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Wednesday, September 19, 2012

"Savings promised by the government and vendors of information technology are little more than hype." - WSJ

The Wall Street Journal has just tossed a large cup of cold coffee on HIT.
OPINION September 17, 2012, 7:25 p.m. ET
A Major Glitch for Digitized Health-Care Records
Savings promised by the government and vendors of information technology are little more than hype.

In two years, hundreds of thousands of American physicians and thousands of hospitals that fail to buy and install costly health-care information technologies—such as digital records for prescriptions and patient histories—will face penalties through reduced Medicare and Medicaid payments. At the same time, the government expects to pay out tens of billions of dollars in subsidies and incentives to providers who install these technology programs.

The mandate, part of the 2009 stimulus legislation, was a major goal of health-care information technology lobbyists and their allies in Congress and the White House. The lobbyists promised that these technologies would make medical administration more efficient and lower medical costs by up to $100 billion annually. Many doctors and health-care administrators are wary of such claims—a wariness based on their own experience. An extensive new study indicates that the caution is justified: The savings turn out to be chimerical.

Since 2009, almost a third of health providers, a group that ranges from small private practices to huge hospitals—have installed at least some "health IT" technology. It wasn't cheap. For a major hospital, a full suite of technology products can cost $150 million to $200 million. Implementation—linking and integrating systems, training, data entry and the like—can raise the total bill to $1 billion.

But the software—sold by hundreds of health IT firms—is generally clunky, frustrating, user-unfriendly and inefficient. For instance, a doctor looking for a patient's current medications might have to click and scroll through many different screens to find that essential information. Depending on where and when information on a patient's prescriptions were entered, the complete list of medications may only be found across five different screens.

Now, a comprehensive evaluation of the scientific literature has confirmed what many researchers suspected: The savings claimed by government agencies and vendors of health IT are little more than hype...
 OK, pretty damning. But,let's surf over to the abstract page of of one of the referent "scholarly" papers cited in the WSJ article's cited meta-analyic study, "The Economics of Health Information Technology in Medication Management: A Systematic Review of Economic Evaluations."
Conclusion. The quality of the economic literature in this area is poor. A few studies found that HIT may offer cost advantages despite their increased acquisition costs. However, given the uncertainty that surrounds the costs and outcomes data, and limited study designs, it is difficult to reach any definitive conclusion as to whether the additional costs and benefits represent value for money. Sophisticated concurrent prospective economic evaluations need to be conducted to address whether HIT interventions in the medication management process are cost-effective.
 Meta-analytic research, recall, is comprised of studies that study other studies. So, this effort is akin to "Dr. Joyce Brothers Does HIT."

To conduct the study, faculty at McMaster University in Hamilton, Ontario, and its programs for assessment of technology in health—and other research centers, including in the U.S.—sifted through almost 36,000 studies of health IT. The studies included information about highly valued computerized alerts—when drugs are prescribed, for instance—to prevent drug interactions and dosage errors. From among those studies the researchers identified 31 that specifically examined the outcomes in light of the technology's cost-savings claims.
I'm gonna hold my fire until I can get access to the McMaster thing. We'll see. Although, I will crack on this from the WSJ article:
It is already common knowledge in the health-care industry that a central component of the proposed health IT system—the ability to share patients' health records among doctors, hospitals and labs—has largely failed. The industry could not agree on data standards—for instance on how to record blood pressure or list patients' problems.
That is unfair. "Failed"? It's just getting underway. We've known of the knotty "interoperability" problem for quite some time, and a lot of smart people are working tirelessly to solve it within the paradigm of private market HIT.

Much more to come on this. In the imterim, I exhort you to read the numerous accruing companion WSJ article comments (107 at this writing).

The heads-up on the WSJ thing came by way of being copied on a response to our CFO Dan Memmott by Sharon Donnelly (pdf), our SVP of Corporate Strategy (and who used to be our REC Executive Director).
Thanks for sharing. I appreciate the perspective of industry unduly driving the political agenda.

