Readers and commenters (on e-CareManagement and The Health Care Blog) quickly grasped that a social networking platform could play a very useful role in coordinating our health care, yet also agreed with the conclusion that Facebook wasn’t  “it”.

So let’s ask the question again: Could Google+ be your platform for care coordination? This post will

• Describe Google+ and Circles
• Discuss how Google+ gets past some of Facebook’s limitations as a care coordination platform
• Comment on Google+ as a care coordination platform (promising, but too early to tell) (more…)

Let’s take a minute to consider the mechanics of how this will occur. You’ve received a prescription, and it directs the pharmacist to tailor the medicine to YOUR genetic profile.

Consider two possible scenarios of how this transaction might happen. You’re on the phone with your pharmacist:

1) “OK, you need my DNA sequence. I keep my genetic profile in my mattress…let me get it and I’ll read it out loud to you.  C, A, T, G, G, A, T… no,  that was actually a G…let me start over.  C, A, T, G, G, A, T… (19 hours later) … T, and G. Can you read that back to me to make sure you got it right?”

2) “You have permission to access my DNA sequence at my health URL (or maybe a health record bank, or perhaps hand her a flash drive, or ??).

Still think you’ll never use a PHR?

In my mind, the issue isn’t WHETHER, but WHEN.

Yes, I know that adoption has lagged and that surveys suggest 7% or less of the U.S. population has used a PHR.

Stay with me on this one for a minute. You’d have to have two underlying beliefs to conclude that PHR systems won’t eventually emerge:

• That health record data will persist in non-electronic formats, i.e., paper
• That people won’t have interest in accessing or using their health record data (more…)

(click on the graphics to link to original sources)

Regular readers know that I find Professor Clay Christensen’s theory of disruptive innovation to be a useful lens to explain industry evolution. Let’s look at two recent health IT initiatives and see why one is working and the other is stalled.

(more…)

“If banks can exchange funds electronically through the ATM system, why can’t my doctor and hospital exchange information electronically?”

Keith Boone’s concise article “A Doctor is Not a Bank” explains why this conclusion about healthcare interoperability is overly-simplistic.

…and Keith’s article reminded me of an even deeper explanation presented in the National Academies’ Frontiers of Engineering series — Why Health Information Technology Doesn’t Work, by Elmer Bernstam and Todd Johnson. The table below summarizes the differences between health data and banking data.

  (more…)

What struck me about the list is that the state-of-the-art is stand alone applications — I didn’t see any that had any connection to an EHR (electronic health record).  Here’s the top 5 to give you a flavor of what’s on the list:

1. Medscape
2. Micromedex
3. New England Journal of Medicine
4. Epocrates
5. Free Medical Calculators

I expect that this list will begin to look very different in coming years as EHRs continue to open their platforms to outside developers…and applications will increasingly be integrated into direct patient care.

Doctors love iPads…not surprising? But, how might you explain this?

There are at least two different possibilities:

• Coincidence Theory
• Conspiracy Theory

The Coincidence Theory

So doctors want to access EHR software through the iPad…what’s the big deal?

Apple has built a great new hardware platform with the iPad. There’s nothing else like it in the marketplace.  While other companies are building competing tablets, Apple’s has been the only viable option in the market for over a year.

(more…)

Webinar Title: An Impending Marriage: Electronic Health Records (EHRs) and Care Management Software

The presentation will be geared at practicing clinical case managers in health plans, hospitals, disease management companies, and similar organizations:

• Describe market forces driving integration of EHRs and care management software. 
• Review care management software survey data and stimulus funding for EHR adoption. 
• Describe a 3 stage framework for the evolution of EHRs and care management software. 
• Characterize benefits to patients and impacts on care manager responsibilities.

The event is sponsored by HealthSciences Institute and the PartnersinImprovement Alliance.

When:

Friday, February 4, 2011
11:30 am Eastern Time
10:30 am Central Time
9:30 am Mountain Time
8:30 am Pacific Time

Your Presenters:

Vince Kuraitis JD, MBA
Better Health Technologies, LLC

Garry Carneal, JD, MA
Schooner Healthcare Services

More Information and Registration:  Click here.

Early Feedback on PCAST 

• Limited. The first commentaries were primarily by technical and/or clinical bloggers. The mainstream HIT world had remarkably little initial reaction to the Report. 
• Respectful of the imprimatur of “The President’s” Report and noting some of the big names associated with the report (e.g., Google’s Eric Schmidt and Microsoft’s Craig Mundie.)
• Focused on technical and/or clinical perspectives around two broad themes.
  • The vision is on target:  “extraordinary”, “breathtakingly innovative”.
  • These guys didn’t do all their technical homework. The range varies, but the message is consistent. 

Today’s POV on PCAST 

What  a difference a six weeks makes.  (more…)

I’ll share a couple of particularly useful and well written analyses and commentaries by colleagues.

Health IT guru and thought leader Dr. John Halamka writes about The Proposed Stage 2 and 3 Meaningful Use Recommendations in his blog.

This is a great article to get a thumbnail overview of all the proposed recommendations. John lists 38 criteria and provides a quick commentary on how challenging he sees each of them. (Keep in mind that he’s CIO at one of the most HIT-advanced health systems in the country — your definition of “easy” and his might not be alike.)

(more…)

A full list of objectives for Stages 1, 2 & 3 is available in the PowerPoint presented to HITPC.

The proposed objectives contain a mix of items that are:

• Unchanged from Stage 1
• Similar MU criteria with higher implementation goals, e.g.,
  • Stage 1: CPOE for Rx orders 30%
  • Stage 2: CPOE for 60% of Rx, lab and radiology orders entered by licensed professionals
• Clarifications or more detailed specifications
• Discretionary objectives moved to core set
• New items

Here’s a list of proposed new objectives for Stage 2 MU: (more…)

The reviews are filtering in and I’m seeing two major themes: 

1. The vision is on target:  “extraordinary”, “breathtakingly innovative”.
2. These guys didn’t do all their technical homework. The range varies, but the message is consistent. 

Here are some early critiques of the PCAST report. Let the debate continue! (more…)

Remember the penguin problem described by economists?

No one moves unless everyone moves, so no one moves. 

Overcoming the penguin problem has a lot to do with creating expectations. A recent writing by Dr. James O’Connor in Physician Practice expresses a voice from the physician community that I’ve never heard before.  His essay is entitled “Meaningful Use — Doctors Have No Choice”.

(more…)

We’ve spent the past year creating the MU (meaningful use) requirements for Stage 1 of the HITECH act.  As shown by the diagram above, Stage 1 focuses on Data Capture and Sharing. Now it’s time to begin to focus on Stage 2 (Advanced Clinical Processes) and Stage 3 (Improved Outcomes).

The current generation of EMRs (electronic medical records) were designed primarily to assist care providers with clinical documentation, billing, and maximizing revenues. They were not designed to enable care coordination and optimize population health.  

This essay is the first in a new, ongoing series that will highlight:

• Design and metrics for Stages 2 and 3 of the HITECH act
• Companies and care providers developing and using applications targeting Stage 2 and 3 MU objectives

This first essay will provide an overview of what we’ve seen in Stage 1 and what we might expect in Stages 2 and 3. (more…)

Of course, you’d never see this type broad support for centralized EHRs in the U.S.

Is this good or bad? You can decide for yourself…but at the very least this caught my attention as illustrating communitarian vs. individualistic tendencies in different world nations.

Pop quiz: Among early-stage companies that are successful, what percentage are successful with the initial business model with which they started (Plan A) vs. a secondary business model (Plan B)?

Harvard Business School Professor Clay Christensen studied this issue.  He found that among successful companies, only 7% succeeded with their initial business model, while 93% evolved into a different business model.

So let’s take this finding and reexamine our human nature. In light of these statistics, what makes more sense:

• Defending Plan A to your dying breath?
• Assuming Plan A is probably flawed, and anticipating the need for Plan B without getting defensive?

