Friday, November 30, 2007

AHIC and E-prescribing mandates

The news reports repeat the clarion call - "let e-prescribing begin!"

iHealth Beat summarizes in a November 14 report:
The American Health Information Community on Tuesday voted unanimously to recommend to HHS Secretary Mike Leavitt that the Bush administration draft federal legislation to mandate the use of electronic prescriptions for Medicare providers, Modern Healthcare reports (Conn, Modern Healthcare, 11/13).
Other sources include Secretary Leavitt's informative blog
The mandate came from the AHIC meeting in Chicago on November 13

Where did this come from? Clearly there were many forces at work to the eyes of this writer (who was in the audience a good part of the time) and there were many concerns expressed.

This writer was struck by the extent to which the group was focused on many other issues at the expense of e-prescribing. But a few individuals kept pulling the agenda back to this critical topic. No one made a stronger impression on this writer than Mr. Craig Barrett, CEO of Intel and a Member of the AHIC Group.

One got the impression that AHIC support for e-prescribing in part came despite the agenda and not as a product of it. The group spent a good part of the meeting hearing of NHIN contracts that have not yet exchanged data, physician surveys that showed (again) the reluctance to adopt EHRs (and why); of a purported need to certify personal health records (because big companies are involved, not because we know what they should be yet) and some comments by the Commissioner of the FCC. Throughout the transcript, one sees an effort to postpone action on e-prescribing till the January meeting.

In the middle of this was the voice of Mr. Barrett, continually trying to bring the group back to focus on e-prescribing. This writer - obviously fixed in the belief that doing something about e-prescribing is more important than many of the other topics on the AHIC agenda - was glad to see one of America's most effective business leaders try - repeatedly - to get action. It seemed painfully obvious that inaction is either because collectively the health care industry is not convinced that full e-prescribing can be pulled off successfully (and many of the spokepersons are therefore misleading) or that the current government body is reluctant to impose mandates. Both, of course, may be accurate statements...or neither...

Enclosed are some quotes from the transcript (bold face added by this writer)

After discussion of current standards initiatives by Secretary Leavitt:

MR. BARRETT: I have a question that may turn into a comment. And the question really is for Kerry and Mark. I heard a lot this morning about the safety and well being of our patients as our highest priority. And Kerry, if I understood what CMS is doing about electronic prescriptions, it's you're creating a standard without requiring usage.

And I'm still looking at all of the data that suggests that thousands or tens of thousands of people in this country are impacted each year because we don't have 100 percent e-prescription. And so my question is, this is the 17th meeting of this august body. We've discussed this at meeting number one, two, three, four, then we went dark, and now we're back at 17. Where are we?

MR. LEAVITT: There may come a time when we require -- right now we don't require it as a condition of writing a prescription, but if you write an electronic prescription, then you must use our standards. And certainly, there is a considerable push out there to do that. I believe Mr. Serota wrote us last week or the week before about that. We are not, you know, completely deaf to those exhortations, but we're not yet in a position to require it.

DR. KOLODNER: But it will happen.

MR. BARRETT: What meeting number do I have to come back to to get there?

MR. LEAVITT: I can't predict that number for you.

DR. KOLODNER: One of the things, Craig, for those of us who have been in healthcare systems, especially large healthcare systems, what we found is that as good as something might be as an idea, that until you have a base in there that in some cases may be up at the 30 or 40 percent range, you haven't worked through all the issues. And if you put an arbitrary date in before having that, at least in the healthcare arena, it has sometimes caused a problem. Now, the question is how you put incentives in, so you can get to that more quickly rather than starting with the stick.

MR. BARRETT: You ought to talk to your friends in the IRS or the EPA. They don't seem to hesitate to put requirements in without the necessary base involved. I'm just -- I go back continually to the issue of patient safety as our highest priority.

This is an obvious issue, and we seem to just be moving ever so cautiously and slowly on it when we could make a giant leap and perhaps facilitate the movement of the infrastructure and the capability. I knew I'd get to my comment. I had to give you a question to get started, though. [laughter] And I did.

DR. KOLODNER: Okay. Chip.

