Monday, March 23, 2015

Putting Meaningful Use 3 in Context

On March 20, 2015 the stars aligned to produce four simultaneous events that will never again coincide during the life of human civilization. The first three, the vernal equinox, a total solar eclipse and a new supermoon, were brought to us by the stars themselves, and the fourth one was thrown out there by the government. The regulations for Meaningful Use Stage 3 were finally published. Meaningful use of electronic health records (EHR) was presented to us back in 2009 as part of a stimulus bill to help the crashed economy and to improve the quality and affordability of health care services for all Americans. The program is administered by the Centers for Medicare and Medicaid Services (CMS) and implemented by the Office of the National Coordinator for Health Information Technology (ONC).

In its first stage, the meaningful use program delivered billions of dollars to technology companies that specialize in manufacturing EHR software, and ensured that clinicians of all types are no longer wasting time and resources on individual flesh and blood patients, but instead are meticulously collecting computable data for the sharing economy. This preliminary phase saw an order of magnitude increase in the number of small EHR companies and public/private, not-for-profit, certification and accreditation enterprises, along with a sharp decrease in the number of small medical practices. The second phase of the program, weeded out most new entrants into the EHR software market, solidifying the gains for large technology vendors. Physicians became disenchanted, lost interest and lost joy in their profession. Participation in the program plummeted posing a real threat to desired outcomes. Not to worry though, there is enacted regulation and legislation pending to crack a bigger and better whip on dissenters.

The brand new third phase of the meaningful use program sports a “keep your eyes on the prize” attitude and is forging ahead towards the finish line, bravely oblivious to the difficulties experienced in previous stages. Of course, six years into the program, one would expect to see some results indicating that all this money we are spending is moving the needle towards meeting the stated “do no evil” targets. There are no such preliminary results, and we are told that it is too soon to ask, because we won’t be able to see real improvements until the entire program, which is getting bigger and more expensive with each passing day, is completed. In the meantime, we are advised to entertain ourselves with an interminable stream of roadmaps, peppered with gaudy infographics supported by toddler level cartoonish videos, and continue to pay our taxes, leaving the thinking and planning to smarter people.

I will not waste your time with point by point analysis of the new meaningful use regulations, because I am certain the “industry” will produce the customary collateral, and because it is basically more of the same. If you have no idea what meaningful use is, you can stop reading now and go enjoy your last moments of blissful existence. For the rest of us, let’s just highlight a few tidbits that seem particularly helpful to practicing physicians.

Patient Engagement

If you had difficulties meeting the stage 2 quota of patients who view, download or transmit their medical information, the stage 3 regulations offer some relief. Just like you need not see, examine or treat real patients any longer, and can instead virtually analyze their computerized profiles, actual patients themselves need not engage with you electronically anymore. Instead you can provide something called an application programming interface (API) to your EHR, so a piece of software can extract information from your EHR on behalf of your patients, while bolstering the sharing economy.
There is nothing more engaging than having your colonoscopy reminder and eventual results pop up in your iTunes. Apple could presumably use anybody’s Apple ID to obtain medical records from any health care facility once one agrees to Apple’s terms of service, which nobody reads and which could contain informed consent to such health promoting activities. Since no EHR vendor is going to supply you with a thousand APIs, or agree to support connections from hundreds of little vendors, Apple is a likely candidate, and so are a handful of other very large sharing platforms.

Quid pro Quo

Just so you don’t feel left out of the sharing economy loop, meaningful use stage 3 requires that you accept data generated by your patients (sometimes unbeknownst to them) into your EHR. Of course Apple Health comes to mind again, but maybe other wearable snooping device manufacturers could be accommodated as well, at least in the initial stages. Since in the future, you will need to treat patients electronically without actually touching the person whose name (or number) is on that record, it will be very useful to open your EHR and see two years of hourly vitals monitoring graphs, before you initiate your next Skype session.

Practice Policies

Meaningful use stage 3 is adding a host of structured and codified data elements that you will need to collect and record. To that end, you should consider updating your policies as follows:
  • Require each patient to provide an updated resume at least once a year, because you need to continuously collect and update work history, including positions held, and financial information.
  • In collaboration with your attorney, create a crosswalk based on State laws and meaningful use regulations regarding what you must ask or are barred from asking your patients. For example, in some states you are not allowed to ask about guns in the domicile, and for meaningful use you must inquire how often your patient goes to church, and whether he or she is a homosexual (regardless of your specialty). It’s a fine balance and you don’t want to break any laws.