We question many of the assumptions underlying HITECH Plan A. We also want to talk about the need and content for Plan B in a constructive way.

In this essay we’ll discuss:

1) The Need for HITECH Plan B

2) Questioning Assumptions — Issues to Reconsider in Plan B

a) Rewarding Incremental Progress
b) Addressing Root Causes for Non-adoption of EHR Technology
c) Questioning Health Information Exchanges (HIEs) as Building Blocks for the Nationwide Health Information Network (NHIN)
d) Catalyzing Movement Toward Modular EHR Technology
e) Focusing Incentives on High Leverage Physicians
f) Recalibrating Expectations for EHR Technology Adoption
g) Getting Bang-for-the-Buck in Achieving Meaningful Use Objectives
h) Comprehensively Revamping Privacy/Security Laws vs. Tweaking HIPAA
i) Maximizing Sync Between HITECH and PPACA
j) Leveraging Potential for Patient-Driven Disruptive Innovation
k) Promoting EHR Adoption Beyond Hospitals and Physicians, e.g., long-term care, home health, behavioral health, etc.
l) Dumping Certification

3) Summing Up

(more…)

.

….or to be more specific, HITECH is synergistic with payment reform that could come from the recently passed national health care reform legislation — the Patient Protection and Affordable Care Act (PPACA).

We’ll keep this post fairly short and try to avoid many of the more divisive aspects of this topic. The need for healthcare payment reform is well understood on both sides of the aisle:

Realizing the full potential of health IT depends in no small measure on changing the health care system’s overall payment incentives so that providers benefit from improving the quality and efficiency of the services they provide. Only then will they be motivated to take full advantage of the power of electronic health records. Dr. David Blumenthal,  New England Journal of Medicine, April 9, 2009

(more…)

by Dave deBronkart (e-PatientDave), Vince Kuraitis, and David C. Kibbe

So far this series has looked at HITECH participation by hospitals (grumbling but in the game) and physicians (wary, on the sidelines), kudos for ONC’s three major policy points, and how HITECH is already moving the needle on the vendor side. Today we’re going to look at the reason the whole system exists: patients.

It’s possible to look at the patients issue from a moral or ethical perspective, or from a business planner’s ecosystem perspective. In this post we’ll simply look at it pragmatically: is our approach going to work? It’s our thesis that although you won’t see it written anywhere, the stage is being set for a kind of disruption that’s in no healthcare book: patient-driven disruptive innovation.

We’ll assert that in all our good thinking, we’ve shined the flashlight at the wrong place. Sure, we all read the book (or parts), and we talk about disruption – within a dysfunctional system.

If you believe a complex system’s actual built-in goals are revealed by its actual behavior, then it’s clear the consumer’s not at the core of healthcare’s feedback loops. What if they were?

We assert that to disrupt within a non-working system is to bark up a pointless tree: even if you win, you haven’t altered what matters. Business planners and policy people who do this will miss the mark. Here’s what we see when we step back and look anew from the consumer’s view:

1. We’ve been disrupting on the wrong channel.
2. It’s about the consumer’s appetite.
3. Patient as platform:
   • Doc Searls was right
   • Lean says data should travel with the “job.”
   • “Nothing about me without me.”
4. Raw Data Now: Give us the information and the game changes.
5. HITECH begins to enable patient-driven disruptive innovation.
6. Let’s see patient-driven disruption. Our data will be the fuel.

(more…)

Most of the press coverage and attention to HITECH has been to the “buy” side of the market:  The central question here has been: “Will doctors and hospitals buy and use EHR technology?”

Meanwhile — and much more quietly — the sell (vendor) side of the EHR market is already dramatically different than it was a year ago. We observe change occurring at at least three levels:

1. HITECH as Policy Change
2. HITECH as Mindset Change
3. HITECH as Technology/Business Model Change

(more…)

While this might sound like a criticism of the way HITECH has been implemented, it’s not intended that way — it’s a commentary on 1) the complexity and scope of change that will be required to make HITECH successful, and 2) the level of protective entrenchment existing American health care today.

Rather, we believe that the Office of the National Coordinator (ONC) for Health IT – Dr. David Blumenthal and his staff — have done a superb job in interpreting and defining key aspects of HITECH legislation. We’re big fans.

For those of you who have been following our writings over the past 18 months, think of this post as a summary and status report on the extensive incumbent (cat) vs. innovator (dog) dialogue:

1. A Recap  — The Stagnant Electronic Medical Record (EMR) Market Before 2009
2. ONC Gets It Right In Three Major Interpretations and Definitions of HITECH

a) Meaningful Use (MU) Emphasizes “Meaningful”, Not “Use”

b) Vendors Get a Level Playing Field With Certification

c) Lightweight, Open Standards Promote EHR Interoperability and Modularity

(more…)

However…I can’t help but comment on John’s misleading story “CCD Standard Gaining Traction, CCR Fading” in The Health Care Blog. He writes:

In a number of interviews with leading HIE [Health Information Exchange] vendors, it is becoming clear that the clinical standard, Continuity of Care Document (CCD) will be the dominant standard in the future.  The leading competing standard, Continuity of Care Record (CCR) appears to be fading with one vendor stating that virtually no client is asking for CCR today.

I have four beefs with John’s essay:

1. It’s no news that HIEs prefer CCD.
2. HIEs are not representative of the broader health IT market.
3. The narrow findings don’t justify the broad conclusion.
4. The CCD and CCR standards are more complementary than competitive

Let’s look at these one at a time.

(more…)

Thank you for being a loyal user of the Revolution Health Personal Health Record. Unfortunately we will be discontinuing this service as of the end of February 2010 and removing all records, information, and data from the Revolution Health Web site.

So that you don’t lose the information you’ve entered into the system, we strongly suggest that you download your personal records as a PDF to print and save for future reference. To do this, simply follow these instructions:

1. Log in to your Personal Health Record.
2. From any page of your record, click on the “printable version” link on the top right corner of any page. When you see a pop-up box asking you to “Select the following sections to include in your print out,” simply make sure that the sections you want to print and save are checked and then click the “Submit” button.
3. Once the PDF is created (this only takes a moment), you can print directly from it and/or save it to your computer. To print the PDF, click on the printer icon at the top left of the page. To save it, click on the disk icon to the right of the printer icon.

If you encounter a problem printing or saving your records, please e-mail our customer service department at CustomerCare@revolutionhealth.com for assistance. Even after the Personal Health Record is no longer available, Revolution Health and our partner sites will continue to offer you the same great health information and community pages as always. We hope you continue to visit Revolution Health often to take advantage of our offerings.

Thank you,
The Revolution Health Team

What happened here????  what’s the lesson?

Medicare announced today that it is extending its Personal Health Record (PHR) pilot project for residents of Utah and Arizona.

This is a waste of time and taxpayer dollars. Those of you who read my blog know that I’m a big fan of PHRs, but you have to know when you’re backing the wrong approach.

What’s wrong with this pilot project? A lot:

(more…)

• Keep it simple; think big, but start small; recommend standards as minimal as possible to support the business goal and then build as you go
• Don’t let “perfect” be the enemy of “good enough”; go for the 80% that everyone can agree on; get everyone to send the basics (medications, problem list, allergies, labs) before focusing on the more obscure
• Keep the implementation cost as low as possible; eliminate any royalties or other expenses associated with the use of standards
• Design for the little guy so that all participants can adopt the standard and not just the best resourced
• Do not try to create a one size fits all standard, it will be too heavy for the simple use cases
• Separate content standards from transmission standards; i.e., if CCD is the html, what is the https?
• Create publicly available controlled vocabularies & code sets that are easily accessible / downloadable
• Leverage the web for transport whenever possible to decrease complexity & the implementers’ learning curve (“health internet”)
• Position quality measures so that they will encourage adoption of standards
• Create Implementation Guides that are human readable, have working examples, and include testing tools

Commentary:  These new guidelines are the right answer…let’s hope they are Dr. Halamka’s “final” answer.

