Intelligent Healthcare Information Integration 4/17/09

Two Thirds of the NHIN by 2010 (or, Not Your Daddy’s CHIN)

The Nationwide Health Information Network. By 2014. That’s the timeframe we’ve all heard about since GWB, Michael Leavitt, David Brailer, et al, began the ball rolling from a governmental initiative perspective about five years ago. So, half the time has passed and we’re halfway there, right?

OK, it seems Sisyphus had an easier time reaching the mountaintop with his boulder than we’re having with this NHIN rock. It has been more than 25 years since some pretty smart people saw the advantages of using electronic brains to assist with the collection, manipulation, and dissemination of healthcare information. Yes, we have seen the pioneers and the early adopters join in the uphill shove, but we are currently so far away from any sort of national healthcare data sharing that it is almost comical. (Have you ever tried to aggregate old records for a patient who has seen three doctors, two ERs, an urgent care, and a couple of health departments in the past few years?)

So, on to Step 3 of the “Official Grunt-in-the-Trenches Complete U.S. Healthcare System Overhaul and National Health Information Network in Five Easy Steps Disruptive Innovation Package.”

Is it really possible to achieve 70% of the NHIN by 2010? (Well, maybe 2011, but NHIN and 2010 have a better rhythm!)

Yes. Period.

I know, I know. Many with far bigger brains than my little peanut tell us the interoperability difficulties, the interfaces required, the rules, and the regulations are almost insurmountable with our current systems. And, maybe … maybe they are correct. With “our current systems” maybe there is no hope. But, have you ever noticed how many times throughout history that the prominent intelligentsia got it wrong? Have you noticed how many times those who discuss why things can’t be achieved are eclipsed in the historical record by those who say, “Why not?”

Well, here goes my next shot at “Why not?” and – hey, it could happen – a historical footnote. (For the first shot, see Step 2.)

We have been focused upon building these big center systems – the RHIOs, HIEs, and their ilk – and then figuring out how to connect all these silos, these disparate giant Sequoias of information. Well, first, did I miss something? Don’t we have connectivity? Doesn’t this massive information exchange system already exist as a little thing called the Internet? (Internets, according to some.) So, if you and I can exchange information – as we are right now, regardless of where you are – how is it that we need these massive health information exchange projects to send data across town? Is health information somehow different? Does the exchange of health data involve some unique form of electrons or a specialized set of zeroes and ones compared to lay data? Doesn’t seem to be a problem for first cousin Finance.

Why not…consider a different approach to both linking healthcare professionals and motivating participation in the Grand Healthcare Digitization Project, participation of both providers and the general population? Does the fact that we have already invested oodles of money in current projects preclude the thought trail which veers sharply away from the current, overly beaten track?

Why not … convince health systems and providers to understand that patient health data is not “owned” by anyone except the patient, that sharing that info is not counterproductive to corporate profits but rather contributive, once all are duly linked?

Why not … start building a system less filled with silos, less federated, and begin endorsing truly integrative designs, designs which take advantage of the connectivity we already have and utilize that connectivity to motivate usage?

What I’m saying is, there are certain systems and/or design elements already available which could integrate and inspire usage and adoption of both providers and public. We are not focusing upon them, at least in part, because of earlier (and some current) failures of integrative-type systems. (CHINs, RHIOs, etc.) Regrettably, those systems had some grossly neglectful design flaws: they were built upon financially unsustainable models and/or they did not take basic human motivations into sufficient consideration.

