Thursday, January 17, 2013

Half Gov Half Degov Venti EMR Lite

Somewhere between the 20th century Bank ATM and the 25th century Tricorder, lays the EMR that we should have today. Somewhere between the government-designed Meaningful Use EMR and the Holographic doctor in Star Trek, there should be a long stretch of disposable trial-and-error cycles of technology, changing and morphing from good to better to magical. For this to happen, we must release the EMR from its balls and chains. We must release the EMR from its life sentence in the salt mines of reimbursement, and understand that EMRs cannot, and will not, and should not, be held responsible for fixing the financial and physical health of the entire nation. In other words, lighten up folks…..

A patient’s medical record contains all sorts of things, most of which diminish in importance as time goes by. Roughly speaking, a medical record contains quantifiable data (numbers), Boolean data (positive/negative), images (sometimes), and lots of plain, and not so plain, English (in the US). The proliferation of prose and medical abbreviations in the medical record has been attacked a very long time ago by the World Health Organization (WHO), which gave us the International Classification of Disease (fondly known as ICD), attaching a code to each disease. With roots in the 19th century and with explicit rationale of facilitating international statistical research and public health, the codification of disease introduced the concept that caring for an individual patient should also be viewed as a global learning experience for humanity at large. Medicine was always a personal service, but medicine was also a science, and as long as those growing the science were not far removed from those delivering the service, both could symbiotically coexist. Fast forward to today. Medicine has developed significant heft and doctors are now mere “frontline” workers in the “trenches”. This implies the existence of something large and controlling behind those frontlines, and everybody comfortably positioned away from the trenches has been watching Moneyball. So the health care chameleon, morphing from an ATM into an airplane just to shrink back into a cheesecake, is now curling up into a baseball, and demanding all sorts of data so Billy Beane can miss the World Series more efficiently. There is of course a slight problem preventing medical ex-players turned general managers from gathering data for medicometrics. In health care, the players have to record their own stats, and they don’t like doing that because it is a bit difficult to hit and run while holding a computer.

Another reason why gathering data in health care seems to be a tall order is the lack of something called “interoperability”, or in layman words “EMRs don’t talk to each other”. But talking is not a good analogy, because this is America and everything should be likened to a car. So using the car analogy, it seems that the government is buying everybody a big huge SUV and making sure the proud owners load it to the hilt with health care data, but in its infinite lack of wisdom, the government neglected to build suitable interstate roads and bridges, so all those lovely SUVs are idling in people’s garages, raring to get out and hit the open roads. This governmental failure is inexplicable considering that we have a long history of building infrastructure first. So first we built the oceans and then we built the ships; we created the trails just before we tamed horses; we first built all the railroads and then someone built a train; we built the Autobahn and then they invented cars for it. Makes perfect sense…..

There is only one problem with this convenient version of history. Those SUVs supposedly sitting idle in health care’s garages are making very profitable night runs all over the place, because the roads and the bridges are really there already, and all sorts of other cars and trucks are jamming the interstate of technology all day and all night, and some funky contraptions are even flying. Imagine that. But imagination doesn’t seem to be the strong suit of health care analysts and advisors, so the attacks on government failure to build infrastructure for interoperability are incessant. We have technology savvy Congress members writing selfless indictments and the folks at the RAND corporation who at the behest of EMR manufacturers, predicted seven years ago that EMRs will save the nation, just came out with an explanation for the failure of their prophecy to materialize, blaming the same lack of interoperable infrastructure. The AMA in its thoughtful comments on Meaningful Use proposals is reiterating the need for government to pave the roads because its members cannot possibly be expected to bear the expenses of building highways from scratch. Using all the right words and a proper measure of righteous indignation, the government is reaffirming its commitment to build said infrastructure any day now. And round and round we go. As long as there is the faintest chance that the government will allocate a little more taxpayer money to build health care interoperability infrastructure, the chorus of complaints will not be silent.

In the meantime, out on the existing slick networks of interoperability for all but health care, activities are bustling with seemingly something new every day. What if the government just told all complaining and procrastinating health care stakeholders to literally take a hike and hit the road? What if the government told EMR vendors to go figure out what their customers want on their own, instead of providing a sanitized version of what the government believes EMR customers should want? What if instead of spending the newly minted trillion dollars coin on a brand new interoperability system for health care, the government would allow EMRs to travel on existing technology highways, and leave well enough alone?