Feedback from the community has been mixed:

(more…)

Dear Dr. Blumenthal,

I was honored to receive a personal email from you today. However, after reading it, I conclude that you must have intended to send this email to Judith Faulkner, CEO of Epic Systems.

I really liked what you said about working toward interoperability:

The HITECH Act calls for the “development of a nationwide health information technology infrastructure that allows for the electronic use and exchange of information and that…promotes a more effective marketplace, greater competition…[and] increased consumer choice” among other goals.  (Section 3001(b))  This means we cannot support arrangements that restrict the secure, private exchange of information required for patient care across provider or network boundaries.  Some of these arrangements may improve care for those inside their walls.  But ultimately, they have the potential to carve the nation up into disconnected silos of information, and thus, to undermine the vision of a secure, interoperable, nationwide health information infrastructure, which the law requires us to establish.  Consumers, patients and their caretakers should never feel locked into a single health system or exchange arrangement because it does not permit or encourage the sharing of information.

So you will probably just need to resend your email…

Vince

Dr. John Halamka — Vice Chair of the HIT Standards Committee of the ONC and one of the most vocal and influential figures in health IT — writes a blog post this morning entitled “The Genius of AND”. Halamka reasonably summarizes the essence of the debate about standards and interoperability as being between “the healthcare informatics crowd” (cats) and the “Internet crowd” (dogs):

He notes that the debate shouldn’t be about one or the other POV prevailing (“either/or”), but about integrating both points of view (“and”):

..we need to embrace both approaches – the right tool for the right job depending on what you want to achieve.

For provider to provider communication which requires the exchange of documents with non-repudiation as the medico-legal record for direct clinical care, the CDA/CCD has great metadata and the ability to support structured data as well as free text discharge summaries/operative notes/history&physicals.

For a summary record that represents a snapshot in time of problems, medications, and labs for transmission between EHRs and PHRs, the CCR and other formats such as Google’s CCRg or PDF can do the job.

I’m absolutely stunned…and speechless.

(more…)

The letter is directed at 10 EMR (electronic medical record) vendors, and asks very pointed questions about whether the vendors have been negligent in not addressing patient safety issues in their technologies.

Senator Grassley, you have the scent and you’re on the trail.  There are several other questions you should be asking these vendors: (more…)

BrightTALK is sponsoring a complimentary Electronic Health Record Summit this Tuesday, October 20, 2009.

David C. Kibbe MD, MBA and I will be presenting “Introduction to Clinical Groupware and the Clinical Groupware Collaborative”

Clinical groupware is a new and evolving model for the development and deployment of health information technology (HIT) platforms and applications having the following characteristics:

• Use of the Internet and the web for EHR technology.
• Explicit design for information sharing and online communication among providers and patients/consumers.
• A modular or component architecture upon which applications can be aggregated to meet specific clinical and workflow tasks.
• Patient/consumer engagement tools that facilitate ongoing health management and care coordination.
• Interface and data exchange standards for information sharing that emerge in a market-driven manner.

The Clinical Groupware Collaborative is in a formative stage organization. To date, representatives from over 50 companies have expressed interest. We are working to be formally incorporated in November 2009.

To register, attend live, or view afterward on-demand, click the following link:  http://www.brighttalk.com/webcasts/6114/attend  

Here’s a full listing of the other Electronic Health Record Summit presentations:   

Kaiser Permanente’s Journey and Ultimate Success with Health IT, Andrew M. Wiesenthal, The Permanente Federation

Prescribing the Best Security for Your EHR System, Andrew Klein, Product Management at SonicWALL

Business Associates Now and Then: HIPAA, EHRs and the HITECH Act, Susan Miller, Security & Privacy Workgroup Chair, WEDI

Fraud & Abuse in the EHR, Jean Bishop, J Bishop Consulting

New HIPAA Rules and EHRs: ARRA & Breach Notification, Raj Goel, Brainlink International; Jim Sheldon-Dean, Lewis Creek Systems

Three Forcing Factors of Electronic Healthcare Records, Kim Singletary, McAfee

How Great EHRs Empower Participatory Medicine, e-Patient Dave deBronkart, Society for Participatory Medicine co-chair

Here’s a copy of our PowerPoint slides…

and here’s DMAA’s writeup:

Helping physicians and hospitals meet the “meaningful use” criteria for federal support for health information technology under recently passed legislation represents a keen opportunity for the population health management industry, presenters at this session said yesterday.

Vince Kuraitis, JD, MBA, of Better Health Technologies, LLC, and Don Storey, MD, of RMD Networks, presented a look at the evolution of HIT and the electronic medical records systems from a strongly proprietary model with little interoperability to new model of integrated, modular applications from various vendors sharing common languages and platforms.

(more…)

I’m writing to extend a warm personal invitation to learn more about the Clinical Groupware Collaborative (CGC).  To-date, purely through word-of-mouth over 40 companies have expressed interest in the CGC, and we expect that you’ll be hearing a lot more about us over the coming months.

Our meeting will take place next Tuesday, September 22, 6 PM in conjunction with The Forum 09, the annual meeting of DMAA: The Care Continuum Alliance.  More details are provided at the bottom of this post.

I’ll address a few questions that might be on your mind.

Q. What is Clinical Groupware? 

(more…)

Two issues have rightfully surfaced front and center in the public’s understanding of HITECH Act implementation:

• ” definition of “Meaningful Use” of EHRs, and
• ” definition of “certification” process for EHRs

…and we applaud the progress of the workgroups and the HIT Policy Committee in addressing these issues constructively.

However…a THIRD issue lurks – “Data harmonization at the expense of data liquidity“, or put another way – “misplaced pursuit of one (and only one) language at the expense of practical communication.”

On August 20, the HIT Standards Committee approved recommendations to bring forward to the HIT Policy Committee meeting later this September. 

In this post, we will:

1. Summarize aspects of the HIT Standards Committee’s recommendations that are problematic
2. Develop an analogy to illustrate how the recommendations will limit innovation and increase barriers to communication.  Our analogy:

The Standards Committee recommendations are like mandating that everyone in the U.S. be required to speak Latin by 2013.

Dr. Blumenthal has wisely anticipated that there could be a situation where in his role as national coordinator that he should not follow a Committee’s advice:

“This committee does provide advice to the national coordinator, but it does not make policy,” Blumenthal said, with a noticeable emphasis on “not.” [iHealth Beat; August 18, 2009]

Dr. Blumenthal, this is exactly the situation you have anticipated. (more…)

Many of us have enjoyed a few good minutes of fun having our fortunes told by soothsayers who claim they can predict our future based on patterns of tea leaves in a cup or the playing cards we’ve pulled from a deck.

We pay a few dollars for the entertainment and if the fortune teller is skilled, we are temporarily impressed by his “insight.” But once we leave the carnival, we come back to our senses. Fortune-tellers can’t predict the future.

With its latest announcement, the Certification Commission for Healthcare Information Technology (CCHIT) appears to have entered the fortune telling business.

And if information provided on blogs published by its founders is to be believed, some EHR vendors plan to have their fortunes told by the former EHR certification monopolist.

Background

In June, ONC’s HIT Policy Committee released a Meaningful Use Matrix and proposed that it should serve as the basis for EHR certification as mandated by ARRA, the economic stimulus program signed into law last winter.

The Matrix consisted of five “Health Outcomes Policy Priorities” and associated Care Goals, Objectives and Measures. The Committee anticipated that the latter would be transformed into EHR certification criteria. (more…)

The Federation of American Hospitals (FAH) sent a letter to Dr. David Blumenthal (National Coordinator for Health IT) arguing that “Meaningful Use” funding should not be tied to achievement of quality measures.  The FAH is the trade association for for-profit hospitals; the letter is dated August 26 and a copy is available on the HealthHombre website, with a deserved hat tip.

