Yesterday, David Blumenthal published a very thoughtful post on the HITECH Act as a foundation for information exchange in which he reflected on his own personal experience as a doctor. That experience included the often frustrating realization that he could not obtain a complete longitudinal record of his patients (customers) due to either (or both) technical or business barriers. In his post, Blumenthal goes on to elucidate on how the HITECH Act’s language is purposely worded to remove such barriers as the healthcare sector transitions from a provider-centric model to one that is patient (consumer) centric.
Following are our own reflections on Blumenthal’s post based on the reality of the market today and where Chilmark sees it heading in the future. Specifically, we’ll tackle each of Blumenthal’s bullet points in order.
HITECH Act squarely tackles the commercial barriers. Yes, HITECH funding is clearly earmarked in support of open and secure exchange of data, in fact it was one of the three core attributes of meaningful use (information exchange for care coordination) defined in the legislative language. But HITECH Act and its provisions only pertain to those that accept the $$$ and it remains to be seen just how many entities sign-on.
Blumenthal closes his first bullet point with:
Consumers, patients and their caretakers should never feel locked into a single health system or exchange arrangement because it does not permit or encourage the sharing of information.
Ideally, this is the end result but not so sure how we get there from here. In Boston, a very competitive healthcare market with some of the best healthcare informatists in the business, organizations and subsequently consumers are extremely challenged to get their data, let alone share it. The video clip below from Microsoft on the deployment of Amalga for the Wisconsin HIE gives some idea as to how this might work, but even in this case, it is limited to ER, there is no consumer control. We are in for a very, very long journey.
[youtube=http://www.youtube.com/watch?v=Wk_6NQVfpPQ&hl=en_US&fs=1&rel=0&color1=0x5d1719&color2=0xcd311b&border=1]
HITECH tackles economic barriers. Not really. Sure, $36B is a heck of a lot of money for the HIT market and the potential follow-on penalties for not adopting an EHR may be significant for clinics and hospitals that derive a large proportion of revenue from CMS, but that is not necessarily the case for smaller, private practices where it is estimated that 80% of care actually occurs. For smaller practices that do not serve a large CMS population, the reimbursement of $44k/physician does not pay. The incentives, frankly, are not the powerful tool that Blumenthal claims they are for a significant portion of the market.
HITECH tackles the technical barriers. Huh? Not sure how he came to that conclusion. Maybe in time if the stars all align perfectly, such will come to pass but today we have a host of legacy systems that do not talk (inter-operate) with one another, strong disincentives for HIT vendors to actually create truly interoperable products (the more open and interoperable you are, the easier it is to be replaced with a competing solution) and then there is that whole issue of adoption mentioned under economic barriers above.
Yes, Blumenthal is correct in that the HITECH Act does instruct HHS to continue its investments in creating a nationwide electronic exchange for health information (the NHIN which will become the Health Internet). But even here there have been challenges. The technology stack of the NHIN today, created by beltway bandits and not those deeply immersed in HIT, is crippled. Hopefully, as was presented at the Harvard ITdotHealth Forum, the feds will open up and actively solicit the guidance and input of those that were present, and others to create an NHIN that is truly usable.
HITECH provides the building blocks for information exchange across jurisdictions. Yes and No. Certainly the HITECH Act will fund HIE initiatives in virtually all states with the $560M+ that was announced in early fall (States submitted their proposals earlier this month). This will certainly accelerate activities at the state level for HIE build-out but the question remains: Will these state activities actually be able to devise a truly sustainable business model? To date, it is rare indeed to find a public HIE that is self-sustaining.
Beyond the issue of funding these state HIE is the much thornier issue of the myriad of state laws and policies as it pertains to the distribution and sharing of medical records. The only recourse may be a “super-DURSA” (caution PDF) passed by Congress to supersede state policies, which could prove quite challenging.