MR. KAHN: I'd just like to reinforce what Craig said. I think in the case of an institution like a hospital, where you've got computerized prescription order entry, you have an institution that can bring people along. And I agree with the sort of reaching the 40 percent. But I think in terms of individual physicians, you're not going to get to 40 percent in this century unless you acquire it, frankly. You're not going to get to 50 percent. You're not going to get to 20 percent. So I think it's really the only way to go. You're going to have some use, but it's not going to happen until you just tell people. And I think this is one area where if you tell them, I think they're going to have to do it.

MR. BARRETT: There may be some parallels in some other aspects of business. For example, Congress, in its infinite wisdom, passed something called Sarbanes-Oxley. Every public corporation in the United States had to immediately change the way it did business, had somebody looking over its shoulder, public auditors, public reports about how you did this, how you did not do it.

It cost us all millions of dollars. I think it cost my corporation something like 25 or $30 million a year for the first three years or so. And documenting every aspect of our doing business, and every decision we made. And how every internal control operated.

This is not a new issue. Every other business in the United States has done this. As I keep trying to remind this audience, I know that medical care is different. Everybody says their industry is different, but there are innumerable instances where massive changes have taken place almost overnight in the way we do business. Somehow, we're more resistant in this area than every other business that I know of.

There ensued additional discussions and the Secretary left the meeting, as it continued and drew to a break, the following conversation took place....

MR. HUTCHINSON: I don't know if we want to take this topic on before the break, but going back to this e-prescribing conversation about the benefit incentives and how do you drive it and should it be mandated. You know, there's -- we don't need any more studies. There's plenty of data out there that suggests the value and the benefit that comes out. Most recent ones that came out from Henry Ford Medical Center that spent well over a year looking at this issue, and where the benefit lies. And the fact is, all the participants in the prescribing process benefit by automating this process.

DR. KOLODNER: Let me bring us to a close at this point. I think there are a couple of things that we know of. First of all, the Secretary wanted us to engage in a further conversation about e-prescribing, and we, I think, don't have the energy to do that today. But what I would like to do is to, in fact, make sure that we do that in January. Lillee, maybe the EHR Workgroup can spend a little time helping to frame that. It will align with David coming back with the full report, and not based on 400, but based on 3,000 responses. And yes, Craig, they are mail survey, and the problem is, did we --

MR. BARRETT: We've discussed this on and off for 17 meetings. The issue is, if you believe Kevin's numbers, and he's quoted those numbers every damn time, they haven't changed. I have to believe they're right. Thirty percent of the doctors do 80 percent of the work. You want a tipping point. Go up to 30 percent of the doctors. By the way, what we do here means nothing.

It's what you guys do that means something
. You have the purchasing power. You have the control to say -- not these are the standards, but these are the standards and you will be reimbursed if you do it this way. Period. I mean seems to me this is the simplest possible decision that somebody has to make. It's not a discussion topic. We've discussed this painfully several times.

If I sound like I'm frustrated, yeah, I'm frustrated. In the business world, this would have been a done deal 17 meetings ago. Slam dunk. Get on with it.
Falls in your guys' court.

DR. KOLODNER: I think one of the things, and Kevin, maybe you can work with the EHR Workgroup and I'm not sure who else. But one of the issues about the 30 percent is how many actually are Medicare versus pediatrics and versus other chronic illnesses. Because they may or may not be the federal Medicare dollars, and it may be more widespread. But if we -- I think if we can begin to tee up the data to have this discussion continue in January, I think that we -- hopefully, we'll put it at the beginning of the -- or near the beginning, because we're also going to have AHIC 2.0, but to have it when we have the energy and we can have more data that we can see about driving forward, as you'd like to drive forward, Craig.