The article seems to confound two things: saving from HIT in cost of health care and saving from HIT in cost to the provider using it.

The evidence for the first is not there yet. Some think we have built the base needed to get the discrete actionable data to support electronically coordinating care and point of care clinical decision support that will eventually gain the savings. Others see us (primarily due to standards lag issue?) as far from there and legitimately question how current EHR and HIE architectures can support the needs of ACOs and other program designed to improve care and lower cost.   We may have a role in helping our community providers evolve together to a coordinated state that is required to see these benefits.

The second, savings to the practice or hospital, is almost completely dependent on the way the provider plans and implements HIT. Those doing it well reap huge savings in their operating costs. Unfortunately this often includes allowing them to document care in a way that they are reimbursed more, which of course drives the overall cost savings of healthcare in the wrong direction. 

No magic bullet here – just a lot of work!

Some pushback in the HIT press:
A little patience for the health IT revolution

How long did it take American farmers to widely adopt hybrid corn?

Honestly, I don't know, but I do remember what I was told about that kind of adoption—30 years.

I was age 22 at the time and had just started my agriculture extension training with the Peace Corps in Sierra Leone, where we learned the basics of rice paddy construction and swamp rice cultivation. It wasn't until later, when we were posted to our villages to serve our two-year hitches, that we learned just how hard it was going to be to convince wary farmers to abandon their familiar but ecologically destructive slash-and-burn cultivation techniques.

While covering health information technology during the past 12 years, I've thought a lot about that warning against short-run overexpectations. I thought about that warning, again, reading a recent article in the Wall Street Journal, "A Major Glitch for Digitized Health-Care Records."...

...Interoperability is a failure only if your time line is too short and you begrudge the incomplete successes that are happening around us. E-prescribing, one form of interoperability, is soaring. In a couple of years, the federally sponsored Direct protocols will similarly become the method of choice for peer-to-peer communication, replacing the phone and fax machine. Even the far more complex query-and-response form of exchange is coming along. Earlier this month, the VA demonstrated a potential breakthrough in consent management technology for privacy protection using Direct and off-the-shelf standards from HL7.

"This is no time to go wobbly" on health IT, to borrow a line from Margaret Thatcher. The past and future public investments in health IT were—and will be—both proper and necessary.

Now is the time to execute and innovate—and, yes, to be watchful and even critical. But also, and maybe of the most importance, it's time to be patient...

More pushback:
Asking the Wrong Questions About the Electronic Health Record

...Now that we have made an important investment in EHRs, we need to figure out how to use this new technology to address the fact that the healthcare system is a mess.  We need to figure out how EHRs can promote coordination of care across sites, seamless flow of good clinical information, and smart analytics, to name a few things.  We simply can’t do that in a paper-based world.  I am sure that the healthcare industry single-handedly keeps the fax machine industry alive.  We need to stop. Period.  Every other part of our lives has become electronic and the benefits are clear.  Our lives are better because we bank online, communicate online, shop online.

The debate over whether we should have EHRs is over.  Can we fix our broken healthcare system without a robust electronic health information infrastructure?  We can’t.  Instead of re-litigating that, we need to spend the next five years figuring out how to use EHRs to help us solve the big problems in healthcare.
Emphatically agree. Once again, down in The Weeds' -
“A culture of denial subverts the health care system from its foundation. The foundation— the basis for deciding what care each patient individually needs— is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new,secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information.

Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information. If businesses were permitted to operate without accounting standards, the entire economy would be crippled. That is the condition in which the $2½ trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.”…

…this subject matter may seem like just a variation on current policy concerns with using “health information technology” to bring “evidence-based medicine” to “patient-centered” care. Yet, current policy fails to comprehend the needed discipline in medical practice and thus fails to define precisely what is needed from health information technology. A dangerous paradox thus exists: the power of technology to access information without limits magnifies the very problem of information overload that the technology is expected to solve. Solving that problem demands a meticulous, highly organized, explicit process of initial information processing, followed by careful problem definition, planning, execution, feedback, and corrective action over time, all documented under strict medical accounting standards. When this rigor is enforced, a promising paradox occurs: clarity emerges from complexity.”

