Megatrend Spotting: Health Plan Role of Having “Best Data About YOUR Medical Conditions” is Up for Grabs

Who has the most comprehensive data about YOUR clinical conditions?

For most people, the answer today is “your health plan”, but it’s not at all clear that health plans will continue to have this role in the future.

As physicians and hospitals adopt EHRs, it’s foreseeable that clinical data about patients will be far more available and accessible.

Will patient data become:

  • A jockeying point for control and business advantage between health plans and care providers,
  • A collaborative opportunity to optimize clinical care and care coordination, or
  • Both?

Is HITECH Working? #3: ONC got it right on the 3 major policy interpretations: Meaningful Use, Certification, Standards

We concluded our last post in this series with a blunt prediction that “key physicians will sit on the sidelines” and that clinician non-adoption of EHR technology is a potential “deal-breaker for the success of HITECH”.

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

The Third Rail in HITECH Implementation: “Please Don’t Make Us All Speak Latin”

By Vince Kuraitis and Steven Waldren MD, MS.  Dr Waldren is Director of the Center for Health Information Technology at the American Academy of Family Practice (AAFP).

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.

HIT Policy Committee Recommends “Minimum” Certification of EHRs

At last Friday’s meeting, the HIT Policy Committee adopted the recommendations of the Certification and Adoption Workgroup.

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

UL - the standard in safety

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

Is the Health Data Liquidity Glass Half Empty or Half Full?

Glass 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.

Dogged Optimism: Five Innovative Aspects of HITECH

HEBHITECH1 If you’re a dog (an innovator), what’s there to smile about over HITECH?  Quite a bit.

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:

Goldilocks: “Markle’s Framework for Networked Personal Health Information is Just Right”

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.

NEJM and NYT Discuss “Tectonic Shifts” of a Personal Health Information Economy

Vince Kuraitis and David C. Kibbe, MD MBA

Tomorrow’s edition of the New England Journal of Medicine contains an article entitled “Tectonic Shifts in the Health Information Economy”.  While we have not yet fully digested this article, it’s clear that the authors’ description of the “Health Information Economy” closely parallels our initial description of the Personal Health Information Network (PHIN).

The main thrust of the NEJM article is to discuss implications (good and bad) relating to clinical research. The NEJM article is also highlighted in a New York Times piece entitled “Warning on Storage of Health Records.”

In anticipation of our webinar tomorrow sponsored by Healthcare Informatics, we wanted to bring these articles to your attention ASAP.

As a first pass at discussing these important articles, here are a few highlights from the NEJM article.  Whether you prefer the label the “Health Information Economy” or “Personal Health Information Network (PHIN)”, these excerpts describe the potential magnitude of the tectonic shifts:

Table of contents for the series--The Personal Health Information Network (PHIN)

  1. Birth Announcement: the Personal Health Information Network (PHIN)
  2. Feds Call on Google and Microsoft to Breathe Life into the NHIN
  3. NEJM and NYT Discuss “Tectonic Shifts” of a Personal Health Information Economy
  4. Picturing the PHIN as One Interoperable Network
  5. The Yabuts of Sharing Data Between Google Health and HealthVault

Feds Call on Google and Microsoft to Breathe Life into the NHIN

Vince Kuraitis and David C. Kibbe, MD MBA

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):


Birth Announcement: the Personal Health Information Network (PHIN)

Vince Kuraitis and David C. Kibbe, MD MBA 

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.