Failure is Not an Option

2010 is drawing to an end amongst a flurry of activities in the Health IT field. In a few short days 2011, the year of the Meaningful Use, will be upon us and the stimulus clocks will start ticking furiously. In addition to the yearlong visionary activities from ONC, December 2010 brought us two landmark opinions on the future of medical informatics. The first report, from the President’s Council of Advisors on Science and Technology (PCAST), recommended the creation of a brand new extensible universal health language, along with accelerated and increased government spending on Health IT. Exact dollar amounts were not specified. The second report from the Institute of Medicine (IOM) is a preliminary summary of a three-part workshop conducted by the Roundtable on Value & Science-Driven Health Care with support from ONC, and titled “Digital Infrastructure for the Learning Health System: The Foundation for Continuous Improvement in Health and Health Care”. The IOM report, which incorporates the PCAST recommendations by reference, is breath taking in its vision of an Ultra-Large-System (ULS) consisting of a smart health grid spanning the globe, collecting and exchanging clinical (and non-clinical) data in real-time. Similar to PCAST, the IOM report focuses on the massive research opportunities inherent in such global infrastructure, and like the PCAST report, the IOM summary makes no attempt to estimate costs.

Make no mistake, the IOM vision of a Global Health Grid is equal in magnitude to John Kennedy’s quest for “landing a man on the moon and returning him safely to the earth” and may prove to be infinitely more beneficial to humanity than the Apollo missions were. However, right now, Houston, we’ve had a problem here:

1. The nation spent upwards of $2.5 trillion on medical services this year
2. Over 58 million Americans are poor enough to qualify for Medicaid 
3. Over 46 million Americans are old enough to qualify for Medicare 
4. Another 50 million residents are without any health insurance
5. The unemployment rate is at 9.8% with an additional 7.2% underemployed
6. This year’s federal deficit is over $1.3 trillion and the national debt is at $13.9 trillion

In all fairness, the recent Federal investments in Health IT were spurred by the HITECH Act, which was a part of the ARRA, a recession stimulus bill aimed at injecting money into an ailing economy and creating jobs, while improving national infrastructure. It was not explicitly intended to reduce health care costs or improve access and affordability (that came later with PPACA). Perhaps adding an EHR to every doctor’s office was viewed as the first step towards building the Learning Health System. However, somewhere along the road to fame EHRs were magically endowed with powers to provide patients “with improved quality and safety, more efficient care and better outcomes”. Perhaps these claims came from EHR vendors’ glossy marketing collateral, or perhaps it was just wishful thinking, or perhaps this was a forward looking statement for the fully operational grid of a Learning Health System, or maybe this is just incorrect use of terminology. Health IT is much more than EHRs and Health IT can indeed help improve efficiency, i.e. cut costs, in several ways.

Administrative Simplifications

Section 1104 of the PPACA contains a roadmap for administrative simplifications “to reduce the clerical burden on patients, health care providers, and health plans”. Eligibility transactions must be standardized and deployed by 2012, electronic payments by 2014 and claims, certifications and authorizations by 2016. Physicians spend about 14% of revenue on billing and insurance related functions, while hospitals spend 7% - 11% and health plans spend around 8%, not to mention the aggravation involved. Why do we have to wait 6 years before this particularly wasteful activity is completely addressed? If there is a place where health care can learn from other industries, this is the one. Both the banking and retail industries have solved this problem many years ago. It is trivial to imagine swiping a magnetic card at the doctor’s office to verify eligibility, obtain authorization, and exact dollar amounts for patient responsibility, while initiating a real time payment transaction from insurer to provider. The complexities of a thousand different plans can be easily accommodated by computer algorithms and the technology is available in every supermarket and every gas station. For all those joining Congress in 2011 with the intent of altering PPACA, could we alter Section 1104 and shorten the timeline by a few years?

Fraud

The National Health Care Anti-Fraud Association estimates the costs of health care fraud to be 3% to 10% of expenditures. Despite all the publicity, credit card fraud is estimated to cost 7 cents per each $100 in transactions, or 0.07%, with issue resolution times estimated at 21 hours. This is yet another lesson health care can learn from the financial industry. Granted, purchase patterns in health care are different than the market at large, so the anti-fraud algorithms will need to be tweaked and specialized. Computers are very good at this and from watching the President’s bi-partisan meeting on health care reform last year, I thought this is one area where everybody agrees that something needs to be done. There is nothing tangible in PPACA regarding the use of Health IT for fraud reduction.

Duplication of Tests

If you prescribe electronically through Surescripts, you can see a patient’s medications list courtesy of the PBM. PBMs and insurers know exactly what medications they paid for. They also know exactly what procedures, tests and visits they paid for, and who performed them. Would it be a huge stretch of imagination to envision a display of the last 6 months of tests paid by the insurer every time you attempt to order a test? No, insurers don’t have the results, but if you saw that the patient had an MRI last week, would you order another one today? Or would you call the facility for a copy? When you prescribe electronically, the PBM insists on showing you the formulary and drug price for the individual patient. Why not show you prices for the tests you are about to order, and help you and the patient choose lower priced facilities, just like they steer folks to prescribe generics? This has nothing to do with clinical decision support or changing the way medicine is practiced. These are examples of very simple, common-sense, immediate solutions for reigning in costs without disturbing quality of care.

The Global Learning Health System presents a compelling vision. I wish that the President would commission the necessary budget estimations, go before Congress and in a JFK style oration request appropriations for defeating Cancer (or some other scary thing), appropriations which will include funding for the Learning Health System global grid. It is possible that if such Learning Health System existed today, or could be quickly deployed, it would provide solutions for most health care problems we currently have. However, it is pretty clear that such a system will take many years and many billions of dollars to build. In the meantime we have an immediate problem, which requires an immediate solution with immediately available tools, and no, failure is still not an option.