- Lawrence Weed, MD and Lincoln Weed PhD, “Medicine in Denial
None of which mandates being an unreflective, Pollyannish HIT cheerleader, to wit,

Epic FAIL!
County health doctors air complaints about county's new $45 million computer system
By Matthias Gafni, Contra Costa Times
MARTINEZ -- One of every 10 emergency room patients at the county's public hospitals in September left without ever being seen by a doctor or nurse because of long waits -- a number rising since implementation of Contra Costa's $45 million computer system July 1.
One patient waited 40 hours to get a bed.
Dr. Brenda Reilly delivered the troubling news Tuesday afternoon to county supervisors. She was one of three dozen doctors in the supervisors' chamber complaining about EPIC, new computer software aimed at integrating all of the county's health departments to create a federally mandated electronic medical record for patients.
To allow for the major computer program installation and conversion, administrators cut doctors' patient loads in half, in turn cutting the number of available appointments in half.
In a letter to the supervisors, Dr. Ori Tzvieli -- medical staff president whose union has been negotiating a new contract with the county -- along with 14 doctor co-signers pleaded for administrators to continue scaling back physician workloads because doctors are over-stressed. Six doctors have left this year, said Dr. Keith White, a 22-year pediatrician.
"We were not ready for EPIC and EPIC was not ready for us," White told supervisors. "As a result, the providers are struggling to provide safe and effective care for 100,000 citizens of the county, many of whom are very ill. We often feel that we are failing. We are very tired... many doctors have left and all are considering leaving."...
Ouch. The runaway market share leader in "certified" EHR, both ambulatory and inpatient. Talk about "Major Glitches."


This hit my inbox last night:
Hi Bobby,

Thank you so much for applying for a press pass and congratulations on being chosen to attend the upcoming Health 2.0 Fall Conference in San Francisco on Oct 7-10 2012! We only choose the best and most qualified applicants to attend our exciting conference.

The press pass gives you access to the Health 2.0 conference and DC to VC. Below please find the instructions for registering and let me know if you have any problems...

...Please let me know if you have any additional questions or problems regarding registration and we look forward to seeing you in San Francisco soon!

Best regards,
Health 2.0
I am really grateful. HIMSS12 was a blast, and I will cover this event with equal gusto.



My beloved niece April was married this past weekend in Marquette, MI. I scored one big-time on this photo.


Now-husband Jeff Nyquist is Dr. Jeff Nyquist, Vanderbilt PhD in neuropsychology, CEO of Upper Peninsula Home Health, Hospice and Private Duty. I want to get to talk shop with him at some point regarding long-term care HIT.

Power couple.

Any excuse to go to Marquette and see my sister and the kids. Jeff calls me "Uncle Bobby." I love that.

Downtown Marquette, shot from the reception restaurant balcony looking back up the hill.

What a cool little town.

My new grandnephew Anthony (8 wks old) agrees (Great Aunt Cheryl was holding him out on the balcony when I shot that).



At the 6th Annual Fall Conference you will see the very latest technologies in Health 2.0, and we’ll maintain our tradition of hosting leading thinkers and fascinating conversation. This fall, new technologies will be presented in contextual environments woven around a developing narrative which illustrates the transformation occurring in the space. Change doesn’t come easily and a true, universal transformation requires the analysis, connection and redefinition of categories across all parts of the system. We’ll dive deeper into these issues with topics like big data analysis, personalized medicine, price transparency and keynotes from Health Futurist Joe Flower and Aetna CEO Mark Bertolini. Over two days we will progressively illuminate on stage, through mini-environments and discussion, that Health 2.0 is everywhere – it touches how we live, how we eat, how we interact with providers, patients and more. There’ll be lots of media coverage, hundreds of potential customers, and scores of potential partners to meet. If you want to get involved in health care innovation, you need to be at Health 2.0!
I booked my flights today. Awesome agenda. Starting with
Health Law 2.0
Health 2.0 has created a pre-conference session entitled Health Law 2.0 that addresses the pressing legal issues for both large and small Health 2.0 companies.   We have identified several key legal issues that face companies in the regulated world of health care and created two tracks of programming — one focused on Patient/Consumer Legal Issues and the other focused on Legal Issues with Providers, Plans and Life Sciences.