Here’s the skinny on attaining 60-70% of the NHIN (OK, it’s a somewhat chubby skinny):

a) Small communities and their associated small community hospitals serve an estimated 60-70% of the U.S. population. (See where this is going?)

b) Let’s utilize the power of “community,” a strong force within small towns, to help inspire adoption and conquer the learning curve necessary for this “paradigm shift.” (Sorry…I hate such corporate-speak clichés, too.) Enabled consumers and ancillary medical services providers – EMS, police, fire, sheriffs, home health, hospice, health departments, school nurses, etc. – will entice physicians to adoption by their creation of a need to which the docs can respond, this response being something of a forté for most clinicians. (Commercials with the local fire chief and Little Timmy or Grandma Gertie, who were saved because emergency responders had access to important health data at critical moments will drive digital participation far more than, “Look, see how many demographic or health history boxes we have for you to fill out.” Enabled patients will begin to ply their caregivers for participation with community-based digital care basics.)

c) The “Promised Land” of EHR/PHR use involves all of the tremendous information, subsequent insights, availability, and integration said info will provide. But, we delay our journey by focusing upon all of the wonders to come. Small bites, small sips – that is what consumers and physicians need to start along the path out of the Paper-filled Desert. Don’t blind them with the overwhelming roar of the “Voice of the ‘Almighty’ EHR.”Rather, allow all us Moseses to hear the Word and feed the people those portions which they can tolerate as we attempt to lead them out of the paper-filled desert. (Read this as: Institute small, valuable tools in modular form that can provide immediate, real life value and then build upon this foundation with additional modules providing increasing value in tolerable, stepped progressions.)

d) Using the tools mentioned in Step 2 – an end user-friendly system with simple, familiar tools and goops of support and education, along with an open, but secure, design that is inclusive (read: non-proprietary or, at the very least, one that works and plays well with others) – we establish a local non-profit governance organization to oversee and insure local concerns. (A for-profit corporation to help establish and support these local 501(c)3s would likely be more fleet-footed than a governmental oversight org.

e) Within each community, while we enable bridging the digital divide in these typically less technologically advanced populations, we would create a minimum of 10 to 20 new jobs (20 X 2,000 = 40,000 new jobs) for support and education services. We would also enable small hospitals to retain employees, a current, major challenge. (Our local hospital recently had to let 50 people go: 50 X 2,000 = a possible 100,000 jobs saved.)

f) Utilizing a combination of tools, such as the Health Record Bank, so pleasantly detailed at HIMSS by Drs. Deborah Peel and Bill Yasnoff, along with the Integrated Health Record (IHR,) as discussed in Step 2, we could create a patient-centric, patient-controlled, community-driven healthcare model which, with one of the available integration/exchange engines – for instance Medicity’s Care Collaboration Platform – would allow for a truly inclusive, integrated healthcare community system. All could participate, including new and legacy systems.

g) Such community systems, based upon designs specifically for small communities, would not provide Mayo-esque, Rolls Royce-type digital healthcare magic. They would, nonetheless, provide what small communities actually need: the initial Honda Civic version that may have few bells or whistles but can get us from paper (here) to electronic (there) healthcare – or at least down the first part of the journey. Once small communities have given up their horse-and-buggy (paper full) systems, they will be able to actually share basic healthcare data seamlessly, as their systems’ similarities will allow such sharing, and we can add new modular enhancements as people become more and more comfortable with their new mode of healthcare data transportation (less paper.)

h) Small communities rarely have competing hospitals. Sharing data between such communities would not engage the “it’s my data, you can’t have it” seen within larger centers. With appropriate consent and protections, sharing across the biggest HIE pipeline (the Internet) between small communities would only boost information access, enable less costly care provision, and promote small center usage by consumers who can receive higher quality care closer to home.

To recap (i.e., the skinny skinny):

• Most folks get care outside of giant centers in small communities and their associated community hospitals (60-70% of NHIN)
• Design specifically for small communities (i.e., no ill-fitting trickle down)
• Graduated, modular development (no “drink from the fire hose”)
• Immediate, real world value to inspire participation (school & home health & nursing home & hospice telemedicine services, care reminder services, real “saved lives” via first responders now)
• Patient-centric, community-driven (LOADS of support/education, opt-in only, local governance)
• Community to community connectivity with Aspen-like interrelatedness (compared to our current siloed Sequoia-like systems)
• User-friendly, customizable, intuitive, simple, familiar tools (think cell phone apps, JAVA, Flash, video, “fun” elements, community kiosks, local education sessions by locals, door-to-door help and support)
• Utilize “natural human motivations” to inspire co-adoption and conquer learning curves (en masse, in community, we are more inspired, more driven)

I promised at least a Tweet about funding and sustainability. So…

Funding? – Obama.