The F Words of Health Care

Vassily Kandinsky, 1923

Fragmentation, Fee-for-service and Futile care are the trifecta of what is supposedly ailing our health care system, or non-system, as it is fashionably described nowadays. Modern health care has reached its crisis point not due to hordes of people keeling over and dying in the streets, as they did during historical health care crises brought on by plagues and famine, but due to exploding costs of delivering decent care to all people. Since the issue now is mostly financial, health care as a discipline is attracting the interests of those who practice the dismal science of Economics. Over the last two centuries, economists have successfully addressed the F words in other industries with spectacular results in developed countries, so why not apply lessons learned to health care? 

The obvious reason to treat economists with suspicion in health care is the quintessential argument that people are not widgets, but there is another problem. Most tried-and-true solutions for increasing availability and quality while lowering costs of products are not accounting for the other explosion occurring as we speak – the Internet.  How can this assertion be true when we are in the midst of a government sponsored spending spree to computerize medical records and adopt Health Information Technology (HIT)? Apparently, even those who lead and define the HIT revolution are reluctant (or unable) to grasp its full implication, thus they are consistently underestimating the power of the Internet to serve the individual, and as a result are hedging their bets on technology with classic industrial models from days gone by.

In a 2008 Health Affairs article, Dr. Donald Berwick has defined what has become the official goal of policy making for the Secretary of Health and Human Services. Better known as the Triple Aim, the goals are to create better health, provide better care and lower costs of care. If you look at health care as just another industry, the Triple Aim translates into a better product with a better process at a lower cost. Well, when put this way, the solution is pretty obvious and it has been obvious for over two centuries. We must address the F words: eliminate Fragmentation by aggregating independent artisans in one physical location, stop paying Fee-for-service (piecework) and pay salaries instead, and most important, eliminate Futile work by standardizing the process. In short, apply the industrial revolution to health care and realize the economies of scale that brought prosperity and happiness to the developed world. Except that for some strange reason, this solution doesn’t quite work in health care.

Case in point: Federally Qualified Health Centers (FQHC). FQHCs started out in the early 1960s as community run clinics to provide medical care to the poor. By the mid-nineties, and with the best of intentions, the Federal government and the Centers for Medicare & Medicaid Services (CMS), created funding grants and reimbursement methods to support these clinics. Today there are thousands of FQHCs of different types, operating in health care shortage areas and providing team-based comprehensive care including preventative care, basic primary care, behavioral care, dental care, lab and pharmacy services, mostly to Medicaid beneficiaries and the uninsured, but also to small numbers of Medicare and privately insured patients. FQHCs must use mid-levels to provide and coordinate care and must report on quality measures. In return, FQHCs receive millions of dollars in grants for building and improvements, have access to cost effective workforce, can obtain free malpractice protection, are tax exempt and are paid more than double what a private practice is paid for Medicaid services. By all accounts, FQHC are addressing the triple Fs of health care rather well, but how are they doing against the Triple Aim objectives?

Studies are mixed regarding quality of care provided by FQHCs, and patients cared for by FQHC are largely sicker than those seen in private practice. Interestingly enough, neither Medicare, nor privately insured patients are flocking to FQHCs, in spite of the financial advantages offered, particularly to Medicare patients, and in spite of the spiffy state of the art facilities. This may, or may not be, an indicator for perceived quality of care. How about lowering costs? Do FQHCs provide care at a lower cost than, say, an independent solo private practice?  Adding direct reimbursement rates, grants, tax breaks and other benefits, FQHCs visits cost more than twice the amount paid by Medicaid to private practices, which cannot compete with FQHCs and all but disappeared from areas where FQHCs operate. What would have been the results if twenty years ago CMS would have decided to increase Medicaid fees and pay for uninsured visits to independent practices, instead of exclusively backing the creation and operations of a separate but equal clinic system for the poor? We may never know for sure.

FQHCs are only a small example* of why economies of scale are not easily achieved in health care. Large hospital organizations and even fully integrated health systems, which may be providing better care (or not) seem equally incapable of reducing costs in spite of attacking all three Fs, or seeming to do so, and there are two reasons for this failure: a) larger health care facilities have disproportionately larger overhead costs and b) large systems are better equipped to charge more for services, which renders their efficiency efforts less urgent. And this is not a matter of opinion. CMS acknowledges this built-in inefficiency as evident in the physician fee schedule which pays an additional “facility fee” for services provided in hospital owned outpatient clinics, presumably to cover the extra overhead. Surprisingly, CMS is consistently creating incentives and regulations to accelerate provider consolidation into these big inefficient and expensive systems. The only possible explanation would be that CMS is betting that elimination of the last two Fs (Fee-for-service and Futile care) will be easier in a consolidated environment and the gains will ultimately exceed the losses from doing away with independent practice (Fragmentation). What about information technology? Well, it is supposed to help with process standardization, data collection and performance measurements, similar to what computers do in every other industry.

We have all seen the infomercials for high-tech hospitals, where a bunch of doctors are seated around a conference room table, each holding a laptop or tablet, presumably discussing patients in a team environment. There is something very wrong with these pictures. First, it costs us a fortune to have all these physicians in one room. Second, there is almost no added utility for them to be using computers instead of passing around a piece of paper, and computers are expensive. Third, there is no patient in the room. Now let’s imagine a different picture: a primary care physician sitting in his office, with a patient next to him, both interacting with a computer on which a Skype conference is taking place with an oncologist sitting in his own office thirty miles away, a surgeon in a hospital lounge in the city and perhaps a radiologist half a continent away. Everybody on the call has access to the same electronic medical record, appointments can be made in real time, literature can be consulted and shared, prescriptions can be changed and a common care plan agreed upon by all and understood by all can be created and by using intelligent predictive analytics tools various options can be explored. Perhaps a family member in a different country is conferenced in and perhaps the patient is at home or in a break room at work. Perhaps there’s an electronic sign-up sheet for the oncologist, if the patient wants to ask something else later and have a physician friend in New Zealand listen in. And with one click on a PayPal button all doctors are paid for their time.

