumers in some way, whether directly or indirectly.

Employers can act as smart purchasers on behalf of patients to a certain extent, by locking in financial incentives to behave in certain ways and by demanding more from their health insurers or providers. The Group Insurance Commission tiers physicians and hospitals, for example, and structures financial incentives accordingly. Putting boundaries around what patients can demand will only get us so far, however.

What we'd all like to see is patients individually acting both as better consumers of their health care dollars AND better users of the health care system. Yet, it's hard for them to do this on their own -- our health care delivery system is too complex, and they've already become accustomed to playing a certain role in the physician-patient relationship. Actionable education is the key to bringing about this change, and that's where the Partnership for Healthcare Excellence comes in. Check out their site -- you might just learn something.....

Geek Doctor Emerges

2007-11-04T06:22:00.000-05:00

So I've been greatly remiss in not putting in a plug for John Halamka's blog. I learn something new every time I talk to John, and now the world can too.

Best of luck John!

My kingdom for an inter-operable vendor!

2007-11-01T12:06:00.000-04:00

The following was forwarded to me by one of our vendors (which is ironic, once you see the content).

The heads of the two leading health IT projects in the world -- Richard Granger of the UK's Connecting for Health, and Richard Alvarez, the head of Canada's Infoway -- spoke at a recent conference and complained loudly about the state of the health IT industry (see "NHS chief chides vendors for promising more than they deliver").

"Vendors! You can't do these projects without them, but many of the products proferred can't do the job," exclaimed Granger. Adding to the fray, Alvarez stated: "Vendors continue to say they can do it -- but they can't. We don't have a single vendor that is truly interoperable."

Noting that the American approach is to proceed more cautiously -- through standards development, certification, evaluation, ROI calculations and multiple panels and commissions -- Granger quipped: "Some people lack the spine...to bring about systemic benefits and seek only to engineer point-to-point benefits." This approach, he said, is "doomed to fail."

I've got only one thing to say about Granger's comments: Hear, Hear!!

Congratulations to our local health plans!

2007-10-29T16:31:00.000-04:00

The votes are in and once again Massachusetts health plans are the best in the nation, capturing three of the top four slots in the national "America's Best Health Plans" rankings (see Harvard Pilgrim ranked top health plan in nation). Harvard Pilgrim, Tufts Health Plan, and Blue Cross Blue Shield of Massachusetts were rated top performers in clinical performance and customer satisfaction by the National Committee for Quality Assurance (NCQA).

We often hear about how blessed we are to live in a state with such world-class medical institutions -- and it's true, we are. What gets less attention, however, is that we in the Commonwealth have such terrific health plans -- non-profit, well-managed, focused on our state, and community-minded.

Health insurers get a lot of criticism -- and not all of it undeserved (my parents are physicians -- believe me, I've heard it all). Yet, in our overly complicated "non-system" that we call a health care system, health insurers are for many patients -- and especially the sickest ones -- the glue that holds the whole thing together. So, let's give some credit where credit's due and praise our local health plans who have shown themselves to be world-class in their own right.

Okay, I'm finished with today's blog and now it's time to get back to running the business.....Next year's premiums are going up by how much?!

The challenges of secondary uses of data

2007-10-25T09:55:00.001-04:00

Part of the presumed value of greater health information exchange lies in so-called "secondary uses" of data, i.e., using patient data for activities that go beyond payment/treatment/operations, such as bio-medical and health services research and clinical trials. Many health information exchanges (including those sponsored by MAeHC) have taken an "opt-in" approach to data exchange, whereby a patient's information cannot be disclosed to "the network" without prior permission of the patient.

This has left open the question of what to do about secondary uses of de-identified data, however. HIPAA does not require patient permission if the data being used is fully de-identified, and many HIE projects are operating on the presumption that secondary uses are okay as long as they release only de-identifed data, which HIPAA allows them to do.

I've been in an increasingly large number of conversations with HIE projects around the country who are saying that even though HIPAA allows it, they're going to ask for blanket permission from patients before they release even de-identified data. And they're hoping that this "belt and suspenders" approach fully protects their activities.

Some new work sponsored by the Institute of Medicine suggests that this approach may be the minimum requirement for satisfying increasing patient demands for privacy protection (see Striking a balance between privacy and health). Of over 300 patients surveyed:

38% said that they'd want researchers "from each research study....to first describe the study to me and get my specific consent for such use";
19% would allow use of de-identified data without consent as long as the research was overseen by an IRB;
13% would not want their data used for research "under any circumstances";
8% said an upfront "general consent" would be enough for use of their data in future research projects;
1% said researchers could use their data without their consent

The implications are pretty startling. We have a serious disconnect between what the law allows and what patients want (and expect). Over 80% of people would NOT want their data to be used for research without their consent, even if it was de-identified and overseen by an IRB. And while it's hard to read from the survey's summary data, a large fraction may want some type of consent for each use.

There's a lot of hope that health trusts and personally controlled health records will solve all of this by giving patients ultimate control of their health information. We're a long long way off from being able to give patients that type of control, so we'll be facing these issues for a long time to come.

There's obviously no "right" or "wrong" here because it is what it is. On the other hand, we should always be cautious about surveying people about abstractions -- a little education and concrete experience may change people's perceptions dramatically. That said, the threshhold on privacy protection is clearly getting higher, and what may have seemed like conservative approaches to privacy protection yesterday may become barely adequate tomorrow.

George Clooney's heart's in the right place, but his head isn't

2007-10-24T10:44:00.000-04:00

One of my favorite news sources, People magazine, is reporting that George Clooney thinks that the Palisades Medical Center should go easy on the 40 employees who illegally looked at his medical records (see George Clooney Addresses the Leak of His Medical Records). The employees have been suspended without pay for a month. While I love Mr. Clooney as an actor, and am very sympathetic with his politics, on this one I think his compassion has gotten the best of him.

Unauthorized disclosures of patient information happen all the time. Most of the time it's unintentional and no harm is done. With intentional disclosures, there is a temptation to tailor punishment to motive -- specifically, to separate cases where a person looks at a record "with malice" from cases where it's "without malice". That's clearly what's going on at Palisades, and implicitly, in Mr. Clooney's head. I assume that the punishment would be different if an employee was found to be stealing Clooney's identity, or looking for his address or phone number to stalk him.

As more health care institutions convert to electronic medical records, there is increasing concern about privacy protection, and most of that concern is understandable and well-placed. The enormous benefits that can come from greater use of EMRs will go unrealized if we adopt a cavalier attitude on technologies and policies related to patient privacy. Suspending workers without pay in this case strikes me as being unbelievably lenient. If I was a patient at Palisades Medical Center, I would switch immediately to an institution that has greater respect for the trust that I've placed in them as the custodian of my records.

For docs, there's more to email than meets the eye....

2007-09-21T17:21:00.000-04:00

An interesting piece in yesterday's Seattle Post-Intelligencer -- "The doctor will e-mail you now." The Group Health Cooperative has completed a study on physician-patient email and found that, contrary to the fears of many physicians, email doesn't affect profits and seems to improve patient satisfaction and perhaps even the quality of care. Though emails do reduce the number of patient visits, which reduces revenues to the practice (but benefits patients and health insurers), emails also reduce the number of phone calls, which reduces direct and indirect costs. Seems like the revenue loss was made up for by cost reduction.

GHC also found that email interactions focused more on "prevention and overall health goals", and one physician suggested that as a result his visit mix had changed so that more of his office visits were focused on acute care. Hopefully the study took into account the higher reimbursements per visit that would accompany such a shift -- if not, the move to email might even result in a net profit increase to the practice.

Given that primary care physicians in Massachusetts are already at capacity, I find it hard to believe that emails would reduce their visits -- it would just reduce their backlog. And in the meantime, the GHC study suggests that it would increase profits, quality of care, and patient satisfaction.

This shouldn't be surprising. Since the most scarce resource is the doctor's in-person time, it's optimal to channel as much acute care as possible into that time, since it gives the highest reimbursement to the physician and the greatest satisfaction to the patient. A practice will get higher reimbursement and deliver higher value by using email to siphon off non-acute visits so that the practice can focus office visits on acute care. And the beauty of email is that for a large number of patients, they'll self-select -- if they have a non-urgent question, they'll email it and not take up office time that the practice wants to devote to acute care anyway.

I'm working with some physicians now who used to do email with patients but found it too time-consuming and have now either quit or have started charging patients for it, which has reduced the number of emails dramatically. Judging from the GHC results, these docs might want to take a harder look at the economics of email.

One Step Forward for Dossia

2007-09-20T07:35:00.000-04:00

Things are finally looking up at Dossia. The PHR project was launched awhile ago with all sorts of ballyhoo and misplaced optimism by a consortium of companies, led by Wal-Mart and Intel. After very low uptake by employees, and a disasterous falling out with their vendor, the project seemed to be on the brink of collapse due to an ill-conceived strategy, lack of expertise, and poor execution. It's most recent announcement suggests that they've solved at least the second problem.

The Wall Street Journal reports that Dossia has signed an agreement with folks at Childrens' Hospital of Boston to base the Dossia infrastructure on the Indivo architecture that has been under development at Childrens' for many years (a free preview of the article is available at WSJ, and there's a press release on the Dossia site). Dossia should be congratulated for bringing the Childrens' folks on board. If you ask me, Indivo is the most thoughtful and firmly grounded PHR project in the country, bar none. The folks behind Indivo -- Drs. Isaac Kohane and Ken Mandl -- are bonafide informatics heavyweights, and they've been thinking about this and experimenting with it for a very long time.

I don't think Dossia is out of the woods yet though. While I'm in complete agreement with the Dossia vision (and indeed, very few people in this field disagree with the vision), and they've now got the best informaticians on their team, I still think that their strategy is naive. The basic argument remains: Is higher health IT penetration going to happen from the demand-side (ie, consumers using their PHRs to push their doctors to adopt EHRs) or the supply-side (ie, fostering greater EHR use among providers to make PHRs relevant in the first place)?

My own view is that the demand-side approach is premature right now because there isn't enough electronic information available yet to make external PHRs (ie, PHRs that aren't connected to any particular provider or insurer) an attractive value proposition for most patients. Most clinical information right now is non-structured, non-electronic information that is held by fragmented, disorganized, paper-based provider networks. Some information can be assembled, like medications from health insurers. It falls off pretty quickly from there though. A lot of folks look to the national labs as a source of electronic info, for example, but their penetration is highly variable by market and generally quite low (on the order of 10% in Massachusetts is my guess). And don't even think about external PHRs getting information out of hospitals and doctors' offices -- it's so far from being scalable that it's not even worth talking about.

Overall, I think that we still need to focus on the supply-side -- figure out how to get more EHRs and HIEs into the hands of physicians so that more meaningful information is available to doctors and patients alike. Demand-side pressure can work too, I think, but not through PHRs, but rather, by patients' choosing providers who have EHRs.

That's the way it's working for me. I've signed up with a national PHR company, but for me it was too much work for too little gain. Rather than expending any effort on a PHR where I had to do the work and that was still unlikely to bring my info together easily or effectively anyway, I voted with my feet and moved my care to a provider (Harvard Vanguard) who already has an EHR and can make my information available to me through their own patient portal.

I may not have "control" in the sense that access to my records is governed not by me but by Harvard Vanguard's corporate policies, but if they gather and enter the information for me, AND store it, AND give me electronic access to it for free, that's a worthwhile trade-off to me. In return, the work that I'm willing to do as a patient is to channel my care to providers who are already integrated -- physicians at Harvard Vanguard and the hospitals they're connected with -- rather than spending my own time and money (or having my employer spending MY time and money) trying to integrate unwieldy information from disparate, disconnected providers.

I may not have direct "control" of my info, but I've invested my trust in an organization that I'm confident won't abuse it, and I'm not at all worried that my employer will get access to my info. It's in the hands of my doctors, which is exactly where I want it to be.

Dress codes for doctors

2007-09-18T10:03:00.000-04:00

Today's Boston Globe had a little snippet entitled "Hospitals ban ties, jewelry for doctors". Apparently, concern about infection control has led British hospitals to ban physicians from wearing ties, jewelry, and long sleeves.

I'm sure that there are valid reasons to do this from an infection control perspective. Most convincing to me, though, was the statement by the Department of Health: "Ties are rarely laundered but worn daily...They perform no beneficial function."

I wish that all government policy statements were as succinct and to-the-point.......

Looking at EHR adoption growth from the supply-side

2007-08-31T01:01:00.000-04:00

One of MAeHC's EHR vendors, eClinicalWorks, has made Inc. magazine's Top 500 Fastest Growing Private Companies in America. eCW has won plenty of accolades in health industry rankings, but this is the first time that I've seen an EHR company rank highly in national comparisons across all industrial sectors; with over 2500% growth, they ranked #34 overall, #4 among all software companies, and #1 among Massachusetts companies. Congratulations to Girish Kumar, Mahesh Navani, Dr. Rajesh Dharampuria, and the entire eCW team.

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.

Portland suffers from the tyranny of the status quo

2007-08-23T22:07:00.000-04:00

The Health Data Exchange Group of Portland, Oregon is apparently on the verge of collapse, according to the Portland Tribune ("Record-sharing stalls"). The Tribune article is a very penetrating look at the difficulties of launching and maintaining an HIE.

