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.
by Vince Kuraitis JD, MBA and David C. Kibbe MD, MBA
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
by Vince Kuraitis, Steve Adams, and David C. Kibbe MD, MBA
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
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:
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:
Will the recently passed HITECH legislation — the federal stimulus funding for health IT — encourage innovation? or will it lock in outdated electronic health record (EHR) technology?
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.
On balance, HITECH favors cats by about 60/40.
by David C. Kibbe MD, MBA
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.
“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:
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):
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!
- 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.
Do local Health Information Exchange (HIE) participants have the right economic motivations to make them work?
A report released this week raises strong doubts. The study — Creating Sustainable Local Health Information Exchanges: Can Barriers to Stakeholder Participation be Overcome? — was funded by the U.S. Agency for Healthcare Research and Quality (AHRQ) and conducted by the Center for Studying Health System Change (CSHSC). The term HIE is often used interchangeably with RHIO (Regional Health Information Exchange).
What’s different about this study? The CSHSC report goes a step further than other recent reports documenting minimal progress by most HIEs and questioning whether HIEs have a business model. Through interviews with HIE participants — hospitals, physicians, health plans, employers — it brings evidence from the horse’s mouth suggesting
- the rationale TO share data is WEAK, and
- the rationale NOT TO share data and to preserve the status quo is STRONG.
The next question becomes “Is it time to get off the dead horse?” Does it make sense to put more time and energy into a flawed model model and further delay national efforts to create interoperable electronic health records? Are HIEs doing more damage than good?
Here are some of the key conclusions: