Adam Bosworth’s Weblog

Mark Leavitt has written an angry post in the Health Care Blog about some concerns David Kibbe has with the current administration health plans. (Full disclosure – David Kibbe is an adviser to Keas and a friend).  I understand Dr. Leavitt’s annoyance, but what is really happening here is a result of a deep fear among many of us that the new ARRA health bill will miss out on an incredible opportunity to actually make a difference in how health care is practiced. This fear can be paraphrased as a fear that only the incumbents will be allowed to be “certified EHR’s” and arguably the incumbents haven’t really made as big a difference in how health care is practiced as one would hope.

Let me explain.

The simplest way to describe what the administration seems to want is to be able to insure more people (a LOT more) at a lower cost (since otherwise the total costs go up a lot). Many of us have a strong belief that we can only lower costs and/or improve health-care if we make the consumer part of the solution, what is often called “patient engagement”. At the end of the day, episodic care treating people only when they get seriously sick, enough to go to their doctor or the ER isn’t ideal. What we believe is ideal is teaching people to keep a constant eye on their health and keep them out of the doctor’s office and especially out of the ER.  One might think that the forthcoming funding for Electronic Health Records (EHR’s) would support systems that deliver this sort of patient engagement and long-term patient wellness and thus help lead to better support for patient engagement. But in fact, many of the  traditional EHR’s have not focused on this at all, hence our fear about giving them a de-facto monopoly.Secondly, most small practices can’t really afford to use big iron EHR’s. Even if it is free, they can’t really afford to do it because it will still require training, more time per patient potentially, and so on. Lastly, more EHR’s don’t work with other EHR’s so that coordinated care across practices isn’t supported and most people who are elderly or who have serious illnesses have more than one physician treating them.

The way around this is to build systems that don’t just duplicate what physicians do today during their face to face meetings with their patients, but rather provide new capabilities that will help with continuous and coordinated care and can generate additive revenues for physicians and then evolve by adding those features that automate the current physician activities as demanded by the physicians. What would such systems support? They would support having a way to chat with or exchange messages with a patient for a fee so that unnecessary office visits can be removed and the patient is more likely to reach out for help. Think eVisit-lite. They would support a simple way to monitor the health of a patient who either has a chronic disease or is on path to developing one again for a fee so that physicians are actually getting paid for keeping their patients healthier as opposed to being punished for it since, ideally, it will result in fewer visits/procedures over time. In short these systems will support physicians  managing an ongoing paid relationship with the patient rather than an episodic one measured only by in-office visits.  What should be done about helping physicians who are afraid of losing time to retraining? These systems should be as easy to use as a Southwest airlines reservation page. These systems should have a cost is so low that physicians don’t care. Most of these points aren’t typical of most of the big EHR’s currently being sold. Again, hence our fear that a de-facto monopoly of the incumbents will lose this opportunity to let 100 disruptive innovations flower.

It is my opinion that the bar for “meaningful use” and a “certified EHR” should be limited to the following:

• Easy way to share electronically computable data about medicines and labs with the patient’s URL’s of choice. These URL’s would point to the services that are helping/advising/monitoring the patient in a patient controlled way. This alone should be enough to declare a tool certified because it empowers consumers to take charge of their own health. This is also the backbone of cooperative care since then multiple physicians, regardless of vendor or practice, can exchange and share computable health data about a patient.
• Easy standardized way to support an inbox both between physicians using different EHR’s (think email today) and between patients and their physician/nurse/physician’s assistant. This should be optional, but Medicare and insurers should be encouraged to pay for such support. Kaiser has found that the burden isn’t high and it cuts in-office visits significantly. This should certainly be sufficient for meaningful use because this, in conjunction with the first point ensures that physicians can coordinate care for a patient. It also frees up the patient to pick the best other doctors who provide the best care, regardless of practice because the collaboration can occur across practices.
• Support for ePrescribing, largely, to be honest, so that the prescription information can flow to the patient.
• Easy way to put patients on ongoing fee-based computable care programs and monitor how they are doing sending alerts to the physician where necessary so that physicians know when their patients are trending in the wrong direction. Something as simple as monitoring blood pressure and weight and ankle swelling can prevent repeat heart attacks. Something as simple as monitoring total steps taken a day and blood sugar and meals can prevent serious diabetic complications. But physicians aren’t paid to put patients on such plans or for the time to monitor them. Instead we wait for catastrophe and pay for that.

Not one of these except for ePrescribe duplicates existing physician work flow . These are new services that should generate new revenues for physicians all focused on continuous and coordinated care. Most people don’t get these services from their doctors (Kaiser is always a notable exception precisely because, I believe,  they are actually paid to keep people well).  And these are the services that will truly drive patient engagement with their health and with their physicians. Ultimately, it is my premise that patient engagement with their physician is the key to unlocking our health system, driving true innovation and converting it from a sick care system to a true health care system. There is an excellent post by David Brailer, the former National Health Information Technology Coordinator, supporting the urgent need for innovation and patient engagement in health care.

I ask Dr Leavitt and CCHIT to help ensure that the funds unlocked by ARRA be used to support these capabilities in as open and easy a way as possible and to avoid, at all costs, a de-facto monopoly in the physicians’ offices by the current EHR vendors by defining meaningful use of certified EHR’s to meet only the few and simple requirements listed above.

Best two books I’ve read on health in the US this year were:

Flatlined and Overtreated

Both make it so clear that we have to fix the system that you wonder how some Senators can continue to blithly insist that there is no problem and that we have a “pretty good system”.  We have good doctors and technology. The system itself, as these books make clear, isn’t good at all.