First, let me concede that they make a reasonable point on p. 3 when they say “Under it’s framework, the Policy Committee has recommended that HHS should adopt a measure for 2013 requiring a 10 percent reduction in preventable admissions from 2012 to qualify as a meaningful EHR user.”  This measure deserves discussion.

Here’s the implicit threat of a lawsuit — the nuclear bomb: (more…)

This post is a foundational overview of characteristics of network industries.  Much of the terminology will deserve deeper discussion, but we have to start somewhere.

In his book The Economics of Network Industries, Professor Oz Shy lists four characteristics of network industries.

The main characteristics of these markets which distinguish them from the market for grain, dairy products, apples, and treasury bonds are:

1. Complementarity, compatibility and standards
2. Consumption externalities [network effects]
3. Switching costs and lock-in
4. Significant economies of scale in production

In this essay, I’ll quote from Dr. Shy in explaining each of these characteristics.  I’ll also offer a few thoughts as to how these characteristics apply to healthcare. More specifically, I’ll discuss physician adoption of EHRs (electronic health records) and patient adoption of PHRSs (personal health record systems).  

Why a PHRS instead of a plain old PHR?  Think of a PHRS as a PHR data repository platform bundled with multiple high-value applications. For a more detailed explanation, read here.   

Let’s look at the characteristics of network industries one at a time.

(more…)

There’s a double meaning to the title of this new series: Healthcare Crosses the Chasm to the Network Economy

At the level of technology, it’s a reference to Geoffrey Moore’s bestselling business/technology book — “Crossing the Chasm”. The Chasm here is the huge gap between early adopters of technology and mainstream users. The book describes the process of bringing specific technologies into mainstream usage.

At the level of clinical care, its a reference to the landmark 2001 report by the Institute of Medicine — “Crossing the Chasm”.  Here, the Chasm is a reference to the quality/safety gap existing in American healthcare, with major systemic recommendations for how to cross the chasm toward clinical improvement.

In this series, the “Crossing the Chasm” is a reference to both technology and clinical care — and to the interdependence between them. I believe we’re entering a new era in healthcare, marked by passage of the HITECH Act Federal stimulus legislation, but of which HITECH is only the beginning . While to a casual observer HITECH Act might seem focused on electronic health records (EHRs), it goes far beyond that.   

Over the past several years, I’ve had the privilege to work with many leading-edge clients who understand that health IT interoperability, networks, and platform/application technologies and business models will reshape health care over the coming years.  This has given me a chance to do a deep dive into understanding companies, business models and literature from outside health care, and then thinking through implications for health care companies (much blogging and book forthcoming).

This series will pull on concepts, terminology and lessons from two disciplines:

(more…)

Between the initial recommendations in July and the adopted recommendations in August, one critical word was added to the definition of “certification”.  That one word is “minimum” — and this one word expresses the correct approach and philosophy for the government’s role in the certification process for EHRs.

In this post I’ll address why a “minimum” approach toward certification makes sense: 

• Why “Minimum” Certification is Right: More Like UL
• Why Current CCHIT Certification Based on Functionality Risks Irrelevance or Lock-in to Outdated Technology

Why “Minimum” Certification is Right: More Like Underwriters Laboratories

(more…)

Over the past several years, many diverse initiatives have arisen offering partial solutions to systemic problems in the U.S. health care non-system. 

We see Meaningful Use Criteria recommended by the HIT Policy Committee as a unifying force for these previously disparate initiatives. These initiatives have included:

• Patient Centered Medical Homes (PCMHs)
• Regional Health Information Organizations (RHIOs)/Health Information Exchanges (HIEs)
• Payer Disease/Care Management Programs
• Personal Health Record Platforms — Google Health, Microsoft HealthVault, Dossia, health banks, more to come
• State/Regional Chronic Care Programs (e.g., Colorado, Pennsylvania, Improving Performance in Practice)
• Accountable Care Organizations — the newest model being proposed as part of national reform efforts

Today

While there are some commonalities and overlap, to-date these initiatives have mostly arisen in isolation and are highly fragmented — they’re all over the map. Here’s a graphic representation of the fragmentation that exists today:

Tomorrow

The HIT Policy Committee recently recommended highly detailed Meaningful Use criteria for certified EHRs.  Doctors and hospitals who hope to receive HITECH Act stimulus funds will have to demonstrate that they are meeting these criteria; the criteria are not yet finalized.

The Committee website describes the central role of the Meaningful Use criteria:

The focus on meaningful use is a recognition that better health care does not come solely from the adoption of technology itself, but through the exchange and use of health information to best inform clinical decisions at the point of care.

The HIT Policy Committee also is recognizing that there are multiple routes to achieving Meaningful Use beyond the traditional EMR 1.0, e.g., modular Clinical Groupware software.

While some might view the Meaningful Use criteria as limited to the world of health IT — something happening “over there” — we see much more going on. We believe the Meaningful Use criteria are becoming a powerful unifying force across the health system, with potential to converge previously disparate initiatives.  Here’s our conceptual representation:

(more…)

Over the past few days, several of my respected colleagues have written excellent blog posts essentially asking “Does Google Health have life?”

• Scott Shreeve — CLEAR! Shocking Google Health Back to Life
• John Moore — Is Google Health Irrelevant?
• Will Crawford — Future of Google Health

I share their observations and sentiments.  I see Microsoft HealthVault as a serious business strategy while Google Health is more like a hobby (one of probably hundreds at Google).

Are there reasons Google should stick around healthcare? Absolutely!  Off the top of my head, I can think of five:

1. Google brings unique competencies to health care information seeking.
2. Google Health is doing a good job on a shoestring budget.
3. Healthcare is ripe for disruptive innovation.
4. Microsoft needs competition.
5. Microsoft HealthVault and Google Health are more complementary than competitive.

Let’s take these one at a time. (more…)

Economists call it “The Penguin Problem”  — No one moves unless everyone moves, so no one moves. 

The role of user expectations is crucial in getting penguins to move off of ice floes and in the successful adoption of new network technologies.  I’ll cover two main points in today’s essay:

• How “The Penguin Problem” Helps Explain Low EHR (electronic health record) Adoption To-Date
• How Recent Federal Actions Are Setting Higher Expectations for EHR Adoption

The Penguin Problem and Low EHR Adoption To-Date

While not the only factor, the role of user expectations is a crucial element in explaining the adoption of new network technologies. Harvard Business School Professor Tom Eisenmann explains:

(more…)

…and the title of the eHealth Initiative’s Sixth Annual Survey of Health Information Exchange says it all:

Migrating Toward Meaningful Use

What’s happening here?

(more…)

There is no question,” says Sterling “that the selection and implementation of an EMR is a ‘bet-the-practice’ proposition. If you fail, you end up with more costs and greater frustration.…” (emphasis added)

The real question that Joe the Doctor is asking himself is “…’scuse me, but WHY am I being forced to bet-my-practice on an EMR in the first place?  I’m not a gambler.”

The problem here is not in health information technology (HIT) per se, but in conceptualizing EMR 1.0 as an all or nothing proposition…pass vs. fail, white vs. black, bet the practice and win vs. bet the practice and lose.

This is exactly why a modular and incremental approach to HIT — clinical groupware, EHR 2.0 — makes more sense than the monolithic bet-the-practice approach of EMR 1.0. Physicians shouldn’t have to bet-their-practice on EMR implementation success.

Click on the graphic to download a copy of today’s BrightTALK webcast.

Here’s a full listing of the six eHealth Summit topics (Eastern Time).  Click on the links to attend any or all of the webcasts.  The series will be recorded for future on-demand access. 

EHR 2.0: Federal HITECH Act Creates Opportunities Beyond EMRs

8 Jul 2009 11:00 am

Presenting Vince Kuraitis, Principal Better Health Technologies

Data Convergence in Life Sciences and Healthcare

8 Jul 2009 12:00 pm

Presenting Greg Nelson, President and CEO, ThotWave Technologies

Continua Health Alliance – Interoperable Telehealth Solutions 

8 Jul 2009 2:00 pm

Presenting Rick Cnossen, President & Chairman of Continua Health Alliance

The Future of Disease & Care Management for the Chronically Ill 

8 Jul 2009 3:00 pm

Presenting Jaan Sidorov, MD, The Disease Care Management Blog

(more…)

The last article in this series — Time for EHRs to Become Plug-and-Play — used words to describe a major industry shift underway in health IT.

