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Wednesday, October 22, 2014

Operationalize THIS!


For optimal enjoyment, read the entire 63 page pdf ONC slide deck while listening to Weird Al's "Mission Statement."


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ON DECK

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More to come...

Monday, October 20, 2014

Interoperability solution? HL7® FHIR® -- We ® Family

FHIR® – Fast Healthcare Interoperability Resources (hl7.org/fhir) – is a next generation standards framework created by HL7. FHIR combines the best features of HL7’s Version 2, Version 3 and CDA® product lines while leveraging the latest web standards and applying a tight focus on implementability.

FHIR solutions are built from a set of modular components called “Resources”. These resources can easily be assembled into working systems that solve real world clinical and administrative problems at a fraction of the price of existing alternatives. FHIR is suitable for use in a wide variety of contexts – mobile phone apps, cloud communications, EHR-based data sharing, server communication in large institutional healthcare providers, and much more...


A central challenge for healthcare standards is how to handle variability caused by diverse healthcare processes. Over time, more fields and optionality are added to the specification, gradually adding cost and complexity to the resulting implementations. The alternative is relying on custom extensions, but these create many implementation problems too.

FHIR solves this challenge by defining a simple framework for extending and adapting the existing resources. All systems, no matter how they are developed, can easily read these extensions and extension definitions can be retrieved using the same framework as retrieving other resources.


Example Resource: Patient
This simple example shows the important parts of a resource: a local extension, the human readable HTML presentation, and the standard defined data content...


I hope no one's thinking this will be an example of "UX-friendly." OK, let's just focus in on the patient name coding for a moment.


"Family?" Well (ignoring for the moment the lack of reference to a "middle name"), how many ways might we see some of these data expressed in the myriad ONC Certified EHR RDBMS dictionaries (and all manner of databases more broadly)?
  • Last
  • Lastname
  • Last_name
  • LName
  • First
  • Firstname
  • First_name
  • FName
Etc. Assuming case insensitivity here. e.g., from the Open EMR tables:


I'd love to get a look at the data dictionaries for the major commercial EHRs, but they are all closely held "proprietary" structures. ONC should be able to examine them, though.

Now, were HL7 FHIR -- 'scuse me, HL7® FHIR® -- to be adopted by ONC as the comprehensive uniform data dictionary standard I have long advocated, perhaps this aspect of the Health IT problem would be largely solved.

Given that that's supremely unlikely, though, we inevitably remain faced with a huge point-to-point or hub/spoke data mapping "interoperability interface" task.

Do some combinatorial math. Recall from the dreaded undergrad stats or finite math class?


Assume, for outset simplicity, six mainstream EHRs whose names come readily to mind.


What are the maximum possible bidirectional data map interop interfaces via which to enable comprehensive data exchange? Going clockwise around the ring, starting with eCW:
  1. eCW -- e-MDs
  2. eCW -- Epic
  3. eCW -- Practice Fusion
  4. eCW -- Cerner
  5. eCW -- athenahealth
  6. e-MDs -- Epic
  7. e-MDs -- Practice Fusion
  8. e-MDs -- Cerner
  9. e-MDs -- athenahealth
  10. Epic -- Practice Fusion
  11. Epic -- Cerner
  12. Epic -- athenahealth
  13. Practice Fusion -- Cerner
  14. Practice Fusion -- athenahealth
  15. Cerner -- athenahealth
See the recursively diminishing (n-1) pattern? Combinatorics 101. In this example, n = the 6 EHRs, m = 2, the requisite bidirectional interfaces (we assume here bidirectionality of data exchange capability). Consequently, 6! ("factorial") = 6 x 5 x 4 x 3 x 2 x 1 = 720, (n - m)! = 4 x 3 x 2 x 1 = 24, times m! (2 x 1) = 48, and 720/48 = 15.

Easier to simply count the 15 connecting lines.

OK, let's scale up a bit, taking just today's ONC CHPL Certified EHR data, and using only the subset of "complete ambulatory and inpatient EHRs," 482 of them.

Combinatorally, we're talking 115,921 bidirectional data exchange interfaces. Were we to compute all 1,963 certified products, the number would be 1,925,703.

Several necessary observations:
  • The ONC CHPL list surely overcounts the EHRs, given that the list is not "de-duped" for actual named products. It includes all versions for which a vendor's product has passed Cert. Nonetheless, to the extent a newer version of EHR "x" has data dictionary modifications, it's appropriate to count it. Suffice it to say with confidence that the problem is a huge one.
  • My observations here are simply about the nominal aggregate 2-way interface numbers. Deeper down will be the myriad metadata "data typing" issues within each interface, going beyond simply the spelling of each variable name. Data types matter when it comes iterative health data exchange. Information corruption resulting from data dictionary definition variability propagates.
  • Relatedly --  to use the Open EMR example (the only one I've seen readily available, given that it's open source): The Open EMR RDBMS is today comprised of 169 tables encompassing 3,731 variables. "N" number of certed EHRs, times "M" number of data cross-maps, times "V" number of vars, well, need I elaborate?
  • Q: Would a hub/spoke architecture be simpler and more manageable (in particular once we expand the discussion beyond traditional EHRs and out to mobile, etc)? -- where the "hub" would be the central translation and routing service.
Maybe ONC simply does not have the regulatory authority to require that CHPL applicants submit their data dictionaries for confidential study and assessment in order to size the scope of the data cross-mapping task required for seamless "interoperability" / data exchange. But, absent someone analyzing the issue, my concern is that we'll simply face more years of a fervent yet Quixotic Standards® Promulgation® Industry® in lieu of a sorely needed actual, single interop standard.

