Mark Frisse's Policy Blog

Incentives for e-Prescribing

noreply@blogger.com (Mark Frisse) — Sat, 17 May 2008 16:09:00 +0000

Recently, and around the time of a hastily-called meeting by the Brookings Institution on e-prescribing, I was asked about incentives.

I have been following this only peripherally, so I made a lot of calls and sent a lot of emails. I drew some conclusions that may be my own bias filtered through what I want to hear, but I present them nonetheless.

The Southeast Michigan e-prescribing initiative is one of the most impressive success stories. Incentives to prescribers were $500 - $1000 with recurring incentives with P4P. Some up-front funds were used for infrastructure.

This writer believes the most important determinant of success was the involvement of every significant organization involved in the effort. Rather than just focusing on the prescriber, this project was initiated by employers (the auto makers) and involved actively retail pharmacies, plans, PBMs, SureScripts/RxHub, vendors, and prescribers. I believe it was the strength of this guiding community coalition that made this project an ongoing success.

Details can be found through a Powerpoint Presentation or through a search engine.

A similar experience was found in Horizon BCBS of New Jersey – one of the groups involved in the CMS e-prescribing trials last year. In this case, a commitment had been made over time.

One could therefore argue that a similar, broad-based cultural shift had taken place by the time the trials were initiated.

There are many examples in which plans provided significant financial incentives to practitioners but where results were wanting. In most of these efforts, physicians were provided with some combination of hardware, eRx software, mobile phones, telecommunications subsidies, and P4P approaches. In one effort, the program increase total reimbursement 1% (not just eRx-associated) if one met certain simple adoption milestones. Practitioners received another 1% if used a more extensive EMR system. Additional funding of another 5% or more could be attained if one met other P4P milestones. Interest in the program was low. The incentives (particularly the 1% of total increase in plan payments, did not seem to foster change. No pharmacy participation was mentioned.

Prematics seems to have a different approach. This vendor focuses on the high prescribers. Payment is through plans or other intermediaries to the vendor, and not to the practitioner. Payments are based on transaction fees in the range of $1-2. These fees are correlated with the estimated savings of $55 for every brand-to-generic shift. This model assumes and works towards linkages with pharmacies and other involved stakeholders. It focuses “incentives” to the prescriber on ease of use, flexibility, and convenience. These payer-to-vendor models do not preclude additional provider compensation for pay-for-performance, outcomes, or more effective and efficient medication management programs. Such incentives just aren't used to capitalized the infrastructure (and one wonders what happens to the self-pay patients; are they "free riders"?)

In my view, the e-prescribing pilots suggest the following:

Adoption is low but increasing rapidly as critical masses are achieved in communities.
It is a system-level issue involving pharmacies, providers, intermediaries and other critical programs.
Training and expertise may come from national or state-level expertise, but the real change happens locally.
Systematic, community-based approaches like SE Michigan take the most effort, but the guiding coalition and the critical mass focusing on the cultural and organizational issues suggests a far higher likelihood of success.
Incentives for a single provider have to be significant (at a minimum of 5% increase), but the Prematics model suggests that simply providing better systems more responsive to workflow might foster adoption. (Were I in practice, I am not sure I'd want to have my infrastructure costs assumed by a payer or intermediary, since, this is money that could be paid directly to providers for services.)

From the intermediary or employer side, brand-to-generic shifts so offset many of the costs; the question is: can the same shifts be assured without e-prescribing? I think perhaps so; certainly PBMs push drug trend before eRX (through tiered co-payments), and the differential profits realized by retail pharmacists influenced a lot of pharmacy generic shift behavior.

This brief posting is not particularly comprehensive or rigorous. But the simple question is:

To what extent does X incentive to one party in a transaction lead to Y results independent of the incentives to other parties in the transaction? (i.e. can you just give money to physicians and expect results if the system in which they practice is not ready for change?)
To what extent - and how - do system-wide or community-based initiatives involving more parties influence adoption and use? what are the overall costs and benefits of these?

To me, community-based approaches involving pharmacy, prescribers, intermediaries, employers, and government are the best way to go.