In this Internet age, manufacturing style physical consolidation is not only unnecessary, it is cost prohibitive. Modern lifestyles and modern medicine have created a need for doctors and patients to collaborate and the Internet is providing the means to accomplish such collaboration without having to physically gather everybody under one expensive roof. There is no need to obliterate the operational efficiencies of private practice and replace it with the bloated bureaucracy of large institutions, and there is no need to dispense with long lasting doctor-patient relationships in favor of computerized care coordination, and there is absolutely no need to substitute a bunch of numbers in a computer for a real patient. The Internet is decentralizing and individualizing everything from politics to manufacturing. Health care is, and always has been, decentralized, individualized and based on the local patient-doctor dyad. The resemblance is striking. We either embrace the fully aligned collaborative nature of the Internet to achieve better health, better care at lower costs, or engage in a doomed effort to impose an unnatural centralized command and control structure in health care just because it worked well for nineteen century steel manufacturing and because policy makers don’t truly understand the magnitude of the connectivity revolution.

* According to the Kaiser Family Foundation FQHCs had about $12.7 Billion in revenues in 2010, 75% of which came from Federal and State agencies. They served almost 19.5 million patients with over 77 million encounters. Simple math yields a cost of approximately $165 per encounter.

Health IT and the Carob Tree

At a certain point in time, somewhere in America, someone stated that people should all have lifetime, complete medical records. Sounds reasonable and I presume nobody ever asked, “Why?” As time goes by and health care services in America are approaching an unsustainable 18% GDP, the mythical lifetime record is quickly becoming panacea to the obvious problem health care has become. Americans accustomed to thinking about their health care as “the best in the world” are now being instructed that American health care is fraught with errors, needless deaths, unsafe treatments, uninformed physicians, unsanitary hospitals and basically stuck in the stone age of technology. And all this while sucking inordinate amounts of cash from simple-minded folks who have “no skin in the game” and thus completely oblivious to being robbed, bankrupted, maimed and killed by greedy health care providers and industry financiers. Don’t know about anybody else, but I am positively terrified... mortified... petrified... stupefied... by this.

Enter the aforementioned lifetime health record, a.k.a. “EHR for every American by 2014”.  EHR in this context denotes collections of information or data, not a software product. Instead of overstuffed manila folders and oversized yellow envelopes, each one of us will have a complete electronic dossier, stored somewhere TBD later, chock full of every lab result and imaging study we ever had, all blood pressure, weight, height, temperature, etc. ever taken, all pre-op, post-op, consultation and progress notes ever written, all diagnoses and medications, all cuts and bruises, all chief complaints and histories and all treatment plans that we followed and even those that we did not. When our EHR is ready for use, doctors will be making fewer errors, order fewer unnecessary tests, make more informed decisions, prescribe safer treatments and charge less money for more thorough work. Well, maybe the last one is a bit of a stretch….

Problem #1: Do we really need a comprehensive lifetime health record? Here and there, particularly for small children with chronic conditions, such record will be clinically meaningful. For the vast majority of Americans, a lifetime EHR may be a cute thing to have but not really a necessity. One may need records for recent years if managing chronic disease or battling a potentially fatal diagnosis, but for everybody else, including the exotic case of someone ending up in the ER unconscious, buck naked and all alone, the most you will need is a brief summary of vital information. So if we don’t need our pre-school growth charts and we don’t need an itemized litany of every URI we ever had, every story we told our doctor and every “RRR, normal S1, S2 and without murmur, gallop, or rub” ever recorded, what is it that we do need? I guess a reasonably healthy 40-year-old could derive some joy from perusing his comprehensive lifetime record – “Look honey, that awful cold I had in the winter of 87’ when we went skiing for the first time was really pneumonia. No wonder I broke my leg the next day… It’s all here. Isn’t this great?”  When the same 40-year-old goes to see his new family doc the next day for persistent “heartburn”, his 87’ adventure would be largely irrelevant, and if he ends up unconscious and naked at the ED that night, they may be interested in his recent “heartburn”, but still have no use for information on his hapless skiing vacation 23 years ago.

As Dr. David Kibbe aptly observed, what we, or our health care providers need, very much depends on the context. Defining a relevant superset of information should of course be left to practicing physicians, but if I had to define such superset, I would go with immunizations, problem list and medications (current, with option to view historical), allergies, a couple of years of lab results and imaging studies (longer for certain studies), standard major medical and family histories and for chronic or serious conditions, the last few physician notes. Interestingly enough, these data elements are already being captured in structured and codified manner by most currently available technologies. If money were no object, I don’t see a downside to cataloging and retaining every tiny piece of information, provided that it can be contextually filtered for different circumstances. But judging by the billions of dollars being spent on HIT, money is a very big object indeed and either way, those who care for unconscious, naked people presenting at the ED in the middle of the night, should not be expected to peruse lifetime records.

Problem #2: How do we get access to either comprehensive or contextually appropriate information? As we all know, our “fragmented” health care system is nothing but a collection of data “silos” maintained mainly on paper under lock and key by greedy providers, no doubt purposely so in order to maintain a competitive advantage in a brutal health care market where an overabundance of physicians are fiercely competing for an ever dwindling number of patients . Or maybe not…. Perhaps traffic of clinical information has been severely hampered by that one antiquated oath physicians still take which commands doctors to keep patient information downright secret. Either way, since in most instances people are treated by multiple providers, medical information must be shared between providers and certainly must be available to patients electronically (faxing, copying and phone calls are so uncool). Unfortunately, we don’t have a national healthcare system where all providers are employed by one entity, conform to one set of policies, use one technology platform and clinical data is easily shared. We do, however, have a few “look alike” entities such as Kaiser and the VA. Why not do away with the remaining “fragments” and consolidate our health care in a handful (a single one would be too Socialist) of fully integrated systems? It would certainly simplify things for HIT grand-designers and programmers.

The financial system, our beacon of informatics wisdom, has resolved this pesky problem long ago, as evident in the world-spanning network of ATMs, where card carrying customers with unique identifiers can exchange several bytes of information with their remote financial institution. For those desiring comprehensive financial records, there is Yodlee and Mint, which will aggregate all your financial accounts in one cloud based dashboard free of charge (any takers?). Strangely enough this hallmark interoperability accomplishment did not require federal funding, government committees or a compulsory “universal financial language” (arithmetic seldom does). One can never be certain, but it is possible that financial IT experts were less obsessed with fostering/stifling innovation and more concerned with providing pragmatic solutions to real problems without requiring that banks change the way “financial services are delivered” or that smaller banks cease to exist in order to simplify software programming.