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NEW FROM EHR SCIENCE

Dr. Carter never disappoints.

Tables verses Documents: A Reason for Using NoSQL?

Dr. Carter responds to my heads-up:



He and I agree totally on standardizing data elements.

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CODA: AND, "HOW®"
A Bestselling Author Claims To Own The Word 'How' And He's Launched A Lawsuit Over It

A best-selling author is suing Greek yogurt company Chobani for using the word "how."
Dov Seidman, who wrote a business management book called "How: Why How We Do Anything Means Everything," says that Chobani's new marketing campaign infringes on his trademark of the word...
Lordy. We have far too many lawyers.
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P.S.

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More to come...

Thursday, October 16, 2014

The latest Interoperababble news

We interrupt our regularly scheduled  24/7 Ebola panic for a bit of other news...

'Actionable' steps to interoperability
JASON task force offers its final report to ONC
Tom Sullivan, Healthcare IT News, October 16, 2014


JASON, a group of independent scientists who advise the federal government, issued a November 2013 report to the Department of Health and Human Services, the Office of the National Coordinator for Health IT and the Agency for Health Research and Quality on the matter of interoperability...

Here are the half-dozen recommendations the JASON task force made to ONC, as co-chairs David McCallie, vice president of medical informatics at Cerner, and Micky Tripathi, CEO of the Massachusetts eHealth Collaborative, explained them:
  1. Focus on interoperability. ONC and CMS should re-align the meaningful use program to shift focus to expanding interoperability, and initiating adoption of Public APIs.
  2. Establish an industry-based ecosystem. A Coordinated Architecture based on market-based arrangements should be defined to create an ecosystem to support API-based interoperability.
  3. Set up Data Sharing Networks. The architecture should be based on a Coordinated Architecture that loosely couples market-based Data Sharing Networks.
  4. Enable the Public API as basic conduit of interoperability. The Public API should allow data- and document-level access to clinical and financial systems according to contemporary Internet principles
  5. Create Priority API Services. Core Data Services and Profiles should define the minimal data and document types supported by Public APIs
  6. Institute the government as market motivator. ONC should assertively monitor the progress of exchange and implement non-regulatory steps to catalyze the adoption of Public APIs.
"Market motivator? Hmmm... No more federal money. "Non-regulatory" incentive steps? "Loosely couples market-based Data Sharing Networks?" "Loosely?" Oh, yeah, that's swell.

What's not to love?

Expect several more years of wheel-spinning and cludge-fix outside-in band-aids. After which we'll issue ONC Ten Year Interoperability Plan 2.0 (assuming their budget hasn't been zeroed out by then).

Clinic Monkey
Thus endeth today's edition of The Interoperababble News.


WE NOW RETURN YOU TO YOUR REGULARLY SCHEDULED NIGHTMARE

America doesn’t have an Ebola epidemic, but it’s been infected with a whole lot of fear-mongering, finger-pointing and downright nonsense lately. Politicians, in particular, have unleashed a whirlwind of irresponsible speculation and policy prescriptions with no basis in reality.

Senator Rand Paul is telling reporters that you can catch Ebola at a cocktail party — an unlikely prospect, unless if, for some reason, you manage to make contact with the bodily fluids of someone who’s actively sick with the disease. Todd Kincannon, the former general counsel and executive director of the South Carolina Republican Party, declared that the “immediate humane execution” of U.S. Ebola patients would somehow save lives. Lawmakers on both sides of the aisle continue to push for travel bans, despite experts’ warnings that they could make the crisis worse. And a vocal contingent of conservatives is convinced that the threat of an infectious disease from West Africa warrants sealing the U.S.-Mexico border — an enormously expensive and probably impossible to execute solution...

Sanity.

Ever-predictable insanity:


Infographic from Sermo: The problem withe Ebola preparedness.

SATURDAY MORNING UPDATE:
ALL EBOLA ALL THE TIME

From my email inbox.


Also:
The Ebola Voter
Thirteen ways Democrats and Republicans are exploiting the virus for political gain.
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More to come...

Wednesday, October 15, 2014

Are we about to descend into mass national psychosis?


Ms. Peel, that is just irresponsibly inflammatory and unhelpful. You are out of your depth. Stick to your privacy knitting. It's "Ebola," not "EHRbola."

More Deborah Peel.


Unjustified sanguinity regarding the relative safety of paper charts commencing at 13:34.
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BTW: Just up at THCB:
Angry Nurses Tell of Ebola Patient’s arrival at Texas Hospital
...After arriving at the emergency room with high fever and other symptoms of the disease , the nurses said the patient was kept in a public area , despite the fact that the he and a relative informed staff that he had been instructed to go to the hospital after contacting the Centers for Disease Control in Atlanta to report possible Ebola symptoms.

The nurses said the patient was  “left for several hours, not in isolation, in an area” where up to seven other patients were. “Subsequently, a nurse supervisor arrived and demanded that he be moved to an isolation unit, yet faced stiff resistance from other hospital authorities,” they alleged.

Duncan’s lab samples were sent through the usual hospital tube system “without being specifically sealed and hand delivered. The result is that the entire tube system … was potentially contaminated,” they said.
The statement described a hospital with no clear rules on how to handle Ebola patients, despite months of alerts from the Centers for Disease Control and Prevention in Atlanta about the possibility of Ebola coming to the United States.

“There was no advanced preparedness on what to do with the patient. There was no protocol. There was no system. The nurses were asked to call the infectious disease department” if they had questions, but that department didn’t have answers either, the statement said. So nurses were essentially left to figure things out on their own as they dealt with “copious amounts” of highly contagious bodily fluids from the dying Duncan while wearing gloves with no wrist tapes, flimsy gowns that did not cover their necks, and no surgical booties, it alleged...
National Nurses United
A dicey time right now, epidemiologically. The TV and radio news have been about little else today. And, the crazies are out in full force trying to foment xenophobic and domestic political hatred and panic. See, e.g., the racist hashtag "#Obola."