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:

[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.

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."

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......

Minnesota mandates EHRs by 2015

2007-08-22T17:45:00.000-04:00

I like to think that Massachusetts is at the forefront of health IT in the US (okay, okay, the truth is I'm seriously torn because I have a VERY soft spot for Indiana as well). But the news coming out of Minnesota is that they may soon be able to lay claim to top spot in health IT. According to Government Health IT News, the state of Minnesota has mandated: 1) electronic claims by Jan 2009; 2) e-prescribing by all providers serving state employees and their dependents by 2009; and 3) "interoperable EHRs" by all physicians and hospitals by 2015.

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......

HHS Secretary Launches Blog

2007-08-21T06:48:00.000-04:00

For those who haven't seen it, HHS Secretary Mike Leavitt has launched a blog. Only three entries so far. The really interesting parts are his running descriptions of what he does every day. Less interesting, the rest of the entries so far read like speeches and policy pronouncements.

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!

Medicare takes the plunge

2007-08-20T06:26:00.000-04:00

Medicare will soon stop paying hospitals for the cost of treating "preventable errors, injuries, and infections that occur in hospitals" according to a front-page story in yesterday's New York Times. I'm not an expert in this area, but my naive observation is that this single policy change will mark the beginning of dramatic changes in health care reimbursement -- and perhaps health care delivery -- in the coming years. (Plenty of experts have weighed in on this -- Paul Levy has some links to them).

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.

Breaking it to the American public

2007-08-14T21:13:00.000-04:00

Sunday's New York Times had an excellent editorial: "World's Best Medical Care?" The article begins as follows:

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.

The Dossier on Dossia

2007-08-13T11:18:00.000-04:00

My friend David S. has been politely but earnestly pushing news items to me in order to spur me to get back to blogging. For the record, it's not so much lack of fodder but lack of time that undermines my blogging frequency -- with an increasingly complex and fast-moving company, three complex and fast-moving children, and one fast-moving (but not complex) lab-mix puppy, it's been unbelievably difficult to find the time. Many many thanks, though, to David S. and the others who have inquired about the blog and expressed interest in its return. And of course, more fodder always helps....

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.....

RHIOs still a tough row to hoe

2007-06-15T07:06:00.000-04:00

This week's GovernmentHealthIT reports the dissolution of the Northeastern Pennsylvania Regional Health Information Organization ("Pennsylvania RHIO to close"). This follows on the demise of the Santa Barbara County Care Data Exchange. In the coming weeks another relatively high profile effort will announce their decision to dissolve.

There are over 200 HIE efforts across the country, most still burning through their initial grant funding, trying to find the elusive "sustainability" model. None have yet been able to replicate the successes of the only self-sustaining efforts to date: Indiana Health Information Exchange, HealthBridge, and MA-SHARE.

It's worth noting that the lines of business that have made these efforts sustainable so far haven't been about ubiquitious sharing of data, per se; success in these efforts has come from creating a single "pipeline" that efficiently channels disparate streams of data. The successful product/service areas have used technology to create economies of scale in basic backoffice functions, and collaboration to convince participants to outsource these functions to the "RHIO".

This general model can be replicated in many other places, so there's still plenty of opportunity out there, but it's not a universally applicable solution. Making this model work in other places where it fits, and establishing other value-generating product/service areas where the model doesn't fit, will be key to getting more RHIOs firmly in the win column.

David Brailer Returns

2007-06-06T00:30:00.000-04:00

Today's New York Times reported the launching of Health Evolution Partners, a private equity fund led by Dr. David Brailer. Everyone in the area of health IT will remember David, the first National Coordinator for Health IT (ONC) and architect of the Strategic Framework for Health IT.

Brailer's idea is to apply private equity (he has $700M from CalPers to start) to a new type of niche: products and services that can exploit new developments in health information exchange to reduce fragmentation of care and improve quality, safety, and efficiency of health care delivery. This hasn't been an area that has typically drawn much private capital for a few reasons.

First, there are barriers to entry in becoming a domain expert. Health care delivery is so darned complicated that there are fewer people with both deep domain knowledge and investors' acumen than there are in other market sectors.

Second, investments in health care delivery don't typically meet the hurdle rates that typical venture capitalists apply to their investment decisions. The health care delivery value chain is convoluted, at best, as are the distribution of costs and benefits across the value chain. In addition, while the costs are crystal clear, the benefits aren't; benefits such as reductions in ED visits due to better preventive care, for example, take a long time to get realized and are hard to measure.

Finally, a lot of investors just think that health care delivery isn't really a market, and thus, they don't want to invest in a sector where they don't know the rules or how the rules are made. I used to work in the Pentagon and found a similar attitude among many investors toward the defense industry.

Yet, there's opportunity in health care delivery for those who can thread their way through the thicket. It requires some patient capital (perhaps VERY patient capital) and a unique combination of expertise in the nitty-gritty of health care delivery, business/economics, and technology. Health Evolution Partners seems like it's got the perfect combination of these assets -- I wish them well.

IT Writer, Familiarize Thyself

2007-05-31T22:36:00.000-04:00

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.

Clarifying a recent Information Week article

2007-05-29T23:00:00.000-04:00

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.

Pennsylvania maps out an EHR strategy

2007-05-25T01:31:00.000-04:00

The Pennsylvania eHealth Initiative (www.paehi.org) 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: $$$.

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

2007-05-24T06:00:00.001-04:00

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.

IT advances that are changing the rules

2007-05-21T08:25:00.000-04:00

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.

An EMR Mandate -- Let's Go!!

2007-05-17T06:05:00.000-04:00

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:

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.
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.
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.
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.
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.

"Free" EHRs: A Faustian bargain on patient privacy?

2007-03-19T00:26:00.000-04:00

One of the biggest barriers to wider adoption of electronic health records (EHRs) is affordability. Regardless of whether you "rent" (ie, pay a monthly fee for access to a web-based product) or "buy" (ie, purchase a license to put the software on your own computer), the first-year costs for a respectable system are $15K-$25K per clinician. It was inevitable, therefore, that some "free" products would enter the market. As it turns out, there's no such thing as a free lunch.

First came a non-commercial alternative, VistA-Office, which the government has already paid for. VistA-Office is the office-based version of the VistA system that has been so successfully deployed in the US Department of Veterans' Administration, and it can be downloaded without charge from a non-profit, government-sanctioned vendor called WorldVistA. Of course, there's more to the cost of an EHR than just the software, so though the license is free, a potential user would still have to pay for hardware, implementation, training, support, and maintenance. Nevertheless, it's always great, and economically efficient, when the government is able to create commercial spin-offs from work it's already funded.

If VistA-Office can be thought of as a non-commercial approach to "free" EHRs, Practice Fusion, a San-Francisco-based startup is its hyper-commercial opposite. Launched last August, the company's original plan was to offer their EHR without charge in return for access to the deidentified clinical data generated by users, which the company would sell to pharma companies, insurers, and researchers. If that isn't controversial enough, the company announced last Friday that they'll be partnering with Google's advertising arm, AdSense, to put context-sensitive ads on the EHR in real-time. As described in the San Francisco Chronicle: "When a doctor using the service calls up a patient's health record, AdSense will recognize certain keywords -- such as "diabetes" -- and ads related to that condition will appear on the page."

I assume that all of this is HIPAA-compliant, though it would take some convincing that no places or dates of service are being compromised when ads are being delivered to a physician's EHR in real-time based on what they type into the system. And we haven't event talked about state laws yet.

Regardless of whether it's legal, this approach does pose issues for physician-patient trust. For example, does a physician really know what they're getting into? The slippery slope has already been demonstrated. In August, the story was:

The “completely hosted, community-based model” EHR will be subsidized on the back end by selling de-identified data to insurance groups, clinical researchers and pharmaceutical companies, said CEO Ryan Howard.

Now, seven months later, it's clear that selling data isn't going to generate enough revenue.

Practice Fusion's deal with Google is what makes a free medical records system possible. Google's AdSense program will generate ads that will be displayed as the records system is used.

What's next if that doesn't work? If I'm already using the product, do I get a say in how it's expanded? If I don't like that, is my only option to leave, with all of the switching costs that that would entail?

Practice Fusion claims that health insurers will be eager to get into this action as well. Insurers have a hard enough time trying to keep patients on their formularies. How much harder will that be when drug ads are being inserted into the physicians' thought process at the point-of-care?

Purely on a user-interaction level, I'm not sure how many physicians will like having ads on their screen (actually, I am sure but I don't have any data to back me up). It's already a challenge to figure out how to present meaningful medical information on a screen without overloading the user. Dynamic ads won't help that.

Finally, but most important, how will patients feel about this? The first time a patient sees a Paxil ad pop up on his physician's screen, the questions will start flying. And the physician will be in the awkward position of saying that those ads don't affect his/her decision-making, that the company generating those ads is Google, but not to worry, through the magic of technology, Google has no access to private medical records (and the physician will be crossing his/her fingers hoping that that's true).

Practice Fusion's CEO says that "he does not expect data-sharing will be a concern to physicians who accept the free EHR." If that's true, it's only because they haven't asked their patients yet.

Farewell, Santa Barbara

2007-03-13T23:45:00.000-04:00

For those who don't follow this stuff, last week marked the official demise of the Santa Barbara County Care Data Exchange (their website is already down -- there's some background here). The Santa Barbara project was a pioneering effort launched by (among others) David Brailer, the first and former head of the Office of the National Coordinator for Health IT.

The project struggled for many years with a variety of issues, but never did go live. After 8 years and over $10 million, the project leaders finally called it quits. A report in Government Health IT cites legal and technical costs associated with privacy protection as the final straw (see Privacy, funding doubts shutter Calif. RHIO). In a presentation given to the eHI Connecting Communities coalition (subscription only), one of the project's leaders emphasized that technology was not the issue, and that lack of a detailed and viable business plan undermined the project's long-term prospects.

I think there will be many lessons and cautionary tales coming out of this pioneering effort -- they'll probably dribble out over time. Sad to say but this could be the first of many "RHIOs" that throw in the towel for lack of a real business model.

Employers take the pledge

2007-03-10T06:47:00.000-05:00

Secretary Leavitt on Thursday extracted a "pledge" from some large employers in Minnesota to push for better access to health care information for their employees. The article (Employers take on a new health challenge) reported this as follows:

Executives from 3M, Wells Fargo, Target Corp., Carlson Cos. and other Minnesota companies met with Leavitt and then signed a pledge to seek better health care information for their employees. The companies employ 3 million workers, Leavitt said, which will make them an influential force when demanding cost and quality information from health insurers and their networks of hospitals and doctors.

I'm assuming that the "pledge" is very general and doesn't specify what it means to "seek better health care information." I do think it's great to create a sense of urgency among employers and patients about the need for better health information, and this type of "pledge" seems like a great use of the Secretary's bully pulpit.

I don't know whether these employers are going to think of this pledge as mere paper, or as something that they're actually going to put some energy behind. If they do act, I hope they focus on investing in their own health care supply chains -- by thinking of creative ways to facilitate EHR adoption and local health information exchanges in their own communities, for example -- rather than on splashy but empty electronic edifices like personal health records (PHRs). Employers will get way more for their dollar by investing directly in improvement of health care delivery through greater health IT penetration, which will then make available the type of information that will ultimately make PHRs worthwhile.

I hope that these employers take their pledge to the Secretary seriously and use it as a way to coalesce around meaningful, collaborative initiatives, as they've done in Indiana (please see: Congratulations Indianapolis). It's becoming clear (to me, at least) that effective, widespread implementation and use of health IT won't happen until employers start to manage health care delivery as a supply chain issue.

How much would you pay for another year of life?

2007-03-08T00:39:00.000-05:00

Lee Gomes has an article in Wednesday's Wall Street Journal about medical technology ("A Technology Writer Confronts Wizardry In Today's Hospitals" -- subscription required). After being admitted to a hospital for 10 days with pneumonia, Gomes marvels at the latest imaging and lab technology, but notes that the bill for his 10-day stay was $125,000 (not including physicians' fees). And then, he concludes:

...I doubt that I would have declined any of the high-tech wonders I was offered. Who would? And that attitude is a main cause of our soaring health care costs. The decisions that are in our best interest as individual patients, in the aggregate, help push things into crisis. We can't afford the remarkable system we've been smart enough to build.

Study after study has concluded that development and rapid introduction of advanced technologies are the main driver of health care cost growth in the US. Consumers don't face the price of such technology introductions because of insurance, but given the stakes involved, who among us wouldn't want our insurance company to pay any amount more to reduce our risk of dying by even 1 percentage point? The question is, as Gomes implies, how do we reconcile our individual desires to spend anything to increase the odds of saving our own lives, with the real affordability issues that it raises?

Economists have approached this question by sneaking up on people. Rather than asking directly, "how much should Harvard Pilgrim pay to save your life?", they look at how people evaluate risk every day, and then calculate what this implies about how much they "value" their lives. Or put another way, how much they would be willing to pay for this if they could make the assessment in a rational state of mind clear of the medical crisis that they're facing at the time, and they had to pay on their own?