Sometimes pictures help to make a point. Here are several diagrams that you can also download as PowerPoint slides.

 Computer Industry 1983 to 2002

  Source: Venkatraman, N. Winning in a Network Centric Era, 2006

Blueprint for Health IT Shift

From EMR 1.0 — 2008…

…to Clinical Groupware/EHR 2.0 — 2012 (more…)

The remarkable report, “Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home,” published in the May/June issue of Annals of Family Medicine, the Nutting Report, makes this point about the state of primary care IT offerings:

Technology needed in a PCMH is not “plug and play.” The hodge-podge of information technology marketed to primary care practices resembles more a pile of jigsaw pieces than components of an integrated and interoperable system.

Surprise!  Well, actually, no surprise.  We all recognize that health IT implementation in family practices, even under the best conditions and with the best of planning, is difficult and can be an ongoing challenge.   

What is surprising to us, however, is that Dr. Nutting and co-authors make this comment in their recommendations section:

…[I]t is possible and sometimes preferable to implement e-prescribing, local hospital system connections, evidence at the point of care, disease registries, and interactive patient Web portals without an EMR. (more…)

The forthcoming definition of the “meaningful use” of health information technology will set the direction of the Obama administration’s strategy for health IT adoption, said David Blumenthal, the new national coordinator for health IT. Government HealthIT, April 28, 2009

…but not everyone sees eye-to-eye on the definitions of “meaningful use” and “certification”.  [See the first post in this series for a refresher on the dog (disruptive innovator) and cat (incumbent EHR vendor) points of view.]

Markle Foundation –  Best Articulation of the Dog (Disruptive Innovator) POV 

Achieving the Health IT Objectives of the American Recovery and Reinvestment Act
A Framework for ‘Meaningful Use’ and ‘Certified or Qualified’ EHR
Markle Foundation; April 30, 2009

HIMSS and EHRA — Best Articulation of the Cat (Incumbent EHR Vendor) POV 

HIMSS Publishes Its Definitions of ‘Meaningful Use’
HIMSS News; April 27, 2009

HIMSS Electronic Health Record Association Executives Testify at NCVHS Hearings on ‘Meaningful Use’ Criteria
RedOrbit; April 28, 2009

Many Others Weigh In…. (more…)

For those of you who have not seen earlier posts in this series, please understand that the reference to “goes to the dogs” is a great compliment.

In a joint press release, the American Medical Association and Covisint unveiled an agreement yesterday:

Compuware Corporation (NASDAQ: CPWR) announced today that its Covisint subsidiary signed an agreement with the American Medical Association (AMA) to deploy an innovative health information exchange solution delivering value to its 240,000 member physicians and the physician population at large….

Covisint will enable AMA physicians to have access to a variety of health information technologies via an AMA-branded, web-based solution.  The AMA said it will use the Covisint platform to deliver to physicians a variety of products, services and resources aimed at increasing medical practice efficiency and facilitating the adoption of health information technology (HIT), including help with implementing electronic health records (EHRs). Current product categories that the AMA is exploring include: practice management tools, resources for professional development and clinical management services. The new platform will provide personalized content, search capabilities and learning and networking opportunities, among other valuable offerings

The features of Covisint’s offering are described on its website.

This deal is a  slap in the face to incumbent EMR vendors who have been attempting to develop the electronic plumbing in physicians’ offices for the past decade. You could interpret it as a vote of no-confidence in EMR vendor abilities to develop these web-based collaboration and care coordination tools.  It’s at least a strong expression of “we’re not going to wait around to see whether you can extend your existing EMRs with these types of capabilities”.

…and it’s a strong validation for the technologies and business models of emerging, innovative companies enabling EHR 2.0 capabilities, e.g., RMD Networks, Shared Health.

What are some other possible implications?

(more…)

by Deven McGraw JD, MPH, Center for Democracy & Technology

Introduction

There has been considerable discussion lately about whether or not the stimulus legislation (ARRA) extends HIPAA coverage to commercial vendors of personal health records (PHRs) any time they contract with entities already covered by HIPAA like hospitals, health plans or physicians groups.  (For those of you who don’t know, HIPAA is the Health Insurance Portability and Accountability Act of 1996.  The HIPAA privacy and security regulations form our national health privacy and security rules.)

The provision in question (Section 13408) states that “each vendor that contracts with a covered entity to allow that covered entity to offer a personal health record to patients as part of its electronic health record” is required to enter into a business associate agreement with the covered entity.   Under ARRA, business associates must comply with key provisions of the HIPAA privacy and security regulations. 

In this post, I argue that PHR vendors should be covered under HIPAA only under certain circumstances.  PHRs should be governed by a comprehensive framework of privacy and security protections, but HIPAA would provide inadequate privacy protection for people using these tools (at least as the HIPAA rules are currently structured).  As a result, I argue that this provision in ARRA should not be read to require the automatic application of HIPAA to PHR vendors any time they contract with covered entities to offer a PHR.   Instead, I suggest that HIPAA should cover a PHR vendor’s activities when the nature of the relationship between the vendor and the covered entity (hospital, health plan, physician office) primarily concerns the vendor performing a service for the covered entity. 

However, where the contractual relationship is primarily about improving the value of the PHR to the consumer, HIPAA should not apply.  (I know, not an easy line to draw – but I do suggest some factors that should influence the decision.) 

Finally, I urge the prompt adoption of separate, targeted privacy provisions to protect consumers using PHRs so that the choice is not HIPAA or limited protections under other federal laws. 

Why Not HIPAA – Isn’t it Better Than Nothing? (more…)

Modifications to HIPAA Privacy Laws: Impact on Microsoft HealthVault, Google Health, and other PHRs. 

We’ll explore how recent changes in privacy provisions of  ARRA/HITECH Federal stimulus legislation affect personal health information (PHI) platform companies (e.g., HealthVault, Google Health,  Dossia) and personal health record (PHR) companies.

Health IT expert and journalist Neil Versel described the issue in the April 7 issue of BNET Healthcare:

Although Google and Microsoft have gotten plenty of attention for their Web-based personal health records, both companies have long maintained that they’re not bound by the privacy protections of a 1996 federal law known as HIPAA. And despite a recent HIPAA change — one intended to extend its privacy provisions to services like Google Health and Microsoft’s HealthVault — both companies still insist they’re not bound by the law.

…“Our understanding is that HITECH, which is the jargon for [the health IT] part of the legislation, did not change the definition for a covered entity or a business associate, so our service is offered directly to the consumer,” Google Health Product Manager Roni Zeiger told Modern Healthcare last month. “[O]ur understanding is that we are neither a covered entity nor a business associate,” he continued. “We’re providing a service directly to the consumer or a patient.”

Microsoft offered a similar assessment at the annual Healthcare Information and Management Systems Society conference in Chicago. “We’re still outside [of HIPAA],” said David Cerino, general manager of Microsoft’s Health Solutions Group.

Not everybody agrees with Microsoft and Google. Versel commented in his own blog:

Excuse me? I’ve been struck since Day 1 with the arrogance Google seems to be exhibiting with its entry into healthcare …  it seems to me Zeiger is intimating that the law doesn’t apply to Google.

In the BNET article, Versel also quotes David Brailer, the first head of the Office of the National Coordinator for Health Information Technology at HHS: (more…)

What a difference in attitude! Compare two press announcements from April 5:

1) CCHIT:  Interoperability Isn’t Doable With Today’s Technology .