For-Profit Health Information Exchanges

noreply@blogger.com (Mark Frisse) — Tue, 13 May 2008 19:20:00 +0000

In a May 8, 2008 Government Health IT article written by Nancy Ferris entitled "For-profit HIEs are the answer, entrepreneur says," Dr. Elliott Menschik, president of HxTechnologies, is quoted extensively from a recent Capitol Hill Steering Committee on Telehealth and Healthcare Informatics. (All quotes are taken from Ms. Ferris' article and not from primary sources.)

Follow this link to the Government Health IT article

Dr. Menschik's company "began with grant funding from the National Institutes of Health, but that funding ran out last year. Now Menschik is in discussions with two large insurers in the Philadelphia area, Independence Blue Cross and Aetna, about sponsoring the project." "Working with radiologists, his company is developing a for-profit HIE that will deliver radiology images to doctors in Philadelphia....In New Jersey, HxTechnologies is building the New Jersey Health Information Exchange for a client, the AmeriHealth subsidiary of Independence Blue Cross."

According to Ms. Ferris, Menschik's claims that the current push for “altruism-driven” HIE is not getting results because “the lowest common denominator approach paralyzes participants.” Ferris states that the "need to achieve consensus on every issue slows the process to a crawl, and fear of antagonizing anyone means that the actions with the greatest potential impact are avoided. The projects are dependent on grants that eventually end, leaving the HIE without enough funds."

His model focuses on health plan funded-radiolology information exchanges. (Think of it as a pharmacy benefits manager for radiology.) Indeed, many pharmacy data aggregators, laboratory information providers, and other data services also are for-profit in structure. (But not not necessarily profitable at this juncture.)

If the coverage is reflective of Dr. Menschik's views, his concerns on the lowest-common-denominator have been justified by the glacial pace of the NHIN as broadly constituted. But the alleged slow pace of a broadly constituted NHIN in no way should lead one to conclude that the only alternative is to embrace models such as Dr. Menschik's as the only alternative. We need both.

According to Ms. Ferris, Dr. Menschik suggests that "for-profit, businesslike HIEs are the way to go in the current environment, according to a company president who says the free enterprise model can deliver results better, faster and cheaper. "

Are these claims true?

Better? For whom? For patients? providers? plans? all of the above?
Faster – if mobilizing capital is important, perhaps. But to what end?
Cheaper? How will we know since we won’t know the true price buried within the cost structures of health plans and intermediaries nor will we have any comparisons if transparency efforts do not advance.

A Flawed Argument
The argument placing for-profit models in opposition to non-for-profit models is flawed. The claim that one model provides a solution to one problem does not refute the validity of a claim that is not the logical opposite but rather a complement directed at different tasks. Specifically, a radiology exchange funded by health care plans does not in and of itself refute the value of a broader, community-based health information exchange, particuilarly since these exchanges in some way serve as an imperfect proxy for a consumer-focused health care information system. Furthermore, the "for-profit" vs. "non-profit" argument is secondary if not irrelevant. A more important argument is over the rising role of heavily-funded and economically "disruptive" personal health care records offered by Microsoft, Google, Intuit, Dossia, and many others.

The issue is raising capital. Health plans - for-profit or non-profit - get much of their capital simply because they get our money first and essentially distribute it, whereas new models for innovation - be they new technologies, new drugs, or new approaches to information management - can only thrive if they obtain new capital (via IPO or angel funding) or by trying to demonstrate value to the health plans and other intermediaries who already have our health care dollars.

Dr. Menschik's company sounds like a good idea. If the numbers work, it will bring immediate value to payers. Like a PBM, this approach is almost certain to garner the attention of intermediaries with fiscal responsibilities. Like other initiatives to constrain costs, it almost certainly will demonstrate cost savings and will incur the wrath of some who lose revenue (e.g., Dr. Menschik's radiology colleagues). Like other initiatives, the costs of the infrastructure may be high.

In the final line of the article, Ms. Ferris states that "substantial amounts of federal funding for HIEs would be a good alternative to the business-driven efforts he [Menschik] is advocating. But that kind of financial support does not seem likely to be forthcoming...."

This is the point. The real struggle is among the advocates of a purely driven health care system and the advocates of a system dominated by intermediaries. As Menschik's model would suggest, there may be room for both. But the success of one model devoted to certain purposes and markets does not necessarily support the claim that other models will fail either financially or from the perspective of the public interest. And purely for-profit endeavors are to be found in both.

