Meeting halfway

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

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

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

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

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

P4P may finally be growing up

I've heard anecdotally that health plans are retrenching on so-called pay-for-performance (P4P) reiumbursement programs because they're not getting the return that they hoped to get. There seems to be some evidence of this in the data as well -- projections from 18 months ago suggested gushing growth (see The state of P4P programs), but the trend more recently seems to be on refinement rather than expansion (see It's everywhere but measuring effectiveness of P4P is challenging). There seems to be a trend out there away from pure P4P and toward mixed reimbursement models that blend in capitation with performance-based payment, exemplified by two new approaches.

First is the so-called "medical home" idea, which has been articulated and promoted by a variety of medical specialty socieities (for example, see Medical home could rescusitate primary care and Joint Principles of a Patient-Centered Medical Home Released by Organizations Representing More Than 300,000 Physicians). While a lot of the focus of the medical professionals has been on bolstering primary care, the business community has recently jumped on the bandwagon because of the financial benefits of the approach. Bridges to Excellence estimates that the medical home approach yields savings of $250-$300 per patient per year by reducing unnecessary specialist and emergency room visits and preventing acute medical episodes that result from poor preventative care (see Group Offers Doctors Bonuses for Better Care). Since the average primary care physician cares for roughly 2000 patients, this can add up to real money real fast.

The second approach is in the creation of alternative payment models such as that announced by Blue Cross Blue Shield of Massachusetts earlier this year (see A New and Different Way to Pay for Care). This approach has had some early bumps, but it's still early (see Blue Cross faces uphill climb over flat-sum payments).

The best description I've seen of the benefits of moving back toward some type of capitation model is in Benjamin Brewer's column in yesterday's Wall Street Journal (Finding a Medical Home May Be Just What the Doctor Ordered). Dr. Brewer gives an excellent ground-level view of what it means to pay physicians to manage patients instead of acute episodes, and why such an approach might really offer benefits to patients and physicians alike.

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

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

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

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

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

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

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.

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.

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.

We don't know what we don't know

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

All in a day's work

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

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

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

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

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

What would Say say?

The French economist Jean Baptiste Say is famous among economists for Say's Law, which essentially states that supply creates its own demand. When I was taught Say's law in school, it was positioned from the start as a discredited theory that was important to a fringe element, but otherwise largely dismissed by John Maynard Keynes and others in the mainstream of neoclassical economists. Today's article in the New York Times about gastroenterologists made me think that Say's Law, while maybe not generally applicable, might be alive and well in certain sectors of the economy. Health care delivery, for example.

The article describes how gastroenterologists might soon face a crisis as technological advances in imaging technology may make virtual colonoscopies preferable over actual colonscopies. Since colonoscopies are performed by gastroenterologists and virtual colonscopies by radiologists, this could represent a signficant shift of patient traffic away from gastroenterologists.

In a well-functioning market, this trend would, over time, foster decreases in the supply of gastroenterologists. The Times article suggests that this won't be the case, however, because gastroenterologists will find something else to do to make up for the lost income, such as performing other types of procedures. Thus, while the number of colonscopies performed may go down, they will be replaced by other types of gastroenterology procedures. As one physician noted in the article, "We have a lot of organs. The esophagus, the stomach, the small bowel, the liver, the pancreas. I think we've got a lot to do."

This phenomenon is not unique to gastroenterologists. Dr. Jack Wennberg and his colleagues at Dartmouth have made a cottage industry of showing how regional variations in medical practice are directly linked to the relative supply of specialists who perform the practice. Certain regions have more C-sections not because they have more high-risk pregnancies, but rather, because there are more ob/gyn's in the area. The ghost of Say lives on.

Of course, Say's Law doesn't apply everywhere. Purveyors of health IT have implicitly applied Say's Law in the past, but with disasterous consequences. About 20 years ago the CHINs (community health information networks) adopted this Kevin Costner view of economics ("if you build it, they will come") and as a result none of them are still standing. A number of the "RHIOs" out there today may suffer the same fate. We've found in our MAeHC pilot projects that the demand for HIE products and services is actually multi-dimensional and complex. While results delivery and basic electronic data exchange are minimum requirements, applications like electronic referrals tracking, quality data aggregation, and forms routing are also important to physicians. HIEs that launch without deep consideration of what physicians are actually demanding do so at their own peril.