Certification Commission for Health Information Technology (CCHIT), Interoperability: Supplying the Building Blocks for a Patient-centered EHR , April 5, 2009

This report…(is)  also an attempt to inject a dose of reality into the discussion of interoperability – from practical expectations for the near term and future years to the challenges of developing software architecture and implementation guides that can execute new interoperability criteria uniformly and successfully.

2) New York Presbyterian/Microsoft: We’re Creating Patient Data Liquidity Today!

New York-Presbyterian Hospital Pioneers New Personal Health Record, Press Release; April 6, 2009

Patients can reference their actual, up-to-date health records, which are organized and stored through Microsoft’s Amalga and HealthVault technologies and stored by the patient in a personal account following visits to their hospital, doctors and health care providers.

(more…)

One of the potential dangers of limiting $17 B HITECH federal stimulus funds to electronic health records (EHRs) is the risk of locking-in outdated technologies. Let’s consider what this might mean.

If you think of today’s EHR technology as EHR 1.0, what might EHR 2.0 look like? This post presents a number of innovative ways to conceptualize EHR 2.0:

• EHR as Platform + Applications
• EHR as Clinical Groupware
• EHR Integrated with PHR
• EHR as Software-as-a-Service (SaaS)
• EHR as a “Publish-Discover” Search Engine
• EHR + Disease Management Services = Care Coordination
• DRT-Enabled EHR

My point here is not to provide an exhausting listing of what’s possible, but simply to get you to begin to think about what’s outside the existing EHR box. These concepts are not mutually exclusive and you’ll see there’s overlap.

Let’s look at each of these innovative approaches. (more…)

On March 24, Stand for Quality — a new group representing 165 diverse health care organizations — called for a new era of quality in health care. Their white paper is titled Building a Foundation for High Quality, Affordable Health Care: Linking Performance Measurement to Health Reform .

The perspectives of Stand for Quality are a remarkable break from the past and have significant implications for future investment in health information technology. The Stand for Quality document unequivocally supports the dog  (disruptive innovator) POV — that providers should be paid for improvements in quality and outcomes. It rejects the cat (incumbent EHR vendors and supporters) POV — that providers should be reimbursed for simply acquiring health IT , with the expectation that quality will naturally follow.  (For a refresher on definitions of the dog/cat POV, see the first post of this series .)

Stand for Quality is a who’s who list that includes substantial representation from the physician, hospital, and health plan communities, as well as many others.  A listing of initial supporters is provided at the bottom of this posting.

The key recommendations of the white paper are:

• We must improve quality in health care and make it more affordable.
• Performance measurement is a core building block to provide high quality affordable care
• Public investments are needed to support the performance measurement, reporting and improvement enterprise.
• We should build upon the existing public-private performance measurement, reporting and improvement enterprise.
• Investment in health information technology should be linked to improving care (emphasis added).
• Performance measurement must be dramatically expanded, but measurement alone is not enough.

From having barely been on the radar screen six months ago, is the dog (disruptive innovator) POV rapidly becoming the majority perspective? Here’s the text from the 5^th recommendation:

(more…)

Even though I am a self-admitted dog person, Hoover is my buddy.

Hoover got a new shoebox as a Christmas present.  While most cats are very tied to their existing surroundings and don’t like things to change, Hoover is not your average cat.

The following photos were taken over about a two week period. Hoover hopes you enjoy them! (more…)

Sometimes laws are passed and the statute itself represents 95% of the work — there aren’t many details to figure out or loose ends to tidy up.

That isn’t the case with HITECH. The HITECH statute is just the beginning.

Whether you’re a cat or a dog, you’ll have hopes and fears about aspects of HITECH that are unclear or yet to-be-determined (TBD).

These include:

(more…)

What do cats (incumbent EHR vendors and their supporters) have to smile about over HITECH?

A lot.

…and it’s not very complicated.  HITECH directs $17 B to the cat community, and leaves scraps for the dogs.

(As a refresher, the cat POV is that HITECH stimulus funds should simply pay directly for electronic health record (EHR) technology — that providers will figure out how to use the technology to improve quality and outcomes; the dog POV is that HITECH should pay for improved quality and outcomes — change incentives and IT will naturally follow. See the first post in this series for more detailed explanations.)

There are three aspects of HITECH that are particularly favorable to cats: (more…)

In the first post of this series, I suggested that HITECH favors cats by about 60/40 and noted that the single most cat-like feature of HITECH is providing incentives for physicians and hospitals to acquire and implement EHRs  — but only EHRs. Reader “Mark” commented:

“How does this work out to 60/40? Looks to me like 100% cats.”

Let’s look a bit deeper to see how HITECH creates opportunities for disruptive innovation . (As a refresher, the cat POV is that HITECH stimulus funds should simply pay directly for EHR technology — that providers will figure out how to use the technology to improve quality and outcomes; the dog POV is that HITECH should pay for improved quality and outcomes — change incentives and IT will naturally follow. See the first post for more detailed explanations.)

The next three posts in this series will examine various aspects of HITECH from differing points-of-view:

• What’s dog-like (innovative)?  — today’s post.
• What’s cat-like (protecting incumbents)?
• What’s yet to-be-determined (TBD) or unclear?

The Need for Innovation

Lack of innovation is the heart of the problem in today’s health IT marketplace. Writing specifically about the market for hospital EHRs, my colleague David Kibbe and I have previously characterized the prevalent HIT business model:

• Proprietary, non-interoperable software
• Low volume, high margin sales (there are only about 5,000 hospitals in the country)
• Customers (hospitals) have high needs for installation support and customization. Customization for individual customers further challenges opportunities for creating interfaces and achieving interoperability.
• High costs of purchase and installation result in high switching costs and customer lock-in.

We questioned whether interoperability was in the economic interests of current health IT vendors:

• Interoperability will tend to commoditize data and reduce opportunities for high margin pricing
• Interoperability will reduce customer needs for software customization
• Interoperability will reduce switching costs and potential for lock-in
• Although it might seem contradictory…hospital customers aren’t asking for it

The market for physician EHRs is very similar.

What’s needed are technology and business models that will create disruptive innovation  in today’s HIT marketplace.

How Does HITECH Create Potential for Disruptive Innovation?

Here are five aspects of HITECH that lay groundwork for future innovation in health care: (more…)

It’s a mixed bag — HITECH legislation  is both dog-like (innovative) and catlike (protecting incumbents).  I’ll refresh your memory below on more specific definitions of cats and dogs.

Among many other reasons, HITECH is dog-like primarily because it has ended the question of WHETHER the U.S. is really serious about health IT reform.  HITECH spells out clear policy goals working toward interoperable health IT and dedicates an initial $19B in federal stimulus funds to begin the work. HITECH begins to create an environment for innovation in health care reform.

There are many open questions as to HOW best to go about this — how to spend the federal stimulus funds in ways that encourage innovation.

HOWEVER,

On balance, HITECH favors cats by about 60/40.

Why?

(more…)

Here’s a recap:  On a Saturday evening Dorothy took her 86 year old aunt to a hospital in Montgomery, Alabama. Frustrated after an overnight stay in the ER which she said yielded “little treatment”, she requested a copy of her aunt’s medical records before leaving. When she was told that it was hospital policy to request records “in writing”, Dorothy escalated her requests for the records. Refusing to leave without the records, she was brought to the floor by security guards and arrested on charges of  criminal trespassing.

The Chicago Tribune reports that Dorothy has been VINDICATED! (more…)

What would you call health care software that:

• Is Web-based and networkable, therefore highly scalable and inexpensive to purchase and use;
• Provides a ‘unified view’ of a patient from multiple sources of data and information;
• Is designed to be used interactively – by providers and patients alike – to coordinate care and create continuity;
• Offers evidence-based guidance and coaching, personalized by access to a person’s health data as it changes;
• Collects, for analysis and reporting, quality and performance measures as the routine by-product of its normal daily use;
• Aims to provide patients and their providers with a collaborative workflow platform for decision support; and
• Creates a care plan for each individual and then monitors the progress of each patient and provider in meeting the goals of that plan?