JON STEWART CHIMES IN


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EHRbola UPDATE
...Long promised as the panacea for patient safety errors, electronic health records, in fact, have fragmented information, too often making critical data difficult to find. Often, doctors or nurses must log out of the system they are on and log into another system just to access data needed to treat their patients (with, of course, additional passwords required). Worse, data is [sic] frequently labeled in odd ways. For example, the results of a potassium test might be found under “potassium,” “serum potassium level,” “blood tests” or “lab reports.” Frequently, nurses and doctors will see different screen presentations of similar data, making it difficult to collaborate.

Another technological issue is the flatness of electronic records: Much of the information looks the same — a series of boxes to check and pre-formatted text that makes highlighting an urgent or important issue difficult. Electronic records, with their cut-and-paste functions, create what doctors call “chart bloat.” The announcement that Duncan’s electronic records totaled 1,400 pages illustrates this phenomenon. Poor record presentations may well have contributed to the hospital spokeswoman’s initial statement that Duncan’s temperature was only 100.1, when in fact the hospital’s records show it increased from that to 103 by the time Duncan was discharged four hours later...
From the Dallas Morning News.

In my email inbox this morning.

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WHO LEFT THE LID OFF THE BOTTLE OF STUPID?
Sadly, it has reached the point where we will not feel safe unless we ban travel to and from Liberia, Sierra Leone, and Guinea. The reason this is a sad moment is that there is a good chance it could interfere with the flow of health care and resources to and from these countries. Not only that, but, historically, when a country suffering from a growing epidemic has felt cut off from the rest of the world, the fear quotient has risen, and people afraid of the contagion have attempted to flee. Unfortunately, when people hastily attempt to escape imposed restrictions, they tend to take fewer precautions, which increases their chances of catching the dreaded disease.

But first and foremost, although we are members of the world health community, we must worry about our own public psyche here in the United States. If our leaders can’t give us a sense that we are protected, we must achieve it by imposing a ban.


- Marc Seigel, MD
Lordy.
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More to come...

Tuesday, October 14, 2014

Continuing with "competition" and federal "incentives." A Meaningful Market failure?

Regardless of the merits of EMR or the cause of the lack of widespread adoption to date, it is not immediately clear that HITECH subsidies would materially affect the investment decisions of private firms. Prior research suggests that, despite their intentions, such subsidies may not actually stimulate private investment. Peltzman (1973) introduces the notion that government subsidies might crowd-out private investment, and provides evidence of dollar-for-dollar crowd out in investments in higher education. Most of the subsequent research evidence also casts doubt on effectiveness of government subsidies for promoting aggregate private investment.
From

INVESTMENT SUBSIDIES AND THE ADOPTION OF ELECTRONIC MEDICAL
RECORDS IN HOSPITALS

 
David Dranove
Craig Garthwaite
Bingyang Li
Christopher Ody
Working Paper 20553
www.nber.org/papers/w20553

Interesting paper (If you don't have a NBER account, the paper costs $5).
1. Introduction
Critics of the United States health sector have long pointed to its combination of high costs and poor outcomes, such as a high rate of medical errors (IOM, 2001). An often discussed source of these problems is the relative low utilization of information technology compared to other industries (Gartner, 2010). Many health policy analysts and academics suggest that the widespread adoption of Electronic Medical Records (EMR) will transform the US healthcare system, simultaneously reducing costs and improving outcomes (Hillestad et al., 2005; Buntin and Cutler, 2009). Several studies suggest that increasing the use of EMR will increase efficiency and either decrease health care expenditures, increase quality, or ideally both (McCullough et al., 2010; Miller and Tucker, 2011; Freedman et al., 2014). Summarizing this literature, Buntin et al. (2011) found that over 90 percent of studies found positive outcomes from EMR.
Despite these purported benefits, EMR adoption has, until recently, been largely confined to large healthcare systems; smaller and independent hospitals, as well as other medical providers, have remained on the sidelines. This suggests that either (a) there is a meaningful market failure that creates a separation between the private and social benefits of EMR, or (b) many providers are unconvinced about the benefits of EMR and have taken a “wait-and-see” approach to this investment decision.

Several unique features of the health market could cause a market failure with respect to EMR adoption. For example, hospitals have found that being a high quality provider has a relatively weak relationship to patient volume (Cutler, Huckman, and Landrum, 2004). The lack of a strong volume response limits the potential profits from investments in quality. In addition, the existing reimbursement system for most hospitals means much of the lower costs resulting from more efficient care or better health outcomes flows to other entities. Absent an increased use of bundled payments or more effective shared savings programs, hospitals are unable to fully capture the value created by their spending on EMR. Instead, these benefits are split across a wide variety of public and private payers, none of which individually has the incentive to increase reimbursement rates to the level necessary to cover the costs of EMR.

Given the potential collective action problem, there could be a case for taxpayer subsidies for EMR. This would alter the benefit/cost calculus for potential adopters, leading more providers to conclude that benefits outweigh the (now subsidized) costs. This may be a justification for the United States government’s heavy involvement in promoting the adoption of these benefits. These efforts culminated in the 2009 passage of the Health Information Technology for Economic and Clinical Health Act (henceforth, simply HITECH). HITECH provides up to $27 billion to promote adoption of EMR [emphasis mine] and encourage the adoption and what regulators have described as the “meaningful use” of these systems by hospitals and physicians. HITECH also specifies future cuts to Medicare reimbursement rates for hospitals that do not maintain meaningful use standards (ARRA, 2009).

