New Medicine – First, Show Me the Money

This is a warning shot across the bow of the mighty health care ship which seems to be changing course in search of calmer waters to carry the riches stowed deep in its rusty hull. I have no arsenal to fire anything more than sporadic warning shots through the descending darkness, but this ship is now on a collision course with the American people, the 47% that Gov. Romney scoffed at and an equal number that is yet to be awakened by the ringing disaster bells. The navigation chart used by the captains of this ship, mapping an America full of dumb and gullible people, too fat and too lazy to make any sudden movements as the corroding ship sails through their bodies, is woefully incorrect. Americans may be slower than most, more forgiving than others, but sooner or later, the health care ship will have to battle the people, and it will be sank, or emerge victorious at the conclusion of the American experiment.

A couple of weeks ago I wrote about Dr. Ezekiel Emanuel’s thinly veiled fury at the medical profession which seems reluctant to accept promotion to the rank of Puppet Captain of the health care ship. That is beginning to change, and this week’s issue of JAMA carries a brief manifesto from three physicians accepting the Captain bars and calling on all colleagues to do the same. The piece, titled “First, Do No (Financial) Harm”, is a succinct summary of health care’s new prime directive: First, Show Me the Money. Before recommending a course of treatment, doctors should first assess the patient’s financial capability. To deflect any remnants of ethical questioning, the authors suggest that assessment of financial status should be undertaken for all patients, not just the obviously poor. This in their learned opinion eliminates the appearance of discriminatory practice, and appearances are the major concern here, because this navigation strategy will have to be packaged by some Mad Men for consumption by the presumed stupid masses. [Note to EMR vendors: Perhaps financial prowess should be another vital sign that the nurse can collect during intake (e.g. how much can you afford to shell out of pocket? Nothing; Up to $100; Up to $1,000; Up to $10,000; Up to $100,000; No Limits), and decision support would be objectively provided by the EMR during Assessment & Plan. This should probably be added to Meaningful Use Stage 4.]

The example provided in the article is of course treatment of mild back pain, which requires no treatment. This, and MRI for headaches, or antibiotics for a cold, are the preferred examples to illustrate the benefits of cost consciousness by both providers and consumers. Nobody dares venture into the conversation that will have to take place with a cancer patient, other than Oregon, of course, which is mandating that this “conversation” takes place before the state will pay for anything. If the “conversation” did not result in the impoverished, sick, depressed and frightened patient asserting his or her “cultural values and preferences” to forgo expensive treatment (as all poor people should), the State will pull the plug anyway, thus empowering those who fail to be empowered on their own.

Let’s go back to MRIs and physical therapy for back pain which is a subject better suited for polite conversation. The authors provide us with a very thoughtful script on how a doctor would go about the difficult conversation of gently avoiding overtreatment of back pain. First you find out if the patient has any money in their wallet, then you proceed with the unrelated task of explaining that an MRI is clinically inappropriate. The latter can probably be skipped if the empowered patient doesn’t know enough to ask for an MRI. The next step is to tell the (poor) patient that beneficial treatment, like physical therapy is too expensive for him/her, and suggest self-care at home (an illustrated sheet of exercises should help). To round it up for those with no money and no real insurance, you could amicably suggest the patient’s “local yoga class”. This is how you “[o]ptimize care plans for individual patients”.  The optimal care plan for someone living on the 10th floor of a housing project is most definitely a “local yoga class”. Marie Antoinette must be smiling in her headless grave.

A couple of years ago, my son’s friend, Kenny, got injured during a football game in his high-school senior year, and needed surgery on his knee. Since Kenny did not have a car, and even if he did he was in no condition to drive after surgery, my son drove him to the downtown clinic for post-op follow-up. Kenny came out of the exam room limping cheerfully since the nurse said that he is all good to go and does not need to come back. My son, having had his own surgical encounter with football’s unintended consequences earlier that year, was a bit surprised and asked where Kenny should go for his physical therapy.  According to the friendly nurse, Kenny didn’t need any fancy PT. The boys walked out, one furious and the other limping and smiling sheepishly. I haven’t seen Kenny since that year and I don’t know if he is still limping, but this formerly bubbly and faster-than-the-wind running back has not shown up at the traditional, and immensely popular, Thanksgiving high-school reunion football games ever since.

From the dawn of civilization to the current day and most likely well into the future, the rich and powerful in all social orders enjoyed better access to better medicine than members of the human species who are poor and powerless.  Similar to disparities in other life-sustaining goods and services, enlightened governance systems have attempted to minimize (not eradicate) these differences in medical service provision due to an emerging sense of social justice and also because prosperity seemed to accrue to better nourished, better educated and healthier societies. A nation founded on the premise that individuals have an inalienable right to pursue happiness cannot weave social injustice into the very fabric of its existence, and expect to thrive. We know this, because we tried similar schemes before, and failed in what were arguably the darkest and most perilous moments in U.S. history. 

Utilizing inherently trusted individuals to prevail upon the unfortunate that what seems like injustice is actually good for them in the long run, is not a novel idea. Substituting betrayal by physical healers in clinics, for indoctrination by spiritual leaders in churches, is a minor innovation. Internalizing and institutionalizing pure evil wrapped in misleadingly kind and gentle rhetoric, while inflicting much pain and suffering on countless human beings, is also a sure recipe for the ultimate destruction of the perpetrators no matter how righteous they believe they are. Doctors, who are tempted to accept compliance with the newly created Captain positions on the misguided health care ship, without questioning its opiate laden navigation route, are simultaneously terminating the medical profession’s days of glory.  There will be no joy. There will be no trust. There will be no prestige. There will be no respect. And there will be no financial privilege. Captains of this doomed ship are a dime a dozen and they all reside below deck.

In order to protect privacy, names and locations mentioned in this post have been changed, as have certain physical characteristics, quotations and other descriptive details.