The panels we have assembled include the leading experts in each topic who will provide an overview and important updates.  The panel also will work through some interactive examples of problematic arrangements and provide insight on how to avoid legal risk.  In every session, there will be ample time for questions.

The tracks will run concurrently and you may attend sessions in either track.  This is a wonderful opportunity for all Health 2.0 companies to delve deeper into the legal issues so they can make better choices as well as identify potential opportunities and capitalize on them.  It’s also very useful to hear what different experts think about a particular issue so you can make informed decisions.

We look forward to seeing you at the Health Law 2.0 pre-conference!
You can bet I will be there. Then, Monday Morning:
Leading Health Futurist, Joe Flower, will discuss the practical solutions that health care organizations need to implement to deliver health care at half the cost. Joe is a regular columnist who contributes to Hospitals and Health Networks, has spoken at thousands of health care meetings and is the author of a new book Healthcare Beyond Reform: Doing it RIght for Half the Cost.

Aetna CEO, Mark Bertolini will discuss the how his company is leading the pack in a transformation from insurance company to health tech services company, while bringing along its partners -- both providers and technology companies -- and its customers -- employees & consumers. Last year they introduced the iNexx platform and in 2012 they are debuting the CarePass consumer platform, and on our stage will announce the results of the Aetna CarePass Platform and Medication Reminder Developer Challenge.

I've written of Joe's impressive work before:


Got it on Kindle last night. Looks like a safe bet for $9.99. I already know my "basics" and then some, but it never hurts to get another perspective. This is spot-on:
I believe that the range of approaches that many organizations are using creates a strong need for process improvement professionals to be “tool agnostic” and fluent in several improvement dialects. This would position these improvement practitioners to serve as trusted advisors or coaches to business leaders rather than true believers that specialize in the one best way they know to improve work.
-  Page 34, Kindle Edition.
UPDATE: While nominally "method agnostic," a quick first scan reveals this book to be fairly "Lean" favorable. A good thing, in my view. I like in particular the specific attention paid at the end to "knowledge work" (i.e., like, uh, HIT software development and management, ja?).

A handful of my conceptual visual mapping "workflow" overviews:

Click to enlarge.


National Association Created to Represent Regional Extension Centers for Health Information Technology
New national group formed to provide a strong voice for the 62 Regional Extension Centers that provide assistance and guidance for the adoption and use of health information technology.

Silver Spring, MD (PRWEB) June 21, 2012

A new national association has been formed to provide a strong voice for the 62 Regional Extension Centers that provide assistance and guidance for the adoption and use of health information technology. The Association of Regional Centers for Health Information Technology, or ARCH-IT, represents Regional Extension Programs and the unique needs of the independent health care providers served by RECs in every state across in the United States...

I know these people must be tired of me calling them out (and, note that I have not personally outed them). But, I'm still on the lookout for that "strong voice."

I have no Beltway Gucci Gulch experience, but, the lobbying strategy -- uh, "trade association strategy" -- escapes me. Nonetheless, I suppose should there be no federal dollars tied up in this "effort" (via the RECs), it's none of "my business."

WASHINGTON (HealthcareIT News) – There are no set appropriations for how much the federal government can spend on rewarding providers who adopt and use electronic health records under the Medicare and Medicaid meaningful use EHR incentive program, according to National Coordinator for Health IT Farzad Mostashari, MD.

"Whoever qualifies, gets paid; there's no hard cap," said Mostashari, who gave a keynote at the Annual Policy Summit for the Health Information Management and Systems Society (HIMSS) on Wednesday.