Problem #3: Should we plant a carob tree? Legend has it that carob trees require 70 years to reach maturity and bear fruit (more like 7 really), thus planting a carob tree is a selfless act to benefit posterity. There is a remarkable disconnect between the voice of physicians who treat twenty, thirty patients every day, one patient at a time, and physicians in the academia and those in “leadership” roles who routinely converse about population health, bio-surveillance and clinical research. Doctors who make a living by touching patients today, not tomorrow and not after Meaningful Use Stage 5 has been achieved, usually find that an EHR has very little to contribute to the quality of care they deliver to the one patient in front of them. Health IT is promising them a paperless future, devoid of software and hardware both, where every metadata tagged digital piece of information about their patient is “a click of a button” away. Health care delivery will become well informed, efficient and flawless to the point that the patient may not even need to be “seen” in order to be treated. Magically frightening? No; just futuristic technology which may come to fruition in, say, 70 years. Perhaps EHRs are our carob trees.

Moral: If you insist on planting nothing but carob trees, you will starve to death and there will be no one left to enjoy the fruits of the carob tree.

Thoughts on the PCAST Report

The President’s Council of Advisors on Science and Technology (PCAST) released a report this month ambitiously titled “REALIZING THE FULL POTENTIAL OF HEALTH INFORMATION TECHNOLOGY TO IMPROVE HEALTHCARE FOR AMERICANS: THE PATH FORWARD”, complete with current state of HIT analysis and authoritative recommendations to ONC, CMS and HHS on how to proceed going forward. Initially, I skimmed through the 90 pages of the report and very much liked what I saw. PCAST is recommending a federated model for health information, with medical records stored where they are created and a comprehensive view aggregated on the fly on an as-needed basis by authorized users, including patients and their families. PCAST is urging ONC to significantly accelerate efforts in this direction.  Perfect. And then I took a deeper dive into the details of the report, and disappointingly came across a series of misconceptions and questionable assumptions surrounding what is basically a very good, albeit expensive, strategy.

The State of Affairs

The classic opening to all HIT reports seems to be the obligatory comparison to “other industries”: “Information technology, along with associated managerial and organizational changes, has brought substantial productivity gains to manufacturing, retailing, and many other industries. Healthcare is poised to make a similar transition, but some basic changes in approach are needed to realize the potential of healthcare IT”. While this is true, we should also recognize that medicine is very different than other “industries” in that it lacks 100% repeatable processes. For example, the entire process of manufacturing, packaging, ordering, delivering, stocking and selling a box of Fruit Loops is exactly the same for every single Fruit Loops box. Automation of such process is easy. Unfortunately, people are not very similar to Fruit Loops boxes, and paradoxically, the lack of appeal and utility of current EHRs is in large part due to EHR designers thinking about Fruit Loops instead of the many ways in which people express Severity or Location.

The PCAST report continues with the common mantra regarding our “fragmented” health care system and the fee-for-service model which is preventing the availability of complete health information at the point of care and the advantages of larger health systems which, unlike small practices, “have an incentive to provide care efficiently and reduce duplication or extraneous services when possible”. They must be referring to Integrated Delivery Systems (IDN), since large hospitals and multi-specialty groups have many incentives, but reducing extraneous services is not one of them and if there is an entity which lives or dies by achieving efficiency, it is the solo or small practice operating on abysmal margins. Either way, we need technology recommendations for an existing health care system, not so much for some utopian system were payers and providers cheerfully align their interests with patients and tax payers in general.

Legacy and Condensed Water Vapors

Unsurprisingly the overarching thread in the report is describing current EHR systems as “legacy” systems, which will eventually become obsolete and make room for “innovative” technologies delivered via the Clouds. I can see how using centrally deployed and managed applications (not really a new concept) can be easier and more cost effective for most providers, but does the software have to reside in a vendor datacenter in order to qualify for a “no more software” stamp of approval? Would the many Epic installations accessed remotely by physicians qualify as Clouds? Or must they be deployed in an Epic owned datacenter, and be natively browser based, in order for the software to mysteriously vanish? Or perhaps Epic is too large and thus too heavy to ascend to the clouds? Epic, the fastest selling EHR system in the country, is a “legacy” product built on the 1960s MUMPS programming language, and so is VistA, the Veterans Affairs (VA) EMR, which seems to be a physicians’ all-time favorite. Perhaps the European Space Agency knows something we don’t, since they are taking MUMPS straight through the clouds and all the way up into outer space to map the Milky Way Galaxy.

After affixing the “legacy” label on the EHR industry incumbents, the PCAST report repeatedly emphasizes the government’s role in creating a “vibrant market of innovators”, particularly the “disruptive” type, citing the example of ARRA incentives leading to “substantial innovation and competition” and “more affordable systems and improved products”. This is pure fantasy. Some of the smaller, previously most affordable, EHRs have been forced to double their prices in order to comply with regulations. Most of the larger (legacy?) products have maintained their pre-ARRA pricing, or increased them. And then there are the literally all cloud, and no software to speak of, vendors, who preyed on physicians before ARRA and are continuing to do so after. It seems that Apple and its iTunes App Store has created the illusion that any kid with a completed “Programming for Dummies” curriculum can whip up a useful clinical decision support application in a couple of weeks, sell it on the App Store for $0.99 and help us all get healthy, if we would only give him access to mountains of personal medical records.

Privacy or Lack Thereof

The beauty of the PCAST recommended solution for health information exchange (details below) is that privacy preferences are built into each data element. Anyone attempting to access personal health information would be required to authenticate and validate that the patient’s privacy policy allows access to the requested data element. Moreover, all data will be encrypted both at rest and in transit between users, thus barring all intermediaries from reading or storing any personal information. Rock solid plan; that is until you run into this statement: “It seems likely that the modifications to HIPAA enacted in Subtitle D of the HITECH Act—in particular those that require covered entities to track all disclosures to associates—will further stifle innovation in the health IT field while offering little additional real-world privacy protection”. The PCAST authors seem to dislike the idea of tracking disclosures of personal health information.  Somehow, uninhibited disclosure (or outright wholesale) of patients’ private information to “associates” is a necessary condition for “innovation”. Makes you wonder what exactly is meant by “innovation”.