Cost Effectiveness of Health Information Exchange

At some point it was decided that the exchange of clinical information between facilities of care is lacking in both quantity and quality, and it was further decided that a drastic increase in frequency of such exchange will improve the health of people and the quality of care they received, while reducing costs of health care. The idea, which is almost as old as medicine itself, has been perfected by physicians over centuries of evolving documentation standards and sharing of knowledge in general. As medicine became a service provided by a bewildering array of entities in parallel and/or in sequence over one lifetime, the need for clinical information exchange increased exponentially, making this particular activity a perfect candidate for computerization in the Internet age. Since all computerized functions are better and cheaper than their manual predecessors, it was decided that the Nation must engage in sophisticated exchange of health information to the point where one’s medical records are omnipresent wherever one may need or want to perform, or have performed, a health related function. That’s nice, a bit creepy perhaps, but nice nevertheless, possibly useful, and certainly very convenient.

The Department of Health and Human Services (HHS) is the government agency in charge of making Health Information Exchange (HIE) a reality in this country. A recent HHS pamphlet published in Health Affairs provides an update on the state of HIE for the first term of the current administration (2008 to 2012), spanning the first four years of legislation, rulemaking and financial incentives in support of computerizing medical records and their exchange across facilities of care. The results are based on a survey of hospitals that were asked if they “electronically exchange/share” any one of four types of clinical information (clinical summaries, medication lists, lab results, radiology reports) with other hospitals or ambulatory providers inside or outside their own system. The study shows (see below) that the rates of hospital exchange/sharing of information with any other entity, which stood at 41% in 2008, jumped to 58% by 2012. That’s a whopping 17% over 4 years or slightly over 4% per year on average, although there is a clear acceleration after 2010 when financial incentives became a reality.

(source Health Affairs)

According to CMS reported numbers, the government paid out roughly $14.5 Billion in incentives to hospitals and health professionals by the end of 2012, or approximately $850 Million for each 1% increase in self-reported electronic exchange/sharing of health information by hospitals.  The survey did not inquire about the levels of such exchange, so there is no way to ascertain if hospitals with affirmative responses are exchanging all clinical information of the types listed, most of it, some of it, or occasionally some things here and there. A quick back of the napkin calculation indicates that upwards of $27 Billion will be needed to sustain the current growth rate for the next 8 years or so, in order to achieve universal exchange, and that’s without counting the startup costs of State HIE organizations, Regional Extension Centers and other grant making activities for this purpose, not to mention privately funded infrastructure and operational expenses. And here I have to make a confession: these dollar amounts are in a realm of finance where I cannot tell if these are reasonable expenditures, an incredible bang for the buck, or outrageous waste.

It makes perfect sense that making pertinent information electronically available at the point of care is helpful, and test results, clinical summaries and medication lists are obviously pertinent in most cases. But then, it also makes perfect sense that propping a clogged artery open with a stent should be very helpful in most cases. What is not obvious without additional research is whether there are cheaper and less invasive methods to achieve the same results. Does the most cost effective method of making clinical data available at the point of care consist of a nationwide network of big-iron servers and Federal protocols, continuously fed by hundreds of thousands of clinicians furiously typing and clicking away at hostile terminals? Maybe. Maybe not.

Unencumbered by any doubts, HHS is proposing to forge ahead with “Principles and Strategy for Accelerating Health Information Exchange (HIE)”, because “real-time interoperable HIE” is critical to the success of the Affordable Care Act and its various programs. Note that HIE just got a couple of extra qualifiers prepended to it. Interoperable exchange implies that the exchange is taking place between machines (not people), and that those machines can both exchange information, and understand it well enough to put it to some use. Interoperability is all about the exchange of computable data elements and their analysis. So having a piece of paper (or a PDF) containing all pertinent information, magically appear in the hands of a hospitalist or other care provider, on-demand, does not qualify as interoperability. It doesn’t qualify as real-time either, because real-time in computer language means just as it happens, with no delays and no waiting, so when the doctor updates something in his computer, the hospital computer knows right away, and vice versa.

And how does HHS propose to reach this ubiquitous HIE state? There are lots of steps to accelerate, strengthen, advance, enable, align, support, educate and other operative actions, involving standards, stakeholders, committees, agencies, States, ecosystems, policies, guidance, regulations, incentives, rewards and such, all meshed together in a “multi-year approach that is consistent, incremental, yet comprehensive”, culminating with HIE becoming “standard business practice for providers”. If you are tempted to discard this as fluff, think again because “HHS’ approach to accelerating HIE among health care providers is expected generally to follow a natural lifecycle of incentives followed by payment adjustments and finally through conditions of participation in Medicare and Medicaid programs”. A natural lifecycle indeed...

The Contrived March to Scarcity in Health Care

A recent survey of physicians, conducted by Tilburt and colleagues and published in JAMA, finds that most doctors support measures to improve the quality of care, but are opposed to financial schemes aimed at reducing health care utilization across the board, and physicians do not believe that the responsibility for escalating health care costs lies solely with the medical profession, with 85% opposing the denial of “beneficial but costly services to certain patients because resources should go to other patients that need them more”. While over three quarters of respondents reported being aware of costs of care, and agreed that discouraging use of expensive treatments with limited benefits is a good idea, 78% believe that doctors “should be solely devoted to [their] individual patients’ best interests, even if that is expensive”.  The vast majority of the 2556 respondents to the survey place responsibility for escalating costs of care on multiple entities, such as insurers, hospitals, trial lawyers (i.e. malpractice law), patients, government and physicians themselves, with no single mea culpa directed exclusively at doctors. For some reason, this complex view of the health care industry seems to enrage health reform advocates, and none more so than Dr. Ezekiel Emanuel.

Dr. Emanuel’s reaction to the survey findings, published in the same JAMA issue, begins by establishing the usual and customary sense of urgency. According to Dr. Emanuel, health care costs are responsible for increases in college tuition, crippling levels of student debt, stagnation of workers’ wages, federal deficits and national debt. Although Dr. Emanuel left out unemployment, over dependency on fossil fuels, Detroit’s bankruptcy and the sub-prime mortgage crisis, all of which could be tied back to costs of health care equally well, he did not miss the opportunity to ascribe “the same reason bankers are averse to many aspects of banking reform and transparency in derivatives and other market matters” to physicians opposing his preferred brand of change. Why would a respected scientist need to resort to this type of rhetoric?