Sustainability? – A permanent Obama aristocracy.

Seriously, yes, we could certainly receive a tremendous bang for a chunk of the Obama bucks. (60-70% of the NHIN using less than 1/3 of the ~$38 billion already planned – e.g., projected costs are far less than 5 million per community X 2,000 communities = <10 billion) Anybody else know of a system or design which could attain two thirds of the NHIN for such a bargain basement, fire sale price?

Sustainability must be derived from a variety, a community, of sources. Just as the community can help drive adoption, so, too, can the community model drive a diversity of ongoing income sources. Besides having EHR vendors pony up some of the development costs for products destined to enhance their ongoing revenue streams, others should participate in supporting this communal sandbox: local employers, local hospitals and physicians via savings and enhanced earnings, HRB service fees, community-based grants via the aforementioned local non-profit, insurance company rebates and support, local levies, and, of course, the traditional small town bake sales and fish fries. Yes, yes, just kidding on those last two, but the point is, with a coordinated effort and a seriously detailed plan, sustainability can be obtained using the same community-based mindset. (It is difficult to detail this adequately within the constraints of a blog…er…”News & Opinion” site. No dis intended, Mr. H!)

Finally, the runway model skinny:

• Start with the basics in small test tube environs, provide adequate growth media, let the system grow along natural growth lines, allow Aspen-like spread and interrelatedness (maybe we should call the system, Pando?) deriving scale via reproducibility, and “allow” all of the beneficiaries to feed and water it ongoing.

As I said, I know there are many really smart people out there who are going to point out the bazillion reasons why this can’t work. Personally, I’ve never found intelligence to be a substitute for initiative. Those who depend upon nay-saying and “why you can’ts” tend only to limit; I more prefer to heed the call of the “Why Nots.”

Still to come:

Step 4: Equalizing the Playing Field (“Open” is not a Four Letter Word; Systems That’d Suit)
Step 5: Verdant Health (Lush, Full, Eco-friendly, Yet More Jobs – “Green” in Every Sense)

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached through http://madisonpediatric.com or doc@madisonpediatric.com.

News 4/16/09

From AF: “Re: In-office medication dispensing. A-S Medication Solutions, a division of Allscripts, is trying to sell doctors in-office medication dispensing so they can make money on it like a pharmacy would. Has anyone had success with this?” I have to say I personally knew nothing about this subject, but have now completed “In-office Medication Dispensing 101”, with the help of the A-S website. A-S claims the average profit is $3.75 to $5.25 per prescription, depending on the medication and insurance. The Stark regulations say this is all legal as long as the patients belong to the physician. And, the physician can direct staff to dispense medications on his/her behalf. Readers will have to tell us if it is worth it. By the way, Allscripts is actually selling off this division, though they will continue to sell the solution through a co-marketing agreement.

SRSsoft announces that Valley Oak Orthopaedics (CA) de-installed a CCHIT-certified EMR and replaced it with the non-CCHIT-certified SRS hybrid EMR. SRS is clearly making a statement that CCHIT certification alone does not guarantee the product will be efficient solution. The administrator of the three-doctor group is quoted as saying,”We chose the SRS hybrid after the existing traditional EMR in our practice drained our productivity and became unusable.”

A local paper examines the move to electronic health records across the Sarasota, FL community. Included is the story of a two-doctor pediatric and internal medicine group that moved to EHR nine years ago. Despite the $70,000 per physician up-front cost, the physicians believe the system has improved their record keeping, facilitates the transfer of records to other physicians and patients, and provides excellent tools for proactive and preventative care. We continually hear stories about how EHRs are not yet doctor-friendly, so it’s nice to hear a few success stories now and then.