Mostashari said the federal government estimates it will pay out around $20 billion in incentives before the program shifts to a penalty in 2015, but there is no fixed budget set in the HITECH Act that mandated the program. The government recently announced it has paid out nearly $7 billion since the program began in 2011...
There is, however, a hard cap on REC funding, which will be gone this time next year. And time is rather quickly running out to do anything substantive about that.

More shortly. NIST 2014 CEHRT Testing Stds, 2nd wave release, more HIPAA breach follies and fines, more on "usability," AAFP on PCMHs and APNs, DURSA, #VDTnow...


Maybe I'll just start a new post. Some of the topics will just continue, as always.

Kansas HIE to hand over authority to the state
September 20, 2012, Anthony Brino, Contributing Editor, Healthcare IT News

TOPKEKA, KS – The Kansas Health Information Exchange will dissolve itself and hand over operations to the state’s health department after a long stakeholder debate about the costs of the public-private HIE, and its regulatory role, in a state with a growing provider-based HIE network.

The Kansas Health Information Exchange (KHIE) board voted last week to transfer its operations to the Kansas Department of Health and Environment by October 2013, when federal grant funding is set to expire. The plan still needs to be approved by the state legislature.

Cost was apparently the largest factor behind the decision. Staffing KHIE as an independent body was estimated to cost $400,000 a year, and the board was considering charging fees from providers or HIEs. Shifting KHIE’s regulatory operations to the state would cost about $54,000, state officials have estimated...

Created in 2010, KHIE evolved from an HIE commission created by then-governor and current U.S. Health and Human Services secretary Kathleen Sebelius. Initially intended to be an HIE, it eventually sought to be more of a regulator, as health systems started building their own infrastructure and connecting to the Kansas Health Information Network, a statewide HIE built with private funding by the Kansas Hospital Association and the Kansas Medical Society.

KHIE’s public-private nature has at times been controversial, and the effort to scale back what some might consider a bureaucracy comes as Republican Governor Sam Brownback’s administration is trying to scale back the role of government in other areas, like transitioning almost all of the state’s Medicaid recpients into managed care organizations.

It’s not entirely clear what will happen to the remainder of the roughly $9 million KHIE received from the Office of the National Coordinator.

“We would like to have some of the stimulus funds," Laura McCrary, executive director of the Kansas Health Information Network, told Government Health IT in August.

"There’s about $5 million left, and we’re hopeful we’ll get a portion of that," McCrary said. "It’d be great to have a bridge fund" for exchange infrastructure in the works.
Hmmm... a BobbyG Photoshop Moment inexorably ensues...

I have to wonder whether the HIT politics in Kansas are as fraught as they are in my state, Nevada. Our situation differs materially, in a way (perhaps it's sort of the inverse). HealtHIE Nevada is not the ONC HIE Grantee. Nevada DHHS is (though we are the ones with "boots on the ground" at this writing).
The Office of Health Information Technology is responsible for administering Nevada’s ARRA HITECH State Health Information Exchange (HIE) Cooperative Agreement, facilitating the core infrastructure and capacity that will enable statewide HIE and coordinating related Health IT initiatives...
As the initial phase of implementation to the State  Health IT Plan, NV DIRECT will soon be deployed.  NV DIRECT will allow participants to send authenticated, encrypted patient health information directly to known, trusted recipients.  This electronic capability will enable providers to share relevant and authorized patient medical information directly and securely with each other.
This latter thing (NV DIRECT) goes to stuff like the DURSA (Data Use and Reciprocal Support Agreement), which I am now tasked with assessing, with respect to resources likely to be necessary for compliance.

You don't just sign a DURSA pro forma.

One last thought before firing up a new one. OK, my Coda can be longer than most peoples' blog posts, I know. Dr. Rob Lambert wrote an interesting post the other day, "Care on the Continuum," wherein he discussed more on his decision to go "Direct Care" (i.e., Direct Patient Pay).
My change from a traditional practice to direct-care has caused me to challenge some of the basic assumptions of the care I’ve given up to this point.  Certainly, the nature of my documentation will radically change with my freedom from the tyranny of E/M coding requirements.