Of course, a large number of providers failing to adopt EMR is not conclusive evidence of a market failure. Many hospitals may have remained on the EMR sidelines because adoption costs are high and they are not convinced that these systems will deliver the promised benefits. Indeed, while many studies have found positive effects from EMR, the magnitude of the cost savings are, at best, modest in comparison to the large installation costs (Agha, 2014; Lee et al., 2014; Himmelstein et al., 2010)...
"Up to $27 billion." Well, what have we gotten for our money, given that we've doled out nearly all of it by now? (~93% by these end-of-August numbers relative to the $27 billion cited -- although ONC will insist that there is no upper disbursement limit in HITECH.)


From the CMS.gov "latest monthly Payment and registration Summary Report" (pdf). I screen-scraped the stuff off into an Excel sheet so I could tabulate the relative payout percentages. ~60% of MU money has gone to hospitals.*
* There's no deeper drill-down within these CMS reports as to how much disbursed Medicaid MU incentive money was "A/I/U" -- simply "Adopt, Implement, or Upgrade" to an ONC Certified EHR in first year participation, without having to comply with any individual core or menu criteria.
From the Dranove et al paper:


So, we're getting maybe an estimated ~10% (transient?) near-term lift for all the MU money spent on the inpatient side (the focus of this paper)? Have we, in the ever-juicy words of athenahealth CEO Jonathan Bush, simply served to "schimulate a bunch of losers"?

How much of this acute setting money went to Epic? (Our latest HIT whipping boy in the current EHRbola dustup.)
5. Discussions and Conclusions
Many prior studies find that government subsidies fully crowd out private investments. In contrast, we find that HITECH increased the cumulative adoption of advanced EMR among independent hospitals by 10 percentage points in a short period of time. Given that slightly over half of independent hospitals had advanced EMR by 2008, this implies that HITECH accelerated EMR adoption by more than one in five non-adopters. This is not surprising. Based on the limited pricing information that is available, the cost of installing and operating an EMR system by an average-sized hospital is at least $10 million and could be much higher. The average non-adopter as of 2008 could have expected to receive $2.1 million in HITECH subsidies for the first year and $5.3 million in total. If adopters were at the high end of the subsidy spectrum, then incentive payments could be higher than $10 million – though it should be noted that many of these hospitals may also face higher costs of adopting advanced EMR. Thus, HITECH incentives represented a sizable percentage of total adoption costs.


It is tempting to interpret these results as an unmitigated success, i.e. HITECH spurred adoption while only paying a fraction of the cost of these new systems... However, there are two reasons to take a more skeptical view of the merits of HITECH.


First, it may have been politically impractical to dedicate HITECH funds to these marginal adopters, both because this may have been seen as unfair to early adopters and also because HITECH incentives are also used to promote meaningful use. As a result, total HITECH payments dwarfed the subsidies to marginal adopters. It is instructive to compute the total HITECH subsidies per adopting hospital. We estimate that 67 percent of hospitals would have adopted by 2011 without HITECH and that 10 percent of hospitals adopted because of HITECH...


Second, these HITECH funds may have simply accelerated an ongoing trend, and therefore the rate of adoption realized by 2011 would have been achieved soon thereafter – by 2013 according to our estimates – without HITECH funds. Again notwithstanding meaningful use, the expenditures of HITECH appear to have simply provided two additional years of EMR use at facilities that may have been unsure about the product’s ultimate value. Given that hospitals are still trying to figure out how to systematically use HIT to boost quality and reduce costs, briefly accelerating adoption at this juncture is not obviously desirable. Thus, it may be better to ultimately judge HITECH on the impact of meaningful use requirements on outcomes such as costs and quality, something that has yet to be determined. And if meaningful use is the ultimate goal, it seems quite possible that this could have been achieved at a much lower cost...
Interesting indeed. So, where do we go from here? One structural problem with assessing large, expensive national initiatives (in this instance ARRA/HITECH) is the lack of a control group. You don't invade half of Iraq and see how things turn out relative to the control. And, speculating that government HIT subsidies might "crowd out private investment" is mostly just that -- speculation, conjecture that would be rather difficult to confirm or refute empirically. Nonetheless, I found Peltzman 1973:


A bit of apples-to-oranges in that paper, as it was about higher education subsidies 40-some years ago. Nonetheless, there do appear to be some applicable cautionary theoretical assertions, though I rather doubt that anyone can argue that HITECH reduced Health IT deployment. Maybe an unevenly effective type of EHR deployment (regarding which myriad critics would likely nod in agreement).

Again, JD Kleinke:
Given what is at stake, health care should be the most IT-enabled of all our industries, not one of the least. Nonetheless, the “technologies” used to collect, manage, and distribute most of our medical information remain the pen, paper, telephone, fax, and Post-It note.

Meanwhile, thousands of small organizations chew around the edges of the problem, spending hundreds of millions of dollars per year on proprietary clinical IT products that barely work and do not talk to each other. Health care organizations do not relish the problem, most vilify it, many are spending vast sums on proprietary products that do not coalesce into a systemwide solution, and the investment community has poured nearly a half-trillion dollars into failed HIT ventures that once claimed to be that solution. Nonetheless, no single health care organization or HIT venture has attained anything close to the critical mass necessary to effect such a fix.

This is the textbook definition of a market failure. All but the most zealous free-market ideologues recognize that some markets simply do not work. Indeed, reasoned free-market champions often deconstruct specific market failures to elucidate normal market functioning.
That was written in 2005. Nine years later, proposals regarding proper and effective means of incentivization toward the laudable national goal of universal, interoperable Health IT deployment remain controversial. It's difficult to see just how unfettered free market mechanisms will get us there.

