Posts Tagged ‘EHR’

doctor-computerProf. David Blumenthal, the new head of ONC, makes some disturbing comments regarding the Stimulus Bill, HIT and HITECH Act  in his article in the New England Journal of Medicine (NEJM). The article is not completely off-base as he does a very good job of describing the basics of the HITECH Act, its intentions and some of the very real challenges that the feds face in actually executing on the language of the Act.  But there are a couple of areas where Blumenthal’s interpretation of the Act raises concerns.

The first pertains to HITECH Act language regarding extension of HIPAA compliance to Google and Microsoft where he states:

It extends the privacy and security regulations of the Health Insurance Portability and Accountability Act to health information vendors not previously covered by the law, including businesses such as Google and Microsoft, when they partner with health care providers to create personal health records for patients.

At this time, neither Google or Microsoft provide the PHR to a hospital who then provides it to their customers.  Rather, the current model that both Google and Microsoft are using is one that supports portability of the consumer’s health record allowing the consumer to invoke an export of their records from the hospital to one of these Personal Health Systems (PHS), of course provided the hospital establishes a link to a PHS.  Our interpretation is that in this scenario, HIPAA does not extend to Google or Microsoft, as the consumer drives the transaction of data flow.  Hopefully, others in HHS will convince Blumenthal of this as well as otherwise, such HIPAA extensions may thwart portability and subsequently consumer engagement and ultimately control of their records.

The second Blumenthal comment that caught us off-guard pertained to the term “certified EHR” where he states:

ONCHIT currently contracts with a private organization, the Certification Commission for Health Information Technology, to certify EHRs as having the basic capabilities the federal government believes they need. But many certified EHRs are neither user-friendly nor designed to meet HITECH’s ambitious goal of improving quality and efficiency in the health care system. Tightening the certification process is a critical early challenge for ONCHIT.

While we certainly agree with Blumenthal that defining the critical terms of “certified EHR” and “meaningful use” is paramount and must be done quickly, yet judiciously, his views on certified EHR, as defined above are downright frightening for two reasons.

First, he condones the work of CCHIT as certifying the minimum capabilities for EHR.   Minimum capabilities?  If anything, those minimum capabilities are already restrictive in defining use of specific standards and models that do not provide the flexibility for true innovation.

What is even worse though, is that Blumenthal appears to want to extend certification requirements to “user-friendly” and defining how “quality and efficiency” will be embedded within an EHR.

User-friendly? There is simply no way you can certify such – end of story.  Let the market define what is user-friendly by what a doctor or hospital chooses to purchase.

Quality? Maybe, just maybe you can ask for the simplest of quality metrics to be recorded within the EHR, but highly doubt that is something you want to certify.  Would it not be better to simply verify quality actions supported as part of meaningful use reimbursement?

Efficiency? That is certainly not something you can certify and falls in the realm of implementation (process mapping/workflow) and training.  You can’t certify that!

Suggesting that we tighten the certification process is heading in the wrong direction.  Instead, we need to actually relax the certification process to encourage innovation in the HIT market allowing developers to create solutions that will truly provide value to their users while concurrently meeting the broader objectives of delivering better care and better outcomes.  Creating light certification criteria and focusing more on what outcomes we wish to see occur as a result of broad HIT adoption is where Blumenthal and his staff need to focus their energies.  To do otherwise will lead to a stifling of innovation, stalled HIT adoption among physicians and ultimately a poor investment of the tax payers’ dollars, which we can ill-afford.

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Final Stimulus Bill Released

senateLate last night (10:45pm EST to be exact) Congress released the negotiated final version of the Stimulus Bill (The American Recovery and Reinvestment Act) that is on its way to Obama’s desk for signature, which is expected on Monday.

We’ve downloaded the massive bill, which combined (it’s currently broken into two parts, Division A and Division B) comes in at about a 20MB PDF.  Once we’ve had an opportunity to extract the HITECH Act portion of the Bill, we’ll be providing a more detailed analysis on where that $19B is headed and how.  Not expecting much change as the original Senate and House versions were quite similar with largest divergence appearing to be with the Privacy provisions of the Act.

Update: Finally got the files downloaded.  To make it easier for you that are only interested in HIT, need only download Conference Report Division A – HITECH language begins on page 286.

And if that is not enough, you can always read the Opinion piece from the WSJ’s Feb 11th edition (Health-Tech Monopoly) which, oddly enough, shares some of our opinions on the HITECH Act.

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congressWe are heading down the wrong path.