Practice Simplifications

In return for a bit more administrative work, meaningful use is opening a path for you to unload some of the clinical burden to technology vendors. You will need to subscribe to certified clinical decision support services that will gently integrate into your workflow, guide your thinking in an unobtrusive manner and record your actions in the background. For example, you would be able to avail yourself of automatically created order sets issued to your patients, based on their recorded symptoms and measurements (precision medicine starts here). This should save you time which could be better spent on examining Fitbit streams or analyzing curriculum vitae documentation.  

Safety and Stability

Whereas the preceding points are of interest to end users of EHR products, the government in its infinite and supreme technical wisdom has come up with 431 pages of dicta for software developers ranging from how to think about software development to how to market their products, down to proper capitalization of common words such as Health vs. health. If you were entertaining the titillating notion that the EHR market would eventually transcend its growing pains and come up with some cool stuff that will make you actually want to use software in your practice, rest assured that the government is protecting you from such folly.


If you are a brilliant young entrepreneur thinking of putting together a small team of dedicated and knowledgeable buddies to build a really good and useful software product for doctors, forget about it. The 431 pages published by ONC are the highest barrier ever erected to entry into a market, with the possible exception of the market for weapons of mass destruction. If you are already up to your eyeballs in health IT, perhaps have been there for a long time, but are a small and agile development shop, your days are numbered. The ONC regulations are designed to bankrupt small technology vendors, just like CMS regulations are designed to bankrupt small practices. Innovation in health care technology is as dead as a door knob.

The meaningful use regulations have been written by and at the behest of global technology firms, both EHR and general tech, employing a novel form of lobbying, which uses current and future corporate/government employees, board officers and grant-dependent academics, with a list of conflicts of interests as impressive as I am sure their credentials are, to act as volunteer advisory groups to government agencies. There is plenty more in the new meaningful use rules and regulations, but there really is very little point in analyzing this stuff, because there is absolutely nothing you can do to change it. It is however heartwarming to see that Qualcomm, “an American global semiconductor company that designs and markets wireless telecommunications products and services”, representing the future of health care, is “beyond pleased and finally vindicated”. Hope you are too….

Monday, March 2, 2015

Obamacare Cheesy Poofs

One of the most revolting pleasures in life is to read learned opinions and in-depth analyses of consumers’ behavior written by beautiful people clad in designer clothing, dining at eclectic chic trattorias or enjoying the occasional canapé under crystal candelabra at their favorite charity gala. These wondrous creatures, having pored over a few disjointed numbers selectively allowed to escape from our struggle with health care, are informing us that there are good news worth celebrating at tonight’s black tie fundraiser event.  If you happen to be one of the uninvited or just invisible for all practical purposes except exploitation, you are welcome to go ahead and break out a can of Bud Light and a new bag of store brand Cheesy Poofs for the occasion.

Obamacare is working better than anyone dared to hope. Following the astounding news that some 30 million people have Obamacare, we are now told that the way we buy Obamacare insurance on the public exchanges is good news for the canapé people. Why? Because we are finally exhibiting typical shopping behavior in health care, which is what consumers ought to do, and which has been shown to reduce prices of things in every other consumer market. Typical shopping behavior means that consumers have no brand loyalty, and no long term commitments to anything. Instead, “price sensitive” consumers (“poor” is not a term used in polite company) are in a constant frenzy to find the cheapest product available, regardless of quality, utility, or benefit to themselves or society. 

It turns out that about one third of Obamacare exchange shoppers switched to new insurance plans this season. Nobody knows what they switched to or why they switched, but that’s not important right now. The good news is that they switched. Switching between the typical narrow network health insurance plans sold on the Obamacare exchanges, means that consumers switched their doctors and sometimes hospitals. It means that medical care is viewed as a commodity, like Cheesy Poofs. One brand is as good as the other, and the dollar store brand is the best. That’s how the free market works, except under the candelabra.

The entire notion of having your own doctor is pitifully presumptuous. How many of us have our own lawyer or accountant? Warren Buffet certainly does, but the rest of us do just fine with episodic roadside legal and financial services, and Internet do-it-yourself tools and advice. For the very poor who become afflicted with severe legal problems, an attorney usually paid minimum wage or nothing at all, will be provided by the state. No separate safety net exists for financial trouble, but debtor prisons are flourishing. Expecting medicine to remain different is a sign of old age, failure to innovate, and deteriorating mental capacities.