For example, airbags are known to save lives, and there was a time when you would pay extra to have airbags installed in your car. Question is, how much were people willing to pay for airbags that would reduce their risk of serious injury by some known percent? Once you know that, you can make a guess as to how much value they're placing on their own lives.

Sounds dodgy, I know, but it turns out that researchers who've done this across a number of categories have found surprising consistency in peoples' valuations. David Cutler, an economist at Harvard, has done a lot of work in this area. He surveyed a number of studies and found that most value an additional year of life between $75,000 and $150,000.

So, back to the Gomes article. Is $125,000 too much to pay? Looking at his picture in the paper, I'm guessing that he's in his 40's, with many happy years ahead of him. Given the nature of his pneumonia (he was in the hospital for 10 days!), this technology probably reduced his risk of dying or having serious complications by a substantial amount compared to what he would have faced, say, 50 years ago.

Do the math and the conclusion seems obvious: Gomes got a bargain......

Question: Do you know where your credit card info is? Answer: Literally, everywhere.

2007-03-07T06:20:00.000-05:00

Those of us in health care IT are obsessed with security, and rightly so -- we're dealing with some of the most personal information imaginable, and none of this works if it doesn't engender the trust of patients and physicians alike. So, I guess I'm more attuned to security policies and technologies than any normal person ought to be.

With that in mind, I was intrigued by the story that the restaurant chain Ruby Tuesday is moving to an "ultra-secure credit card processing system". (Maybe it's just me, but their adding the word "ultra" here doesn't make me feel better -- reminds me of Animal House, when Dean Wormer puts Delta House on "double secret probation"). As described by the company's hometown newspaper, The Daily News Journal, the system "leaves no credit card information at the restaurant and is instead sent to the bank in encrypted form."

I'll bet that most people would be surprised to learn that they weren't already doing this. You kept my credit card information? But you already got your money -- who gave you permission to keep it beyond that. You're going to start using encrypted communication? You mean, you don't do that now???

A USA Today story on the same topic reports that some restaurants like Hooters and Legal Seafoods are now looking at using mobile credit card systems that allow the credit card transactions to happen at your table. (Many possibile jokes here -- I'm not going there.) I was in Europe last summer with my family and I noticed that every restaurant we went to in Spain and France had such devices. I don't know why the US is so far behind.

The story also reports that Massachusetts (my home state) is considering a law that would penalize companies for credit card data breaches. That's interesting, because Massachusetts is one of a minority of states that doesn't have a breach notification law today (please see: Massachusetts among 16 states that don't have breach notification laws).

I've written before about my personal experiences at Marshall's and Home Depot where I learned how much info they keep (please see: Identity theft and digital records). Think of all of the loosely protected mini-repositories of credit card info out there -- basically every store you go to -- and how much of that information is flying through the ether without basic encryption protections. Patients and physicians should take comfort knowing that modern health IT systems and processes aim higher than that.

Are PHRs the chicken or the egg?

2007-03-06T05:12:00.000-05:00

Interesting shifts in the focus of national HIT spending.

Federal attention (and presumably resources) has turned from EHRs and HIEs to personal health records (PHRs). The following report refers to comments by Dr. Robert Kolodner, President Bush's head of health IT:

Kolodner said that most Americans will have EHRs by 2014, and personal health records will drive that effort. Progress will increase in pace as a tipping point toward healthcare IT adoption is reached, Kolodner said.

You can see the whole report here: ONC fields tough questions Town Hall meeting.

ONC plans on backing these words with resources. The next round of federal contracts for health information networks are due out in April, and according to Kolodner, the next projects will be required to "empower patients to manage their own data." Speaking further, Kolodner said:

They have to enable the patient to identify how they wish to view their own information, to choose how the trust to share data, to control access to data by others, and for how long.... Individuals will also be able to correct errors in their health information. The actual correction process will at first be manual, but in the future it will hopefully be automated.

You can see the whole report here: Majority of market now adopting value-driven healthcare, Leavitt says.

This is somewhat of a shift in priorities from the original vision laid out by Kolodner's predecessor, David Brailer. The original Framework for Strategic Action created in 2004 had PHRs as the third goal, behind EHRs and HIEs.

I've written before about my belief that PHRs can't be the driver of HIT. EHR penetration is so low at present, and hospital systems are so hard to connect to, that there isn't enough electronic data available yet to make PHRs interesting to consumers (please see You can't get blood (or data) out of a stone and Hi, I'm from Wal-Mart and I'm here to help....).

Further, by framing this goal as having "most Americans" rather than "most physicians" on an EHR by 2014, ONC is going after the highest hanging fruit. According to the National Ambulatory Care Survey, 90% of outpatient visits happen in small practices, yet, according to the CDC, penetration of "good" EHRs is only around 9% generally, and much much lower in small practices.

I hope I'm proven wrong, because the point is to get it done in any way that works. Maybe we can get consumers to pound the table for PHRs. And maybe that pounding will get physicians to feel the urgency to get EHRs in order to meet their patients' demands for data to populate these PHRs. And maybe substantial federal dollars focused in this way can create a market.

With all due respect to Dr. Kolodner and his tremendous efforts and vision, I think it will be an enormous challenge to have most Americans on an EHR by 2014 even if we funded EHRs directly. Getting to that goal indirectly through demand generated by PHRs will be even more challenging.

Lessons from Scotts Miracle-Gro

2007-03-04T22:57:00.000-05:00

Sunday morning's Weekend Edition show on National Public Radio had a story about a former employee of Scotts Miracle-Gro who is suing the company after it fired him for being a smoker. Scott's policies are also the cover story of last week's issue of Business Week ("Get Healthy -- Or Else").

If this doesn't convince us that we need to get employers out from between people and their health insurance, I don't know what will. If we expect employers to bear a large share of the burden of health insurance costs and administration, we can't complain too much when they try to pull (grasp?) at more levers to control those costs. (Indeed, part of the argument for keeping the current system is that employers are "smart buyers.")

The problem is, they reach a point where they can't squeeze out any more efficiencies through furthering tinkering with benefit design and supply chain management. Inevitably, they have to start trying to influence demand for healthcare, and they can't do that without plunging deeper and deeper into the private lives of their employees.

Employers are starting to realize that they've "hit the wall." Sometimes this manifests itself in hare-brained schemes, like Wal-Mart's Dossia PHR project. It's now escalated to the point where they too want out of the health benefits business entirely, and they're willing to ally with their adversaries to do it (witness the joint proposal from Wal-Mart and the largest union in the country to do away with the current health care system by 2012 -- "Better Health Care Together").

We've heard many times about how US-nameplate automakers spend more on healthcare than they do on steel. The cost argument doesn't bother me that much, frankly, because even if we moved away from an employer-based model, the costs would flow back to them in some way anyway. If we provided it through the government, as many other industrialized countries do, corporate taxes would undoubtedly go up to pay for a share of this. Taxes on individuals would go up as well, which would reduce disposable income, thereby reducing demand for cars, and ultimately cutting revenues to the automakers.

There is obviously inefficiency in forcing every company to become expert in optimal benefit design, but in a reasonably efficient market economy like the US, the "general equilibrium" result would be that corporations would for the most part end up close to where they are now economically. At the end of the day health care has to get paid for, and those costs can't get shifted away "cost-free".

So, while employers couch the need for change in terms of cost, I don't think that's why we should change the system. It's not the cost to businesses that is the most pernicious aspect of our employer-based healthcare financing system, it's the cost to all of us of having businesses become social engineers. If you don't think this is real, think about this: Scotts requires its employees to "pee in a cup" to test for nicotine. Urine tests to check compliance, not with the law, but with company policies.

The attorney for the former Scotts employee says that the company shouldn't be permitted to fire smokers, because of the slippery slope effect -- first it's smokers, then it's obese people, drinkers, motorcycle riders, and mountain-climbers. His solution is to disallow employers from doing this.

He's right, of course, that these lines are hard to draw. But companies need to have some levers to control costs. They could, for example, do other things short of firing smokers -- deny them access to health insurance benefits, for example, or make them pay the difference between a non-smoker's premium and a premium that accounts for their greater actuarial risk.

I'm all for compelling people to pay the extra cost of risks brought about by their voluntary behavior; it's economically efficient and fair. The real point though is that regardless of whether your employer's policy is to fire you or just charge you more, they still have to make a judgement about whether you belong in the high-risk category in the first place. And the more such risk-adjusted refinements they try to pursue, the more they need to know about the intimate details of your life outside of work.

In this way, employer-based insurance virtually forces companies to encroach on their employees' privacy. That, more than anything else, is why we should get rid of it.

Another "Mission Accomplished"?

2007-03-03T06:04:00.000-05:00

President Bush on his weekly radio address last weekend declared that "America has the best health care system in the world...".

This week's Healthcare IT News has the following headline:

Majority of market now adopting value-driven healthcare, Leavitt says

Secretary Leavitt said that "we are close to achieving interoperable standards and a system-wide transformation," according to the article.

'Nuff said..........

Congratulations Indianapolis! (And I'm NOT referring to the Colts)

2007-03-02T00:07:00.000-05:00

The Indianapolis Star last week had a story about the launching of a quality reporting system by the Indiana Health Information Exchange (IHIE). This is a truly exciting development, not only for Indiana but also for the many fledgling health information exchanges around the country.

The national health information exchange movement is at a fragile point at present, as the over 200 "RHIOs" across the country struggle with the question of how they'll sustain themselves once their grant money runs out. IHIE offers a shining example (arguably the shining example) of how a health information exchange can offer innovative programs that deliver value on business terms, transform health care delivery, and (hopefully) improve the quality and cost-effectiveness of health care over time. In short, they're starting to realize the vision.

The program itself is called Quality Health First of Indiana, and it builds on the community-wide results delivery service that IHIE already runs, and the Indiana Network for Patient Care created years ago by the now legendary Regenstrief Institute. The program will merge data from insurance claims with laboratory results from the IHIE system to create benchmarking reports to track physician performance. It will also generate alerts and reminders for physicians to improve tracking and follow-up of patients with chronic conditions -- this will give physicians better tools to monitor and improve themselves on the indicators that they're being measured on.

What's really unique and powerful about this program is the coalition of stakeholders that are backing it. In particular, the Employers' Forum of Indiana played a central and lead role in bringing purchasers and the health plans together with providers to agree on a set of measures that would be considered by all to be meaningful and actionable. IHIE had the platform to bring together the data, which made data collection and report delivery affordable and minimally invasive to the physicians. The health plans are funding the operations. They're paying IHIE to pull together, process, and deliver the reports. They're also paying physicians to participate at the outset ("pay to play"), and will then provide incentive payments for quality improvements over time ("pay to perform").

Another innovation is that they're bringing together claims data (from Medicare as well as local plans) and merging that with real clinical information drawn from the health exchange. That gives physicians a more complete picture of themselves than they're able to put together on their own.

In Massachusetts, we've done well on the claims and reporting side, but less well on the clinical integration side. We have the benefit of a groundbreaking program in its own right, namely, the Massachusetts Health Quality Partners. It's more far-reaching than the Indiana program in that it's statewide, the data is publicly reported, and it also brings in patient perspectives. MHQP isn't an HIE, though, so they don't have the clinical data and the resulting alerts/reminders capability that IHIE has brought to bear. The purchasers and insurers are also not nearly as engaged in the conversation in Massachusetts as they have been in Indiana.

The hardest part of achieving the health information exchange vision is lining up the economics. Insurers and purchasers (and patients) stand to benefit the most, but they have in most cases treated this as a problem that physicians need to solve themselves. IHIE and the Employers' Forum of Indiana together have cracked two nuts: they've gotten employers and insurers to invest in their supply chains by putting together a reimbursement package that allows everyone to realize value, and they've integrated claims data across payers, and clinical data across providers, and married the two in a way that no one else has yet accomplished.

So, if it's not already apparent, I'm impressed. Congratulations to Marc Overhage of IHIE and Dave Kelleher of the Employers' Forum! We're inspired by your vision, applaud your successes, and looking forward to learning more.

Maybe health care's not so different after all......

2007-03-01T06:00:00.000-05:00

The following is an outline of a recent Wall Street Journal article:

Costs are rising, and a large purchaser is putting pressure on its providers to invest in technology to reduce costs and make data collection easier. The providers complain that while they’re being forced to make the investment, the purchasers are going to reap the benefit. Further, providers argue that the new technology hasn’t simplified their offices, but on the contrary, has created more complicated workflows. Consumers are concerned that their privacy will be compromised by this system that makes their personal data electronic.

Sounds like another tired tale of the barriers to adoption of electronic health records, doesn't it? Well, it isn't.

The title of the article is “Wal-Mart’s Radio-Tracked Inventory Hits Static” (subscription required for the full article). It's not about health care at all, in fact, but the parallels with the ongoing discussion of barriers to adoption of EHRs seemed striking to me.