The Grand Solution

Let me say this again. I love the distributed data concept at the heart of PCAST’s recommendations. No big databases in the sky here. All the pieces of one’s medical record are housed by the institution that created each piece. When someone needs access to a record, or part of a record, an authorized query is issued (think Google search) and the requested information is located and aggregated across multiple data stores and displayed on the requestor’s computer screen (think Google again). The mechanism to achieve such wondrous task is by and large the same one Google uses, with added layers of security and privacy. These tools are dubbed "data element access services (DEAS)" which are nothing more than customized search engines for health information, maintained and operated by large health systems or purposefully built entities. As is the case with Google search, medical records will need to be indexed if the DEAS are going to find them. For this purpose, PCAST suggests “a universal extensible language for the exchange of health information based on “metadata-tagged data elements””. In plain English, medical records will be broken into atomic data elements, each having attached information describing the element (patient identifiers, what it is, when recorded, how, by whom, etc.) and most importantly who can access it (patient directed privacy rules). The search engines will presumably use these metadata tags to locate actual data elements, without ever needing to read the data itself, and return the results to the querying user. Of course, there are more questions than answers at this point, and some interesting discussions too, but the general concept is sound and very innovative.

Beware the Legacy Giants

While PCAST was deliberating and formulating its recommendations, at least one “legacy” EHR vendor was implementing the solution. During its user conference in October, Cerner unveiled “Chart Search”, which is a semantic search engine using Natural Language Processing (NLP) and a specific ontology to allow users to intelligently search a patient’s chart. As in PCAST’s recommendations, Cerner is indexing all medical records and is storing the indices in its own datacenter (cloud). The use of NLP and clinical terminologies, such as SNOMED, allows Cerner to perform contextual searches by concepts (searching for beta-blocker will return all occurrences of Atenolol, Metoprolol, etc.) and rank the most clinically pertinent results on top. You can view a very brief presentation of this feature, shown by my favorite family doc, Dr. Karl Kochendorfer, here. The Cerner semantic search is different than PCAST’s recommended solution in many ways and of course, right now it is limited to Cerner charts in one physical location, but it is real and currently used by actual physicians. Looks like those old “legacy” giants are still packing some punch after all.

In summary, PCAST’s basic concept of where HIT should be headed is very appealing and properly ambitious. The serious considerations given to privacy, security and patient preferences are refreshing, but in order to support the fascinating research agenda proposed in the report, government will at some point need to step in and curb the enthusiasm of Cloud owners, severely curtailing the commerce of medical records. I would have preferred that PCAST refrained from the fashionable and rather baseless assumptions on how innovation occurs and the equally worn-out subtle advocacy for unproven changes to our health care delivery system. Other than that, very interesting report.

Full disclosure: I have no financial interests in Epic, Cerner or any other EHR vendor

Top 10 Accomplishments of American Health Care

It’s that time of year when the OECD publishes its "Health at a Glance" comparative health indicators, and The Commonwealth Fund follows with an international survey of health care related activities. A cursory review of these documents always ends up with the customary assessment of American health care: much more expensive than all others, wasteful and inefficient. But this is the month of December, and health care workers are people too, so maybe a short moratorium on bad news and criticism may be in order, allowing these folks to pursue a little bit of happiness during the Holiday season. A deeper dive into the vast amounts of data in the OECD report exposes all sorts of measures where the United States health system performs magnificently. Therefore, without further ado, let’s look at the top 10 achievements of American health care.

Number 10: Generic prescription rates in America are highest in the world. In fact the rates are so high, that the OECD didn’t dare show them. The best generics utilizer in the OECD report was Germany at 76% of prescriptions volume in 2011. The U.S. comes in at a whopping 80% in 2011 and 84% in 2012. Not only that, but the U.S. is also #1 in per capita spending on medications, and if 80% are low priced generic drugs, imagine how many more drugs we get to take. This speaks volumes about our new value based health care system.

Number 9: America was once again able to maintain the second lowest number of physicians per capita among developed nations, and well below the OECD average. Obviously, this spells productivity like no other metric can, and it’s most likely due to labor saving innovations, such as Electronic Health Records. With medical school graduation numbers at the bottom of the pack, the future will no doubt bring many more innovations to further increase the efficiency of American doctors.

Number 8: Americans are making big strides in technology use for communicating with their doctors. We beat practically every single developed country at some email metric, which is irrefutable proof that Meaningful Use is working.

Number 7: As in previous years America is holding the line on hospitalizations. Way below the OECD average and practically last in cancer discharges (except Mexico, where they don’t have cancer), our health system figured out much more cost effective ways of treating an increasingly older population, which leads us to #6.

Number 6: No one, and I mean no one, spends less of their health care money on hospitals than the U.S. We are #1. And no one spends more than us on more efficient outpatient care, which includes inpatient physician services when billed separately. It seems that all those inflammatory articles in the media regarding hospital price gouging, are pure nonsense.

Number 5: Not only does America have less hospital beds than most OECD countries, we are not using them very much. With an occupancy rate second to last, it seems that if we closed a third of our hospitals, as some reformers are suggesting, we would be just fine (with room to spare), and we could save oodles of cash. Finding inefficiencies that are easy to fix is a good reason to celebrate.

Number 4: Quality of care for the people that do end up in a hospital is pretty good. On multiple variables of mortality and surgical complications, the U.S. is consistently among top performers. Not absolute best, but a top performer nevertheless. Not to mention that compared to the best performers, your chances of leaving an American hospital with an instrument lodged in your bowels are much lower than in some very high performing countries. For all the alarmists having visions of Jumbo Jets crashing out of the sky daily, killing thousands of innocent patients unbeknownst to anybody else, slow down folks, there are no Jumbo Jets; maybe a Cessna here and there, but definitely no Jumbo Jets.