When I was running Google Health I would constantly hear how it was impossible to download health data because of the doctors notes and conditions and lots of fancy stuff that wouldn’t be interoperable. And I agreed. I focused entirely on getting labs and meds to be generally available because these seemed to be the only two things that were computable and not dependent on the vagueries of the hospitals and EHR’s. There is a wonderful post up on on ePatients.net by e-Patient Dave detailing what happens when you try to get more and actually get less. The post is a constant reminder to start small and make sure that what you’re doing works. It is also a reminder that the big systems because they aren’t paid for by the consumers or reviewed by the consumers or ever see the light of day are a terrible mess. Like everything else hidden in the dark, health data is crawling with mistakes. Let’s let the light in!!

The New York Times has a dire warning that the $19 Billion that ARRA calls to spend on electronic health records (EHR’s) could be wasted.  They bring up two valid concerns. The first is that physicians will not use EHR’s to improve the quality of healthcare, but primarily just for record keeping. The second is that the government will not require simple open standards that all comers can easily use to drive innovation and new cheaper solutions.”

It is certainly a risk and some of the answers aren’t intuitive. The ARRA act calls for meaningful use of the EHR’s and the NY Times article assumes that meaningful use is determined by improving care and curbing costs. This is of course the goal and if the EHR does a good job of real-time clinical decision support, it will undoubtedly improve care.

But it is an error to conflate physicians using EHR’s with curbing costs. To curb costs it is essential to create more ways and more choices for patients to own their computable health data thus enabling patients to use their data to get help and advice. This is usually called Data Liquidity and it empowers patients by adding choice into the equation. Put simply, EHR’s should, at the patient’s request, send the patient’s data (and it is the patient’s data after all) to their PHR (personal health record) of choice. Then, instead of being reliant on a single overworked physician to understand and interpret their data, they can have access to many tools and many people to help them stay healthy and on their own dime. History has shown that choice and competition lead to far better and more cost-effective results.

Some object to this model of patient controlled PHR’s. In the current issue of NEJM there is an article by Drs Paul  Tang and Thomas Lees suggesting that the best PHR is one tethered to the EHR. They argue that only this way can there be a shared patient record and only this way is the patient’s security and privacy be assured thanks to HIPAA. The article further contrasts the untethered PHR to the one run/managed by the doctor by suggesting that only the latter will help the patient to easily manage and understand their blood pressure and glucometer readings with intelligent doctor oversight.,This is very much a false dichotomy.

First, HIPAA does not give patients the ability to control who can see what of their data. It simply makes sure that only a doctor treating them can have access to it. But the patient has no fine grained control. Microsoft’s HealthVault, by contrast, does provide such protection. Clearly no one would use a PHR that leaked their health data so the business imperative for PHR’s to be secure is actually far greater than provider imperative.

Secondly, as the article points out, many patients see many doctors. The odds that all one’s doctors work for the same institution with the same EMR are both slim and presuppose, again, a lack of choice for the patient.

There is a much simpler solution. First, require the newly “certified” EHR’s that ARRA will pay for to share the patients Labs and Med’s and Conditions in a standard computable way with the patient’s PHR on patient request. Many countries  have long since figured out how to do this using SNOMED codes. Surely we can do the same using standard encoding’s for the Meds, Conditions, and Labs and standard XML formats like CCR and CCD to describe the patient data. Indeed many health organizations have have already done just this with Google Health such as Beth Israel Deaconess, Cleveland Clinic, Quest Diagnostics, CVS and Walgreens.

Second, provide extra rewards to EHR’s that support interoperable secure messaging using a standard way to exchange messages. Then patients can own their data, have a wide range of choices and still have an efficient way to communicate with their doctors. And a huge side benefit will be that doctors can now see the bigger picture of what is happening with their patients outside of their own practice.

All this will lead to truly collaborative medicine with a payoff that can only come from informed decision making and feedom of choice by the patients.

Building Keas has been more than a full time job for the last 9 months; exciting, rewarding, occasionally difficult, and overall enormously fun. Mostly, as we have hunkered down to build Keas, I have avoided giving speeches or anything else not required to get the product launched.

But I did agree to give a talk at TEPR and I gave it this week. I gave it because we’re at an extraordinary point in our history. We have a new administration who actually wants change and can see that the current health care system needs to change.  The basic thesis of the speech is that our health care system is broken and on track to get worse, and that the only way to fix this is to get truly participatory health care between the doctors and the patients and their other health coaches. Surprisingly, as I point out in the talk, we can make a major dent in our current $2.3 Trillion of costs by covering every single American who has health issues for $50 Billion or just over 2% of the cost. Of this money, only $3.6 billion would actually go to the people building the Health IT systems. The rest, as is called out in the talk, would go to provide incentives to consumers and health providers alike to work collaboratively on their health and, in particular, for consumers to be able to be the stewards of their own health with online and ongoing support from the health care community.

Other than that, this is an exciting moment at Keas. We raised a bunch of money in December so we’re well funded (although we’re carefully husbanding our cash). We are just about to launch our first pilots. We have an amazing team but we are still looking for 2 good programmers including one who is really gifted at user interface, Javascript, CSS, HTML, etc. In addition, we’re looking for one totally can-do doctor, passionate about improving the health system, collaborative health care, and online patient support and willing to do whatever it takes to make that happen at a startup’s salary.