Some excerpts from the article are below (I learned from Paul Levy’s blog not to copy the entire article):

Wal-Mart Stores Inc.'s next leap forward in ultra-efficient distribution is showing signs of fizzling....
A pioneer in low-cost practices widely copied by competitors, Wal-Mart has pushed its suppliers to use exotic radio-activated tags to chop labor and inventory costs anew. But tests using the tags aren't showing any savings, and suppliers forced to invest in the relatively expensive technology are grumbling....
Wal-Mart is pushing the RFID technology on the idea it will increase efficiency and eventually save everyone money -- manufacturers as well as Wal-Mart. Yet as Wal-Mart searches for an answer to its rising costs, suppliers are saying RFID isn't it....
The current generation of RFID tags cost about 15 cents apiece while bar codes cost a fraction of a cent. Beyond the tags, suppliers have had to bear the cost of buying hardware -- readers, transponders, antennas -- and computer software to track and analyze the data.... On top of that, suppliers say that instead of saving labor, RFID tagging actually takes more: While bar codes are printed on cases at the factory, because most manufacturers have yet to adopt RFID, those tags have to be put on by hand at the warehouse....
More problems have come into play in recent years, including...consumer concerns that once the tags are on each item on a store's shelves -- from tubes of toothpaste to personal computers -- that they could be used to track individual buyers....

Wal-Mart wants to get the value of this technology, and they want to do it fast. I suspect that they will eventually just invest in their supply chain by splitting the cost of the RFID investments with the suppliers. Happens all the time in every industry: "Require" your suppliers to do it themselves, but if they don't do it fast enough, or well enough, or it threatens to put them out of business, roll up your sleeves and partner with them to make the joint investments that benefit everyone.

For some reason, most health insurers and purchasers (and even Wal-Mart) aren't applying this same logic to their health care delivery supply chains. That isn't as much a market failure as it is a failure of imagination.....

What is the federal approach to privacy and HIT?

2007-02-28T06:16:00.000-05:00

While I was away on vacation last week, HealthcareITNews published the following: "Federal privacy panel leader resigns, raps standards". It describes how privacy expert and advocate, Paul Feldman, has resigned his position as co-chair of the Confidentiality, Privacy, and Security Workgroup of the American Health Information Community (AHIC).

For those of you who don't know, AHIC is an advisory group -- chaired by HHS Secretary Mike Leavitt -- that is supposed to make recommendations to the federal government on how to accelerate HIT adoption. Since 9 out of its 18 members are federal or state government employees, I'm not sure how much of a "community" it really is, but that aside, it's chaired by the Secretary himself so it's clearly important. (Then again, since the government is responsible for 2/3 of all health care spending in the US, maybe the government is under-represented on this panel. And maybe we should more seriously consider a single-payer model since we're almost there anyway. But I digress.....)

It's hard to know from the outside what's really behind public resignations of this type, but the very fact that it's happened is not good. Feldman's letter of resignation cites the following:

We have determined we are unable to continue given that the workgroup has not made substantial progress towards the development of comprehensive privacy and security policies that must be at the core of a nationwide health information network (NHIN)...We support the development of an NHIN with strong and enforceable privacy and security rules in place and believe that the failure to achieve a privacy framework acts as a significant barrier to a robust and secure environment for e-health.

It would be one thing if this was an isolated incident. Unfortunately, it comes on the heels of a GAO report whose title says it all: "Health Information Technology: Early Efforts Initiated but Comprehensive Privacy Approach Needed for National Strategy". And last summer, the National Committee on Vital Health Statistics issued a report with similar findings.

While I wouldn't say this is much ado about nothing, I do think it's much ado about the wrong thing. Both Feldman and the GAO focus on the need for standards for a national network, citing President Bush's goal of having this in place by 2014.

As interesting as that discussion might be, I don't think an interoperable national network is going to happen by 2024, let alone 2014. Indeed, we don't even know what we should argue about because we don't know what such a network would look like, let alone when it would be created. For example, if the only justification for a national network is to aggregate deidentified data for population health measurement, there are a whole host of issues that we don't have to argue about. Worrying about too many of these details now is like fretting over relocation policies for coastal communities displaced by rising seas from global warming -- let's worry about it if the time comes.

Where we should focus attention is on where the action is: state- and local-networks. Many such networks will be up and running in the next few years (including three MAeHC networks before the end of this year). Yet, there is tremendous variation in state privacy policies at present. For many states, HIPAA is the binding constraint. For others, like Massachusetts, state privacy standards are much higher.

Anyone putting systems in place right now is basically making up a whole bunch of stuff as they go (with varying degrees of diligence). They're doing this because they have to. Federal and state laws aren't nearly clear or detailed or coherent enough, lessons learned in one state don't always translate to other states, and the urgency to get systems in place won't wait for the law to catch up.

Yet, the question remains, shouldn't a citizen of Louisiana or Ohio expect to have the same basic privacy protections as a citizen of New York or Massachusetts? That question won't be answered by setting policies for a national network that may never be built -- rather, it requires discussion of how to regulate state- and local-networks that are already being built, and in particular, on whether HIPAA and other federal privacy statutes and regulations provide an adequate floor of privacy protections for such networks.

The federally-sponsored Health Information Security and Privacy Collaborative (HISPC) is currently doing an inventory of state-level privacy policies, which is a necessary step in the right direction. (The MA-HISPC project is doing this work for Massachusetts.) The first results from this work are going to be presented in Washington on March 5-6. Whether this work is progressing nearly fast enough to address what's already happening on the ground remains to be seen.......

A sober discussion on the state of health care

2007-02-26T05:55:00.000-05:00

The March 2007 issue of Boston magazine ("Here's to your health") has a fascinating roundtable discussion on health care delivery in Massachusetts led by Jerome Groopman (local physician and writer for the New Yorker), and including:

Paul Levy (Beth Israel Deaconness Medical Center)
JudyAnn Bigby (MA Secretary of HHS)
Paula Griswold (MA Coalition for the Prevention of Medical Errors)
Charlie Baker (Harvard Pilgrim Healthcare)
Kathleen Davidson (formerly of Boston Medical Center)
Victoria McEvoy (MA General West Medical Group)
Teresa Schraeder (New England Journal of Medicine)
John Wong (Tufts-New England Medical Center)

(It looks like Boston delays on-line availability of its current issue, so if you want to read this in the near future you'll have to either buy it or speed-read it while you're in line at the grocery store).

Among a lot of interesting threads in the discussion was the following:

Quality measurement is difficult in part because physicians currently resist measurement, rightly (Bigby), wrongly (Levy), or innately (Baker);
Financial incentives that differentiate among physicians using quality measures are problematic because they are too crude (McEvoy), or they measure the wrong things (Groopman, Bigby);
One of the biggest problems in health care is that we don't devote enough resources to primary care (Groopman, McEvoy, Baker, Levy), but we're not going to get new money into the system, and reallocating funding from specialties to primary care is pretty much impossible unless Medicare does it first (Baker);

The biggest disconnect (I couldn't tell if it was a real difference of opinion) was on the issue of whether the system is in crisis because of too much change or too little change.

Making the case for too much change, Schraeder argues that the intrusion of "industry" into what has traditionally been been a "non-profit public service" has taken control away from physicians, which presumably has hurt the quality, safety, and efficiency of care. (Schraeder's assertion is only true if you think of independent physicians as being "non-profit" which, of course, they're not.) McEvoy argues that current quality measures imposed by insurers are distorting care away from higher quality, by forcing physicians to spend too much time on the wrong things (and collect data on the wrong things), and not enough time listening to and managing patients.

On the other hand, others argued that the problem is that we've had too little change. Groopman notes that physicians misdiagnose patients perhaps 20-25 percent of the time in the traditional model. Though the Boston article doesn't elaborate on this point, Groopman's article (What's the trouble?) in the January 29 issue of the New Yorker does. In it he describes how snap diagnoses that often turn out to be wrong are the result of traditional and long-standing physician training and decision-making approaches. Not, as McEvoy suggests, from being forced to see too many patients or from the need to fill out templates. Furthering the argument that we need more change, not less, Wong points to the now well-known results from "How good is the quality of healthcare in the United States?" that we only get good care 50 percent of the time.

At one point in the discussion, Charlie Baker noted that the problems of health care are "profoundly more difficult than most people realize." After reading the various viewpoints in this discussion, I think that Baker is a wild-eyed optimist....

Keeping my fingers crossed for Kaiser

2007-02-15T21:50:00.000-05:00

There was a depressing story in today's Los Angeles Times about Kaiser's $4 billion EHR implementation project. Apparently, technical problems with the project have dramatically increased costs (by about $1 billion) and are also threatening patient safety. Not suprisingly, morale seems to be dropping faster than George Bush's credibility (okay, maybe not that fast), and it's not clear that management has fully grasped the seriousness of the situation, as reflected in the following pair of quotes:

"This is the worst [technology] project I have seen in my 25 years in the business," said Andrew Brewer, a systems analyst for Kaiser who worked on the project for two years before voluntarily leaving the HMO last week.
"This is one of the largest and most ambitious efforts anywhere in the world to modernize our healthcare system," Kaiser Chief Executive George Halverson said. Considering that, he said, "it couldn't be going better."

As one who's also on the front lines of EHR implementations, I feel Kaiser's pain. Large-scale EHR implementation is extremely challenging, and the end-users are usually not nearly as flexible and forgiving as they should be given the immaturity of the technology.

Though they're a continent away, I'm worried about Kaiser's implementation, because a failure at Kaiser will reverberate throughout the healthcare industry. Why is that? It's because when you tick off the key success factors for effective EHR implementation, Kaiser seems to have it all.

As an HMO, they are both insurer and health care provider, which means that they stand to capture all of the benefits of their EHR. They can order their physicians to use the systems in ways that offer the greatest value, and they can fully capture all of the gains that accrue from better outcomes, higher safety, and cost efficiency. They've got world-class researchers who can use the EHR data to not only better measure their own progress, but to also generate tons of interesting and ground-breaking research. Finally, they've got an extremely capable staff, and they're using one of the best EHR products from one of the most highly regarded EHR companies in the industry (Epic).

In short, if Kaiser can't get this done, and also show that they're getting real value after it's up and running, there'll be a lot of disillusionment about the prospects of getting it done among the 80% of physicians who don't have an EHR today -- physicians who don't have anywhere near the sophistication, resources, and incentive that Kaiser has.

So, best of luck, Kaiser, in your efforts to turn this around. I'm rooting for you!

Is CCHIT becoming the Good Housekeeping Seal of Approval?

2007-02-14T06:42:00.000-05:00

The Certification Commission on Health IT recently announced that, in 9 short months, it has certified 55 EHRs. This means that 25% of the EHR market is now certified.

Maybe it's just me, but I wonder if this is an indication that we've set the bar too low. Don't get me wrong -- the CCHIT is driven by people who are way smarter than me on this stuff, and they're doing excellent work. And clearly, the market has suffered from a lack of standardization.

Yet, I had expected (perhaps naively) that CCHIT certification would help drive an industry shakeout. But as I see the numbers and scan the list of vendors who've made the grade, that's looking less likely (go here to judge for yourself). Rather, this is looking more and more like the type of ubiquitous certification - UL and Good Housekeeping come to mind -- that provides a broad level of comfort around very basic criteria that define minimum capability, but don't do much to separate the wheat from the chaff.

There is an argument that the UL-type of very basic standardization is market-expanding (and therefore, good). In markets where consumers have a hard time distinguishing among products on their own (due to product complexity, for example), strong brands will dominate unless other sources of trusted information or assurance are available. For example, I can't tell whether the wiring in my toaster is safe, but the UL label assures me that it's been built according to standards that minimize safety risks -- a valuable assurance that we've come to take for granted in the US and Europe. (I lived in India for awhile where, after a few good electric shocks, I learned to appreciate the safety that this type of certification provides.)

A recent Business Week article argues that CCHIT's approach to this type of market-expanding certification is changing the EHR industry:

EHRs require hardware, software, databases, networks, and, at their most advanced, picture archives of radiology and pathology images. Specialized health-care IT vendors such as Cerner, McKesson, Eclipsys, and Allscripts previously sought to establish widespread EHR networks, with limited success. The new federal government initiatives are reinvigorating the field.

Even as these companies renew their efforts to tap the market, they face increasing competition from deep-pocketed first-time entrants. These include the world's top three diagnostic imaging companies, Siemens , General Electric, and Philips Medical Systems, a unit of Philips Electronics.

It's a tempting argument -- but I think it's wrong. The BW article doesn't recognize that the ambulatory EHR market is different than the hospital market, in part because BW has the usual biz pub bias toward reporting on publicly-traded companies. (I especially like their claim that GE is new to the EHR field.)

Of course, there is value in ubiquitous, trusted certification. However, when it goes too far it undermines its own raison d'etre. Neighborhood Watch signs are a good example. These signs are everywhere, which suggests that they have no effect whatsoever. I'm guessing that once every neighborhood got "certified", it just brought everyone back to square one on crime, because the signs were no longer effective tools for distinguishing one neighborhood from another.

In my view the biggest problem in the EHR market isn't that there are too few entrants, but rather, it's that there are too many. There are over 200 EHR companies in the country today, most of them privately-held; pruning, not fertilizing, is what the market needs to grow. A certification process that gives everyone a seal of approval won't solve that problem.

Massachusetts among 16 states that don't require notification of data breaches

2007-02-10T10:04:00.000-05:00

A new survey published in the Journal of the American Health Information Management Association made me aware of something that hadn't caught my eye before. Massachusetts, my home state, is one of a minority of states that DOES NOT have a data security breach notification law. California, which enacted its law in 2003, has the strongest such law in the country and was the inspiration for many other states' laws. In 2006, 27 states had such laws; beginning on January 1, 2007, 7 more state laws went into effect. But not in Massachusetts.

