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.

My kingdom for an inter-operable vendor!

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

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

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

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

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

RHIOs still a tough row to hoe

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

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

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

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

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....