Despite the rounds of applause from virtually all sectors of the healthcare establishment (AHA, HIMSS, AllScripts’ customers, etc.) the HITECH Act, as currently drafted in the Stimulus Bill (both House and Senate versions of HITECH are quite similar), will ossify healthcare IT (HIT) completely stagnating innovation in HIT.  It is also questionable as to how much the HITECH Act will actually contribute to the ulitmate objective; simply delivering better, more cost effective care.

That is not to say that the use of HIT can not improve outcomes, that it cannot improve health, far from it.  What we argue is that this legislation is extremely problematic for it has created an incentive structure that is not conducive to innovation.

Where did the legislature make a wrong turn?

As we mentioned in our previous post on the passage of HR 1, HITECH legislation is providing incentives for physicians to be reimbursed for the adoption of “certified EHRs”.  Certification, by its very nature, is a time consuming (some might say time wasting) exercise. Certification to standards is even worse (ever been a part of a Standards making body – they move at a glacial pace).  Stating that physicians will only be reimbursed for adopting certified EMRs basically puts the death nail into any innovative ideas that break from the cumbersome certification process or don’t adhere to some archaic standard like CCD.

Let us not also forget that the very word “certified” strikes fear into the heart of any Venture Capitalist (VC).  Honestly, who in their right mind would ever invest in a start-up that need to go through some arduous certification process to enter a market, a certification process established by players in a given market?  No, certification is good at creating moats and castle walls and not greenfields that foster opportunities for innovation.

A second key point and maybe even more important one is that if the purpose of HITECH is to deliver better, more effective healthcare than the incentives are completely misaligned.  Just because we reimburse a physician for purchasing a certified EHR, doesn’t automatically equate to their using the solution to deliver effective care. We are providing incentives for actions, not behaviors.

And what’s the alternative?

To truly foster an open market, open innovation and subsequently open adoption of HIT, it is necessary to create a legislative framework of incentives that focus on what behaviors we wish to see adopted by physicians and not which technologies we wish to see them use.

For example, if we were to develop an incentive program that simply asks physicians to do a quick review of a patient’s current medication list prior to writing a prescription for a new medication and include checking for possible interactions, (prof that they checked might be easily monitored through the major eRx clearing house SureScripts) we would see a likely decrease in adverse drug events (ADE).  This could easily be tied to the current eRx push by CMS.

In this example, we are not incenting the physician to use a certain technology, but adopt a certain behavior (check before prescribing).  Imagine the impact if we saw but a 15% drop in ADEs as a result in such change in behavior. Now that’s savings, that’s better healthcare and it is a greenfield of opportunity.  Similar behavioral incentives can be created in numerous other areas.

It is clear that the legislature took the easy path as it is far simpler (and politically more expedient) to create incentives for the adoption of a technology, certified EHRs, rather than the more strenuous task of creating incentives to encourage behavioral change.  Unfortunately, if the current legislation ends up with Obama’s signature, we will be pouring wet concrete into a market with woefully low HIT adoption.  When that concrete sets, it will be nearly impossible to chip-out and we will be left with an edifice of good intentions gone horribly wrong.

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A Blog I frequently visit is that of John Halamka, the CIO at Boston based Beth Israel Deaconess Hospital.  Halamka is also one of those people that has seemingly unlimited amounts of energy, is on all sorts of committees and arguably, one of the sharper minds out there with a deep understanding of healthcare IT.

Halamka put up a very good post yesterday on what he foresees the ideal Electronic Health Record  (EHR) would look like.   Really a soup to nuts review going from clinical notes to images to labs to data  management and everything in between.  Well worth the read.

The only issue I had with the post was in the definition of EHR.  I go under the assumption that EHR=EMR + PHR.  So, while Halamka talks about a future EHR, looking more closely, he seems to be really talking about a clinician focused EMR system for there is no discussion of consumer input, or folding in of PHR information, (just pushing information out into a PHR).  This is a serious flaw, unless of course he replaces the EHR acronym with EMR in his post.

The future will have a consumer that is far more engaged in managing their health and probably a bit more demanding on the doctor.  The engaged consumer will want a greater say in the EHR, via their PHR.  Not accounting for such in the “Ideal EHR” results in an EHR that is paternal and will ultimately fail.

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Here I am at the World Health Care Congress with what appears to be all the major movers and shakers in the healthcare sector, Chairmans, CEOs, Presidents, EVPs – some really big names, some very powerful players. Now I will never claim to be as brilliant as these people, after all, I’m writing this sitting in the audience and not up on the stage giving the presentation. But with all this cranium here at the conference, why do I hear so much dis-information?