I'm not sure how much such laws do -- in Massachusetts, for example, TJX recently reported a huge data spill despite the fact that we have no such law, and according to a recent survey by PricewaterouseCoopers, as many as 1 out 6 companies required to comply with the California law do not do so.

Ironically, the market may be taking care of this in ways that it hasn't been able to before. TJX stock plummeted after the Massachusetts Bankers Association directly linked cases of fraud to the data spilled by the company (click here for an interesting description of this).

There is much talk about the need for more transparency in the healthcare market. Most healthcare organizations aren't publicly traded, of course, but the idea is that patients will vote with their feet if they see meaningful differences in health care quality among providers. If data breaches start becoming more widely reported, data security could become another factor that patients use to decide where they get their care.

Up next on Fox News! Dr. John Halamka!

2007-01-31T22:09:00.000-05:00

It's nice to have a luminary as your front man. Dr. John Halamka -- a founder, advisor, board member and friend to MAeHC -- was on Fox News (live!) yesterday discussing our North Adams project (click here to check it out).

The interview focused on privacy concerns, but of course it wouldn't be Fox News without equal parts sensationalism and distortion:

"A person's private health records are about to become public in one local city, North Adams, Massachusetts."

Just to set the record straight, we are NOT making health records public in North Adams. Let me rephrase this in case there's any confusion: We are NOT making health records public in North Adams. Or in Brockton. Or in Newburyport. Or in any other community that MAeHC sponsors.

What we are doing is launching a health information exchange that will allow medical staff, with patient permission, to exchange health information for treatment purposes and for the improvement of care. This exchange will occur over a private, encrypted network that can only be accessed by authorized medical staff users.

Anyway, as expected, John handled the interview beautifully. Gave the issue the appropriate balance, described the security measures we're putting in place, stressed that patients will choose whether to participate, and finally, crisply explained why a patient might want to make that choice.

By the end he even had the interviewer admitting that it would be good to have health information available in this way. It was particularly impressive given that he was crammed in between stories on a student who wants to rent a girlfriend, and what's happening on American Idol.

Thank you, John, for so eloquently getting out the message on MAeHC's approach to patient privacy and health exchange. But next time, please try to get in before the girlfriend rental story....

North Adams in the news

2007-01-30T06:31:00.001-05:00

Today's Boston Globe has a front-page article on MAeHC's North Adams project. The trigger for the story is the launching, next month, of the first comprehensive, community-wide health information exchange in the country.

I think the reporter, Liz Kowalczyk, did an excellent job of capturing a pretty complicated story. The article accurately describes our approach to privacy and security, and the reach-out that we've done to get patient permission. There are some great interviews with patients as well.

I have only two quibbles with the article. First, it exaggerates the income loss that physicians participating in the program have experienced during the transition to their EHR systems. The article claims that physicians have reduced patient loads by "20% to 50%" during the first month. In fact, the vast majority of practices in the project are back at 100% within 2 weeks of going live. And for a capacity-constrained community like North Adams, this isn't a permanent income loss, because some of those patients get crammed into the schedule in weeks 3, 4, and 5 -- they have nowhere else to go, after all. I'm not saying that they don't have some permanent income loss, because they do -- it's just not as high as the article claims.

My second quibble is that the story doesn't focus enough on the key role played by the community to make this a success. Health information exchange isn't going to happen at a state-wide level before it happens within communities. And that requires higher EHR adoption and the creation of local, sustainable HIEs. The article focuses too much on the state-wide network, which isn't where the action is......yet. There's no case for a state-wide (or national) network until we have greater adoption at the local level, as was made clear at a recent national conference sponsored by the federal government.

Nationally, 30 percent of EHR implementations end in failure -- the MAeHC communities won't have anywhere near that level. And that's not just dumb luck. High adoption requires more than just money -- it takes a community.

In each of our communities, MAeHC has created a community steering committee to oversee and monitor the program, community user groups (physician- and staff-level), centralized implementation and IT support, consumer councils to get patient input, and group training sessions -- all of which are helping to get a high level of adoption. It's not the technology that's the real innovation in North Adams, or Brockton, or Newburyport -- it's the greater sense of community, among physicians and patients alike. You don't get that with random acts of technology -- you get it by engaging a community in a conversation about how to use technology to improve their lives.

In the end, these are tiny quibbles -- I think the article was terrific, and we greatly appreciate the Globe's interest in the story. WBZ radio's interest was a little less welcome in their unexpected 6 am call on my home number this morning. Fortunately, I was already awake -- we appreciate their interest as well.......

Breaking the stalemate -- a malpractice insurer steps up

2007-01-29T23:59:00.000-05:00

MAeHC today announced our participation in a joint initiative to provide malpractice premium credits to physicians utilizing EHRs. The Connecticut Medical Insurance Company -- in a program developed jointly with the Massachusetts Medical Society, Physicians Insurance Association of Massachusetts (an MMS subsidiary), and MAeHC -- will offer credits ranging from 5-20% to Massachusetts physicians who use EHRs.

Malpractice insurers are among the many stakeholders in healthcare delivery who stand to benefit a great deal from widespread, effective use of EHRs and HIEs. Yet, up until now, they've stood on the sidelines, in part because they've been trying to figure out whether EHRs really will reduce risk, but also because they've been economic "free riders" -- happy to capture the benefits of other peoples' investments.

Malpractice insurers stand to be among the biggest winners in the move to digital health records. Some of the greatest sources of liability risk for physicians -- messy documentation, inconsistent collection of family histories, poor tracking of patients -- are addressable by EHRs and HIEs, as long as they're implemented correctly and properly used.

Of course, there could be some increases in risk as we move to modern electronic systems. Breaches of confidentiality, and increased errors while physicians and medical staff become familiar with the new systems come immediately to mind. However, we can work on reducing these types of risks; for example, the CMIC program will require that physicians demonstrate long-term commitment to the EHR and to effective risk management. Implementing EHRs and HIEs within a program framework, such as MAeHC's, dramatically increases the odds of effective implementations and significant net risk reduction. Of course, risk reduction means fewer medical errors, so patients will be the biggest beneficiaries at the end of the day.

Some physicians may not leap at this program because of an ideosyncracy in the Massachusetts malpractice insurance market. CMIC only offers "claims-made" payment terms, which are the standard in most of the country, but not in Massachusetts, one of the very few states where the "occurence" model prevails. I'm not an insurance expert but my understanding of this is that most practicing physicians in Massachusetts would benefit from moving to the "claims-made" model even without this new program -- the EHR credit is just an added bonus. I hope that physician confusion over this issue doesn't prevent them from taking advantage of a program that will offer them real value.

One of the most frustrating aspects of health IT is that the benefits seem so obvious, but they're hard to capture because the economic incentives in our ridiculously fragmented healthcare delivery system are misaligned, diffuse, and difficult to measure. I applaud CMIC's willingness to cut through this morass and put a real program on the table. We believe this is the first such program in the country. Hopefully others will follow......

MHQP leads the way!

2007-01-25T06:42:00.000-05:00

Karen Davis, President of the Commonwealth Fund, has released a report on Models for Achieving the Best Health System in the World. She highlights seven key strategies for improving the US scorecard on high performance health, and gives concrete examples of each.

This is generally a great read, but there's one item in particular that I want to call out. Here's number 5:

5. Increase Transparency and Reward Quality and Efficiency
Increase Transparency Case in Point: Massachusetts Health Quality Partners Increase Transparency
Public reporting of information on the performance of health plans and providers can spur improvements in quality and efficiency, by helping consumers make more informed decisions and by stimulating providers and plans to be more accountable for their results. It can also form the basis for new payment systems that reward providers for excellence and efficiency. Commonwealth Fund surveys indicate that most patients do not have access to the cost and quality information that would enable them to make informed choices, but they very much want access to such information.
Yet, a number of notable initiatives provide purchasers, consumers, and providers themselves with information about quality. With Commonwealth Fund and Robert Wood Johnson Foundation support, Massachusetts Health Quality Partners (MHQP) has publicly released clinical quality data as well as patients' ratings of their experiences with doctors' offices throughout the state. In addition, data on the clinical performance of primary care physicians in Massachusetts are now publicly available at the medical group level.

MHQP is a member of the MAeHC Board of Directors and key partners in our work going forward. Congratulations to Barbra Rabson and the entire MHQP team!

Lessons from little girls and school-teachers

2007-01-24T05:43:00.000-05:00

I saw a pair of interesting stories about the EHR-vendor Misys Healthcare last week.

First was a story in NHINWatch about a $10 million grant program called the Center for Community Health Leadership. Launched 6 months ago by Misys, it just awarded its first grant ($3 million) to the community of New Haven, CT.

I think it's fantastic that a vendor has put money into an initiative like this, and particularly in a community-based approach, which is the only way to derive real and lasting value. A single-vendor approach poses some obvious adoption, technology, and business risks for a community, but where there's no other money available, this is a trade-off that's probably well worth the risk.

There's hopefully a coherent business strategy behind this for Misys as well. It reminds me of Apple's education program, which for 30 years has offered computers to schools at substantial discount. I don't know what the ROI on this program has been for Apple, but it's certainly built a tremendous amount of good will by searing their brand into millions of young, impressionable minds.

The Apple strategy also borrows an important lesson from, of all places, the Girl Scouts. Bury your product in a mission that's beyond reproach, like building girls' characters or educating our kids, and the little girls and teachers will become your salespeople. And they'll do it for free.

I can imagine a coherent, long-term strategy for Misys that involves coopting communities of physicians and medical students into becoming Misys salespeople by giving EHRs to communities and to medical schools. It's probably no coincidence that their first grant went to New Haven, home of one of the country's premier medical schools.

This type of corporate strategy won't work for all companies, however, because it requires a long-term view and a willingness to place high value on the softer aspects of ROI, like good will and diffuse, harder-to-measure returns.

Which brings me to the second article about Misys. The News & Observer reports that the CEO of Misys was fired last week for poor financial results. Put in the context of a yearly operating profit of $35 million, a $10 million grant program probably won't survive such pressure. This points out the risk to communities of going with a single vendor: Will New Haven see all of the $3 million? Will Misys be around to support them 5 years from now?

It also highlights the risk to EHR executives as well. I wonder if any EHR vendors have the intestinal fortitude, the deep pockets, and the patience to take the Apple approach.

Blackberry Cold Turkey -- a response

2007-01-23T06:13:00.000-05:00

My Blackberry broke a few weeks ago (or, more likely, suffered from Verizon's planned obsolescence program to force me to upgrade). I wish I could report that I felt liberated and could go cold turkey, as Paul Levy famously did on his December 18 blog entry. Turns out, I'm embarassed to report, that I can't do it -- I need my Blackberry.

I didn't realize it before but the greatest value my Blackberry provides isn't timely response, it's efficiency. Since I don't spend much time at my desk, I found that without my Blackberry I couldn't get through my daily pile of emails without dramatically readjusting my lifestyle. Not that those emails were all urgent and important -- most aren't, but triage itself takes time. And Blackberrys are perfect for triage.

The result was that email triage started to encroach on the things that I normally did during my scarce computer sit-down times -- like actual work, and writing this blog. And the only way to increase computer sit-down time was to crowd out time with my family and friends.

So, I've returned to my Blackberry-enhanced world -- a happy pawn in Verizon's grand plan.....

Identity theft and digital health records

2007-01-16T14:50:00.000-05:00

This weeks’s Business Week has an article on medical identity theft (Diagnosis: Identity Theft). The article outlines three types of fraud that are apparently on the rise: 1) people who steal an identity to get treatment for themselves; 2) providers who steal an identity to submit fake claims; and 3) providers who misuse information they are entitled to have, in order to pad legitimate claims with fake claims.

Like a lot of articles in the area of patient privacy, I think this one touches on all of the right points but sensationalizes the issue with some egregious anecdotes and a few hyperbolic comments from “privacy advocates”. I’m also not sure how new some of this is. Identity theft certainly isn’t new, nor is fraud in medical claims. The Sopranos even had an episode a couple of years ago that was identical to one of the “new” types of fraud described in the article – organized crime “rings” using an ancillary healthcare provider organization to submit bogus claims. (Though according to HBO’s Mobspeak, Tony Soprano found the “taste” of medical fraud to be much less lucrative than racketeering or bookmaking.)

I’m not going to even try to answer whether our data is “safer” in digital health records, because this is unknowable, and anyone claiming otherwise isn’t being intellectually honest. The BW article gives short shrift to the ways in which electronic records will increase protection of patient information.

There are two different issues raised by the article: 1) how to prevent and detect medical fraud; and 2) how to prevent electronic health records from being used for identify theft (which may or may not be used for medical fraud).

It strikes me that EHRs can be helpful in preventing and detecting fraud in care delivery. The most obvious way is by giving a greater ability for “authentication” than is allowed by paper systems, in particular by incorporating photos in the medical record. Digital cameras are incredibly cheap and even the most simple EHRs and practice management systems allow photos to be attached to records. I’ve been a member of three athletic clubs over the last 2 years (including my local YMCA), all of which use photos for authentication every time I visit. It would hardly be an invasion of privacy for health care providers to do the same.