Back in September 2012, right before the Presidential elections, Dr. Emanuel and 22 other “leading health-policy experts with diverse perspectives” affixed their names to a grand solution to contain health care costs, published in NEJM and proclaimed to “have the greatest probability of both being implemented and successfully controlling health costs”. Some of those diverse perspectives can be gleaned from the attached disclosures of potential conflicts of interest, or in some cases a surprising lack thereof. The comprehensive solution, which Dr. Emanuel briefly summarizes in his response to the Tilburt survey, includes such staples as transition to large integrated health systems, elimination of fee for service, bundled payments, expanding use of non-physicians and introduction of overt cost considerations into clinical decision making to curtail utilization. The solution had more than the greatest probability of being implemented, since it was already being implemented at the time of the NEJM publication. As to having the greatest probability for successfully controlling costs, it seems that physicians responding to the latest survey partially disagree.

When you look at the heart of the survey results (Table 3), it is very difficult to understand Dr. Emanuel’s fury. The majority of doctors is accepting some responsibility for health care costs, and is supportive of “quality” improvements, and somewhat begrudgingly is even onboard with EMRs. Chronic care management, continuity of care, preventive care, evidence-based practice, transparency of performance data, cost-effectiveness research and most other presumed pillars of the Triple Aim garnered wide support from respondents. Although stating that some of the numbers are not as discouraging as others, in Dr. Emanuel’s opinion, “[n]ot unlike the public, physicians embraced reforms that are sufficiently vague that they may offer only modest improvements but certainly will not transform the health care system”. Well, if quality improvements are “vague” and not transformative enough, what is it that we are missing?

First, the survey indicates that doctors are not buying into the concerted vilification of fee-for-service payments, and since the drive to eliminate fee-for-service is based on nothing more than hope, belief and wishful thinking, the only rebuttal to disagreement is vilification of the opponent and contending that “physicians are lapsing into the well-known, cautious instinctual approaches humans adopt whenever confronted by uncertainty: blame others and persevere with “business as usual.”” If those who desire to abolish private practice in favor of systems based care, which is what fee-for-service elimination is all about, have any supporting data showing how corporate medicine is having beneficial effects on costs and quality of care, this would be a perfect time to share it. But since there is no such data, and experience in other countries shows that fee-for-service has no inflationary effects on costs, and perhaps even the opposite is true, philosophical statements will have to do.

Similarly, physicians oppose the thick web of financial carrots and sticks aimed at reducing utilization in general and inpatient utilization in particular. Considering emerging studies (here and here), it looks like those who actually practice medicine understand that very little utilization is amenable to prevention by physicians. There is now, and always has been, very good data indicating that utilization of services in the U.S. is in most cases lower or comparable to other countries, and the difference in levels of expenditures lies mainly in outrageously inflated unit costs. Unit costs, whether bundled, capitated or calculated as salaries are not under physicians control today, and most certainly are not envisioned to be so, in the reformed corporate system. Disputing the merits of readmission penalties and bundled payments is not the same as “denial of responsibility”. In fact, 85% of survey respondents agree to various degrees that “[t]rying to contain costs is the responsibility of every physician”. Well? Is this not puzzling enough to grant the masses of practicing physicians a fair hearing?

Second, it looks like Dr. Emanuel wants physicians to lead, or be the “captains”, of the “all-hands-on-deck” effort to control costs. It’s not enough to provide high quality care and generally be mindful of costs. Something else obviously needs to be done, something that is too uncomfortable to mention perhaps, but should somehow be implicitly understood. A line in the sand has been drawn by the majority of responding doctors who prefer placing individual patients’ best interests ahead of the scarce resources allocation games people dance around these days. Now, Dr. Emanuel has written extensively on allocation strategies for truly scarce resources, such as transplant organs or hypothetical scarcity of vaccines during an epidemic, but on many occasions he made it abundantly clear that these theories do not apply to money as a resource, and that his vision of health care reform does not include this difficult type of rationing. Thus logic would dictate that refusal to engage in denial of care to certain individuals, on behalf of the greater good, should not be the reason for threatening physicians with the doom and gloom of being marginalized into “just another deckhand”. So what is it then? Is there an absolute truth somewhere that escapes all but a chosen few?

It is possible that Dr. Emanuel simply failed to articulate specific expectations on how doctors should lead the cost containment effort, so it may be helpful to look at an example of a physician more than willing to take the lead in this field. Dr. Saurabh Jha, a UK educated radiologist, in a perspective piece in NEJM describes his yearning to become an all-powerful imaging gatekeeper, emulating his hero, a certain radiologist called “Dr. No” somewhere in the UK, who used to deny all radiology orders without ever laying eyes on a patient. Eerily in sync with Dr. Emanuel’s musical vision of a transformative “symphony”, Dr. Jha is pondering who should “orchestrate the contrived march to scarcity of imaging and judiciously dispense the scarce resources” as “value is being redefined”.  The answer is of course, radiologists, and as Dr. Jha explained in a follow-up interview, this is about increasing relevance (no deckhands here), and preventing commoditization of the profession, because radiologists “can't be as ubiquitous as water and expect to command the price of diamonds”. Unlike the physicians in the Tilburt survey, Dr. Jha seems more than happy to take responsibility for cost management and “contrived” rationing, but expects to be “shielded from liability” for any preventable deaths falling outside his equally contrived thresholds for risk.  I am not sure who is going to pony up the diamonds, but I would venture a guess that plenty of hard cash will be forthcoming for this grand deception of the American people.

10 Steps to Prepare your Health App for Monetization

So you released a health app, now what? While waiting for your creation to do its thing and fix health care, there are some steps you can take to increase the odds of its success. Obviously, marketing is very important, but if you are a really good software developer, you probably released something that looks pretty on the outside, while needing many more iterations before it becomes a robust and really useful application. You should have a fairly good idea of what needs to be fixed, what needs to be added and what needs to be changed, if the funds to pay you and your team were forthcoming. Fortunately, this is a perfect time to obtain funding for health apps. There are all sorts of competitions, challenges, incubators, accelerators and crowd funding opportunities specifically for those working on fixing health care, that will not only get you exposure and buzz, but also a few extra development dollars. Make sure you take advantage of them all.

