Meaningful use

June 18, 2009

Obama’s administration took the first important step in health care reform this week. They put up a proposed definition of meaningful use for ARRA (The American Recovery and Reinvestment Act of 2009). There are two key documents to review: a preamble which is excellent and calls out all the key issues that need to be addressed; and a matrix which reviews the planned requirements for meaningful use for the key areas identified for improvement. These are:

  1. Improve Quality, safety, efficiency, and reduce health disparities. – Read Overtreated to learn why this is key
  2. Engage patients and families – Without this, we cannot solve the fundamental cost problems we face
  3. Improve Care Coordination – It will be amazing to see care coordination come into the 21st century
  4. Improve population and public health – They are correctly focusing on measuring what works and who is doing it
  5. Ensure adequate privacy and security protections for personal health data – I believe consumers should control who sees what of their personal health data and am excited to see this supported.

I’m really delighted. This document isn’t perfect in my opinion. In particular, it calls for EHR’s to “provide patients with electronic copy of – or electronic access to – clinical information (including lab results, problem list, medication list, allergies) per patient preference (e.g through PHR). This allows the bad “old days” of tethered PHR’s to continue where as you switch doctors because of changes in your location, insurer, job, or just need a better doctor, or you want to include other doctors in complex care, or want outside or second opinions about your data, you cannot get it because not everyone is using the same EHR. It is key that the patients control their PHR’s and that they can transfer or download or copy this data in as computable a form as is available in the EHR into their PHR of choice.

But overall the committee that produced this document is to be congratulated. Kudo’s and congratulations to the members of the HIT Policy Committee and a special thanks to David Blumenthal. And while there are features in the matrix that aren’t called for until 2013 that I’d like to see in 2011, again, it is an excellent document.

The preamble does an excellent job calling out why we need this and what we need to improve. Don’t change a word of it please!!

It is time to speak up

June 14, 2009

Not only are tempers rising. There is a feeling across the board in health care that it is time to speak up.

Doctors are speaking up. Brian Klepper and David Kibbe just put up an interesting post. Bob Wachter, who I knew when at Google Health, referred to an excellent article by one of my heroes, Atul Gwande in his latest post pointing out that the current system has no discernible efforts to actually manage overall outcomes and costs.  Contrary to the inane platitudes one hears from certain Senators blandly assuring us that the health care system needs no repair, people across the board are pointing out that the system is broken. The center cannot hold. But we will not bow to the prediction in Yeat’s magnificent poem in which the best lack all conviction and the worst are filled with passionate intensity.The system can and must and will be fixed. It is time to speak up.

Watching legislature meet health care is like watching a slow motion train wreck. Witness the bill in contention in NJ right now. Essentially it will prohibit or drastically slow down the sale of innovative products that actually help consumers understand or manage their health. For example a product that prints out a medical history for the consumer to help him/her have a better doctor visit or a product that uses the FDA guidelines to warn about med/med interactions as Google does or a product that helps users collaborate on improving their health will all be prohibited if they actually used “health data” unless the CCHIT specifically licensed them. Imagine if every product to help you budget, plan a vacation and the finances, plan to save for your kids college education or retirement planning all had to be licensed by an agency let alone one that was never intended to do this. That is essentially what the NJ bill does. It is time to speak up.

When tempers rise

May 29, 2009

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.

Great Health Books

May 11, 2009

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.

A wonderful post

April 8, 2009

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 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!!

Data Liquidity or how we can use ARRA’s $19 Billion wisely

March 31, 2009

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.

A simple proposal

February 27, 2009

On Tuesday night President Obama laid down both a problem and a promise. He said, “we must also address the crushing cost of health care. This is a cost that now causes a bankruptcy in America every thirty seconds…and in each of these years, one million more Americans have lost their health insurance. It is one of the major reasons why small businesses close their doors and corporations ship jobs overseas.”  And then he said the new budget would make “the largest investment ever in preventive care, because that is one of the best ways to keep our people healthy and our costs under control.”

Folks, keeping our costs under control and our people healthy will require a new era of collaborative medicine.  What is collaborative medicine? It is a health-care system in which consumers and their physicians work together on an ongoing basis to avoid unnecessary illness and suffering. Imagine doctors who had the time to really help you or those you care about to stay healthy and well.  Imagine if every person who needed help with their health had not only a dedicated online tool to help them manage their health, but also their primary care physician looking over their shoulder to help them follow their personal plan. In general, data shows that mindful and aware people manage their health better. The point of this post is that not only can we afford collaborative medicine — we can afford it with the funds already promised in the stimulus bill.  Best of all, it will save us far more than it will cost us in the long run.

