Ready for prime-time

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

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

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

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......

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

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

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

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"

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

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.....