Chances are that you discovered by now that health care apps users won’t pay you a red cent to use the software. This is fine, because I’m sure you know that Larry, Sergey, Zuckerberg and that cute boy from Tumblr made billions of dollars at very short notice without charging anybody for using their software either, so why not you? The modern software paradigm has nothing to do with pricing products. It has to do with getting as many users on your platform, as fast as you can, and the money will follow. Unfortunately, unlike the olden days of social media, your innovation is competing against thousands of others that look just as good on the surface, 99.9% of which will die an uneventful death. When the dust settles, the spoils will go to those thoughtful entrepreneurs who had the wisdom to prepare for success. So make sure you set aside some of the prize money you win at the next health care app fair to get your invention ready for the day when its name becomes a verb, and here are some suggestions:

1. The Cloud – Yes, cloud is getting a bad rap right now, but don’t worry. People have short memories and even shorter attention spans, and by the time you are ready to rake in the cash, nobody will remember the NSA storm in a teacup. Make sure yours is a truly multi-tenant application with one database that can scale to hold the millions of profiles you will soon have. Whatever you decide to store on a user device should be replicated to the cloud religiously.
2. Open Standards – Even if you rigged a couple of things here and there, now is the time to replace all your data definitions with standards based frameworks. Health care, thank goodness, has an ample supply of those. Use SNOMED, LOINC, RxNorm and keep tabs on national standards development. Even if your app is about fixing lifestyles, you should use standards for your data. No, there are no standards (yet) for eggplant parmesan at lunch, but there are standards for weight, height, BMI, cholesterol levels, smoking status, gender preference, and of course, most importantly, last name, first name, DOB, address, zip, phone numbers, email, marital status, and whatever else you can get without creating suspicion (more below). You probably don’t need all the standard libraries, but make sure your metadata dictionaries (i.e. unique database IDs) are standards based.
3. Data Completeness – Whatever your app does, you should always strive to complete your datasets. If your app is providing eating habits modification tools, you should try to obtain all information pertaining to any possible research regarding food intake, and also any possible research where diet may affect results. If you think about it, this is a very tall order, and you may need to do a little research yourself, but a simple diet app could provide you with opportunities to amass data on people’s race, ethnicity, mental status, family situation, occupation, education, income, leisure activities, medications, acute and chronic conditions, etc. To keep your users calm, you should not make any of these items required fields, but instead gently remind them at various points in the lifestyle modification workflow that, for example, evidence shows that optimal caloric intake is affected by say, ethnicity, and give them an opportunity to update their profile to obtain more accurate evidence-based advice from the app. 
4. Data Validation – Data that is misspelled and inconclusive is useless, so make sure your app knows exactly what the user meant. For example, when you baseline your user’s dietary habits and she says that she is consuming one candy bar at 3 pm every day, ask which candy bar. Snickers? Twix? Kit Kat? Have some pictures display and let her click on her favorite. Is she eating that because that’s what the office machine usually stocks, or because her kids make her buy lots of these products? If your app is a trusted confidant, you can get all sorts of information that will make your profiles well-rounded, and let you provide truly useful advice. Maybe she would be open to switching to PayDay because it has less sugar, or a nice fat protein bar.
5. Open Architecture – Good software is built with growth in mind, and nothing grows software faster than a good set of APIs that you can hook to additional functionality developed by others, or by different teams in your own shop. You don’t have to build those extensions now, but you should have the infrastructure to easily add them in the rosy future. So for our Kit Kat lady, you may have APIs available for candy vendors to provide her a healthier alternative right then and there, such as a coupon for Luna bars which are created specifically for her. You can take it one step further and if you have a pill box reminder app, you can suggest that your user may want to talk to her health care professional about certain new meds that evidence shows are helpful to others with similar drug regimens, and if she doesn’t have the money, AstraZeneca can help. So encapsulate your functionality really well, and use generic interfaces for all your class objects.
6. Personalization – This is the age of personalized medicine, and the deluge of genomics is almost upon us. It is probably too early for most health care app developers to take advantage of that, but there are other smaller things you can do right away. The most important one is to have your users upload their picture. You can say it’s for safety and security, or you can say it’s for before and after progress tracking, depending on what your app does. Either way, I don’t need to tell you what can be accomplished with cross platform face recognition. Another way to personalize a health app is to surround people with friends and family. Give your users the opportunity to add family members to their profile and to discover close friends who may be using your app as well. It doesn’t have to be a social forum. Sometimes people feel better just knowing that others are in the same boat, and all you really need is the social connectivity map (degrees of separation). Be careful here so you don’t blow the trust relationship with your users, and make this 100% permission dependent.
7. Usability – There is nothing more useless than an app that does only one thing, no matter how well. Even if you start with a specific functionality, such as say, tracking calories, you should quickly expand to other services. Sticking with a narrow scope, and refining it ad nauseam, puts your app in danger of becoming a module for someone else’s comprehensive platform. You want your app to eventually be THE platform, so add whatever you can add to your open architecture quickly. Social media links are always a hit. Letting your users tweet about their incredible Crab Shack dinner while also adding the outing to their calorie log, is an example of good usability. Maybe you can enable them to post a picture of the crabs on Facebook to support their active social lives. By the way, if your app has bad news to deliver (e.g. you just ate all the recommended calories for an entire week), don’t be a party pooper; save it for the morning after, when your users are already miserable, thus more receptive to reprimand, and constructive advice on alternative eating establishments.
8. Mobility – This is definitely preaching to the choir, since almost all health apps are available for iPhones and most also for Android. If yours isn’t, fix it now. There is absolutely no point in developing solely for the old web any more. And don’t be shy about utilizing all the goodies that come with geo-location (with permission, of course). If you can capture the location and time where Kit Kats are consumed, you have something really unique, like everybody else.
9. Gamification – Here too, you are probably ahead of the game (no pun intended), but if you don’t have stars, badges and happy sounds in your app, you’ll have to add them. Even 80 year olds in a nursing home enjoy a gold star here and there, not to mention the youths in their thirties and forties. People need to be reminded often that they are special and provided with multiple instant gratifications on the road to healthy lifestyles. An app that constantly tells you how great you are is more likely to be used than one nagging you to do better. Needless to say that you should skimp on text and lavish your users with pictures, sounds and infographics, because people who can actually read entire paragraphs of plain text are not your target market. If you created an open architecture as mentioned above, this is a good place to throw in an API for some personalized (with user name) electronic coupons and other exciting freebies.
10. Taste Your Own Dog Food – The culmination of all your hard work is the creation of a big set of interlinked profiles that can be combined with other available information to provide insights into consumer needs, wants and possibilities thereof. To make sure you are producing marketable goods, you should simulate how others may consume your output. Once you have a little extra cash, go out and purchase readily available data sets, or obtain some that are already in the public domain, and mash them all up to see what happens. If you followed all the steps above, this should be like throwing Mentos into a bottle of Coke. Myriads of luscious patterns will emerge to guide your future development, sales & marketing efforts.