Perhaps the biggest change in my care comes courtesy of the way I get paid.  The traditional way to be paid is for service rendered (either at an office visit or procedures done).  This means that I am financially motivated to give the bulk of my attention to people when they are in the office.  They are paying for my attention, so I try to give them their money’s worth.  The corollary of this is that I tend to not think about people who are not in the office to be seen.  The end-result is an episodic approach to care that is entirely dependent on the patient paying for an encounter.

There is a huge problem with this approach to care: people live their lives between encounters.  Life does not go on hold between office visits for my patients, and the impact of my care is not dependent on what happens in the encounter, but what happens between visits.  My ability to help my patients depends on my ability to affect the continuum.  If I do a good enough sales pitch for a person taking their medications, and if I consider the life-circumstance which may affect their ability to take the medicine, then I am successful.  I don’t learn about the success until their next visit (usually), and I also don’t learn about problems until then.  People are reluctant to call with problems they are having with medications, new symptoms, or other important details, often waiting for many months to tell me things I really want to know.  Perhaps they don’t want to be “one of those patients who calls all the time,” perhaps they don’t understand what I said, or maybe they’re worried I will “force them to come in” to pay for another office visit.  Regardless of the reason, I get very limited interaction with my patients in this episodic care model...

...I keep getting new ideas of how to handle problems differently in this new model of care, but all of them benefit from the fact that it looks at patients before problems pop up, or at least at the time of the problem instead of after a potentially dangerous delay.  The waste in our system is, as has been noted often, huge.  But the assumption that episodic care is the proper model could be the most costly mistake of all.  People are afraid to engage our system because of the cost, and that fear ends up costing everyone by not dealing problems until they are “bad enough.”  Care on the continuum seems to accomplish the main goal of my care: keeping people away from the rest of the health care system unless it’s absolutely necessary.
 I posted a comment.
Very thought-provoking post. Thank you.

This is perhaps a weak analogy, but, nonetheless:

I used to work in Risk Management in a subprime credit card bank. I was the principal “portfolio management” officer/analyst. It was a big part of my job to monitor ongoing the shaky financial “health” of our financially halt and lame cardholders (we used to joke that it was like giving whiskey to alcoholics, granting credit lines to subbies). We had effective data mining pxs and predictive models for everything. Once we booked these people, he had to try to keep them profitably “healthy.”

I was a SAS and S-Plus and all-around RDBMS whiz.

I had access to tons of customer activity data every day. I could track your every transactional “move.”

The principal concerns were, of course, our “patients” “dying” on us (charging off and stiffing us), as well as the relentless outright fraud stuff (i have some funny stories).

We made successively record profits every year of the five that I was there. Data-driven, baby.


Before you go cracking on me, I quit in 2005 to go back into HIT work, at a 23% salary reduction. Today, I could make 3x my current salary (which is not quite what I earned at the bank back then when I left) were I to go back into “distressed consumer debt modeling and management.” The comp package numbers give me pause, but, I will not. Ever again. It’s just too jive. I have to sleep. And look in the mirror.

I will stay in the HIT space until I retire.

I have utter respect for clinicians. I work with them every day. I don’t see how y’all do it.
And then another, later in the discussion, in response to a prior comment:
“In the aforementioned DPC paper, the evidence suggests a significant decrease in ED visits, surgeries, hospitalizations and specialist visits. That may be good for the patient and whoever is picking up healthcare costs but obviously one person’s cost savings is another’s revenue. It’s clear why some orgs won’t embrace DPC if they see it harming their bottomline.”
This has long been the reform conundrum.

“Every misspent dollar in the health care system is part of someone’s paycheck.”

- Brent James, MD, M.Stat, IHC, 1995, during our CQI training sessions in SLC

Brent also noted (paraphrasing here) “Let’s not kid ourselves that we’re gonna QI our way out of the larger problem. Giving the best possible care today only ensures that you’re gonna have an older and sicker and more expensive patient down the line.”

See also “Allocating Health Care Morally,” 1994

It continues to be a socioeconomic and moral perplex.

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