Opacity (plus barriers to entry) still = Margin. And, getting profitably past "first mover disadvantage" remains a tough proposition.
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UPDATE

The Free Market, the Unrestrained Consumer, and Jonathan Bush’s Solution to Healthcare costs
By ANDY ORAM


Many observers have lamented the lack of a true market in health care, and tomes have been written about the rampant distortions in the system. Large provider networks battle large insurers in a game of chicken to set prices. Patients don’t have enough information to make good choices. Costs are hidden from patients by a cascade of employer, insurer, and provider policies. And the US government ultimately provides most of the money.
One of the most prominent advocates for a health care market is Jonathan Bush, a regular speaker at health conferences and author of the recent book Where Does It Hurt? To achieve the potent mix he envisions of innovative entrepreneurship, rich data sets, and long-term care for chronic conditions, he calls for a light regulatory hand and for smashing the current oligopoly in health care.

I see these two goals as somewhat opposed...
I see it as an absurd proposition. Maybe Jonathan Shoot-the-RECs Bush has the financial means to be an "unrestrained consumer," but his is a rarified air upper perch in the wealth distribution.

"Many observers have lamented the lack of a true market in health care"

OK, what, precisely, comprises a "true market?" One wherein there is no government?

Preposterous.
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More to come...

Monday, October 13, 2014

ONC and FTC on Health IT Market Competition

ONC: Promoting Competition to Achieve Our Health IT and Health Care Goals
October 7, 2014, Jodi G. Daniel, J.D., M.P.H., Director, Office of Policy , and
Karson Mahler, J.D.,  Policy Analyst, Office of Policy
ONC has long recognized the need to foster innovation and competition to achieve the nation’s health IT and health care goals. The HITECH Act charged us with enabling the electronic use and exchange of health information—information that will support consumers and facilitate better quality and more efficient care.

A competitive and dynamic health IT marketplace fundamentally supports that mission by encouraging and rewarding innovation that drives improvements in the technologies and services providers and consumers need to strengthen our health care system.

ONC and the Federal Trade Commission (FTC) have begun collaborating in new areas to advance our shared commitment to promoting competition in health IT markets while ensuring that health IT is a driver of quality and value in health care.

In March of this year the FTC convened a two-day public workshop, Examining Health Care Competition. Not only did we participate in a panel discussion, but the workshop also included a session on health IT opened by comments from Karen DeSalvo, the national coordinator for health IT.

At the workshop, we heard plenty of reasons to be encouraged about ways that competition is working to deliver interoperable systems and services. As one presenter put it, since 2009 the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs have inspired the most rapid growth in information technology adoption in any industrial sector in recent history. And with new payment and delivery reforms under the Affordable Care Act, demand for health IT products will continue to grow as providers migrate toward new business models that depend on health IT and health information exchange (HIE) for quality measurement, analytics, population health management, and risk-based contracting.

Despite successes, however, a clear takeaway from the FTC workshop was that health IT markets are not functioning as efficiently as they could be. Commonly cited concerns included:

  • A lack of transparency and comparability for health IT products and services, including accurate and complete information about costs and limitations. Without this information, health IT purchasers may find it difficult to exercise informed choice in the marketplace, despite the availability of competing products and services.
  • A lack of interoperability across health IT products and services, which panelists and commenters explained may limit the potential of health IT and HIE to support improvements in health and care delivery. Because of the lack of mature and widely adopted industry standards for interoperability, a good deal of innovation to date has occurred within what some panelists termed “walled gardens”—closed information sharing networks often based on expensive and proprietary health IT solutions adapted to the needs of existing health care delivery systems. As market-based reforms shift provider incentives towards new care delivery models that reward quality and value, there is a risk that some providers may find themselves “locked in” to rigid technologies or information sharing networks. As a result, these providers may find it prohibitively expensive to switch to new technologies that offer superior value, capabilities, and opportunities for delivering higher quality and more efficient care.
  • Business practices that inhibit or block the electronic sharing or transfer of health information. We also heard concerns regarding developers or providers who restrict information exchange with users of other EHR products or HIE services. Such conduct could include policies or practices that prevent or make it difficult to establish connections (or “interfaces”) to other systems. It could also include price or other contractual terms that limit “data portability” in the event that a provider decides to switch to a different health IT vendor’s product.
  • ONC and FTC intend to work more closely in the coming months to understand these and other competitive issues involving health IT—issues that may limit the ability to realize the goals for interoperability and improved patient care. The FTC’s companion blog post reflects our common commitment to competition as a driver of quality and value in health care, with health IT a vital part of competitive markets.
ONC and FTC are cooperating and sharing information to better understand market dynamics related to health IT. In consultation with FTC, ONC will formulate policies that advance patient care through competition and innovation. Government policy may be able to improve transparency, promote interoperability, create incentives for quality, and reduce barriers to competition and innovation.

For example, to promote more transparent health IT markets—and consistent with HHS’s larger commitment to health care transparency—ONC publishes certification test results and requires health IT developers to disclose certain costs associated with certified health IT products. We also work with industry and other stakeholders to advance core technical standards and functions that reduce the costs of entry and open up opportunities for innovators and new technologies.

We expect to continue to build on and expand these efforts going forward as we encourage greater market transparency by the private sector.

ONC will continue to actively monitor health IT-related business practices that could impede progress towards interoperability or harm competition or consumers. We will also share information and our industry awareness with FTC and assist the Commission to monitor and investigate questionable practices.