Maybe your app will fix health care when it grows up, and maybe it won’t. But as long as you can bring convenience and perhaps a sense of accomplishment to millions of users, along with some serious cash to dozens of customers, you should be all good. Keep your eyes on the prize at all times, because despite all the cheesy inspirational quotes out there, the mega joy is not so much in the journey as it is in the billion dollar destination.

The Holy EHR Wars

"In the same day the LORD made a covenant with Abram, saying, Unto thy seed have I given this land, from the river of Egypt unto the great river, the river Euphrates:" --Genesis 15:18

Some four thousand years later, after numerous detours, major scope reductions, tragedies, compromises and constant upheaval, the Promised Land project is very much a messy work in progress. This is the nature of great promises, and in the here and now, we are contemplating yet another, albeit smaller, promise: ““Hospitals, physicians and other health care providers are clearly taking advantage of recent incentives to embrace the promise  of technology [emphasis added],” said John R. Lumpkin, MD, MPH, senior vice president at the Robert Wood Johnson Foundation.”  The Promise of Technology, as you may have guessed, was not made to us by the Lord Almighty, but instead it seems to be a product of spontaneous creation with mysterious origins.

A few years ago, before the incentives mentioned by Dr. Lumpkin became available, there were dozens of EMR vendors trying to sell software to physicians and hospitals, and like every vendor of any product, they were actively and creatively marketing their wares. Save time and money was a common marketing slogan. EMR websites were sporting all sorts of fancy calculators comparing the costs of doing business on paper to doing business on a computer. The costs of new charts, dividers, paper, ink cartridges, each chart pull, forms, printing paper, etc. were carefully added and compared to the almost zero cost of using software instead. Some fancier calculators even factored in the rent for the additional space needed for chart racks. There were estimates of the number of FTEs that could be let go, or used for worthier causes, and the number of additional patients you can see, if you just buy this or that EMR. Some vendors went as far as advertising better care for patients, with advanced features like automated lab results, pre-built clinical templates and clinical decision support. Folks were kicking tires, shopping around and buying when convinced by ads, sales guys and gals, or even a special discount for the month of August. It was a market, like selling beer, or cars.

But then something strange happened. The United States Government became a believer in the EMR vendors’ marketing slogans. Health care was expensive and not as good or as accessible as it could be, and the EMR vendors promise of saving time and money while providing better care was the perfect solution, particularly since nobody else had anything to offer. Thus the Promise of Technology was born with a silver spoon in its mouth, and was immediately and extensively showered with millions and billions of incentives and resources. The messages on EMR vendors’ websites changed practically overnight from preaching to the infidels to preaching to the choir. Get your incentives, guaranteed, or your money back, was the new slogan. It wasn’t like selling beer anymore. It became missionary work. And, like all great mythological promises, the religion based on the Promise of Technology developed its high-priests, prophets, masses of passive followers, skeptics, and blasphemous heathens destined for martyrdom. The Holy Wars are now in full swing.

Obviously, since the Promise of Technology is promoted by the federal government, its campaigns are better coordinated, better funded and better staffed, and often the full color, multi-media splendor is breathtaking. The latest artillery salvo brings to bear the forces of mighty institutions, such as the Robert Wood Johnson Foundation, the Mathematica Policy Research and the Harvard School of Public Health, in a glossy 82 page report cleverly titled “Health Information Technology in the United States: Better Information Systems for Better Care, 2013”. The report, which does not address either better systems or better care, is a lengthy and multifaceted analysis of the highly successful Meaningful Use program and its effects on EHR technology prevalence and composition in the U.S.  To support the main front, Health Affairs published the research papers and convened a media event to showcase “Health Information Technology Adoption & Use” at the National Press Club in Washington, DC, featuring a star studded panel of experts, heavily promoted through social media, articles, and even national radio. This was the most impressive display of firepower superiority to date.

Basically, the loudly broadcasted, and widely amplified, drumroll is that the Meaningful Use program is working exceedingly well, everybody is buying EHRs and although many “challenges” remain, we are resolutely moving forward, and the Promise of Technology is certain to be fulfilled at an unspecified date in the future. Ample data was presented from multiple sources, processed through multiple software analytics packages, resulting in tables, bar charts, line charts and scatter plots, showing that the prevalence of EHRs of a particular type most conducive to Meaningful Use has increased by 12.4% among physicians and by 28.9% among hospitals since 2010 when the Meaningful Use program commenced and all EHRs were required to be able to support it. This is a very specific way of analyzing EHR adoption numbers, but we need not quibble with the details here. In addition, the Medicaid program for the poor paid out $4.2 Billion to almost 80,000 eligible professionals and 3,000 hospitals for adopting, implementing or upgrading their EHR, and $820 Million dollars to 8,187 eligible professionals and 1,197 hospitals for actually meeting Meaningful Use requirements by February 28, 2013.