Here are a few things that could happen:
  • Nobody would need to “send” prescriptions electronically to pharmacies. If you had the dubious pleasure of flying somewhere lately, you would know that ticketing is now very different. No, they don’t send your ticket electronically to the gate. They just send it to your mobile phone as a 2D barcode that is scanned at the security checkpoint and again at the gate. A patient friendly EMR could generate the same type of barcode for your prescription and send it to your email so you just have the pharmacist scan your mobile device. All security information can be embedded and you can get a refill at a pharmacy of your choice. If you are now formulating objections in your mind because of possibility of fraud and abuse (and because you are invested in the current system), relax, all your worries can be addressed.
  • You don’t like barcodes? No problem. Instead of killing half the Amazon forest in an attempt to give you “clinical summaries” and instead of whining about interfaces with other facilities, what if your doctor swiped a magnetic card and “loaded” it with your clinical summary, while at the other end the hospital or specialist would use one of those Intuit or Square gizmos to read it in, and then “reload” it for your follow up visit with your PCP? Perfectly doable, and applicable to prescriptions, lab tests and even imaging.
  • Still not convinced? Buy a Samsung Galaxy phone and find a friend that has one too. Try to exchange some information with your friend, like pictures, files or music. It’s called S beam and all you have to do is gently bump the phones. Would you like to bump the doctor’s mobile device on your way in, and bump it again on your way out to collect all the new information? This is not fully baked, but it could be if our well-meaning government relaxed its grip on EMRs just a tiny bit.
Comic relief: Not directly related to interoperability, but instead of having to choose between looking at your patient and looking at your computer, what if you could do both at the same time? A couple of years ago Samsung came up with transparent AMOLED displays (see through screens). There didn’t seem to be any good use for the technology, but they forgot health care. Right now if you have a laptop in the exam room, all you can see is the screen and all your patient can see is the cover of your laptop. What if you could see the patient through the screen and what if the patient could see (and touch) the same things you are seeing? Would be pretty cool if liberated EMRs would be allowed to find creative ways to take advantage of such hardware, and there must be hundreds and thousands of better ideas out there, suffocated by pre-adjudications and pre-authorizations and slowly withering away under the Meaningful Use lid.

Does government have a role in health care technology and interoperability in particular? Of course it does. First the government is the largest health care insurer in the country, and as such it has an interest in reducing costs, and since this is (still) a representative government, it should also have an interest in the wellbeing of its citizens. Governmental agencies should rightfully expect a certain level of (reasonable) electronic reporting from those it pays for services and it makes perfect sense to require that certain levels of service be provided, including coordination of care between facilities, which may involve interoperability to various degrees. And finally it is incumbent upon the government to ensure that tools used to provide health care, including software tools, should be safe, just like it ensures that drugs, devices and all other medical paraphernalia are safe (and using the same agency for this purpose). Public health is another domain where a government concerned with the health of the nation can find opportunities to affect positive change. And that’s about half the work required.

The other half should be left to professionals in the “trenches”, whether doctors providing direct patient care or (deep breath here) technology people who can actually write code to support patient care, if patient care is what we want to support. These folks with massive expertise in navigating the all too real interoperability highways are currently wasting their talents on making your washing machine interoperate with your Twitter account. Can you imagine what they could do with your charts and your “workflows” if we let them lose in health care? It’s not the data that needs to be liberated. It’s our collective imagination that must be set free, or at least half free.

Sunday, January 6, 2013

The Crosshairs of a Triple Aim

“Better Care for Individuals, Better Health for Populations, and Lower Per Capita Costs” []

If you stop to think about the holy grail of health care reform, also known as the Triple Aim, it sounds like a grand challenge involving wizardry or wishful thinking or worse, propaganda for the masses, particularly the last part. It’s like attempting to build a better driving machine, with better fuel efficiency at lower cost. Or maybe it’s like trying to make a chocolate cake that is most scrumptious, quicker to prepare and has very few calories. Yeah, right…. You can have one of the three, and maybe two, but certainly not all three. Not that there is anything wrong with trying…. And when it comes to health care it is actually imperative that we try, and failing will have dire consequences for all but the very few who are always shielded from consequences.