I call this Clinical Groupware.  The term captures the basic notion that the primary purpose for using these IT systems is to improve clinical care through communications and coordination involving a team of people, the patient included.  And in a manner that fosters accountability in terms of quality and cost.

Clinical Groupware is a departure from the client-server and physician-centric EHR technology of the past 25 years, a fixed database technology that never really became popular.  It is a substantially new and disruptive technology that offers lower price of purchase and use, greater convenience, and is capable of being used by less skilled customers across a broader range of settings than the technology it replaces.

As the name indicates, Clinical Groupware is intended for use by groups of people and not just independent practitioners or individuals.  It is not the same thing as an electronic health record, but may share a number of features in common with EHRs, such as e-Prescribing, decision support, and charting of individual visits or encounters, both face-to-face and virtual.  Neither is Clinical Groupware bloated with extra features and functions that most providers and patients don’t need and, with good reason, don’t want to pay for.

Some Clinical Groupware may look and feel like a web-based "EHR lite." But Clinical Groupware aims to create a unified view of the patient, assembling health data and information that may be stored in many different places and in several different organizations – including HealthVault or Google Health — which most EHRs cannot do.   Clinical Groupware is an evolutionary approach to a shifting health economy in which doing more is not always equated with better care, and the physician or provider role is transforming from autonomous expert to advisor, partner, and guide.   It is also an organic response to the reality that most health care data in electronic format is dispersed across numerous organizations and companies – e.g. hospitals, labs, pharmacies, and devices – and provides a means of accommodating patient demands for a more participatory practice of medicine.

Let me give a couple of examples of this new and emerging class of health software. (more…)

“Where’s the single best place to get up to speed on how the Feds should  spend $20 billion to advance health information technology (HIT)?”

A colleague asked me this question a couple of days ago, and at first I hesitated.  Then it struck me — Matthew Holt’s The Health Care Blog has become the focal point for discussion of this critical topic.

Matthew’s very recent article — Cats & dogs: Can we find unity on health care IT change? — summarizes the two schools of thought that have emerged over the past two months.

His article is important and notable for a number of reasons:

• He crystallizes the two emerging schools of thought — the dog vs. cat POV (see below)
• He summarizes and links to many other key writings on the HIT spending topic
• He suggests that the dog and cat POV can be reconciled — that there’s a middle road
• He suggests several initial options to reconcile the differing schools of thought.  This discussion should continue.

If you’re interested in disease/care management, this is a topic you should be following closely. While the first decade of DM focused on a services based, call center model — the handwriting is on the wall that the next decade will focus much more on a technology based model.

Companies and organizations involved in disease/care management should be positioning themselves to take direct and indirect advantage of the Federal injection of funds.

Here’s Matthew Holt’s summary of the dog vs. cat perspectives: (more…)

by Vince Kuraitis and David C. Kibbe MD, MBA

Have you ever heard anyone tell a happy story of how easy it is to get a copy of their paper medical records?

Departing Health and Human Services Secretary Mike Leavitt is laying the groundwork for this same story to apply to access to YOUR electronic personal health information.

Here’s an overview to what evolved into a long posting:

1. Analysis: The Leavitt Framework Uses the HIPAA Privacy Rule as a Baseline for Electronic Access to Personal Health Information
2. Implication: Extending the HIPAA Privacy Rule Could Restrict Your Electronic Access to Your Personal Health Information
   • A.The HIPAA Privacy Rule Should Not Be the Baseline for Governing Access to Your Personal Health Information
   • B. Examples: Extending the HIPAA Privacy Rule Creates Barriers and Confusion
3. Implication: Extending the HIPAA Privacy Rule Protects Incumbents at the Expense of Innovators Like Microsoft and Google
4. Conclusion: The Leavitt Framework Creates Bad Public Policy (more…)

It seems likely that the Obama administration and Congress will spend a significant amount on health IT by attaching it as a first-order priority to the fiscal stimulus package. We take the President-elect at his word when he recently said:

"…we must also ensure that our hospitals are connected to each other through the Internet. That is why the economic recovery plan I’m proposing will help modernize our health care system – and that won’t just save jobs, it will save lives. We will make sure that every doctor’s office and hospital in this country is using cutting edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes, and help save billions of dollars each year." (December, 6, 2008)

Whether the health IT money is well spent will depend on how it is distributed and what it buys. Most observers suppose that federal health IT investment dollars will be used to help doctors’ offices and hospitals acquire and implement electronic health record systems (EHRs or EMRs). These are commercial software suites for entering, storing and managing patient health data within a practice or health organization.

We agree that some of the federal health IT money should go to purchase EHRs, especially to doctors and hospitals in rural and under-served areas, which otherwise could not afford them.

The Easy, Wrong Solution

The easy solution would be to spend most of the health IT funds on EHRs. The EHR industry has made it easy by establishing a mechanism to "certify" EHR products if they incorporate certain features and functions.

But the easy solution would not be the right one. (more…)

The current draft of the PHR Certification Criteria specifies use of the HL7 Continuity of Care Document (CCD) as the only endorsed standard for interoperable exchange of information to and from PHRs.  This is extremely short-sighted.

I wrote a comment to the PHR Work Group explaining why it’s important to adopt BOTH the HL7 CCD and the ASTM Continuity of Care Record (CCR) .  I suspect most professionals commenting on these criteria will be looking through the lenses of health information technology, so I thought it would be important to share a different view — one through the lenses of business strategy and public policy.  Here’s my commentary:

(more…)

…that’s my key takeaway from attending the Robert Wood Johnson Foundation (RWJF) Project Health Design (PHD) conference in Washington D.C. on September 17. The conference was entitled  A ‘Report Out’ from Project HealthDesign and Forum on Next-Generation PHRs .

A PHD Fact Sheet capsulizes the evolution from PHRs to PHRSs: (more…)

By Vince Kuraitis and David C. Kibbe, MD, MBA

Once upon a time, there was a little girl named Goldilocks. Like most Americans, Goldilocks had concerns about achieving just the right amount of data liquidity for her personal health information (PHI).

Until today Goldilocks felt between a rock and a hard place:

"I want my PHI to be appropriately liquid — just the right viscosity. My PHI should be viscous enough to flow to my trusted health care providers to use to improve my health and health care.

“Today my PHI is frozen and inaccessible — it’s too cold.

“But I’m worried about the other extreme — the risks of using a personal health record (PHR). The privacy/security advocates tell me that I should be concerned about my PHI being too hot — like steam that’s vaporized and disperses uncontrollably into the atmosphere.

“How do I get it just right? …not too cold, not too hot?"

What happened today to resolve Goldilocks dilemma? The Markle Foundation’ released its Common Framework for Personal Health Information (PHI).

Dossia, Google, Intuit, Microsoft, and WebMD today joined prominent health care providers, health insurers, and consumer and privacy groups in endorsing a set of practices for new internet services that help consumers track and improve their health. The framework defines a set of practices that can help protect personal information and enhance consumer participation in online personal health records.

The Markle Foundation’s accomplishments in advancing this collaborative framework are nothing short of miraculous!

Let’s revisit Goldilocks and the bears to see exactly how the Framework resolves the PHI too hot/too cold dilemma. (more…)

Drs. Mandl and Kohane begin their recent article in NEJM with the statement that “large corporations are seeking an integral and transformative role in the management of health care information,” and then warn that this “will profoundly affect the biomedical research enterprise.”   

At issue for the authors is who controls the information about you and me, our health and healthcare data. Without coming right out and saying it directly, they worry that data in the hands of consumers and patients made possible through PCHR service providers like Google and Microsoft could be dangerous to the nation’s health because of  “commercial interests”.  

So, they are warning us, too.

But, let’s examine the presumption that your personal health information is safest in the hands of the medical establishment (incumbent service and health care provider organizations and the biomedical research enterprise). The real question that their article in NEJM begs is:

how good a job of stewarding our health data is the medical establishment doing? (more…)

Who is the federal  government calling on to breathe life into the Nationwide Health Information Network (NHIN)? Google and Microsoft.