Electronic systems are also helpful in detecting fraud by providing the ability to identify “spikes” in activity that can then be followed up for validity (the article notes this). My credit card company does this now. A health insurer that does this could even use it as a positive opportunity to improve care, customer service, and relationship management – legitimate “spikes” in activity are the result of significant medical events, for which follow-up should be both welcome and appropriate. Honda Motor Corporation called me recently to ask how my local dealer performed during our last service visit. I wish Aetna would call me to ask how my doctor or hospital performed, not only when my activity has “spiked”, but after each visit I make (boy, would they get an earful).

Regarding identity theft, I think that EHRs could seriously reduce one of our greatest sources of risk – medical staff who abuse their privileged access to information. Good EHRs have role-based access, so that staff are able to access only that type of information appropriate to their jobs. Audit logs also allow tracking of access to records and monitoring of user activity. Paper records don’t allow such protections. And while such protections have been available in many hospitals for some time now, making them widely available in physician offices will put literally millions of medical records under a better security umbrella than they’re under today.

Of course, EHRs increase other types of risk by adding more to the amount of electronic data already swirling around the ether, so in that sense they do create greater incremental opportunities for some types of identify theft. This is true for any type of electronic data, however, and I'm not sure how much greater risk it adds on top of what's already out there. I was at Marshall’s department store the other day and they asked for my phone number as part of the payment process for a pair of socks (I didn't give my number to them but noticed that a lot of other customers gave theirs). I’ve also noticed recently that when I return items to Home Depot without a receipt the cashier swipes my credit card and does a search of everything I’ve ever purchased from them on my credit card before giving me a cash refund. I'm sure that these companies have privacy statements detailing what they do with this information -- I haven't bothered to read these statements, nor do I expect to any time soon.

The "digitization" of medical information is just another aspect of a general trend. We don't have to even discuss whether we should stop it, because I don't think we can -- the best protection for patients is to insist that EHRs get implemented in a way that accentuates their positive attributes and explicitly manages any additional risks that they introduce.

Thanks Ron

2007-01-12T17:09:00.000-05:00

Today's Globe had a story about the departure of Ron Hollander from the Massachusetts Hospital Association. I don't know anything about the issues at MHA. I do know that as a member of the Massachusetts eHealth Collaborative Board of Directors and Executive Committee, Ron has been a tremendous booster and we have benefited greatly from his wisdom and enthusiasm. We're going to miss his presence, and we wish him all the best.

Thank you Ron.

"Transparency", or, the emperor has no clothes....

2007-01-12T01:01:00.000-05:00

Government Health IT has an article this week on Medicare's new incentive program for quality reporting ("Quality movement gets boost from Congress"). It describes legislation signed into law in December that will give a 1.5% bonus to Medicare providers who agree to give quality data to the government. This isn't quite P4P, because physicians get the bonus simply for submitting the data, regardless of what the data might show.

This is Medicare's third foray into this type of data collection. The first was DOQ-IT, which provided free EHR implementation consultations to physicians who agreed to give quality data to Medicare. Second, was the Physician Voluntary Reporting System.

Neither of these earlier efforts have made any notable headway on the data collection front. DOQ-IT has spent years trying to create the data collection infrastructure with little, if any, real success (though DOQ-IT's EHR implementation support program has done well and is quite good). And as for the Physician Voluntary Reporting System, well, the name says it all.

This new 1.5% bonus is barely a step above a voluntary system. Since Medicare accounts for about 16% of the insurance market nationally (95% for over-65s), the return to the "average" doc would get diluted down from 1.5% to 0.2%. I have yet to meet a physician who hasn't already done this math in his or her head and decided that it's just not worth it.

All of this has a corrosive effect on the health IT movement. It undercuts those of us who have been arguing that you can't have meaningful P4P without health IT, and you won't get health IT without P4P -- after all, if health IT and P4P really are valuable, wouldn't the biggest payer in the country invest real money in them?

The federal government has put shockingly little money into health IT to date (Blue Cross Blue Shield of Massachusetts has invested more in EHRs than the federal government has). We won't see real progress in health IT at the national level until Medicare puts real incentives and real money into play, because they have a lot of funding and, more important, when they do it others will fall in line.

The latest healthcare catch-phrase from the federal government is "transparency". Unfortunately, the logic behind Medicare's approach to P4P and health IT couldn't be more opaque.....

All for one and one for all?

2007-01-11T09:19:00.000-05:00

This week's Modern Healthcare has an interesting article speculating on whether single-vendor RHIOs, which are rare today, could become a dominant model in the future. They cite as examples Inland Northwest Health Services from Washington state (which is based on the Meditech platform), and EHR of Rhode Island, a physician consortium working with eClinicalWorks.

I think the point of the article is an interesting one, but the examples they cite essentially answer the question of whether this will be a dominant model -- I don't think it will. Both INHS and EHRRI are very ideosyncratic models. INHS has integrated nicely on the inpatient side, but have very little penetration in the ambulatory side, which is always the hardest. I'm not even sure that EHRRI really qualifies as a RHIO -- they're doing excellent work, and have a very good model, but they're really an EHR purchasing/service consortium, not a health exchange.

MAeHC does have a single-vendor RHIO (of sorts) in North Adams, where all physicians are using the same EHR vendor who is also creating the HIE solution (eClinicalWorks). It's not a true single vendor solution because the hospital is on Meditech. We are certainly seeing lots of benefits in terms of ease of interoperability and richer exchange, and managing a single vendor is much easier than the alternative (this is not a trivial issue -- it's a big deal). However, North Adams is also a very ideosyncratic community that may not be widely applicable.

The key here is what gets the highest adoption. Consumer choice theory and empirical research suggest that greater choice will yield higher demand, but too much choice is paralyzing and confusing and may undercut demand. (I can confirm the latter -- I always dread having to buy more toothpaste because of the entire row of options that my local CVS puts in front of me.) This is why MAeHC offered partipating physicians choice but from a set of pre-qualified vendors. Given that "analysis paralysis" is a big barrier to adoption for many practices, this seems to be a good compromise formula for getting high adoption.

There are few, if any, EHRs that are optimal for all types of practices, so going with a single vendor will shut out some participants in most cases. It's possible that a hospital can drive physicians to a single solution based on their hospital platform, but my experience with the ambulatory products offered by the hospital vendors is that they sacrifice a little on the features side but in return for high interoperability with the hospital. Given the trend toward hospitalists and looser affiliation of ambulatory docs with their local hospital, I suspect that fewer and fewer physicians will be willing to make this trade in the future.

Correlation vs causation

2007-01-09T14:12:00.000-05:00

Today's Boston Globe commits one of the classic blunders of inferential statistics -- confusing correlation and causation. The Globe had the following headline:

Beverage reseach tied to corporate dollars

Conflict of interest seen when industry finances studies

The article describes a study from Childrens' Hospital that finds that nutrition research sponsored by the beverage industry is more likely to yield results that favor the industry than are studies that are not funded by the industry (64% versus 46%). The article concludes that industry money biases nutrition research.

Well, it may very well be true that industry money biases nutrition research, and I have no trouble believing that. Unfortunately, this data doesn't prove it, and indeed, could just as easily prove the opposite. Instead of industry money biasing research, it's plausible that causation really works the other way around -- nutrition research may bias the allocation of industry money.

How would this work? Instead of paying off researchers, it may be that dollars get allocated in a more benign way: corporate sponsors scan the research horizon and place their dollars behind scientists and research approaches that are already favorable to industry positions, and thus, are more likely to continue to generate findings that support industry positions.

Industry may not be paying off researchers so much as placing bets on which research is going to go their way. And the problem is, the data would look the same either way -- funding would be correlated with results under either scenario.

This same problem of trying to separate causation from correlation also exists in analyses of corporate contributions to Members of Congress. While the presumption is that oil industry money influences Congressional voting on environmental laws, for example, it may also be the case that oil industry money really just rewards Members who would vote against environmental interests anyway.

I think that researchers would be wise to somehow separate themselves from this money, because it hurts their credibility even if it doesn't affect their research, it's becoming increasingly transparent to the public, and the NIH extramural research model relies on their integrity.

I would also like to see Members of Congress do the same. Unfortunately, credibility may not matter quite so much for them.......

MassHealth and beyond.....

2007-01-08T16:17:00.000-05:00

For those who haven't seen it, Health Care for All's blog has comments from Dr. Joe Heyman on MassHealth (the Massachusetts Medicaid program). Joe is a great reporter of life through the eyes of a small-practice physician, and his comments offer an insightful commentary not just on MassHealth but also on the ten jillion ways that our healthcare system is broken. They also point out that EHRs and HIEs and all of the rest of the RHIO program are not, and cannot be, a panacea for the deeper problems underlying our system.

As MAeHC rolls out EHRs to physician practices (more than 200 physicians live so far!), we are finding that EHRs and first-generation HIEs can address only some of the pain points that are part of an ambulatory physician's everyday existence. There's no doubt in my mind that wider use of modern IT systems will do a lot to improve health care delivery, but perhaps the greater benefit will be in revealing the huge obstacles that technology alone can't solve.

Management tips for HIE development

2007-01-07T23:42:00.000-05:00

The lead story of the business section of today's Times is about Dr. Herb Pardes, head of New York-Presbyterian Health System. Though it doesn't mention it in the article, he is also a co-founder and co-leader of the Markle Foundation's Connecting for Health Steering Group (full disclosure -- I'm a member of the Steering Group).

The article is an interesting look at the dynamics of the big academic hospital industry, the New York hospital scene, and Herb's management approach. A few things about this approach strike me as noteworthy and particularly applicable to the HIE world:

Re-orient thinking from provider-centric to patient-centric
Be attentive to organization cultures and leader personalities
Manage with mix of gut instinct and strong business skills
Bring national perspective to local decision-making

No wonder these principles apply to HIEs. New York-Presbyterian comprises a stunning 52 hospitals, SNFs (skilled nursing facilities), and specialty centers across 5 campuses -- much bigger than any HIE in the country today.

John Halamka reviews operating systems

2007-01-06T07:54:00.000-05:00

I was at a meeting a few months ago with John Halamka, CIO of Beth Israel Deaconness Medical Center. As the meeting was getting organized, I was startled to see him settling in behind a MacBook. This surprised me because I'd come to feel a sort of comraderie and affirmation from being in meetings with John where we were both multi-tasking on our quiet, confident ThinkPads.

After the meeting, in the parking lot, I confronted John on his betrayal (thus revealing all of my own tech insecurities), and he explained that he was doing a review of different operating systems for CIO Magazine. The full review was published in the December issue of CIO, and an update was published this week.

I've come to rely on John's clear and simple explanations of highly technical information for the work that we do at MAeHC. His insights in the CIO review are a terrific read for anyone who wants a clear explanation of the state of the OS market from a consumer's perspective.

Coming soon, John's going to have his DNA sequenced and posted on the web. I'm going to be the first to download it -- I can't wait to get my hands on the recipe for doing everything that he does......

Confidential data -- an eye for an eye?

2006-12-31T08:18:00.000-05:00

Sorry for the blog silence -- I've been on holiday.

While I was away, I saw this interesting poll in USA Today (12/28/06). Over 100 security professionals were asked "How should companies that expose confidential data be penalized?".

Here are the results:

48% -- Make the CEO's private information public
26% -- Criminal fines
24% -- Civil fines
2% -- No penalty necessary

Half (!) of the respondents supported an "eye-for-an-eye" type of justice. This has interesting implications in the medical world ("Doctor, you released my colonscopy results so we're now going to publish yours on the web...").

Finally, remember this was a poll of security professionals -- just imagine what a poll of patients might find.......

Money alone won't solve the EHR problem

2006-12-26T07:03:00.000-05:00

The amednews recently published an article detailing the saga of a practice that had a failed EHR implementation. The article notes that something like 1 out of 3 EHR implementations ends up in failure, which the article defines as a de-install. If you include the EHR implementations that are permanently stuck -- meaning that the practice implements basic scheduling and billing, but nothing else -- that could mean that 1 out of every 2 EHR implementations are effectively failures.

I don't want to get into whether the EHR system or vendor itself contributed to the failure described in the article; both of the vendors mentioned in the article are supported by MAeHC (the practice left NextGen and is now buying eClinicalWorks) . To me, the most important point raised in the article is that lack of money is not the only issue hampering greater EHR penetration -- it's not even clear that it's the most important obstacle.

Factors that contributed to the failure cited in the article are:

Insufficient upfront attention to workflow or process changes required to maximize the EHR's potential
Inadequate project management experience and resoures at the practice-level
Inexperience with contracts -- writing, negotiating, and managing

This confirms for me that EHR investments are probably not worth it (particularly for small practices) unless they're done under the umbrella of an effectively-managed, community-based program (whether driven by a hospital, IPA, PHO, or RHIO/HIE).

Community-based because there's scale in project management, vendor selection, and contract management, and because patients and physicians will get much more value from EHRs that are coordinated with their medical trading partners (other physicians, hospitals, diagnostic centers in their communities).

Effectively-managed because too many of these programs give scant attention to the project and change management piece of the implementation -- they're usually driven by whiz-bang technology plans (with the requisite clouds and lightning bolts) laid out by IT specialists, and assume that templates and worksheets handed to the practice by EHR vendors and others will take care of the rest. In most cases, they can't and they won't.