As we develop the draft nationwide interoperability roadmap, we know a competitive and dynamic health IT marketplace is essential to achieving the vision. Wherever possible, we will use our authorities and coordinate with other agencies to promote transparency in health IT markets, empower purchasers to make better decisions, and eliminate barriers to competition and innovation...

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FTC: Promoting healthy competition in health IT markets 
Tara Isa Koslov, Office of Policy Planning, Markus Meier, Bureau of Competition and David R. Schmidt, Bureau of Economics | Oct 7, 2014

The FTC has been a consistent proponent of competition in health care markets, utilizing our full range of study, advocacy, and enforcement tools. We are equally proud of our track record in promoting innovation and responding to new technological developments throughout our 100-year history. The FTC is well-positioned to monitor competition in today’s burgeoning health information technology (IT) marketplace – relying on our combined expertise in health care, technology, and health-related privacy and data security issues.

At the FTC’s March 2014 Examining Health Care Competition workshop, one panel focused on advances in health care technology, including electronic health records, health data exchanges, and new hardware and software platforms used by health care providers and payers. As panelists explored the competitive landscape, they discussed the goals of interoperability, the potential for health IT to facilitate greater efficiency and coordination of care, and the need to promote continued innovation. They also warned of potential threats to competition from high switching costs, data lock-in, misguided standard-setting activities, and other features of health IT systems and platforms.

Our technology panel benefitted greatly from the participation of two senior officials from the Office of the National Coordinator for Health Information Technology (ONC), the federal agency charged with oversight and coordination in this important area. Since the workshop, FTC and ONC have strengthened our relationships, and we continue to collaborate on many levels. For example, FTC competition and consumer protection staff are playing an active role on the Federal Health IT Advisory Council, the interagency working group that helps to develop the federal health IT strategic plan.

We support ONC’s efforts to develop an “interoperability roadmap[pdf] and related guidance that will promote competition, efficiency, innovation, and coordination of care, while achieving ONC’s overall policy goals. We are working with ONC staff to identify potential competition issues relating to health IT platforms and standards, market concentration, conduct by market participants, and the ability of health IT purchasers to make informed buying decisions. ONC’s companion blog post highlights some of the areas of mutual interest.

In return, we are benefitting from ONC’s expertise and industry knowledge as we learn more about how health IT markets operate, which health IT features are desired by providers and patients, and what types of conduct may benefit or harm health IT competition and innovation. ONC staff are helping us to evaluate issues that may be worthy of additional FTC research, advocacy, and investigation.

FTC staff, together with our ONC partners, will continue to pay close attention to developments in health IT markets. We already know that competition is central to improving health care quality and outcomes, reducing costs, and improving the consumer experience. We and ONC agree that competition in health IT markets is equally important to drive quality and value in health care.
See also The Jason Report.
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"Healthy competition?" Is this stuff simply naive? Isn't that what the Meaningful Use incentive money was to have stimulated? Or, did MU "distort" private market incentives? Now four years out, the feds are gonna promote "competition" precisely how, absent any more funding? What options remain? "Regulation," we are always told, "inhibits competition and innovation," right? It simply inures to the benefit of incumbents, right?

"Free Market" evangelists love their Holy Canon of competition -- until it gets too effective, whereupon they clutch their pearls and poignantly decry "predatory competition" (i.e., those markets with crappy, increasingly nil margins because of -- well -- too many eager ("ruthless"?), adroit ("ruthless"?) competitors and too much price "transparency").

OK, let's recap some Peter Thiel, from a prior post.

4. THE IDEOLOGY OF COMPETITION
CREATIVE MONOPOLY means new products that benefit everybody and sustainable profits for the creator. Competition means no profits for anybody, no meaningful differentiation, and a struggle for survival. So why do people believe that competition is healthy? The answer is that competition is not just an economic concept or a simple inconvenience that individuals and companies must deal with in the marketplace. More than anything else, competition is an ideology— the ideology— that pervades our society and distorts our thinking. We preach competition, internalize its necessity, and enact its commandments; and as a result, we trap ourselves within it—even though the more we compete, the less we gain.

This is a simple truth, but we’ve all been trained to ignore it...


3. RUTHLESS PEOPLE

The competitive ecosystem pushes people toward ruthlessness or death.
A monopoly like Google is different. Since it doesn’t have to worry about competing with anyone, it has wider latitude to care about its workers, its products, and its impact on the wider world. Google’s motto—“ Don’t be evil”— is in part a branding ploy, but it’s also characteristic of a kind of business that’s successful enough to take ethics seriously without jeopardizing its own existence. In business, money is either an important thing or it is everything. Monopolists can afford to think about things other than making money; non-monopolists can’t. In perfect competition, a business is so focused on today’s margins that it can’t possibly plan for a long-term future. Only one thing can allow a business to transcend the daily brute struggle for survival: monopoly profits.

MONOPOLY CAPITALISM
So, a monopoly is good for everyone on the inside, but what about everyone on the outside? Do outsized profits come at the expense of the rest of society? Actually, yes: profits come out of customers’ wallets, and monopolies deserve their bad reputation— but only in a world where nothing changes...
So why are economists obsessed with competition as an ideal state? It’s a relic of history. Economists copied their mathematics from the work of 19th-century physicists: they see individuals and businesses as interchangeable atoms, not as unique creators. Their theories describe an equilibrium state of perfect competition because that’s what’s easy to model, not because it represents the best of business. But it’s worth recalling that the long-run equilibrium predicted by 19th-century physics was a state in which all energy is evenly distributed and everything comes to rest— also known as the heat death of the universe.