Personal services are not scalable, and scalability is the number one prerequisite for productization and marketability, and scalability is predicated on repeatability. A transaction defined by having two people in a room interacting behind closed doors is neither scalable nor repeatable. Once we capture the events in that previously private room, and digitize them into structured data routines, we can abstract a repeatable process definition. To make it scalable, we need to discard the parts that don’t have universal applicability. The result is a good enough product that can be used by most people most of the time, like TurboTax or making your last will and testament online. Oh, and one more thing. To encourage shopping for the cheapest venue, unencumbered by misguided brand loyalties, we need to eliminate any and all switching costs. In health care, we call it interoperability.

Continuity of care is redefined as the existence of a digital dossier called health record, not medical record, and this is a crucial difference, because health is a continuous thing from birth to death, while medical may be episodic and vulnerable to branding attempts. The existence of a public lifetime health record obviates the need for fuzzy interpersonal logic. Any interchangeable resource, human or electronic, can pick up where the previous resource left off. This brings us one step closer to Cheesy Poofs or electronics, where the actual product manufacturer is not the same as the brand name on the box, although once in a while a recognizable brand may be used for advertising (Intel inside) of an otherwise generic product (your laptop) to bestow an aura of quality for those who prefer to think of themselves as connoisseurs.

Health care, as we all love to point out at regular intervals, is different. Before we can plunge health care delivery into retail mode, we must transition health insurance to a retail paradigm. The vast majority of Americans became accustomed to health insurance as a job benefit, like paid vacation days. Often the only decision one had to make was between the crappy HMO plan and the slightly more expensive PPO plan offered by their employer. Nobody read the prospectus because the choice was exquisitely simple: can I go to any doctor I want, or do I have restrictions? Since at most businesses, the CEO (and the CEO family) had to use the same plans offered to employees, everybody was confident that their interests were well represented. We should have known that this was too good to last.

Obamacare is creating a retail market for health insurance. Essentially, the inefficient, unaffordable individual health insurance market model is to be propped up by government subsidies, while its unsustainable and inequitable methodology is copied over to the orders of magnitude larger employer sector. When the transition is complete, health insurance will no longer be a job benefit. Instead, a fixed value voucher will be given out by employers to be applied by employees towards health insurance purchases. Since salaries will not be affected by this change and since the voucher value will be trending to zero over time, most Americans will be forced to shop not just for insurance, but for everything insurance used to buy.

Retail medicine makes perfect sense to the canapé nibblers under the candelabra, because Isabella, the undocumented au pair, is very happy shopping at Walmart for all her health care needs, and she comes from a good upper class home in Venezuela. One can only imagine the entertaining spectacle offered by millions of little consumers scurrying ever each way, like so many rodents on a burning ship, holding on tight to their worthless little vouchers, desperately trying to find a way to pay for medicine. Help is on the way though. Transparency, you see, is the missing ingredient in this newly liberated market. Every Cheesy Poofs bag has a clear list of ingredients, starting with cornmeal, oil and salt, and ending with yellow coloring, and a big huge table of “nutrition facts”. This has been shown to work well for Cheesy Poofs and it is now being applied to health extortion bags, as well as boxes of health providers.

In a moving show of solidarity, the glitterati themselves are participating in this disruptive “sharing economy” because they all use Uber. Uber is replacement for taxis, and if the closest you ever came to paying for a private ride was on your high school prom night, that’s okay, because taxis are disproportionately used by rich people. Cheesy Poofs guzzlers take the bus or drive themselves. Uber for health care has been the wet dream of many entrepreneurs and their two bit consultants. In this “sharing economy”, lots of jobless hungry people provide on-demand unskilled services to more fortunate patrons, and then “share” their fare with a $41 billion global corporation. This business model is several thousand years old and it used to be called pimping in the prostitution field.

The Uberization of health care will require turning the same tricks used in the taxi industry, or the hotel industry, to neutralize licensure requirements for offering a service, any service. The eradication of credentialed expertise, goes by the name of democratization, because discrimination based on one’s education, training and expertise should be abolished in an enlightened society where only pigs can be more equal. Health care is a harder nut to crack though, because of the unfairly large differential between a licensed doctor and all other potential providers of this service, and because licensed physicians are selfishly unwilling to “share”. The good news is that some doctors are starting to come around, and the indisputable success of Obamacare is showing that health care consumer products need not contain real doctors, just like your satisfying bag of Cheesy Poofs contains no real cheese. It’s a miracle of sorts….. Bud Light is still beer. Cheers.