I wouldn't recommend that the government or anyone else dump money into EHR programs unless they're managed under a community-focused program umbrella, laying out clear goals and timelines, coordinated interoperability with key trading partners, funding keyed to execution and adoption milestones, and implementation approaches that force behavior change, and maximize and monitor success.

Programs that fund EHRs on a "retail" model -- meaning that they just make money available to physician practices through grants or tax breaks or other practice-focused incentives -- are destined for high rates of failure and could very well cause more harm than good.

All health care is local

2006-12-23T23:10:00.000-05:00

The Archdiocese of Boston is considering selling the Caritas Christi hospital network, according to a story in the Globe a couple of weeks ago. I hope they don't sell it to a national healthcare chain, because I think that would be a setback to the ongoing effort to create a sustainable regional connectivity infrastructure in the Commonwealth.

What's the connection between the two? The business case for HIEs relies on vertical synergies -- hospitals, physicians, and insurers who share the same patients and collaborate locally to make the handoffs of care coordination as smooth as possible. The value driver here is economies of scope -- getting value by better coordination across the different layers of healthcare services.

This runs at odds with the horizontal synergies that drive national healthcare chains -- hospitals across the country, for example, who share the same management and suppliers, but NOT the same patients. These chains focus on economies of scale -- getting value by better production coordination in a single layer of healthcare service (such as hospitals or insurers). Think Starbucks. Think Walmart.

Vertical strategies are inherently patient-centric, whereas horizontal strategies are provider- centric (or insurer-centric) . Problem is, the quality of care in the US already suffers from being too provider-centric. Horizontal strategies make sense in many industries -- in healthcare, they will make a very bad situation even worse.

In practical terms, a national chain entity will be much less likely to participate in a local HIE, because their IT strategy will be driven by the goals of their national parent, not their local partners. And while their national goals aren't necessarily contrary to local goals, they usually are. And even when corporate and local goals are aligned, it's usually coincidental, it takes a lot of effort to convince corporate management that they're aligned, and it's nearly impossible to coordinate project plans even when the goals are aligned.

Massachusetts is a national leader in regional collaboration in health IT. The biggest reason for this is that the leading players in health care in the Commonwealth are non-profit, Massachusetts-based, Massachusetts-focused companies. This is true on the supply side, where the biggest players are Partners, Caritas Christi, CareGroup, Baystate, Fallon, Berkshire, and Hallmark Health, among others. It's also true on the (commercial) demand side, which is dominated by Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim, Tufts, and Fallon.

Of course it's not all roses and sunshine here, and we still have a long way to go, but the strength of these local players -- who have the incentives and discretion to make local decisions -- creates a fertile (though still fragile) environment for HIEs. We need more local leadership, not less, and I'm thus nervous that the HIE movement will take a step backward if the second biggest hospital system in the state becomes an outpost of a national behemoth.

An analyst quoted in the Globe article stated that Caritas would benefit from a national chain merger because it would "help them coordinate the installation of new information systems...".

The question is, coordinate with whom?

Full disclosure: Caritas Christi and many of the other healthcare entities mentioned in this blog are members of my Board of Directors, and one of the the Caritas Christi hospitals is a participant in our pilot projects. I have not discussed or consulted with any of these entities regarding the issues that I've written about here.

We don't know what we don't know

2006-12-16T05:37:00.000-05:00

Two friends recently sent me emails alerting me to security breaches in the health care industry. Since MAeHC is launching health information exchanges in 3 communities beginning in early 2007, we're very interested in such news.

One breach was a theft of back-up tapes containing medical claims of 130,000 Aetna subscribers (my health insurer!). The other breach came from the theft of a laptop with medical information of 38,000 Kaiser Permanente members in Denver.

I found out about these within the same week (they actually occurred about 1 month apart), and it got me wondering about the incidence of such events generally, and whether it might be getting worse as more data becomes electronic.

There's been a steady drumbeat of news on such breaches since the infamous ChoicePoint blunder in 2005, and the US recently crossed the dubious milestone of 100 million security breach victims since the counting began with Choicepoint.

The best (and most accessible) data I'm aware of is maintained by the Privacy Rights Clearinghouse, which tracks breaches on its website. My quick-and-dirty assessment of the data on the website suggests the following:

The frequency of all reported breaches is increasing. 413 reported breaches in the last 2 years -- 106 in 2005 and 307 in 2006.

Health care providers are a very small part of the problem. Sources of breaches breaks down as follows -- non-clinical commercial enterprises (37%), federal/state/local government (29%), universities (25%), hospitals and ambulatory providers (9%).

Breaches involving medical data may be increasing. 16% (69) of these breaches involved health data, but this share almost doubled over time, from 11% of breaches in 2005 to 19% in 2006.

Most medical breaches are committed by hospitals and the government. Hospitals accounted for most medical breaches (39%), followed by government (20%), health insurers (13%), physician offices (10%), and universities and ancillary services (9% each).

Big breaches involve institutions that have a lot of data. The biggest breaches by far in terms of number individuals affected have been by banks and by the government, which one would expect since they are the institutions that have a lot of data.

Most reported breaches do not seem to involve theft of data for the data itself, but rather, they involve theft or improper destruction of files, tapes, and computers that happen to have private data in them. Not to dismiss the importance of breaches, but the actual damages resulting from these breaches are likely much much smaller than the gross numbers suggest.

There are all sorts of cautions with making too much of this data: is this better reporting or higher frequency of actual breaches? what other types of breaches never get reported? is it higher incidence as well as higher frequency? is the reporting consistent across sectors and over time? are the differences statistically significant (both across sectors and over time)?

Assuming the data are somewhat representative of reality, they seem to highlight some important points for EHRs and health information exchange.

First, the world is full of data repositories. Financial institutions, the government, universities, hospitals, health insurers -- all hold huge stores of our personal information already. The discussion of whether to have a repository in an HIE needs to be had in that context.

Second, what's not reported is at least as important as what is. MAeHC's experience with health care providers is that bigger organizations like insurers and hospitals have a very small frequency of big data spills, which get reported, and small organizations such as physician offices have a high frequency of tiny data spills, which never get reported. Also, it's pretty well known that one of the biggest sources of breaches are insiders, who are often found out but are not publicly reported (for example, this week's Information Week article, the ongoing problem of medical staff trying to peep at VIP's medical records, and the now well-known story of the Diva of Disgruntled who posted confidential information of Kaiser Permanente patients on-line).

Third, breaches seem to be committed by organizations of all sizes and levels of sophistication. Physician offices -- as they become more interconnected with each other and with existing repositories of data -- could add many more chinks to the health data security armor. This isn't because they're irresponsible, it's because they don't have the staff or experience to even know how to address it.

For example, how many physician offices have already gone to Staples, bought a $30 Linksys box, and set up a wireless network that they don't realize is akin to leaving their medical charts in the parking lot in front of their office? How many are remotely accessing their computers using retail products and services that don't have industry-standard authentication and encryption? They haven't really had to worry about all of this up until now, because they're protected by the high friction of exchanging paper records -- the very same friction, by the way, that prevents huge improvements in quality, safety, and cost of care.

We need to get rid of this friction, of course, because the benefits are so huge, but it has to be done under some type of policy and management umbrella that doesn't undermine security. HIEs can play a very beneficial role in this regard, because they can provide the policies, processes, staffing, experience, and technology to bring physicians "onto the grid" in a way that protects everyone's interests.

Happy Holidays from AHRQ

2006-12-12T06:12:00.000-05:00

The Agency for Health Research and Quality will award almost $26 million in grants to support various approaches to improving quality and safety of care through health IT. The Ambulatory Safety and Quality Program is looking at 4 angles on how health IT can be used to improve quality:

Clinicians using IT systems ($9 million for 20-40 grants)
Patient-centered care ($6 million for 15-20 grants)
Enabling Quality Measurement ($7 million for 12-24 grants)
Proactive Risk Assessment ($4 million for 20 grants)

Crank through the numbers and you get an average grant size of between $300K-$400K for 70-100 grants. The applications are due Feb 15.

These grants can be tricky because they can be money-losing if you're not careful -- you typically need to have considerable infrastructure in place already just to break-even. That said, AHRQ is the only real source of federal funds for many health IT initiatives across the country. The woefully under-funded Office of the National Coordinator typically gets only $100 million or so per year, none of which goes to local iniatives.

So even though the economics are questionable at best for many if not most potential applicants, they don't have anywhere else to go. With 165 health initiatives across the country scrambling for funding (according to the last count by eHI), competition for these AHRQ grants is expected to be especially fierce this round. If you have a family member involved in health IT and/or health quality research (and the Boston area has more of these folks than any other part of the country), you'll now understand why they might seem a little distracted over the holidays.

All in a day's work

2006-12-11T05:51:00.000-05:00

I recently visited two of the practices that we’ve outfitted with electronic health records.

The first was a surgery practice whose head physician “greeted” me with a limp handshake and an icy stare and said: “So, you’re the CEO of the MA eHealth Collaborative? Well, that’s not anything to be very proud of, is it?” And before I could say a word, he turned and walked away. His office manager was mortified.

MAeHC has invested about $120,000 in this practice.

At the next practice, I walked in and standing there behind the front desk was a physician in a white coat, talking with the receptionist. “Are you Micky?” he asked. Still smarting from my first visit, I nodded, but hesitantly. He whipped around the front desk, arms stretched as wide as his grin, and hugged me. Yes, hugged me. “Thank you,” he said.

We’ve invested about $30,000 in this practice. Go figure………

A PHR from my health insurer? No, thanks.

2006-12-09T07:19:00.000-05:00

The buzz continues on personal health records. I got a call yesterday from a reporter asking for my views on PHRs. The Markle Foundation's Connecting for Health initiative just released a new report on PHRs (full disclosure: I'm on their Steering Committee). Paul Levy has recently written about Aetna's PHR on his blog.

I saw Aetna's October press release launching their PHR. I'm an Aetna subscriber, and unfortunately, the press release is all I've seen of their PHR. Actually, that's not really true -- they also have a video tour of their PHR on their website. What they don't seem to have is a place for me to actually create a PHR.

Until I can create one I won't know for sure, but I'm kind of hard-pressed to see what Aetna (or any health insurer) could offer in a PHR that would interest me anyway. I'm already able to access all of my claims on their website through their Aetna Navigator tool -- a great tool which has been there for years. I don't use it very often, but I like knowing it's there.

Through claims, Aetna knows a lot about what they've paid people to do to me -- give me a physical, a colonoscopy, some meds, a cholestrol check. What they don't know is the results of these activities. Was my colonoscopy normal? Do I have high cholestrol? That information is contained in my physician's record, which happens to be in a paper chart in Wellesley MA (I can't access it, but I know where it is!). If I had an Aetna PHR, it wouldn't have much more than my claims information, unless I typed it in........which means it wouldn't have much more than my claims information.

I pay thousands of dollars per year in premiums to Aetna. I'm just one customer, but I wish that my health insurer would devote much more money, PR, and imagination to getting an EHR into the hands of my doctor, and stop wasting my premium dollars on a PHR that I can't create and probably wouldn't use even if I could.......

You can't get blood (or data) out of a stone

2006-12-07T10:42:00.000-05:00

More details are now out on the Wal-Mart/Intel health records project. Turns out that it's a personal health records project called Dossia sponsored by the Omnimedix Institute. The project has gotten a lot of attention in the last couple of days. From what I can tell, the effort is, at best, a harmless sideshow. I just hope that it doesn't suck the wind from the sails of the many health IT efforts across the country today.

The reason I think this is a sideshow is that it is based on a faulty presumption, namely, that we can spur EHR penetration by giving PHRs to droves of individual patients. Those patients will want data to fill those PHRs, so the theory goes, and they will, in turn, pressure their physicians to purchase EHRs. Think of millions of patients, with their health-version of Quicken, pushing the "Download" button to get data from pharmacies, hospitals, labs, and physician offices.

The main problem with this approach is that it assumes that there's enough health data out there to make it worth my time as a patient to push the "Download" button. I don't think there is. Furthermore, I think it's a stretch to think that this approach will give enough push to the demand-side to affect HIT penetration.

First, on the availability of data. You have to get data into computers before you can get it out of them. Only 9% of physicians have a good EHR according to the CDC. Hospital use is higher but still not great. According to the American Hospital Association, 37% of hospitals have moderate to high IT implementation, and only 30% have implemented such functions as "access to medical records" and "access to medical history". Perhaps even more telling, a whopping 65% of hospitals say that fewer than 50% of their physicians use the IT that they've implemented.

So, the vast majority of data is still on paper. And even for the data that is electronic, no current systems that I know of have the ability to respond to an outside "query" (like a "Download" request from a PHR). With no physician data and no hospital data readily accessible, Dossia could prove to be very thin record indeed for quite awhile. There are no healthcare analogues to financial behemoths like Fidelity and Vanguard who can deliver a lot of data to a lot of people with a push of a button.

The structure of health care delivery will also make it difficult for even a Wal-Mart to have the leverage to drive higher IT adoption among physicians in this way. Walmart may have 1.3 million employees nationally, but most of them are distributed store-by-store in different health care markets across the country. With about 4,000 retail units in the US, each store employees about 325 employees. So they're spread pretty thin geographically.