Tuesday, November 13, 2007

Leaders can be Great Teachers

On November 13, Secretary Mike Leavitt gave a keynote address to approximately 2,000 health information technology leaders attending the American Medical Informatics Association (AMIA) annual meeting. Aside from the security personnel scanning the audience, one did not get the feeling one was hearing a keynote as much as one had the sense one was in a classroom. He asked the participants to write down key phrases on paper (e.g., "national standards, local control"). He asked participants to draw a map of the country and to identify their community and several other communities they favored and think through with him how each community can retain its identity, advanced based on its own situation, yet conform to areas where standards make sense. As a Chicago analogy, he pointed out that Cubs and White Sox fans may disagree on who has the best team, but they all share the rules of "three strikes, 9 players, and the like." (The "designated hitter" remains an area of standards controversy.)
Secretary Leavitt is a great teacher and communicator. Over time, his ideas have gelled. In particular, the use of the term "value exchange" is an important one because it implies there is more to value than dollars or convenience. Although executive orders force agencies at times to prematurely define terms best left to social evolution (and both "value" and "quality" are in this writer's view these types of terms), the overall HHS formulation of the problem is a good one.

Still, it is a matter of execution. Were the government to focus the debate and frame the questions only, one would have great success. But given the complexity and passion with which every professional involved in health care addresses these questions, we are at present left with a diffuse, over-extended, complex array of working groups, sub-committees and other processes that both impair attention on the most important "quick wins" and, to many cynics, substitute debate over health information technology for the far more critical debate on the very nature of our health care delivery and financing system. At least one individual near this writer said to a colleague during the talk "they are just talking about technology because they can't agree on how to fund health care."

This writer has been critical of the execution of many technology initiatives at the federal level. Each effort - when viewed alone - seems rational in aim if not in time to results (i.e. arriving at what a PHR really is will be an ongoing process over many years, not something executed by contractual fiat or AHIC consensus statement). It is when you put all of the myriad working groups and committees together that it gets confusing. To paraphrase a theological scholar and reviewer, it is as if we have a soccer field with six teams and four balls. Everyone is very actively engaged in running about and kicking, but from the stands, the game makes no sense whatsoever.

The Secretary has the skills and the opportunity to address theses concerns. He can set the rules and move from a diffuse agenda to a more focused one. He can use a newly rejuvenated ONC - now truly committed to "coordination" with other federal, state, and local agencies - as well as the broader apparatus to trim down the debate, put half or more of the working groups and certification groups on the back burner of deliberation, engage established groups, and focus the attention of the entire nation on a few efforts that would give hope that the federal government can do something more than consume time and money. This does not relegate all local action outside of these areas to a backwater, but merely acknowledges that many local issues - even in areas of standards - will logically reconcile over time.

It is regrettable that so many say this Administration is focused on what will make a difference before the next election cycle. These are the cynical realities of American politics. But I think most of us hope to be alive after the election, and the same goes for our family and friends. We will have medical problems, we will have financial challenges; the realities on the ground won't be that different. No matter which party sits in what post in two years, this writer believes the electorate more than anything else wants assurances that our country is making every effort to create a stronger America grounded in personal and fiscal responsibility, united in compassion, and committed to open and non-judgemental debate.

The very best leaders find a way to accomplish something tangible in a short period (my candidate would be effective medication management or as it is often called "e-prescribing). The very best also find a way to shift the perception and to engage the public in a more long-term process of reflection and debate based on asking the right questions. One of these questions is not "who should pay for my health care" (since no one can afford it, really) but rather, "how can I work with others in my family and community to make health care more consistent, effective, affordable, and of higher quality"?

As this writer listened to the Secretary, he was watching a master teacher taking a group through a set of lessons. Like any great teacher, all the Secretary can really hope for is that some of his ideas become the ideas of those in the room and that people act on what they now to believe to be their personal inspiration.

Where the spirit of national standards and local action is concerned, agents of the federal government should realize that the very best "students" don't do just what they are taught but improve on what they learn and make good ideas more actionable within a local environment.

This writer is very glad his teachers don't try to "certify" his life based on what he learned in past decades but instead both trust and hold responsible their student to modify and transform life goes on. The Ten Commandments seem to hold pretty well as standards, but I am not sure about dress codes, speed limits, and man other details.

This writer would do a better job of following through the spirit of his teachers in government if he were assured there were a few critical and realistic short-term and long-term goals that transcend both electoral cycles and partisan interests. We cannot predict the future, but we should be able to count on the values and capabilities of one another if we work towards common goals.