We’d like to welcome Eclipsys, our newest HIStalk Practice Platinum sponsor. Eclipsys has been providing information solutions to healthcare systems and hospitals for many years and just last year purchased Medinotes (which previously acquired the highly regarded Bond CLINICIAN software, now called “PeakPractice”). Eclipsys also offers their physician offices the Sunrise Ambulatory solution. We appreciate their support of our new site!

Tell me if I am wrong to be mildly offended by the title of this article recently published in American Medical News newsletter (produced by the AMA): “How to handle patients who are always late?” I am an on-time person and I hate tardiness, too. I want to know where the article is entitled, “How to handle doctors who are always late?” Maybe it is just my doctors, but I always end up waiting at least 15 minutes any time I have an appointment. While I appreciate that each patient gets personalized attention, I don’t appreciate that unstated message that my time less important than the doctor’s. There. It’s off my chest.

Set your DVR: Jonathan Bush, athenahealth’s chairman and CEO, will preside over the NASDAQ closing bell Thursday April 16th at 3:45 pm ET.

MGMA finds that compensation for medical directorships in non-hospital-owned groups is an average of 69% higher than in hospital-owned groups for all specialties except primary care. Across all specialties, the recruitment and physician education responsibilities yielded the highest compensation. Physicians accepting medical director roles were able to increase their compensation between 80 and 100% or more, depending on specialty.

I got my taxes done at the last minute. Sure hope the government spends my money wisely.

E-mail Inga.

Mark Anderson 4/15/09

My HIMSS Thoughts

Traditional buzz around vendors’ products with not much substance behind their claims. Most vendors were talking about how great sales were going and that the HITECH portion of the ARRA bill was going to really help explode sales. However, when I asked them what was in the HITECH bill, they had no idea of the details.

So the big buzz was HITECH, but …

Many intellectuals and government officials have been convinced that technology cost is the major factor for slow adoption of EHR technology. As we read in the August 2008 article in the New England Journal of Medicine, only 4% of physicians are fully utilizing EHRs in their practices today, with an additional 13% using parts of an EHR. In the hospital setting, HIMSS Analytics estimates that less than 2% of hospitals are using an EMR based on the seven levels of hospital technology adoption.

In reality, cost is a factor, but maybe a minor factor. With over 400 vendors in the marketplace, physicians have numerous opportunities to adoption EHR applications that cost less than $1,000 per year. This equates to less than 0.00033% of a physician’s annual gross income. We believe the real barrier to adoption has been twofold:

1. Physician data entry time increases by 7X over the paper based system, and
2. Physicians are not paid for data entry time.

Therefore, if we cannot decrease the physician’s data entry time, EHR adoption will never take off.

But wait — that’s where HITECH saves the day. The HITECH Act requires data sharing and interoperability between all care providers, thus potentially reducing physician data entry time by up to 75%. Finally, someone in the government figured out that the value of the EHR is in the data sharing between the primary care physician and the specialist, and between the specialist and the hospital, and even more importantly, between the patient and their care providers.

We predict that actual sales will not begin until after the economy turns around, and maybe not until January 2010 when "meaningful use" is is clearly defined.

When the bill was first announced, many organizations were excited to hear that the government was going to help fund EHR adoption. At first glance, most healthcare providers believed they were going to receive funding to purchase an EHR. They were wrong. Physicians who have already adopted EHRs were excited that they were going to receive funding to help reimburse them for their EHR. They were wrong. 

Funding is going to providers who meet “meaningful use” criteria, can report quality indicators to the government, and most important, can exchange patient-specific clinical data with other providers in the community.  Funding will not go to providers that have pre-existing EHRs unless they are connecting to a community HIE. One of the government’s primary goals is to eliminate the silos of patient information within an individual provider organization.

Therefore, the vast majority of the funds within the HITECH Act are assigned to payments that will reward physicians and hospitals for effectively using a robust, connected EHR system.

Mark Anderson is CEO and healthcare IT futurist with AC Group, Inc.