The non-believers come in many flavors and as always in history, are disorganized, fearful, delusional and in violent disagreement with each other. There are those who question only the particulars of the Technology, but basically believe in the Promise, and very carefully profess their deep belief in magic in every article or opinion piece criticizing the current state of Technology. This is a very diverse group ranging in interests from those who aspire to be the high-priests of a new (e.g. open-source, modular, iPad based, interoperable) Promise of Technology to those who just want a more transparent way of managing the journey to the Promised Land.  This group has had some limited success in changing the official rhetoric and in obtaining lucrative positions for its better connected leaders. Then there are the heretics who question the Promise itself in studies or opinion pieces, searching for an ounce of evidence that the Promise will actually be fulfilled. Those are summarily burned at the stake.

And then there is a silent majority that is just trying to survive and pay the bills, but sometimes is compelled to vent anonymously on social media forums, with no tangible results. Once in a while there are skirmishes on the ground like the Affinity Medical Center RNs in Massillon, Ohio who went public with their call to delay EHR implementation, or the California Nurses Association press release highlighting the safety and patient care issues caused by a new EHR at Sutter corporation East Bay hospitals, which stand in stark contrast to the official line: “Electronic Health Records Seen as Key Tool for Hospital Nurses”. These things make the industry headline news for a few days and then are promptly eclipsed by some other spectacular fireworks display from the Promise of Technology bottomless arsenal.

As of June 2013 CMS has paid out over $15.5 Billion in combined Medicare and Medicaid incentives to wealthy individuals and corporations, and spent hundreds of millions more in grants, operations and consent manufacturing efforts. The day quickly approaches when the Promise of Technology will be running out of cash to sustain enthusiasm of the masses for the projected decades-long trek through the desert, but resourceful leaders should manage to elicit additional infusions of dollars by hitting various budget rocks really hard, and perhaps other miracles will occur as well.

Collateral Damage

And then there are the poor, the sickest and the most vulnerable; those who pay the highest price before, during and in the aftermath of all Holy Wars. The White House has a map on its website to answer a simple question: “How will the sequester hurt your state?”, and hurt it will. Tens of thousands of children will not be receiving immunizations, millions of dollars in disaster relief will not be available, thousands of teachers will be fired, millions of meals will not be delivered to sick and homebound seniors, clean air and water will no longer be protected, thousands of schools will not be able to help children who are poor, disadvantaged or have special needs and early education for poor kids will be practically eliminated. A map of local reactions and reports from all over the country is maintained by the Center for American Progress.

There are also the poorest of the poor, the schoolchildren on military bases and Native American reservations whose lives are being derailed for the lack of $67 million, which is 20% of what CMS paid out in Meaningful Use incentives just in the month of June. No, the Promise of Technology did not cause sequester cuts, but it’s not like the billion dollar bills spent on Meaningful Use are rigged to explosive devices designed to blow up if misused to help a child in need either.

Should the DoD Buy Epic, or Cerner, or GE, or…?

The Department of Defense (DoD) is in the market for an EHR solution… again. After a lengthy foray into building its own EHR from scratch (AHLTA), with miserable results, and another shorter detour through the fantasy land of an open-source integrated EHR (iEHR) with the Veteran Administration (VA), during which no material progress was made, other than spending taxpayers’ money of course, the DoD announced that it will begin looking for a commercially available product to suit the DoD’s unique needs. This decision is the source of much angst for some and much excitement for others, because no matter what the DoD decides to do, many more billions will be flowing out of taxpayers coffers and into the hands of a lucky few.

On one hand, since most people served by a DoD EHR will eventually be served by a VA EHR, it makes sense that these two government agencies should use the same product and aggregate a lifelong record for their patients. On the other hand, the VA EHR (VistA), although held in high esteem by its creators and users, is very old, and the VA itself is engaged in a major refurbishing effort through a public open-source framework. Answering to a highly frustrated House Committee on Veterans’ Affairs, looking for explanations and bemoaning the death of the iEHR, the DoD’s Frank Kendall reiterated the insurmountable costs and difficulties inherent in building a brand new EHR from scratch (better late than never, I guess) and highlighted the reasons why VistA is not as obvious a choice for the DoD as it is for the VA. Since the VA has VistA already deployed in all its facilities and it already employs an army of experienced VistA developers, a salvage operation for the aging VistA may make perfect sense for the VA, but none at all for the DoD which will be conducting a complete rip and replace program in the next couple of years.

Now that the self-developed iEHR delusion is dead, the technical controversy is focused on whether the DoD should select an open-source product, either VistA or a derivative thereof, or a proprietary system, such as Epic, Cerner, GE, Siemens, etc. The main arguments against a commercial solution are that the DoD should leverage the billions of dollars already invested in VistA, and that it should adhere to this administration’s preference for transparency and open-source technology. To better understand this conundrum, perhaps some terminology clarifications are in order.

Computer software comes in several flavors, and you may recognize most of these flavors if you researched your own EHR purchase recently:

• Proprietary – Commercially Licensed Software - Licensed commercial proprietary software is software you purchase as a black box. You can install it on your computer and use it as is for as long as you want. This is a license to use the software, and implies no ownership rights for the product. The vendor will usually charge you for upgrades. Most often, particularly for business software, you can supplement this one-time acquisition with a maintenance and support subscription fee that will provide you with upgrades and assistance from the vendor. Think Microsoft Office.
• Proprietary – Commercially Licensed Software + Source Code - Commercial proprietary software may include the source code (for additional fees) and rights to extend the original product for private use. Sometimes instead of the entire source code, or in addition to it, selected integration points (Application Programming Interfaces - APIs) are exposed to clients so they can add/customize certain functionalities on their own. Rights to enhance and augment the original source code for commercial resale are usually corporate arrangements not really intended for mere users of software.
• Proprietary – Subscription Based Software - A more modern variation on the above is software-as-a-service (still commercial and proprietary), where you don’t purchase a license for the product, but instead pay monthly fees for using the software, which is maintained and operated by your vendor. These fees are usually a bit higher than the maintenance and support fees for licensed software, mainly because the vendor has to bear the infrastructure costs in this scenario. This goes by the name of “cloud”. Although the vendor may expose APIs for third party developers, this type of arrangement almost never comes with source code, since the buyer is not running the software. Think Microsoft Office 365.
• Proprietary – Free Software - Free software is software you can obtain without paying either a license fee or maintenance fees. Free software may refer to software that you can download and use for free, or more often, free services provided through software residing in the developer’s datacenters (“cloud”). The larger the provider and the more individually geared the software is, the more likely it is that the provider will expose APIs to third party developers. Think Google anything.
• Open Source – Free Software + Source Code – This is what comes to most people’s minds when they say open-source. This type of software is usually developed and managed in a public framework by an all-volunteer squad of techies who have an irresistible urge to donate their labor to better humanity. There are mountains of open-source projects, some highly professional, others not much more than a hobbyist pastime, and there are almost none in wide consumer use, other than a handful of exceptional non-profit foundations (e.g. the Mozilla Foundation and its Firefox browser or the Apache Foundation and its development tools and modules). Open-source pieces of software are often utilized by commercial software companies to speed up their internal development process. For example, IBM’s Watson includes various open source modules, but Watson itself is neither free nor open source.
• Open Source – Maintenance Subscription Services + Source Code - A slightly different business model is an arrangement by which the software itself is provided for free, including source code, but maintenance, improvements, installation and training are billed on an ongoing basis. Sometimes special requests for features or premium functionality are also available for purchase. The software products available through this model are either developed in house by the service vendor, or obtained from a conventional community developed open-source project and enhanced by the service vendor. This model allows clients to customize the software on their own, if they wish to do so, but it may void or complicate maintenance agreements with the vendor.