The Institute for Health Improvement (IHI) who introduced the Triple Aim philosophy, now adopted by the government, is also proposing a methodology for achieving this, larger than the moon landing, challenge.  The IHI will be having a seminar this spring, where those engaged in achieving the Triple Aim will presumably share success stories and strategies with those interested in doing the same.  IHI believes this learning event is “ideal” for folks working for insurers, employers, government, integrated health systems and other businesses and organizations. Individuals, populations and their doctors don’t seem to be part of the IHI target market. It seems that IHI believes that the Triple Aim of research institutions should be achieved by corporations, for the people of this country and the world in general. It also seems that this particular view is shared by our government, who is feverishly pushing for the creation of corporate health care entities (a.k.a.  ACO), and, patient-centered rhetoric notwithstanding, is largely ignoring doctors and their patients, who are assigned to care corporations sometimes unbeknownst to them.

In addition to a slew of financial incentives/disincentives, Health Information Technology (HIT) is one of the most powerful levers applied to the system in order to change its fabric from a multitude of small and varied health care establishments to a unified landscape of large standardized health services entities, which as IHI, and obviously all other “decision makers”, “thought leaders”, etc., believe are best suited to build a system for achieving the Triple Aim in an orderly and measurable fashion. A health care system as opposed to a sick care system; a system where populations get all their shots and screenings for every imaginable disease, carefully tabulated and monitored to show progress, and a system where care for the sick is optimized for “value” to the IHI “ideal” stakeholders; a system that requires massive computation power to constantly drive costs down by feeding millions of digital histories of people to complex algorithms; a sophisticated supply chain system that replaces continuity of care with electronic coordination of services, and generally keeps the proverbial trains running on time; a system powered by billions of dollars of computers, software and IT guys.

And here is where the “official” strategy gets really weird, wasteful, and luckily for all of us individuals, populations, and our doctors, it also contains the seeds of its own eventual demise. How so? Big business will always be saddled with expenditures on big technology, which is useless for small business, but technology has its own way of growing and advancing, independent of political whims, and independent of governmental master planners. Technology today is on a path to ever shrinking size (and price) and ever growing power, and as such it has morphed itself into a tool that truly empowers individuals and small business because those much maligned programmers, who don’t know anything about health care, are expert at building cool things for people and are some of the most nonconformist and visionary out-of-the-box inventors around. And they are now coming to health care seeking fame and fortune.  But we have to give them time and we have to do our part in this dreadful game of world domination.