On the supply-side, health care delivery is probably the most fragmented sector of our company -- it's very local, among both physicians and hospitals. With fragmentation on the demand- and supply-side of the equation, it's hard to see how a national player like Wal-Mart can exert influence on any given locality. For example, if I'm a doctor or hospital in a community with a Wal-Mart, I'm not going to have that many Wal-Mart employees as patients. So how much influence can their individual "Download" requests really have on my decision to purchase an EHR? In Bentonville, Arkansas, they can probably exert a lot of influence. I'm not sure they can in any other local markets. Sure, there are other employers involved, but it's hard to imagine that their employees' collective demand for PHR data will trickle through to the supply-side.

It's clear that Wal-Mart and many many other purchasers are absolutely fed up with spiralling costs and the seeming inability of the health care sector to modernize itself, and I think their frustration is absolutely justified. I just wish they'd channel their energy in more productive, collaborative ways.......

Privacy Request: Denied.

2006-12-06T06:00:00.000-05:00

Yesterday's Guardian had a startling article on the British National Health Service's approach to patient privacy. The NHS is spending 24 billion pounds (ie, really really serious money) on wiring health care nationwide. They're providing EHRs to all physicians, linking them all up over a national network, and creating a national repository of patient-identified clinical data.

Back to the article. Patients have requested to opt out of the national network and repository, and the Government has rejected their requests!

Polls show that 53% of patients are opposed to having their data on the system, and as a result, 52% of general practitioners are opposed to providing their patient's data to the system without their patients' specific consent. Despite this overwhelming display of distrust, according to the article:

[T]he Department of Health said nobody could have genuine grounds for claiming "substantial and unwarranted distress" as a result of having their intimate medical details included on a national computer system, known as the Spine. For that reason, "it will not agree to their request to stop the process of adding their information to the new NHS database".

Yikes!! On top of the increasingly shrill reports of the technical problems the NHS project is suffering, it's hard to imagine that this project is going to get back on track anytime soon.

Back here in the colonies, we at MAeHC are also setting up data exchanges and repositories in our three pilot communities, but we're going with an opt-in approach, meaning that we won't exchange any patient's data without his/her specific, written consent.

This approach certainly takes longer and is definitely more logistically challenging than an opt-out (or the NHS approach of no-choice), but it appropriately puts the burden on us to get the trust of patients and physicians before we start letting their data fly. The very early returns on our experiment are that patients are overwhelmingly opting in -- still early, still small sample, but encouraging nonetheless. In the long run, I think this will build a deeper foundation for the whole enterprise going forward. When problems arise -- and they will arise -- patients will be more forgiving than if we hadn't asked their permission in the first place.....

Privacy rules

2006-12-05T06:40:00.000-05:00

Sunday's NYT article touched on so many issues it was hard to address them at one sitting. The article asserts that concerns about privacy and security are the major obstacle blocking passage of pending bills on health IT. I wish that was true because it would mean that privacy concerns had become a higher priority than they have been up until now, and that there was agreement on all of other vexing issues in this area. Alas, I don’t think either is true.

Privacy and security are clearly important considerations on lawmakers’ minds, but equally if not more important barriers are:

lack of budget
blurry policy options, stemming from the complexity of health care delivery and little to no understanding at the federal level of the complexity of these issues
disagreement (mostly ideological) on the role of government generally, and the divvying up of power between federal- and state-levels specifically
lack of awareness among the public (or more specifically, voters) of the urgency of taking steps to improve the quality and efficiency of our care

The following commentary from iHealthBeat is indicative:

"Prospects look pretty good" for the 110th Congress to pass health IT legislation in 2007, Michael Zamore, a policy adviser for Rep. Patrick Kennedy (D-R.I.), said in an interview for an iHealthBeat special audio report. According to Zamore, health IT is a "great candidate" for bipartisan efforts because "it's teed up, it's kind of ripe, it's been kicked around, it's had a false start or two," and the "ideas have been percolating and vetted.
"David Merritt, project director at the Center for Health Transformation, said the opportunity still exists to pass a bipartisan conference bill during the 109th Congress' lame-duck session codifying the Office of the National Coordinator for Health IT and allowing hospitals anti-kickback exemptions to provide physicians with health IT equipment.
"Let's not throw away all the progress we've made up to this point simply because of the change in power," Merritt said. However, Zamore and Merritt agree that identifying funding for health IT initiatives with current budget deficits will be a challenge (Rebillot, iHealthBeat, 11/15).

The Democrats on the Hill (especially Ed Markey) do place a greater emphasis on privacy concerns than do the Republicans (outgoing Connecticut Republican Congresswoman Nancy Johnson's bill was silent on the issue, for example), so maybe this will rise in importance in the new Congress. In this environment though, I think cash (or lack thereof) will still be king......

Do the right thing

2006-12-04T07:41:00.000-05:00

Yesterday’s New York Times article on privacy and security of electronic health records, coupled with an article in the Wall Street Journal last week on WalMart’s foray into electronic health records, points to what could be an ominous twist in the movement to expand the use of EHRs and health information exchange in health care delivery. Large businesses -- burdened by spiraling costs of health cost premiums -- are increasingly investing in technologies to gather health information on their employees to try to more directly manage (and, they hope, stanch) the growth of these costs.

I completely sympathize with the plight of these businesses -- MAeHC is a small business, after all. I also applaud their recognition of the key role that EHRs and clinical IT can play in improving health care delivery. Yet, their whole approach raises serious concerns for patient privacy. By creating proprietary systems to gather and control the health data of their employees, these companies are, perhaps unwittingly, stumbling into the most important and fragile issue in the health IT debate.

There is an irony in all of this. Some existing privacy laws, which were designed for paper-based records, don't make sense in an electronic world, and indeed, are in some cases presenting obstacles to better management of electronic data in ways that no one could have anticipated at the time. Many of those laws were designed to prevent employers from getting access to sensitive information that could affect a person's employment status. Employers need to be hyper-sensitive to those concerns. If they appear to be violating the spirit (even if not the letter) of those laws, it will sow seeds of patient distrust and perhaps draconian laws that will undermine not only their own efforts but also the many community-based efforts around the country that are working hard to do this the right way, namely, using IT to empower physicians and patients to improve the cost-effectiveness of care.

While there is a crying need to bring modern IT systems to health care delivery, this effort won’t be economically or morally sustainable if it’s not based on trust. Patients and physicians have to trust the systems being created. Otherwise, patients won’t agree to having their data in these systems, and physicians won’t agree to using them because they’re concerned about their patients’ privacy and about the legal liability associated with breaches of confidentiality. But neither patients nor physicians will trust these systems if they aren’t set up with privacy as a fundamental design consideration, rather than a bolt-on afterthought.

The reason that employer- and insurer-based schemes are problematic is that they undermine what I think of as a core principle of health information exchange – the need to create the healthcare equivalent of a Chinese Wall between those who collect and aggregate the data on behalf of providers to facilitate direct care delivery, and non-providers who would use the data for any purpose other than direct treatment of patients. Just because electronic data is more easily available for treatment purposes doesn’t mean that we permit it to be more easily available for other purposes. Data collection and aggregation may happen in a new way (ie, using EHRs and secure networks), but access has to happen the old way (ie, explicitly negotiated among the owners and key stakeholders). This is the principle behind such leading community-based efforts as the MA-SHARE, RIQI, IHIE, HealthBridge, THINC, and MAeHC.

So how do you do that? Create, operate, and govern these systems by building on the trust engendered in today’s physician-patient relationship. Patients have a well-placed trust in their physicians. Physicians will only use the systems if they’re valuable from a user design perspective and they promote their patients’ welfare. Rather than setting these systems up as proprietary company systems, they need to be set up more like public utilities. Put hospitals, physicians, and patients in joint control of these systems so that they are designed, managed, and governed by those who are going to be using the systems. These key stakeholders will get behind investments in “wiring” the care delivery system to improve quality, safety, and efficiency; what they won’t get behind is investments whose primary aim is surveillance.

I suggest that employers should get out of the business of trying to electronically capture their employees’ detailed health information, and into the business of getting health care providers to embrace information technology that improves the quality, safety, and efficiency of care. It's fair for them to want better data to measure performance, but they can get that without demanding access to detailed patient information. They can create urgency for better system performance using basic supply chain management principles that they're very familiar with: Invest in their healthcare delivery supply chain by setting basic technology and interoperability requirements for their suppliers (ie, providers), and facilitate their providers’ ability to meet these standards.

So, the program would run as follows. First, require physicians to use EHRs, help physicians pay for the upfront costs of getting outfitted with solid EHR systems, and train them and their staff to use the systems effectively. Second, require them to participate in data exchange networks that facilitate the effective coordination of care and the efficient transmission of clinical information. Third, put in place a new funding model that redirects reimbursement toward paying physicians for improving peoples’ health and away from paying them for the volume of care delivered and/or complexities that arise with their patients due to poor physician performance.

All of this is, of course, easier said than done, and no one knows that better than those of us slogging away in the trenches. But if Walmart and Pitney Bowes and IBM and UPS spent more time working with existing community-based efforts, and less time building their own proprietary data warehouses, it would happen faster than they might think, and it would be lasting and sustainable. There are many community-based efforts out there trying to do just this, and they could benefit enormously from the resources (financial, technical, and managerial), encouragement, and old-fashioned kick-in-the-pants that only the business community can provide.

I think the message employers should send to their employees is: “We don’t want your personal health data, but it's in everyone's interest to better monitor the overall performance of our insurer/provider network because the quality, safety, and cost of health care affects all of us.” That would reinforce the message that they’re not trying to undermine the sanctity of the doctor-patient relationship, but rather, trying to improve the performance of the overall system to better serve physicians, patients, and purchasers alike.

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

2006-11-30T18:33:00.000-05:00

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……

Promising data on clinical performance measurement

2006-11-28T06:26:00.000-05:00

A lot of us hold the faith that pay-for-performance will be key to getting wider adoption of health IT systems in physician offices. This faith rests on the assumption that we can get doctors to use EHRs to record clinical data in ways that are meaningful, easy to gather, and comparable across physicians and over time. An article in the most recent issue of the Archives of Internal Medicine highlights the opportunities and challenges here and I think will be just the beginning of a much richer and more realistic discussion of these issues.

The authors of "Assessing the Validity of National Quality Measures for Coronary Artery Disease Using an Electronic Health Record" looked at quality measurement at a large internal medicine practice using a "commercial EHR" (they don't say which EHR they're using). They found that the actual performance of the physicians along several measures was better than their estimated performance, which was calculated from data automatically extracted from their EHRs. They conclude that:

"Profiling the quality of outpatient CAD care using data from an EHR has significant limitations. Changes in how data are routinely recorded in an EHR are needed to improve the accuracy of this type of quality measurement."

My reading of their study is that the authors raise legitimate concerns about the difficulty of using such data, but their conclusion overstates their case. They correctly point out that the real issues are not about technology, per se, but about process -- physicians don't routinely enter data in a way that makes it easy to do accurate calculations. For example, if you don't enter blood pressure readings as numeric data in the blood pressure fields of the EHR, you won't get "credit" for having taken the blood pressure.

More generally, they point to four sources of error:

Wrong diagnosis (ie, person diagnosed as having CAD when they didn't);
Data not entered as numeric or structured data (ie, they may have treated a person with aspirin, for example, but they buried that fact in a text note rather than entering it in the medication list)
Exclusion criteria are not standardized (ie, there's no standard way to record the fact that a patient may not qualify for the treatment in question, which shouldn't count against the physician); and
Measures don't account for patient non-adherence (ie, the patient doesn't comply with the physician's treatment decision, for example, doesn't take a lipid-lowering drug even though the physician recommended it and prescribed it).

Frankly, the only one of these problems that I find new and thus troubling is the third one regarding exclusion criteria, because the others are well known and they will become less severe over time as people get used to them. Entering consistent exclusion criteria is very complicated, however, because they are so measure-, condition- and patient-specific, there are no standards out there that I'm aware of, and the EHRs I'm familiar with don't have a good way to record this information systematically anyway. So, we need to figure out a way to address this issue.

That said, it's not clear how big these problems are in the scheme of things, however. It turns out that even with these problems, the automated measures performed pretty well -- the physicians were at 82% success on the measure they did worst on, which improved to 87% once corrections were made for the issues noted above. On the measure they did best on their scores went from 98% success to 99% after adjustment. While we'd obviously like these measures to be as accurate as possible -- particularly when quality and compensation are on the line -- this level of mis-measurement is surprisingly low given that we're really at the beginning of the beginning of clinical performance measurement.

Perhaps a bigger issue that the study doesn't address is what to do about so-called "ceiling effects." How are we going to tell the difference between physicians who are already high-performing? Is there really a difference between physicians performing at 98% vs 99%? And how do we tell the difference between physicians who are both performing at 100%? This suggests that we'll need increasingly granular measures to show variation in performance, if that's what we want to show. Or, do we just care that physicians get to an acceptably high level?

No one has any answers to this yet, of course, but the data from this study suggest that we may have to figure it out long before at least I thought we would. And doing this without having physicians feel that the goalposts are always being moved could be a much bigger issue than the technical arguments about measures that dominate the conversation today.