Whatever your views on thermodynamics , it’s a powerful metaphor: in business, equilibrium means stasis, and stasis means death. If your industry is in a competitive equilibrium, the death of your business won’t matter to the world; some other undifferentiated competitor will always be ready to take your place.
Perfect equilibrium may describe the void that is most of the universe. It may even characterize many businesses. But every new creation takes place far from equilibrium. In the real world outside economic theory, every business is successful exactly to the extent that it does something others cannot. Monopoly is therefore not a pathology or an exception. Monopoly is the condition of every successful business.
Tolstoy opens Anna Karenina by observing: “All happy families are alike; each unhappy family is unhappy in its own way.” Business is the opposite. All happy companies are different: each one earns a monopoly by solving a unique problem. All failed companies are the same: they failed to escape competition.
Yeah. I'm not sure I'm buyin' all of Thiel without reservation (in terms of general economic theory), but he make some great points. With respect to "fostering competition," recall my February 23rd, 2014 Interop post:


“We should not prescribe specific functionality for the EHR other than interoperability and security.”
 - John Halamka
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Updated, annotated: on the (misnomer) “interoperability” side, from my recurring blog rant.
One.Single.Core.Comphrehensive.Data.Dictionary.Standard
One. That’s what the word “Standard” means -- er, should mean. To the extent that you have a plethora of contending “standards” around a single topic, you effectively have none. You have simply a no-value-add “standards promulgation” blindered busywork industry frenetically shoveling sand in the Health IT gears under the illusory guise of doing something goalworthy.

One. Then stand back and watch the private HIT market work its creative, innovative, utilitarian magic in terms of features, functionality, and usability. Let a Thousand RDBMS Schema and Workflow Logic Paths Bloom. Let a Thousand Certified Health IT Systems compete to survive on customer value (including, most importantly, seamless patient data interchange for that most important customer). You need not specify by federal regulation (other than regs pertaining to ePHI security and privacy) any additional substantive “regulation” of the “means” for achieving the ends that we all agree are necessary and desirable...
See also my post Will the API be the savior of Health IT "interoperability"?
...[A]bsent a solid foundation, it's difficult to see how we erect a durable and useful complex "interoperable" health IT/HIE structure based on myriad proprietary elements.

Visualize going to Lowe’s or Home Depot to have to choose among 1,848 ONC Stage 2 CHPL Certified sizes and shapes of 120VAC 15 amp grounded 3-prong wall outlets.
Yeah, I know, it's not a perfect analogy (analogical perfection is what's known as "redundancy" or "tautology"). Still, the "data" that comprise electricity are free electrons on the move. They have two fundamental attributes, volume (amperes) and pressure (voltage; recall "W=VA"?). Health IT data are ASCII collated binary voltage state representations (ignoring the legacy EBCDIC) comprising numeric and textual symbols (images being specific encodings of the former).

120VAC electrons are rather effortlessly "interoperable." Only proprietary opacity keeps health IT from achieving similar efficient, utilitarian "patient-centered" convenience...
The conundrum:
"Efficient Markets Hypothesis 101: Opacity = Margin."
apropos, let me recap some JD Kleinke, from my June 2011 post "Use Case"
HIT market failure. The underlying cause of Joe’s death is health information technology (HIT) market failure. If the state of U.S. medical technology is one of our great national treasures, then the state of U.S. HIT is one of our great national disgraces. We spend $1.6 trillion a year on health care—far more than we do on personal financial services—and yet we have a twenty-first-century financial information infrastructure and a nineteenth-century health information infrastructure. Given what is at stake, health care should be the most IT-enabled of all our industries, not one of the least. Nonetheless, the “technologies” used to collect, manage, and distribute most of our medical information remain the pen, paper, telephone, fax, and Post-It note.

Meanwhile, thousands of small organizations chew around the edges of the problem, spending hundreds of millions of dollars per year on proprietary clinical IT products that barely work and do not talk to each other. Health care organizations do not relish the problem, most vilify it, many are spending vast sums on proprietary products that do not coalesce into a systemwide solution, and the investment community has poured nearly a half-trillion dollars into failed HIT ventures that once claimed to be that solution. Nonetheless, no single health care organization or HIT venture has attained anything close to the critical mass necessary to effect such a fix.

This is the textbook definition of a market failure. All but the most zealous free-market ideologues recognize that some markets simply do not work. Indeed, reasoned free-market champions often deconstruct specific market failures to elucidate normal market functioning. The most obvious examples of such failures (such as public transit and the arts) are subsidized by society at large because such subsidies yield benefits to the public that outweigh their costs. Economists refer to these net benefits as “positive externalities,” defined as effects that cannot be captured through the economic equation of direct cost and benefit.

The positive externalities of an HIT system approaching the functionality of our consumer finance IT system include reduction of medical errors like the one that killed Joe Wilson; elimination of tens of thousands of redundant and expensive tests, procedures, and medications, many of which are not only wasteful but harmful; and the coordination and consistency of medical care in ways only promised by the theoretical version of managed care. These public health benefits are well beyond the reach of a health care system characterized by the complexities of medicine and conflicts of multiple parties working at economic cross-purposes. They are trapped outside the economic equation, positive externalities of a stubbornly fee-for-service health care system that inadvertently rewards inefficiency, redundancy, excessive treatment, and rework...
Hmmm...

According to [modern economic] theory, everything works like clockwork. If certain individuals (and, by extension, firms) make erroneous choices (rationality does not preclude errors), then other market participants will rush to take advantage of these errors, swiftly correcting the anomaly. Those who acted erroneously will soon realize their error and learn from it. Rational individuals may make mistakes from time to time, but they learn from these mistakes, never repeat them, and improve themselves.