News 4/14/09

The Rhode Island Department of Health releases two reports showing that almost 40% of the state’s physicians have an EMR, with 58% of those report using it more than 60% of the time. In addition, 25% use e-prescribing at least 40% of the time.

AirStrip Technologies receives FDA clearance for its AirStrip OB application for use on the iPhone. The software allows OBs to access virtual real-time and waveform data on mother and baby, direct from the hospital’s labor and delivery units.

AMA President-Elect J. James Rohack, MD sends a letter to USA Today, saying "physicians are eager to embrace new technologies" and that it’s "imperative that there are widely recognized interoperability and security standards in place." Good to know that he believes doctors are on board, even though most are still resisting today’s current technology. At HIMSS last week, we heard the word "interoperability" over and over again, as well as security and privacy. Everyone agrees they’re a necessity, though everyone has a slightly different spin on what interoperability is all about. How long will it take us to get there?

A New York Times article profiles the use of an EMR (from e-MDs) of a rural doctor, who summarizes as follows: "I’ll never go back to the old system. I can always look at the records by Internet, whether I am seeing patients at the nursing home or a clinic or the hospital, or even when I’m as far away as Florida. The change has been tremendously beneficial for my productivity.” For years, Mr. HIStalk has been saying that the main value of electronic records is being able to review and create electronic data from anywhere. Just getting data into an electronic form is where the payoff lives. HITECH should have rewarded providers for sharing data on a national framework such as NHIN, paying them per patient (or, even better, per record type). Using technology is one form of "meaningful use," but making data available to other providers is more so. The power is in the network, not the desktop, but paying for the former will encourage the latter.

A West Virginia doctor and a moonlighting medical resident are the subjects of an HHS search warrant, triggered by a tip that a local pharmacy was "handing out drugs like candy," including the dispensing of 3.2 million hydrocodone tablets in one year in the town of 200 people.

The Boston Globe exposes the potential inaccuracies with personal health records. The piece highlights some of the problems that occur with applications such as Google Health, which pull data from sometimes imprecise claims detail. The advent of ICD-10 codes will help, but don’t expect it to be the panacea. Meanwhile, doctors and patients may view such stories as a good excuse not to embrace PHRs.

BCBS of Minnesota and American Well announce an agreement to provide Online Care services in Minnesota. The program will provide BCBS’s 10,000 employees and family members the option for real-time live interactions with medical care providers via virtual clinics and will connect with HealthVault.

A local newspaper details some of the struggles facing South Carolina physicians as they move to EHR. Among those sited: costs, concerns about the long-term viability of vendors, and the current lack of standards.

The 80 physicians at Elmhurst Clinic (IL) claim it took several years to go fully paperless, but now say their monthly charges are up by more than $1 million. In addition, 2,700 square feet of space previously dedicated to paper chart storage is now office space. Physicians say the move to EHR aids in physician recruitment, facilitates research, and has allowed them to expand the practice.

A national survey of medical offices finds that 18% of offices are observing a 10-25% increase in accounts receivable over the last year. In addition, 28% of the offices are experiencing a 10-25% increase in bad debt expense.

A survey reveals that 67% of medical offices with four or more physicians do not use EMR software. The number drops to 60% without EMR for practices with 26+ physicians. Guess it’s a great time to sell EMR if you have a great product.

E-mail Inga.
E-mail Mr. HIStalk.

Docs on HIMSS

HIMSS: A Doctor’s Perspective
By Joel Diamond, MD

This was my fifth year attending the Healthcare Information and Management Systems Society extravaganza. In the past, this event has all but ruined the chance to spend Valentine’s Day with my wife (she insists that the name HIMSS was perfect for this guyfest). This year, they managed to overlap both Palm Sunday and Passover. Although it is tempting, I will try to refrain from the obvious clichés about techno geeks needing to get a life try to be respectful of the real world.