Regardless of the model employed to obtain software, extensive APIs may or may not be available to third party developers who may be actual users, but most often are not. Software products that expose a good amount of well documented APIs are said to have an open architecture, which is based on accepted and open standards. APIs come in various flavors as well. Some are just plug-ins allowing third party developers to add minimal functionality that does not affect the main product in any way, and certainly does not affect the data layer. Tighter integration that may affect data integrity in the main product is harder to come by and usually requires approval from the original vendor if the software is proprietary. If you have access to the source code, either free or purchased, you can obviously do whatever you want, if you are reasonably certain that you can maintain the software on your own going forward. People or businesses without an IT department are rarely interested in tinkering with source code, so this conversation is really between IT shops, large businesses and true believers in this or that paradigm for software development.

Before returning to the DoD situation, one more word about vendor lock-in is in order. There is no doubt that having the source code (open source or purchased source), and particularly the database schema, makes transferring your data from one product to another a lot easier, if and only if, you have proper IT resources at your disposal. It is possible though, and most often very likely, that if your old product and your new product are very different, data loss will occur no matter how good your IT guys are and no matter how open both products are. Also, it is usually not necessary to have access to every line of code in order to migrate data from one system to another. A clean open architecture based on widely accepted standards is much more important for preventing vendor lock-in and for interoperability in general. Unfortunately none of the choices available to the DoD fit this bill currently, although some may be better than others. So what are the options available to the DoD?

1. Adopt the VA VistA – The DoD rejected this option, but it may be helpful to review it just in case they change their mind again. The DoD could of course obtain the entire VA source code for free, and could also benefit from the VA meritocracy-based framework of open-source freebies donated by selfless defense contractors and eventually by some guy in the Ukraine that is inclined to help the U.S. military save money on software development.
2. Obtain a different open-source product – There are none. The only viable open-source EHR option for large systems, other than the VA VistA is the privately enhanced and maintained VistA offered by Medsphere, which is also contributing enhancements to the VA open source framework. The other VistA derivative is WorldVistA.
3. Buy a commercial EHR – None of those are of course open-source, although if you buy Epic for example, you get the source code, and I would assume that the same is available from all others. A commercial EHR will most likely still need to be tweaked and enhanced for military purposes, whether by the vendor or by the DoD, but it should come out of the box with a lot more bells and whistles than VistA, some useful and others not so much, depending on which one is selected.

Basically, no matter what the DoD chooses to do, they will have access to the source code, and significant programming effort will be required to tailor the product to DoD needs. Most products that could be considered by the DoD have some useful APIs and increasing adherence to standards, but open architecture is not a term that comes to mind in this context. The DoD could hope and pray that the open-source framework established for VistA will produce the software improvements the military needs, or most likely, the DoD will have to pay for all enhancements and new features. In addition to software programming, deploying an EHR requires funds for training and implementation which can easily exceed the software costs by orders of magnitude, particularly since the military has very unique deployment locales.

We may believe that software purchased or built with taxpayers money should reside in the public domain, which almost never happens by the way, but this entire discussion is not really about open-source vs. proprietary products, which is largely irrelevant for the DoD itself, but very much about the plum Pentagon contracts to oversee this mammoth change to its medical records system. The choices are: internally developed DoD resources, a ragtag team of VistA veterans, a newer service entity like Medsphere, a commercial EHR vendor like Epic, or an entrenched usual suspect like SAIC, and most likely a combination of a defense contractor with any one of the lottery winners above. No doubt that as is always the case, the Pentagon will be making a wise, frugal decision, free of biases and bereft of the undue influence of special interests.

Correction 7/14/2013: The original text mistakenly and regrettably stated that WorldVistA is not in active development based on this WorldVistA page. According to the WorldVistA home page, the EHR is very much active and Meaningful Use certified. My sincere apologies to the WorldVistA folks.

Health Care Transformation – It’s not Personal, It’s Business

Why are we transforming health care? Why do we feel compelled to act with such urgency and in such broad reformative strokes? Did we just wake up one morning shaken to our very core by the enormity of having to fill the same medical history form multiple times? Are we driven to bleak despair by the thought of an elderly homeless person having to suffer multiple bouts of disease requiring frequent hospitalizations? Is our battle-forged sensibility to human rights egregiously offended by the realization that some Americans live a few months less than people residing on the French Riviera?  Or is it perhaps the American Dream, having fulfilled itself in all other aspects of our lives, that is now expanding to the next frontier of taming the health care system to individually and respectfully cater to our quest for eternal happiness?  Or maybe it has something to do with cold hard cash…..

