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.
It’s easy. Just have the same requirements for people that we already have for automobiles (which surprisingly is one of the few areas where mandatory insurance is legislated). Once a year every human should submit themself to a health inspection – the results then being made part of a password protected online database accessible to the health care provider at a time of crisis.
The challenge now shifts to the methodology of the annual checkup – how to make it as conclusive as possible as economically as possible, this is something that technology can master.
This is helpful two ways – a person who feels like paying something to self-monitor can enable a third party such as Keas, or one’s own doctor to participate in ongoing health maintenance, plus it will prove invaluable for providers at the time of a medical emergency anyplace in the world.
Legal/privacy issues can be taken care of via existing rules or new legislation as needed to mollify 1984 paranoia.
There is another part of this equation dealing with reimbursements. When you optimize around a single encounter instead of total treatment, you generate a lot of waste. Add to it the cost plus nature of premiums, you tend to get more lip service than action.
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It has been interesting (being an American but not currently living in the country) reading all of these blog posts and seeing the passion and intensity of it all about the ARRA.
The reality is simply that we MUST put on the brakes where the money is concerned.
What (I think) so many fail to realize is that (once again) throwing money at a problem is not the real solution. There is a lot of pause, reflection, observation that must be done prior to the money dump.
INSANITY: Doing the same thing over and over and expecting a different result — Albert Einstein.
>> Comment back from Adam – Yes, we have to cut spending. But most wasted spending in healthcare today comes from redundant scans (MRI’s, …), waiting till people are expensively sick to treat them (Stents, Renal Failure with Diabetes, ), unnecessary care (read Overtreated), paying for expensive procedures rather than primary care (read Flatlined), and billing costs due to our baroque insurance system including their attempt to avoid payment and hospitals attempts to avoid these attempts. We spend over $2.3 Trillion a year. The $18 Billion in ARRA is less than 1% and while it may well be wasted because it may not lead to improvements in any of the above items, it is at least intended to as the Meaningful use matrix makes clear.
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