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.

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.

MA Health Policy Forum

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.

Looking at EHR adoption growth from the supply-side

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.

Minnesota mandates EHRs by 2015

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......

IT Writer, Familiarize Thyself

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

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

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

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

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

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

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

Clarifying a recent Information Week article

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

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

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

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

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

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

Pennsylvania maps out an EHR strategy

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: $$$.

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

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.

Are PHRs the chicken or the egg?

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.

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

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.....

Keeping my fingers crossed for Kaiser

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?

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.

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......

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.

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.

Money alone won't solve the EHR problem

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.