Number 3: Our children are the best in the whole wide world. The Puritan founders would have been so very proud of them. American kids are dead last when it comes to drunkenness and smoking. Although they are just average when it comes to eating their fruits and vegetables, our 15 year old boys and girls are the most physically active of all other OECD nations. Strangely enough, they are also among the chubbiest, but with all that physical activity, this is bound to resolve itself in the long run. It may be too late for us, but the future looks bright for the young ones.

Number 2: America is the healthiest nation in the world, bar none. Yep, you heard right. Almost 90% of Americans consider themselves healthy, and I have no reason to doubt their self-assessment. Much has been said about other countries, having higher life expectancies. The difference between the U.S. and Japan is over four years of life, but consider this: less than 1 in 3 people in Japan report being healthy. I don’t know about you, but 78 years of healthy life sounds much better to me than 82 years of living with disease.

And the Number 1 accomplishment of American health care is (drumroll please) Obamacare. Yes, Obamacare went viral, probably through the Internet or something like that, because Obamacare is now a global phenomenon affecting every single OECD nation.

A couple of weeks ago Paul Krugman, winner of the 2008 Nobel Prize in Economics, and self-described liberal, let us in on a little secret. Obamacare, it seems, is the only logical explanation for the reduced growth of health care spending in the U.S., and Obamacare began “bending the curve” from the moment it was signed into law in 2010, long before it was formally implemented. Since according to OECD data, all other nations have experienced the same “curve bending” effect since 2010, we must conclude that Obamacare has reached all developed nations instantaneously (the Internet is very fast).

And in some cases (such as the UK, not to mention Greece) Obamacare seems to be working even better than in the U.S. So here you go, once again America saves the world…. Merry Christmas American Health Care!

Selecting an EHR for the Patient Centered Medical Home

The conceptual definition of a Patient Centered Medical Home (PCMH) speaks of a physician directed medical practice, oriented to the whole person, where patients have enhanced access to a personal physician and care is coordinated and integrated focusing on quality and safety, nothing more and nothing less, other than appropriate payment to physicians for all activities.

Since concepts are rarely enough, the National Committee for Quality Assurance (NCQA) took it upon itself to provide concrete requirements and formal certification for medical practices desirous of being recognized as Patient Centered Medical Homes. The NCQA PCMH definition consists of nine Standards used to score the practice. This is NCQA’s attempt at translating the original PCMH concept into measurable activities and here is where Health Information Technologies (HIT) and EHR in particular, are formally associated with the PCMH concept. Conspicuously absent from the NCQA standard are the “personal physician” and unless you consider the assessment of language barriers sufficient, so is the “whole person orientation". Most NCQA PCMH elements are geared towards data collection, data analysis, tracking and reporting. Theoretically, you could earn NCQA PCMH designation without an EHR, but the amount of typing, writing, filing and calculating would easily consume your entire day. If you are serious about PCMH designation, you will need an EHR. But which one should you get? Are some technologies better than others for PCMH purposes?

Unfortunately, no one is trying to answer these questions and perhaps this is one of the reasons for the initial mixed results observed in PCMH implementations. The HITECH Act put in motion a monumental rush towards Meaningful Use and associated financial incentives. The Patient Protection and Affordable Care Act (ACA) is initiating another rush, this time towards new payment models and PCMH seems to be at the heart of all innovations. So what should we do first, buy HIT and become Meaningful Users, or transform our practices into an NCQA PCMH? Some would say, let’s do both and others, mostly primary care physicians in small private practice, would say, let’s do neither. In reality, Meaningful Use trumps PCMH right now, since it has hard due-dates and specific dollar amounts associated with it. Moreover, the pervasive opinion amongst PCMH consultants (yes, they have those already) is to get the HIT part over with, before engaging in the complex PCMH "culture transformation". And this is yet another recipe for failure, driven by tactical instant gratification needs and inability to take the time necessary for formulating long term strategies.

Suppose you decide to build a tree-house for your kids. Since you’re a doctor, not a carpenter, what do you do next? You could go on the Internet and figure out what tools and materials you need, measure the big old oak tree in the backyard, talk to the neighbor that just built one and make a list of stuff you would need to buy for the project. Or you could just get in the car and rush to Home Depot because they have a holiday sale on hammers & nails and buy a truckload of random tools and lumber. If you pick the latter route, chances are most of what you bought will be rotting in your garage and the kids will be playing in the neighbor’s tree-house. Similarly, if you want to build a PCMH and randomly purchase some EHR tool just because the Government is giving out rebates and vendors have fire sales, chances are your PCMH will never take off successfully. Below is a list of NCQA PCMH standards and things you need to consider when shopping for an EHR with the goal of eventually obtaining NCQA PCMH recognition (items marked with ** are mandatory).

Standard 1: Access and Communication

1. Has written standards for patient access and patient communication** - An EHR won’t help you write the standards, but it will help you implement them. You should have a scheduler that enables you to easily set aside times for open schedule, allows creation of global scheduling templates and gives you the ability to define your own appointment types, including web visits and email encounters. The EHR should also have the ability to create encounter notes without an appointment and/or a physical office visit.
2. Uses data to show it meets its standards for patient access and communication** - The EHR should have built-in capabilities to report on aggregate schedules and be able to account for email communications and web visits in one comprehensive report.

Standard 2: Patient Tracking and Registry Functions

1. Uses data system for basic patient information (mostly non-clinical data) – Any good Practice Management System will do here.
2. Has clinical data system with clinical data in searchable data fields – This is your Registry. Querying the Registry should be flexible and allow multiple parameters (e.g. all diabetics taking drug A, but not drug B, with A1c in a certain range, who also have a Dx of HTN and have not been seen in 6 months), but should not require that you have a degree in applied mathematics to use it. The quality of registries in EHRs varies wildly. Make sure the reports look clear, that all columns are sortable and that the reports are actionable (i.e. clicking on a data element will allow you to do something about it right then and there, instead of having to print the report out and search for each patient).
3. Uses the clinical data system – If you have that nice Registry, you would probably use it. For this element and the next two, the Registry should be able to report on itself (i.e. how many queries were run in a certain time period – an audit log is not sufficient).
4. Uses paper or electronic-based charting tools to organize clinical information** - Same as above.
5. Uses data to identify important diagnoses and conditions in practice** - Same as above.
6. Generates lists of patients and reminds patients and clinicians of services needed (population management) – With a good and actionable Registry, sending reminders out to patients should be easy, but you need to verify that the functionality to send bulk reminders (by email, phone or mail merge) is there and it defaults to recorded patient preferences for communications.