Thursday, November 1, 2007

Hardening of the Categories

An October 22, 2007 posting on the web site of the National Alliance for Health Information Technology describes an important effort for the Office of the National Coordinator for Health Information Technology (ONC) to develop consensus-based definitions for key health information technology terms. The call for participation states that this effort is being managed by the consulting firm Bearing Point.
The posting states:

The first set of terms will focus on creating and securing industry endorsement of definitions for electronic health record (EHR), electronic medical record (EMR), personal health record (PHR), health information exchange (HIE) and regional health information organization (RHIO).

This need for clarification seems essential if an external entity is to certify a product and tie compensation for services to use of a certified product. I suppose we have - loosely and technically - definitions for terms like "automobile," "truck," and "train." These seem important; if we are all going to share the road with other hurtling vehicles capable of weaving through lanes or rushing through intersections, it is reassuring to note at least that such vehicles have certain predictable characteristics. (If only we could say the same for drivers; somehow this driver is not convinced that licensure confers absolute levels of safety.) Similarly, trains need to run on fixed tracks. I makes sense that one who purchases or rides on a train can be assured that efforts have been made to ensure that such trains both fit and stay on the tracks for which they were designed.

One wonders, however, how exactly one should define an emerging technology or even a functionality within a technology. One wonders what would have happened to the automobile industry if a definition of automobile was prematurely imposed. Initially, our vision of an automobile was constrained by our imagination; few could look past the notion of a "horseless carriage" and envision the wide array of evolving transportation products and services now included in the definition of "automobile."

Similarly, imagine creating economic constraints that would have restricted computer uses to CPM operating systems, cathode ray tubes, and ascii text. Imagine defining a "personal computer" as it could have been done before networking was ubiquitous and at a period when inexpensive email capability was restricted to those with accounts on mini-computers or mainframes. Imagine the competition among vendors if attributes within the definition determined whether or not products could compete for government contracts. Imagine certifying a "library" as a collection of books.

Now think about the term "health." What does it mean? How is "health" different from "medical." These are definitely important issues. As one joins a deliberative body and walks around a machine or set of services searching for an "essence" or set of characteristics that define the product or service, one will, no doubt, get a better sense of what one means by the underlying purposes or aims for which the device or services have been created. Perhaps this is a task best left to theologians, semioticians, and deconstructionist scholars.

One can imagine the process leading to a richer and deeper appreciation for the diversity of services and devices which - when combined - can help us understand more completely the untapped potential to improve health and deliver health care services. Done well - and defined through a set of objectives that are imagined to evolve over time - such definitions can help educate and foster the public debate. Done poorly, or addressed with the intent to gain a near-term advantage, such deliberations lead to anachronisms, obsolescence, and most likely an endless and time-consuming bureaucracy that through its efforts seeks vainly to keep up with the wide range of human creativity and perhaps indirectly constrains such creativity.

This writer is at this juncture skeptical. No doubt the terms "EHR," "PHR," "RHIO," and "HIE" are used in a wide variety of circumstances to address differing aims (a bit like societies use of many other terms including "peace," "tranquility," "war," and even "life"). At the top level, perhaps one needs an effort first to define the term "define" and then a large groups of bodies that define what we mean by "medical," "health," and "exchange." How this effort proceeds will very much dictate the extent to which the process follows the deliberative nature of good scholarship, strong science, or effective policy. Implicit in any definition is an understanding of things, a set of expectations about how others interpret words, and a belief that through more precise definitions, one can make sure that two parties who disagree are disagreeing over the same idea and not, in reality, "violently agreeing" with different uses of a term.

It is important to get this right. It is important to set expectations and to put forth the notion that virtually any definition outside of theological dogma may evolve rapidly. Some terms beg for at least an interim characterization - "EMR" comes to mind. Other terms ("RHIO") may help clarify thinking or may simply lead to an endless morass of irrelevant debate.

One hopes that our definitions are based on our aspirations about our health and that most technologies and systems are viewed merely as a means to an ever-evolving (and hopefully rising) set of expectations about what we as a society can accomplish and how we as citizens can more properly care for ourselves, our families, and each other.