Moreover, the theory says that despite its flaws (neoclassical economists acknowledge that conditions of perfect competition do not actually exist), the free-market mechanism functions in the best possible manner, efficiently determining prices. Prices , as set by the forces of supply and demand, are always fair reflections of real value. There are no “hidden” values or other anomalies. Firm belief in the rationality of individuals leaves no room for accepting concepts such as speculation or instability. At any given time, the market reflects reality and leads to optimality, provided that it operates freely, without any intervention or any meaningless, inefficient regulation. The closer we get to the conditions of perfect competition, the closer both the economy and society get to optimality.

Finally, markets and rational actors— firms and households— do not require any kind of guidance or protection. The system will balance itself in the best possible manner and will find its way. Any central intervention might offer some short-term relief, but it could also sow the seeds of even more serious anomalies and problems.

According to mainstream economic theory , free-market capitalism is more or less perfect and stable, provided that it can operate without any hindrance. But if everything works like clockwork, as the theory claims, then why is the economy frequently hit by violent crises? Why do we see extreme volatility and instability, even in foreign exchange and stock markets, which approximate the features of perfect competition like no other market?

Papadogiannis, Yannis (2014-08-12). The Rise and Fall of Homo Economicus: The Myth of the Rational Human and the Chaotic Reality (pp. 61-62). CreateSpace Independent Publishing Platform. Kindle Edition.
Ahhh... What do I know?
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UPDATE
Lagging interoperability stymies quality
Efficiency continues to suffer and care is not as safe as it should be

Neil Versel, October 13, 2014


Stage 2 of meaningful use is supposed to be about interoperability of data, with electronic records flowing securely between sites as needed to help hospitals and doctors provide better care. But the number of attestations to Stage 2 – just 25 hospitals and 1,277 eligible professionals nationwide had attested to Stage 2 in August, according to CMS – has been anemic, and there is plenty of anecdotal evidence suggesting true interoperability is a long way off.

Meanwhile, efficiency continues to suffer and care is not as safe as it should be.

At a Washington conference on the future of healthcare this month, national health IT coordinator Karen DeSalvo, MD, said that in the absence of interoperability, EHRs will have limited effect on care quality.

"We have to remember that health IT is a tool," DeSalvo said several times that day. "Health is more than healthcare and that health IT goes far beyond electronic health records," she added.

Some now are suggesting that it might be time once again to rethink health information exchange, while many are touting application programmer interfaces as a smart way to connect EHRs to each other and to external data sources...
 Of ourse, he's referring to clinical care efficiency, not "economic efficiency." And, again Will the API be the savior of Health IT "interoperability"?
DeSalvo said the API strategy is merely one way to achieve interoperability, and she praised EHR vendor Cerner for showing "how useful it can be." But interoperability of health information is not exactly easy, and it is not a panacea for all that ails healthcare.
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ERRATUM

From THCB:
Six Sigma vs Ebola
By SAURABH JHA, MD


If another case of Ebola emanates from the unfortunate Texas Health Presbyterian Hospital, the Root Cause Analysts might mount their horses, the Six Sigma Black Belts will sky dive and the Safety Champions will tunnel their way clandestinely to rendezvous at the sentinel place.

What might be their unique insights? What will be their prescriptions? ...


They would be careful in blaming the electronic health record (EHR), because it represents one of the citadels of Toyotafication of Healthcare....

The problem solvers might offer five prescriptions:
  1. Sensitivity training for all physicians.
  2. Mandatory courses on Coursera on Quality and Safety.
  3. A must watch video for all healthcare workers on the importance of communication, with real patients who have been harmed by lack of communication.
  4. Six Sigma liaison person in the hospital and an identifiable safety champion for each clinical section.
  5. An app for Ebola.
I suspect they will tell us that when everyone is responsible for everything no one is responsible for anything.

That when nurses try to be doctors (and accountants for CMS) and doctors try to be managers (and accountants for CMS) there will be a de facto shortage of doctors and nurses...


But only physicians can beat the decline in judgment induced by the epidemic of noisy irrelevancy. If we fail, managerialism will fill its space, leading to further decline, then even more managerialism, a vicious cycle...
Ouch.

MORE ON MARKETS AND COMPETITION

Jean Tirole, Nobel Economist, from Bloomberg BusinessWeek:
The government worries mainly about “horizontal” mergers in which one company buys another that does the same thing. But there’s also a risk in vertical combinations. A monopolist in one part of the production chain–say, a computer operating system–might be able to extend its market power to neighboring links on the chain.


The Chicago School of antitrust economics, personified by the likes of failed Supreme Court nominee Robert Bork, argued in the 1970s and 1980s that attempts to extend a monopoly “vertically” would be irrational because a company could get all the benefits of its market power without merging with one of its customers or suppliers. The Chicago School’s theory was so influential that it caused the Justice Dept. to remove “vertical integration” from the things to watch out for in its official merger guidelines.

The downside of that is less competition and possibly higher prices. The upside is that vertical combinations can encourage competition. “Competition law therefore has to weigh these two considerations against each other,” the Nobel committee wrote in its general-interest explanation of the prize.

“Tirole’s analysis of vertical contractual relationships quickly gained academic acceptance, and it has contributed to a significant revision of competition policy, especially in the U.S.,” the scientific paper explains...
Okee-Dokee. Precisely how unfettered vertical monopolization can "encourage competition" escapes me. Unless, say, it was -- in the case of Health IT -- a regulation "monopoly" in the form of a Data Dictionary Standard?

Another JD Kleinke quote:
"An economist is someone who sees something that works in practice and tries to figure out whether it will work in theory."
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CODA


 Ya THINK?
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More to come...