Standard 3: Care Management

1. Adopts and implements evidence-based guidelines for three conditions ** - The EHR should come with built in clinical decision support from a reputable source, such as USPSTF and this should be updated by the vendor on a regular basis. It should also come with clinical documentation templates, care plans and order sets preconfigured based on equally reputable guidelines. Be sure to ask about it and verify that it is actually as the vendor claims it to be.
2. Generates reminders about preventive services for clinicians – The Registry should be able to be queried automatically in scheduled batch mode for all patients and it should also allow customized configuration to display overdue services when a chart is accessed (you don’t want pop-ups here – a gentle, but bold, reminder on the page itself should suffice).
3. Uses non-physician staff to manage patient care – Every decent EHR will allow you to do this, but it would be nice if the EHR recorded the user who enters data into the various portions of the chart (not just an audit log, but visible indication that nurse A took the vitals).
4. Conducts care management, including care plans, assessing progress, addressing barriers – The EHR should come with preconfigured, evidence-based and fully customizable care plans. It should also have a place to enter goals and subsequently calculate adherence to those goals. This is where you want the longitudinal display, particularly useful for chronic disease management.
5. Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities – This will probably be done by phone & fax for a while longer, but your EHR should have capabilities to interface with hospitals and other providers. Some of the larger vendors have the ability to exchange information within networks of their own customers, and all vendors will eventually have to play nice. I know this is not a popular view, but for interoperability with multiple complex sources, the bigger the vendor, the more capabilities it has.

Standard 4: Patient Self-Management Support

1. Assesses language preference and other communication barriers – All the EHR has to have is a place for you to document language, translator and health literacy status. It would be best if these were structured data fields, because sooner or later, they will require you to report on these things.
2. Actively supports patient self-management** - In addition to your goal oriented care plans and registries, you should have a quality Patient Portal where you can make all this information, along with education materials, available to the patient and his/her family. While most EHRs have Patient Portals now, you need to make sure that they are not just a web page for patients to pay bills and request refills. Whether your patients will use the Portal, or not, is a completely different question.

Standard 5: Electronic Prescribing

1. Uses electronic system to write prescriptions – An EHR certified to work with Surescripts is necessary for Meaningful Use. Here you just need to make sure that the EHR is not just certified by ONC, but also appears on Surescripts’ website and this feature is operational (not all are).
2. Has electronic prescription writer with safety checks – This is also a Meaningful Use requirement, but it won’t hurt to find out if the EHR uses a reputable source for drug and allergy alerts, such as First Data Bank, Medispan or Multum.
3. Has electronic prescription writer with cost checks – Again, check the Surescripts website to make sure that the EHR is certified for Formulary checks (not just sending prescriptions electronically).

Standard 6: Test Tracking

1. Tracks tests and identifies abnormal results systematically** - A nice dashboard, with sortable columns and color coded abnormal indicators should be standard in any EHR you are considering. This should also be actionable with respect to being able to sign-off and inform patients and staff on further actions right from the dashboard.
2. Uses electronic systems to order and retrieve tests and flag duplicate tests – This is the dreaded CPOE. Note that it requires additional intelligence in checking to see if the tests you are about to order are duplicative. This is not a simple task and very few ambulatory EHRs have this feature. Choose with care and beware the endless stream of possible alerts.

Standard 7: Referral Tracking

1. Tracks referrals using paper-based or electronic system** - Many EHRs will allow you to fax referrals from the application. Some will allow electronic transmission to providers using the same EHR or will have interfaces to hospital systems for transition of care. The upcoming Direct Project standards may facilitate this functionality. You should inquire about the EHR vendor’s plans, and capabilities to support implementation of emerging standards at short notice.

Standard 8: Performance Reporting and Improvement

1. Measures clinical and/or service performance by physician or across the practice** - If you have that nice Registry discussed above, you should be able to run any reports you want by physician, by date, by patient group, by practice, by specialty, by insurer, etc.
2. Survey of patients’ care experience – Although, you could do this on paper at check-out, this should be an option on your Patient Portal, which will allow you to measure and report results.
3. Reports performance across the practice or by physician ** - Same as element A above, only now you have to share those reports with others.
4. Sets goals and takes action to improve performance – Not much an EHR can do here, but the Registry should be able to provide reports substantiating improved performance.
5. Produces reports using standardized measures – Not sure why the repetition on reporting, but Meaningful Use has a host of required measures as well. Make sure your EHR can actually deliver on all 44 measures, plus whatever else you may want to measure. Some certified EHRs only have capability to deliver the minimum 6 NQF measures allowing you no freedom to choose what you want to measure, or report on. This too is part of the Registry.
6. Transmits reports with standardized measures electronically to external entities – Several EHRs have Registries that are certified by CMS to submit quality measures electronically. The standard for reporting will be changing soon, and as with interoperability in general, you need to be convinced that your EHR vendor has the resources and ability to roll with the punches.

Standard 9: Advanced Electronic Communications

1. Availability of Interactive Website – This is your Patient Portal, which needs to allow patients to input requests, data and generally communicate with the practice.
2. Electronic Patient Identification – This could mean a user name and password (or something more exotic, if you choose) for your patients to access the portal or it could refer to a unique patient identifier in the EHR. Either way, this is not an issue.
3. Electronic Care Management Support – Everything you do every day will satisfy this element, if it is done in an EHR.

To summarize this litany of standards, if you have any interest in NCQA PCMH recognition, the main functionalities to look for in an EHR, in addition to ease of use and affordable pricing, are a comprehensive Registry with excellent reporting abilities, a flexible Patient Portal, quality clinical content from reputable sources and vendor ability to sustain new standards and regulations, particularly those related to health information exchange. If you want to provide your patients with a compassionate and caring medical home, where they feel safe and well cared for, you will need a different set of “tools”, but perhaps technology can help a little.