This is a simple proposal for how to get us there.

First I want to make a startling point. As I pointed out in my TEPR talk, out of the $2.3 trillion we spend on health care, incredibly less than 1% of it actually goes to the  primary care physicians. Put differently folks, what we think of as medicine — which is seeing our doctor — leaves only about $20 billion in our doctor’s pocket (not counting specialists) out of the total of $2.3 trillion spent. Think what a small percentage of our total health care costs that means are going to our doctors. If you subtract $20 Billion from $2.3 trillion, you get $2.28 trillion. All the rest of that $2.28 trillion is going to insurance filing, insurance processing, hospitals, labs, medicines, imaging, and specialists.

If you want to think about this more personally, our national health care costs average about $7500 for each man, woman, and child and more than $15,000 for people who actually have, or are at risk of having, serious illnesses (probably only 100 million but I figured 150 million here just to be safe). Of that $15,000, less than $100 is going to the primary care physicians to treat you. Because of this, there is a shortage of primary care physicians which is why, when Massachusetts insured all of its citizens, the biggest problem became just getting an appointment.   And, even if you can get an appointment, most doctors have no tools or time to really help you manage your health on an ongoing basis.

Really it seems that there are about 100 million people who need much more active management and care. These are the people who will cost us or are costing us so much money today. How can we help them? We can offer each primary care physician $100 for each at-risk or ill patient each year to provide collaborative online support to their patients and offer a monetary award to each patient who actually reduces his/her risk factors by even one risk factor. What will this cost and could it come out of the $20 Billion just approved for Health IT in DC?

At $100 per at-risk or ill patient, primary care physicians will earn $10 billion more, out of the $20 billion allocated to online innovation. That’s a tiny fraction of the $2.3 Trillion we spend today but it is a windfall for these doctors, like getting a 50% raise This will help attract some desperately needed freshly-minted doctors to primary care medicine. And because at least half of that $2.3 trillion is spent on treating preventable lifestyle diseases, it will not take much for our much-happier primary care docs to have profound impact on their patients lives:  reducing just ONE one risk factor triggers enormous reductions in health care costs.

How much will it cost to deliver the required IT to support collaborative medicine between doctor and patient?  As I pointed out in my talk at TEPR , you will find that those of us creating health IT online would have no problem delivering the tools to the doctors and consumers alike for collaborative medicine for a tiny fraction of $20 billion currently proposed by the legislation. I suggest that $3.6 billion is plenty to pay for systems will enable 100 million people to be helped by doctors, therapists, and coaches alike.

Data consistently shows that offering people a reward, even a modest one, for improving their health increases compliance. We have money left over for this. If $20 billion is being spent, and $10 billion goes to the doctors and $3.6 billion goes to the IT systems to support this,  that leaves $6.4 billion for the 100 million Americans who have lifestyle issues that have led or are leading to disease. Figure that we’re shooting for 15% of them to remove a risk factor. That’s 15 million Americans. With $6.4 billion, we can reward each of them with several hundred dollars each. Even if, optimistically, 30% of them improve we can  still provide about $200 per person as a reward. And the savings to the US of 15 million people dropping even one risk factor will be vastly greater than this. Dropping even one risk factor typically will cut someone’s expected annual health costs by $1000-$2000 – more when they’re older. Not to mention the reward to them of actually feeling better, being more mobile, and the peace of mind to those who love them.  As tax payers we are going to be paying this bill anyway — we should try to cut it now.

My proposal benefits consumers and doctors alike. The doctors are getting paid more to deliver better care that is actually targeted, with the help of IT, at providing ongoing coaching and support for patients to encourage them to improve their lifestyles. Doctors are being paid more to do a better and enjoyable job. The consumers finally have tools to manage their health but with the added value of having the person they most trust in this matter, their primary care physician oversee their progress and plan.  More doctors will become primary care physicians because the pay is better and the job is more fun, which will address the shortage issue we’ve seen in Massachusetts. It will mean fewer patients going to specialists and having lots of expensive treatments and stays in hospitals as they start to make the changes that help them avoid diabetes, heart disease, and the complications thereof.

We’re prepared to spend $20 billion on trying to improve Health IT anyway. Let’s spend it correctly.