For example, the session on PHRs and Consumer Engagement had panelists who could not accurately define the offerings of Dossia, Google, and Microsoft’s HealthVault and in some respects, had it completely wrong. These are the biggest players in this space, or at least will be soon, easily eclipsing WebMD, RevolutionHealth or any other PHR-like entity in the market today. Do they do this on purpose, or do they really just not know? Very disturbing when one thinks that these panelists were chosen due to their purported wealth of knowledge on the subject.

Another one is that red herring that I have ranted on in the past and is certainly a pet peeve, Privacy.  This issue still gets thrown out there by vested interests (and there are plenty of them here) who have little desire to release the records they control to some third party (or only reluctantly release them) that will stand between them and their relationship with the consumer.  Therefore, they throw out the Privacy Bogeyman to scare the consumer and it is really getting quite old.  I have yet to hear of one privacy breach at a PHR vendor, but weekly I hear of one breach after another at both payers and providers. So who is more secure?
The whining that physicians can not go digital because of costs. As I related in my notes from the first day, this should be viewed as an investment in the business.  Granted, there will not be an immediate ROI, but it will come in time, that I am sure of and ultimately, it will allow providers to participate in the future as more and more consumers look to engage their providers over the Web and desiring greater access and control over their records.  Again, a lot of dis-information on the topic that needs to stop.

Well, enough of my own whining.

There really are some great sessions here today including the keynote this morning from Safeway’s Chairman and CEO, Steve Burd. Safeway is doing some interesting things regarding promotion of health and wellness within their family of employees their families and even their customers.

Also intriguing story at EMC where to gain credibility for their PHR initiative, they brought in various medical research institutions to promote their ongoing clinical trials within the PHR and solicit employee participation.  Involving these research institutionsgave the PHR instant credibility and  was very instrumental in EMC’s internal push for PHR adoption. After about four years, adoption of the PHR at EMC stands at 50% of all EMC employees worldwide with adoption still growing.

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Civic Duty?

If you get bored of walking the aisles of HIMSS and can’t bear to hear another vendor pitch, well you could always wander over to a session where people will gather to discuss and reach consensus on what are arguably the 5 most used acronyms in the industry. You can contribute to the discussion as part of your civic duty as there are some in the federal government that believe lack of clarity on these terms is holding back the adoption of healthcare IT (HIT).

But really, does anyone in the right mind truly believe this is the problem with HIT adoption? There are a myriad of issues that are stunting the adoption of HIT that range from poor software to poor implementation of good software, to lack of training and the list goes on and on. Consensus on the definitions of five acronyms (EHR, EMR, HIE, PHR, RHIO) will solve NOTHING as it pertains to actual adoption of IT in the healthcare sector!

Maybe its just sour grapes on my part for I did not win the contract. One of the Beltway Bandits did and for a princely sum of $500,000. Hey HHS, I would have done it for you for a tenth of that amount and you would have the report by now. Better yet, maybe HHS can get its money back and instead go out and buy a box-car load of Diffusion of Innovations by Everett Rogers, the undisputed Bible of how technology is adopted and diffused. Distribute the book to all HHS employees involve in HIT promotion efforts, study it closely and apply the concepts. Guarantee the results will be more productive than this definition effort which you are currently funding. (Note: Moore basically plagiarized Rogers’ work for his own Crossing the Chasm. Diffusion of Innovations is more academic and far more thorough than Chasing the Chasm).

But I digress.

This is one glaring example and quite possibly the most egregious of what is wrong with government efforts to date to drive adoption of HIT (actually gave it a “Golden Fleece Award” when I first heard about it). I have nothing against the many dedicated federal employees that are really trying to do the right thing, in fact, I have enormous respect for them for they really are taking on a herculean task. I just wish some of them would think more and do less.

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Last week the Wall Street Journal online edition released the findings of a November 2007 survey of 2000+ on consumer views of electronic records and privacy.

Some of the key findings:

  • 23% rely on their doctors to maintain their personal electronic medical record  and 3% maintain their own personal health record (PHR).
  • 91% believe they have a right to the electronic medical records maintained by their physician.
  • 77% want ability to schedule appointments by email/electronically.
  • 75% want to communicate to their doctor by email (but the majority are unwilling to pay for such email consultations.
  • Consumers are about 20% more confident that their doctor has an accurate medical history of them if the doctor/care provider is using an electronic medical record keeping system.
  • And probably one of the most significant findings is that consumers realize that electronic records do increase the risk of breach of privacy (61%), they do believe by a 3 to 1 margin that allowing care givers and researchers to use electronic records can improve overall healthcare.

Apparently, at least based on these results, the consumer may not be as concerned about privacy has some may claim.  Yes, privacy is important, but consumers are willing to take some risks, provided thee rewards are better healthcare delivery, ease of interactions with healthcare providers and the potential for better treatments in the future.

You’ll find the WSJ story is here.

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