It is easy for a practicing physician to feel overwhelmed in this universe. Although this year was a bit more subdued, the amount of money spent by IT vendors is orders of magnitude greater than that seen at, say, the equivalent trade show of the American Academy of Family Physicians. I am told that it is exceeded significantly by the Radiological Society of North America conference. You can draw your own parallels to the priorities of dollars spent in actual healthcare.

The official conference was preceded by the Physicians IT Symposium, which was well attended and quite informative. There were similar symposia held separately for pharmacists and nurses. Unfortunately, the lack of integration into the greater conference seemed to reinforce a sense of segregation of real-world clinicians from the bigger community of “Healthcare Information and Management”.  Nonetheless, topics ranging from personal health records, Pay-for-Performance, and the Medical Home were timely and thought-provoking.

That said, the real world clinicians attending for the first time that I spoke with absolutely loved this conference. They told me that they had no idea of the immense amount of innovation and creativity that was out there. They were inspired to take this new sense of potential back to their organizations and push for meaningful change.

I have to agree with them.  Every year I discover my own new perspectives on the possibilities of what can be. The dream of improving patient care through the application of correct technologies becomes much more palpable.

Oh yeah, did I mention that the HIStalk Reception was awesome? Free drinks, great food, the Trump Tower, and a chance to network with some the industry’s real leaders of change. Unfortunately, the event was marred by the truly horrendous choice of emcee for the HISsie awards (inside joke).

Although the mysterious Inga did not reveal herself, the knowledge of her presence was the stuff that dreams are made of …

Clinically speaking.

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.

Thoughts on HIMSS
By RegularDoc

Physician IT Symposium
A one-day event that all docs in IT should consider attending.  Dr. Peter Basch’s talk in the morning was fantastic — the top eight things in IT that need clinician leadership. Another highlight was CIO/Dr. Martin Harris’s presentation about how Cleveland Clinic is using IT and their EMR to expand their ability to take care of patients nationally and internationally.

Dennis Quaid Keynote
I appreciated Quaid starting a foundation to increase public awareness, but he should have focused on that and not started talking about “his vision” of how IT could help (we all know the vision, DQ — stick to your strong points). But then I felt sorry for him when the post-speech questions were actually real IT questions! Maybe you could have a contest for best question one would have asked DQ. For example, I might have asked, “Are you now considering starring or working in a movie that deals with medical errors?" or “If you were Mr. HIStalk in a movie, whom would cast as Inga?"

George Halverson Keynote
I really admire what he and Kaiser have done and agree when he says all we need do is: (1) follow medical best practices; (2) improve caregiver coordination; and (3) have consistent follow through to close any loops. But he knows they have been able to create this “Medical Home” type of environment due to their economic model (one entity owning everything). So, he should careful in making it sound like everyone else just has to try a little harder and use more IT. In other words, the majority of us working in a FFS environment want to do these things, but as we all know, we need to have our reimbursement model change before we can really pull together around this concept.

Alan Greenspan Keynote
Well, he’s very cute in those glasses, but wow — did he think he was in front of some economics professors? Most of what he did was read off a prepared speech that was hard to fully grasp. But it was better when he did occasionally look up and address the audience and when he did the couch interview with Lieber.

Networking
Great, lots of people there — old and new. But, not nearly as many social events as in the past for obvious reasons, thus making it less likely to meet random new people.

Exhibit Hall
I  actually liked that there were not mongo-size booths, although I hated the floor layout — the numbers were just not consistent. On the other hand, I got a good workout walking around and stumbled onto a few booths I might not have otherwise seen.

Other Thoughts
On one hand, there was great excitement about the stimulus package and concern about “meaningful use” and whether CCHIT will be the required standard for EMRs. On the other hand, users in the know (e.g. doctors who use and implement EMRs) focused more on concerns about the usability of EMR systems (or really, the poor usability of most EMRs that create inefficiencies and quality risks).

Said another way, we will get so much more clinical and economic benefits from these systems as they become more usable, either via vendors listening to their current users (rather than prospective users) and/or vendors opening up their systems to allow for more user-defined user interfaces that sit on top of their systems.

RegularDoc is a regular doc.