In our first article of this series describing the Personal Health Information Network (PHIN), we noted early entrants as Google Health, Microsoft HealthVault, and Dossia.  We also noted that the network could grow rapidly, and that others would want to join or link to the PHIN.

With Uncle Sam announcing plans to link to the PHIN, even we are surprised at the speed at which developments are occurring. 

Government Executive reports:

The federal office in charge of creating a national network of electronic health records plans to integrate the system with the health care databases that Google and Microsoft launched last year, on which individuals can store their health records, a top official with the Health and Human Services Department said….

(The HHS official) provided few details on how the office would incorporate personal health records….

Federal interfaces to the health network will be through an entity called NHIN Connect.

Here’s a simplified diagram of our current understanding of how NHIN Connect will link to the Personal Health Information Network (click on the diagram for a larger version):

Commentary (more…)

Two companies — Aetna and Microsoft — have come up with 180 degree different answers.

In this post, I will:

• Describe how Aetna’s and Microsoft’s approaches differ
• Speculate on why their approaches make strategic sense for the respective companies
• Explore how technology and expectations about using PHI for search are likely to change over time

Aetna’s SmartSource and Microsoft HealthVault 

Aetna has adopted a more aggressive strategy of using your PHI to improve search results. Microsoft HealthVault is employing a much more cautious strategy and (for now) has pledged NOT to use personalized health information to target health search.

Aetna is a health insurance plan with an existing member base of 17 million members.  Aetna’s recent press release announced a partnership with Healthline introducing

Aetna SmartSource, the first-ever personalized search engine that mines information from Aetna’s vast data resources to deliver meaningful, personalized health and health benefits information to Aetna members. 

Based on existing medical claims data that Aetna already has about members, your search term will be matched against your own medical history to provide the most relevant results.

Microsoft HealthVault search is different.  From the Microsoft HealthVault Fact Sheet:

Microsoft does not link users’ personal information with HealthVault search queries.

Why the Difference? (more…)

I’ll describe 4 factors behind my thinking:

• Lack of Trust
• Lack of Access to Clinical Data
• Lack of Permission
• Lack of Convenience in Consumer Workflow (more…)

Vince gave me Dorothy’s story to read, and here’s what I said:  GO DOROTHY!   ::::goofy little happy dance:::   Dorothy is my new hero. I love people who are willing to go to the mat for a cause, especially one having to do with the elderly, children, the disabled and less fortunate than we.

Since Vince and I have been overwhelmed by the swamp of details of taking care of our family elderly for about, oh, 13 years – my parents, his aunt and uncle, pretty soon his mom -  nobody knows better than us how utterly nonsensical the systems are.

Our friends call us “The Geezer Whisperers” and email us for advice dealing with their relatives’ health care paperwork nightmares.  Since Vince has a deep understanding of  how American health care got to a point of old ladies being dragged out of hospitals in chains and shackles, and I’ve  demanded a lot of things from hospitals and doctors over the years, our friends think we have all the answers.

Vince is lucky.  He’s famous for being the smartest, most levelheaded, steady, reliable and adorable guy in the world.  Me?  I get the notoriety of being the proverbial rock, as in “between a rock and a hard place.” Taking no for an answer is not in my playbook.  You don’t want to get in my way when I’m organizing something, or you will end up firmly clipped to a barbed-wire clothesline. I can get You-Knighted States Senators to park my car. I take every defective purchase back to the store and always get a cash refund.  When I call the bank, they just waive any fees to avoid the hassle of talking to, uh, me.

Since I’m sure you get the picture by now, just imagine what hospital records departments have had to deal with. When told “you can’t have that” and it’s something I need to take care of someone I love, I am relentless. I’ve always gotten what I came for, but not without some big damned silly, er, disturbances.  No handcuffs have been involved yet, but ….(HINT:  When the guys in uniforms show up, smile and suddenly become unfailingly reasonable. Pisses ‘em right off.  When they leave, you can just swipe the folder and bolt.) (Oops….Um, Vince?  Did you know about that one?)

I’m proud to report that one doctor’s office staff refers to me as “that woman” and now gives me anything I want immediately.  Reputation is not as high on mine and Dorothy’s  lists as taking care of loved ones. If I remain kind and reasonable as long as possible, and only escalate to teeth-gritting, death-stare, devil-voiced determination when the refusals go on and on and on…..it comes out  even with Heaven.

I’ve always wondered if they are suspicious of imposters demanding strangers’ medical records. Do they think I’m selling them on eBay, or something?

So. What would REALLY happen if people like Dorothy were simply handed Auntie’s medical records?  Would anyone turn purple and explode? Would the hospital walls come-a tumblin’ down? Would Britney Spears wake up and smell the coffee? (more…)

The Internet and digital technologies have transformed many aspects of our lives over the past twenty years.  We can get cash at ATMs all over the world; we can book our own airline reservations; we can shop and get best prices over the Internet.

Why hasn’t this happened in health care?  Something is missing.

Recently, major global information and communication companies have announced their intention to bring their technologies and business models to health care.  While the creation of Google Health (GH), Microsoft HealthVault (HV), and Dossia (sponsors include Intel, Wal-Mart, AT&T) are important news items by themselves, what’s more important is what they represent collectively — a new Personal Health Information Network (PHIN). The PHIN and applications developed around the PHIN will fill in many missing pieces and bring health care into the Information Age.

For example, suppose you just found out you have high blood pressure – that’s not uncommon.  Suppose you could easily submit information about your condition using the Google Health platform to receive a service that does the following:

• informs you whether there are clues in your medical history that point to a cause for your high blood pressure
• explains why being overweight can be a contributing factor
• tells you in easy-to understand language what the top number and the bottom number mean (“140 over 90″)
• explains which laboratory tests are necessary
• alerts you to the possibility that one of your prescription or over the counter  drugs could be making your high blood pressure worse
• advises you about the usefulness of using non-drug approaches to treatment
• tells you which treatment drugs have the greatest efficacy and safety for your specific circumstances
• tells you if any of those generics high blood pressure drugs are available at Walgreens for $4 a month
• offers to provide you a map with several Walgreens stores in your city that carry those $4 a month medications

…and many more possibilities we have not yet begun to imagine!

This essay:

• Is the first in a series of articles we’ll be writing to describe the PHIN and why it’s important — expect about a dozen follow-up posts.
• Is an overview of the basic idea — think executive summary or long abstract
• Introduces some new concepts, which we’ll try to simplify and define.  We understand that some of this is not easy reading. ….so we suggest you refill your cup of coffee and settle in. (more…)

Dorothy Tillman wanted it so badly that she was arrested!  Read more at Jaz-Michael King’s blog, A Scanner Brightly.

Hat tip to Jen McCabe Gorman for spotting this amazing story.

A High Level Comparison

Google Health and Microsoft HealthVault Personal Health Information (PHI) Platforms

There’s still not much information available about the specifics of GH, although they did release sketchy information on the Official Google Blog.  I’ll comment on a few of the particulars. (more…)

During the past week two reports were released discussing privacy/confidentiality issues surrounding PHRs.  One of these reports did it the wrong way; one did it the right way.

The general public is just learning about Personal Health Records (PHRs).  We believe that the appropriate way to frame the dialogue for the public is to acknowledge both the benefits and risks:

• Benefits: PHRs (and EHRs) have the potential to save lives, reduce medical errors, improve patient diagnoses, and reduce health care costs
• Risks: PHRs (and EHRs) have risks relating to privacy and confidentiality.  These are significant, legitimate concerns that must be identified and addressed.

Let’s briefly review the two recent PHR reports.

The Wrong Way

The World Privacy Forum (WPF) issued Personal Health Records: Why Many PHRs Threaten Privacy.

This report could have been titled “12,356 Things That COULD Go Wrong With Your PHR.” (more…)