The Implausible Manifestation of a Doctor Shortage

In a New York Times opinion piece Scott Gottlieb, MD joins forces with Ezekiel Emanuel, MD to inform us all that “No, There Won’t Be a Doctor Shortage”, and just to clarify, Dr. Gottlieb goes on to say in a subsequent Forbes article “That Doesn't Mean You'll Have Access To Them”.  Doctors, it seems, are destined to be like the lights of Hanukkah candles – only for looking at, not for using. As tempting as it may be, let’s not hastily assume that the more fortunate members of society, like the authors of these articles, are brazenly suggesting that maintaining a good supply of doctors for themselves, is as simple as denying everybody else access to physicians. Of course not.

To dispel our concerns that an aging population and expansion of health insurance may somehow require more doctors, Drs. Gottlieb and Emanuel urge us to look at the great State of Massachusetts where universal insurance has been in place for years and no shortages have been observed. According to the Census Bureau, Massachusetts has almost double the national average number of doctors per population, and by the authors own admission, its “experience may differ from other areas”. Looking at Mississippi, for example, would have been a stretch I suppose. Either way, policy makers should be all set, since the only place where doctors seem to be growing on cherry trees is our nation’s capital. Other than that, the New York Times article contains the usual innovative fare, being repeated now in most health care journals over and over again. The future holds marvelous technology advances that will minimize duration, complexity and intensity of treatments and non-physicians of all stripes will be delivering most of this now routine care (one interesting suggestion was that pharmacists should deliver urgent care). The main idea is that instead of “expanding our doctor pool, we should focus on increasing the productivity of existing physicians and other health care workers”.

Increasing worker productivity is where America’s exceptionalism truly shines. Labor productivity (i.e. the ratio of output to input) has increased in the U.S. by 254% since WWII (see graph above), and really accelerated in the new millennium. Unfortunately, compensation for this wonderful productivity, took a different path somewhere in the early seventies, hence the gaping divide between America and a handful of very wealthy individuals who benefit financially from productivity gains. The conservative Dr. Gottlieb and the progressive Dr. Emanuel are merely suggesting that this very successful business model should now be applied to the horrendously inefficient health care sector.  If you think about it, it becomes abundantly clear that this suggestion is actually an imperative. If we don’t find a way to integrate medical services in the lower-wages/cheaper-products innovation cycle, all those wonderfully productive workers will be unable to afford the medicines needed to sustain their blessed productivity.

The New York Times opinion piece, and the many others like it, are the theoretical foundation leading experts such as Dr. Gottlieb to conclude that “there’s every reason to believe that technology will continue to make the aging process itself (and the treatment of many diseases) a far less resource intensive endeavor – and ones that require fewer physician inputs for a higher level of “outputs” in terms of improved healthcare”. This is very similar to how restaurant chains, or canned food manufacturers, have a Chef that is shown designing fabulous new dishes, using market fresh ingredients, on TV commercials, but the actual “outputs” in each establishment, or can, require practically no Chef inputs. And this is why health care is strongly encouraged to learn from other industries that mastered the art of maximizing outputs to inputs ratios. Fair enough, but how do we know that we have enough Chefs or doctors to start with? Luckily, Dr. Gottlieb has valuable insights on this question as well. The argument is that “if there was a shortage of physicians, it wouldn’t be so easy for the Obamacare health plans to push around doctors and trim their pay”. The same logic is used very effectively by defense attorneys in rape cases where the victim did not scream or kick hard enough. 

When analyzing things from an economic perspective, shortage of something implies that demand exceeds supply, and demand does not mean need or even want; it means willingness to pay. For example, one could observe that we have no shortage of private trainers, not because people don’t need to work out, or because they wouldn’t want a personal trainer, but because most folks are not willing or able to pay for one. Demand, and subsequent shortage, is also a function of culture. There is no shortage of wholesome and freshly prepared foods today, because our culture has been altered to have different expectations from food. Preemptively changing perceptions and expectations is therefore paramount to preventing shortages. So if back in the 1990s HMOs were “soundly rejected” by the people, according to Dr. Gottlieb, “[w]hat Obamacare, in effect, tells Americans, is that the White House believes many people made the wrong choice when they rejected those HMOs in favor of PPO plans that offer broader access to providers”. Of course we did.

You hear frequently today how fixing health care requires a cultural change; how we must choose wisely and how we should not expect that everything is done to prolong individual lives; how we should become more accepting of death and how we should quit running to the doctor every time we are sick; how we should learn from Rwanda and how we should fear the killing fields of conventional medicine; how we should value fast service and convenience above intrinsic quality. All these things are necessary to bring demand for physician services more in line with productive workers’ ability to pay for medical care, and as worker compensation continues to shrink, we may end up with a surplus of doctors, which in turn will make pushing them around and trimming their pay even easier, as Dr. Gottlieb writes in conclusion: “In the future, there will be enough doctors for you to choose from. Problem is, in many cases, the Obamacare health plans won’t pay for you to see them”. And it won’t need to, because by then, you will be conditioned to not demand to see them.

Everywhere on this planet, physicians’ professional status, autonomy and compensation, are inextricably tied to the same metrics for the patients they serve. It is plausible and perhaps understandable, that physicians who were and still are the highest paid professionals in the land, considered themselves immune to the increased exploitation and marginalization of all other American workers, including highly educated ones. The almost linear relationship between worker compensation and physician compensation, and the mathematical impossibility of becoming rich by tending to a nation of impoverished workers, must have escaped our best and brightest, until now.

The harsh (and unpleasant for some) reality is that unless you can find your way to medically pamper “Internet moguls”, or happen to practice medicine on TV or at the New York Times, you are in the same boat as the McDonald's workers now rioting in the streets, perhaps in a much nicer cabin (for now), but same boat nevertheless. Something to ponder upon…

Update 12/11/2013: For a bit different, but more authoritative perspective, see Prof. Casey B. Mulligan's Economix article today.