Up next on Fox News! Dr. John Halamka!

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

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

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!

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

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

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

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

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....

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?

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

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.....

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

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

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......