If you are a primary care physician in private practice, here are some things to keep in mind:
  • Don’t buy technology that does not serve your patients and does not serve your business. Don’t be tempted by incentives and don’t be afraid of penalties. If you collect say, $500,000 per year and 40% of that is Medicare, a 1% penalty amounts to $2,000 per year or $40 per week. Even if all your billings are Medicare, this still amounts to only $100 per week. Would you buy a stethoscope outfitted with sharp little nail heads (to improve the grip), if someone threatened to charge you $8 a day for using your old stethoscope? Would you hire an assistant to hold the prickly stethoscope for you and a steel worker to sharpen the nail heads periodically, just so you are in compliance with Prickly Use?
  • Do buy technology that serves you and your patients. If you are convinced that a particular EMR will help you provide better care and make your work more efficient, then by all means, go for it. Make sure you understand the total cost of ownership over the next five years or so, and make sure you’re not buying the cow just to get a glass of milk. If all you want is to store your paper charts in a computer, you don’t need a certified EMR. If you just want to communicate electronically with patients and business partners, including labs & pharmacies, you don’t need a certified EMR. If you want to track your chronically ill patients and make sure all are taken care of, you still don’t need a certified EMR. You do need a certified EMR if your patients routinely end up at the ER unconscious, alone and naked, halfway across the country, which seems to be the preferred use-case of those who build “infrastructure” for health care.
  • Today’s technology renders physical location and business affiliation irrelevant to in-person collaboration. You should explore using some of this technology, and much of it is nearly free. A three-way video call with a home-bound patient, a neurosurgeon and you is as simple and cost effective as sending a fax. Heck, you can even conduct the entire thing on your mobile phone while on vacation somewhere nice and warm. This is not a futuristic “tricorder instead of doctor” type of thing. This is an example of real and tangible benefit you, and your patients, can derive from technology this afternoon.
  • Selling your practice to a hospital system because the “business” is too complex and because technology is too expensive (and because you’re scared) is most likely something you will live to regret, bitterly in some cases. Consolidation of health systems is not driven by a desire to achieve the Triple Aim. It is happening in defensive reaction to it, particularly the part about lower costs. You are not being courted (or pressured) because you are a great doctor. The coveted asset is your client list, which once integrated into the massive computerized system of the hospital, renders you irrelevant. There are cheaper ways of providing services in a system not designed for sick care than employing a physician, and those will eventually be put in place, because technology is like nuclear power: it can be used to do a lot of good things, but it can also be used for pure destruction.
  • Look around you. Most people in this country are hurting financially. Way more than you do. People are cutting down on food. Do you think you can cut down on inefficiencies inherent in most practices? Do you think you can use cheap or even free technology tools to accomplish that? Do you know what’s available out there? Are you way too busy seeing patients, and cannot be bothered with details? Instead of hiring accounting firms to valuate your business and lawyers to make believe that you are actually “negotiating” with the hospital, how about hiring a bright business consultant specializing in turning bloated small businesses into lean and mean survivors? We all know that there is a shortage of primary care physicians, which is projected to get much worse over the next couple of decades. If you owned a little gold mine, and the markets projected a shortage of gold lasting well beyond your life expectancy, would you sell your small enterprise to the Newmont Mining Corporation for next to nothing, because upgrading mining equipment is too complicated and way too irritating for your lifestyle? 
  • Stand up and step forward. Keeping your head down and hoping that this too shall pass is not going to work this time around. You have more power than you realize. Speak up, and use technology to make your voice heard. If you are one of those business savvy physicians who figured out how to maintain a sustainable private practice, share your knowledge. Teach. Start a blog. Build a community. Publish a paper. Write a case study (or let me know and I’ll write it for you... ). Every time an independent practice gets swallowed by a system, and every time another physician is forced to abandon his or her patients at the hospital door, something is taken away, from you personally, and from the people you wanted to help when you chose this profession. Your silence is harmful to your patients.
If you are a patient or think that someday you may need to be a patient, consider this:

When you find yourself in a strange room, partially covered by a large paper towel, and otherwise completely naked, contemplating the upcoming prodding of your most private body parts by shiny instruments and strange hands, what do you want to know most about the person about to enter the room? Would you feel better knowing that the stranger turning the knob on that door has an iPhone compatible website for you to peruse from the comfort of your cubicle at work? Would you feel safer knowing that he or she has financial responsibilities and commitments to a faceless corporate office for which your naked body is just a line item on the balance sheet, perhaps a socially responsible balance sheet, but a balance sheet nevertheless?  If it’s your small child under that paper towel, would you be comforted knowing that this person’s prime directive is to minimize your child’s “per capita” cost (not price) of care? And when you’re done making imaginary deals with your God or the devil, would you experience great relief knowing that the doctor walking into the room now is not really “your” doctor, but the shepherd of “populations” and the averter of deficits and fiscal cliffs?

Don’t answer these questions now, or right after you finish your morning run. Answer them when you are actually sitting in that room because Google said that the pesky little thing you found last week is most likely nothing serious, or of mild concern, or a cancer that will kill you in a year or two. Depending on your answers, you may want to seek out an independent physician for your next appointment, because the opposite of “independent” may be hazardous to your health.

The IHI concludes the promotional blurb for its Triple Aim seminar by proudly stating that these seminars were attended by “senior leaders, vice presidents or directors” in the past, and although individuals are welcome, ”experience has shown that Triple Aim implementation is dependent on the collaborative effort of leaders and strong program involvement”, so according to the IHI "leaders", if you’re not a corporation or powerful enough organization, don’t waste your time (and $1,975) and don't worry your little head about it, because individual people cannot make a difference in health care.
It’s probably high time that we took some triplicate aims of our own, don’t you think?