Health care, we are told, is way too expensive. We are also told that this is really our fault because it is our job as consumers to police markets, and health care is a market. The original sin occurred in 1965 when we allowed government and subsequently third party payers to insert themselves into a well-functioning market, which relieved us from the need to exercise stewardship of our finite resources, and induced us to engage in reckless binge consumption of health care resources fueled by opportunistic greed of health care providers. The party, with its smorgasbord buffet and open bar, is over, we are told, because the institutions sponsoring this, decades long, shindig are going broke and cannot sustain our health care debauchery any longer. The obvious solution is that we resume our duties as consumers and actively engage in shopping for health care on our own dime, and at the same time our sponsoring benefactors will endeavor to restructure the wild array of colorful and inefficient sellers into a lean health care machine better suited for modern day mass consumption.

Mass consumption requires mass production, which in turn requires proper division of labor, machines and networked computer software. Mass production increases the value and convenience of services for consumers. Pay attention to the terminology. We are talking about value, as in “how much car for the dollar”, not about absolute quality. A high enough value attribute allows cheap, low quality products and services to be presented as high value bargains for savvy consumers. The term convenience is a lot simpler to parse, since it is really an inverse measure of calories expended for the purpose of obtaining a particular service. You can buy anything today with half a dozen taps on your iPad, while sitting on the toilet, benefiting from the aggregate advice of thousands of similarly situated consumers. Nothing should prevent a modern day consumer from obtaining health care advice from the same locale.

Seriously now, the transition to mass produced health care, or any other product or service, involves the consolidation of physical plants and also consolidation of financial transactions over the supply (or delivery) chain. These administrative simplifications are at the root of so called economies of scale. For example, let’s look at the beef industry, which is much more advanced than health care. First, you consolidate all small ranchers into large operators, and as large as feasible feed lots. Some businesses are vertically integrated and do process their own meat, while others act as subcontractors to meat processing companies. Either way, whether for internal accounting or payments to contractors, the pricing calculations are per head. Nobody bills or gets paid for individual services to cows (e.g. food for cow 1, antibiotics for cow 2, transportation for cow 3, etc.). Obviously some cows eat more than others, or maybe cause more trouble than others, but these differences are averaged out to calculate a capitated cost, which is paid in bulk through contractual supply agreements. In fully integrated businesses, feed lot operators are of course paid fixed salaries and perhaps even productivity bonuses if all the cows can ambulate from the truck to the bolt gun without incident.

Paying per head instead of fee for service has other competitive advantages, since it incentivizes service providers to innovate and manage costs down without micro interference from the purchaser. Obviously some quality assurance and spot checks are in place to make sure that those who pay for health care (or cows) get their money’s worth, and educated consumers get valuable service (or steak). For example, if a broken and fragmented primary care practice with say 5 physicians takes care of say, 10,000 people in a fee for service environment, once the per head model is adopted, the practice is free to fire 3 costly doctors and replace them with a couple of NPs and three or four RNs (i.e. proper division of labor), and save the cost of at least 1 physician FTE. May not be much, but aggregating over large scale operations, the new owners of this once fragmented practice, can realize significant economies. The trick of course is to keep the cows calm and blissfully ignorant while these transitions take place. To that end, satisfaction and experience are religiously measured frequently and all personnel, including any remaining physicians, are trained in soothing bovine communication skills, such as “DON'T SAY THIS: They are making me use this laptop with all my patients, and I can't find anything on it! SAY THIS: Our practice is using a new computer system, so I will be typing what you tell me as we talk. Please let me know if I fail to answer one of your questions.” Openness, honesty and candor, may be important for human relationships, but have no beneficial effects on large scale operations, and may even cause costly disruptions to standard work flows.

Another innovation made possible when purchasers stop paying for actual work or materials and start paying a fixed sum per head, is the ability to empower people to do some of the work by themselves. Computers that are quickly becoming ubiquitous in medical facilities and thousands of consumer facing mobile health (mHealth) apps are aiming at doing just that. Remember the days when you had to call the operator for a phone number, or the store to find out how late they’re open? In the not so distant future, calling a doctor’s office for advice on simple things will be just as anachronistic. So if you are still tinkering with your iPad on the toilet and are getting really annoyed by the mosquito bite on your driving finger, scoot over to your favorite triage app and they’ll tell you what to do.

Holy Mary Mother of God! Louise!!! I have to go to the ER… the computer says no treatment is necessary but the ER thing is right on top… maybe there’s something going around…  and there’s no waiting… I’m making an appointment… go start the car honey… what… you arguing with the computer now?

Wait a second…. What just happened here? Every symptom you punch into this app, no matter how minor, brings up the ER at the top of the list for appropriate choices for this condition, and a list of all ERs in the area with some “more fortunate” ones sporting a button for you to fill out a form letting them know you’re on your way.  Perhaps the new mHealth app developers are much more concerned with people’s health than their legacy EMR predecessors, or maybe we are overlooking something.

We are. Although health care expenditures are bankrupting the nation, they seem to have an opposite effect on some stakeholders. Health insurance companies are thriving. Large health systems are awash in cash. Pharma and device stocks seem to be doing just fine. Health IT vendors are growing by leaps and bounds and private capital is pouring into mobile health app development. Employers on the other hand are the only ones putting money into the system, other than us of course, and they simply can’t afford it anymore, which is the main reason workers’ wages are stagnating. For example if you are single and you made say $50,000 at the turn of the new millennium, and your employer paid for all your health care, and you managed to keep your job to this day, and like your wages, health care costs did not go up faster than inflation, you could be looking at a whopping $71,000 instead of your measly $68,000 due to escalating health care costs. Somehow the inability to pay you this extra bounty is driving your employer to bankruptcy, not to mention despair.  And although the Dow Jones Industrial Average is hovering at an all-time high, hardly indicative of any corporate hardships, the difficulty associated with leaving $3,000 on the table for those who never leave anything behind, is understandable.

So why are we transforming health care, considering that the needs and wants and “rights” of individuals in this country are of no concern to anyone but the individuals themselves? We are transforming health care because $3,000 is a lot of money for those who moved their entire operations offshore for a lot less than that. And we are transforming health care because, as strange as it may sound, there is still some more money to be made from herding people into mass produced health care, as the innovative slaughterhouse pioneers have clearly demonstrated. It’s just good for business, and this is America.