Despite outlining what are seen as some fairly significant challenges to Blumenthal’s upbeat and positive post, like him, we share in the desire to move the proverbial ball forward and more importantly (what we really, really liked about his post) focus on the patient, the consumer, the citizen. In the end, it is they who are footing the bill for this massive initiative to get doctors, clinics and hospitals wired-up. Therefore, is it not they that should ultimately benefit from the HITECH Act through better care, greater flexibility in physician choice and who knows, maybe even receive lower cost of care. A tall order in deed but certainly one worth working towards.
Great Post John! (as usual)
I am far more optimistic since Davids recent remarks actually show a profound shift. It wasn’t that long ago that people weren’t even talking about the needs of the consumer in the publicly funding portion of health IT. I was asked over the summer to literally explain “why” we should even include consumers since there is “no explicit mandate in the funding legislation for it” and had to remind people that in order to have a patient centered health care system you need to start with their needs and design around them. Not that they didn’t support the concept but where was it in the legislation (it is actually a core value of the legislation if you want to end up with a high quality, effective, patient centered health care system)
TECHNICAL BARRIERS Many many people who are late to health IT (and who have never worked in healthcare) don’t seem to realize that there was and still is a multi-billion dollar health IT industry in operation already. John although you nailed the current problem with inter-operability on the head in Boston (where many use in-house systems) but failed to catch that ARRA is already changing and the critically important role of standards and certification and more importantly shifting the locus of control to payers vs providers.
CHANGE IN BUSINESS CASE – In the past vendors (the largest of which is privately held and started by Judy over 20 years ago when she saw the frustration her husband provider had) catered to their customers. Those were hospital systems and there was no business case to exchange data and in fact pro-found disincentives to not remove duplicate tests since they are paid piecemeal vs outomes. You ended up with IT systems that were extremely fast at pulling up individual records (mumps based) but once they were customized it wasn’t easy to exchange data and no one wanted to pay for the IE (interface engine).
ARRA is a game changer since it has shifted the key stakeholder from the providers (hospitals) to the payers (govt, large business and consumers – YEAH) In Palo Alto you have Kaiser, PAMG and Standford all using the same vendor but they couldn’t exchange data electronically (again there was no one willing to pay to do it) and in Seattle you have the UW, Group Health and Swedish Medical Center all using the same vendor – again Epic.
Now however in Seattle they are all working to exchange their data and Epic has a module that makes it easier to do so. In fact with a targeted investment just to link the 150,000 providers who already use Epic (23% of all providers) you can link over 70 million patients. This doesn’t address the bulk of providers who aren’t using a system but by focusing on a quick win (just linking the existing systems) you could for very little cost achieve critical mass. That is a direct result of meaningful use requirements (not even finished drafting) for the exchange of data.
Even if some providers opt out (specialists for example) because they don’t see any need for the seed capital from CMS it is clear that the new standard of care for providers will be a patient centered health care system and the health IT infrastructure to support it.. There might be a few providers who stay on paper but private payers will quickly drop them from their preferred provider panels.
I have seen strong support from the highest levels at ONC for engaging consumers and even stronger support at the National eHealth Collaborative for consumers not simply having a “voice” but that consumer / patient / person centered design will be the norm going forward.
ARRA is seed capital akin to venture capital and much of what we are seeing in terms of resistance by providers and others is typical of any large scale change management process. Once consumers are engaged and empower I expect to see private sector employers, quality groups, private industry, health 2.0 and government coming into alignment and moving very quickly.
Personally I believe that Health IT is the tool that will be the tipping point to move people towards a patient centered health care system that focuses on those with chronic conditions, new compensation models (paying for outcomes and bundles of care, direct pay for primary care), implementing the medical home model and breaking down the walls of where we receive care so that it is where I want it, when I want it and how I want it.
Blumenthal did not mention the pink elephant in the room — the legal barriers to health information exchange. The variety of state laws protecting healthand the complexity of their interactions when exchanging health information across jurisdictions have been acknowledged by HISPC as a significant barrier to HIE. The HITECH Act did nothing to address legal barriers. They will have to be addressed, I believe, before regional and national HIE can occur.