The article begins with the following assertion: "Public-private partnerships to develop health information exchanges? Forget about it. "

I would suggest that the consumer public will not "forget," nor will the next generation remain totally reliant on information whose access is withheld and decisions made by invisible intermediaries. Consumers will want a growing seat at the decision-making table and a rising interest in how their health dollars are spent. Whether this is through for-profits or non-profits, independent companies or community partnerships, is yet to be determined. One size may not fit all.

Memphis Health Information Exchange Beginning 3rd Year of Clinical Operations

noreply@blogger.com (Mark Frisse) — Thu, 08 May 2008 16:34:00 +0000

On May 3, 2008, our Memphis-based health information exchange has been in operation for two years. Funded by AHRQ, the State of Tennesse, and Vanderbilt and governed by the non-profit MidSouth eHealth Alliance, the Exchange has come a long way

TheExchange currently has 356 people using the system for clinical care.

Physician / Provider roles - 199
Nurse roles - 109
Registrars and unit clerk functions - 48

These numbers will change as the last major system goes "near real time" in the next few weeks and as more ambulatory care providers are introduced to the program. The number of clinicians will increase and the number of registrars and unit clerks will decrease dramatically.

Data are accessed by authorized personnel in 30 sites, including 11 emergency rooms, 15 primary care clinics, and 4 hospitalist groups. Expansion to other emergency department settings is taking place in May and June of 2008. Access is only through two-factor authentication and secure Web browsers in restricted settings. 100% of access transactions undergo some form of audit. Use is restricted to clinical settings. No aggregate data or metrics are kept. Patients may "opt out" at the institutional level.

The Exchange grants secure access to almost 3 million patient encounters.

Total number of unique individuals - 1,050,000
Total number of unique individuals with clinical data (not
just claims) - 809,000

Our latest inventory of data elements from the two-years of operation counts:

Over 64 million laboratory tests (growing at an average of 88,000 test results a day).
1.3 million radiology reports (growing at almost 2,000 per day)
Over 16 thousand dictated discharge summaries
Over 218 thousand anatomic pathology reports
Approximately 40 thousand other clinical notes

(Follow this link to compare with our February 2008 update)

More data and implications will soon be found at our Regional Informatics Site

Coordinating Less; Accomplishing More

noreply@blogger.com (Mark Frisse) — Tue, 29 Apr 2008 18:37:00 +0000

On April 28, Government Health IT published an op-ed piece with my consent and participation. It was based on a longer and more spontaneous blog entry at this site. It had its roots in my wish to see more focus and immediate wins in areas that will raise the larger questions.

Follow this link to the Government Health IT op-ed piece

In this op-ed piece, I said:

"One hopes a smaller set of high-priority items will emerge that can be adopted across the health care sector. I believe about 12 of the core services are must-do high priorities, and many others could be set aside for future consideration."

I was commenting on the bewildering array of features and functionalities described in the Gartner NHIN I report. These features are actually more bewildering because each use case in turn added features and desiderata that may or may not be congruent with the larger NHIN list. The simple fact: there are a lot of things that would be nice to have, but the list of things we must have in a "Version 1.0" world may be fewer in number and complexity.

Follow this link to a draft document of the 12 core services I have proposed.

For each, I the pdf document linked above cross-references the relevant NHIN reports. Summarizing in a few words, the 12 core services are:

Data delivery
Look-up
Matching
Summary patient records
Integrity
Choice
Audits
Identity
Authentication
Management
Security
De-authorization

These may be the wrong items, and there may be differing priorities, but this writer at least believes starting with some of the NHIN terms - using these terms and supporting their evolution over time through thoughtful study - seems like one approach.

Russell Ackoff and Mission Statements

noreply@blogger.com (Mark Frisse) — Mon, 28 Apr 2008 15:20:00 +0000

Participating in the AHIC 2.0 discussions, I am repeatedly reminded of an influential talk and paper delivered by Russ Ackoff several years ago. His advice should be heeded when one is talking of ambitious, sincere, and inclusive "public private partnerships."

I have located a copy of this paper attributed to him on Charles Warner's Web Site. It seems to be the paper I read long ago. I reprint in full. Emphases in bold or italics are mine.

MISSION STATEMENTS
by
Russell Ackoff

Most corporate mission statements are worthless. They consist largely of pious platitudes such as: "We will hold ourselves to the highest standards of professionalism and ethical behavior." They often formulate necessities as objectives; for example, "to achieve sufficient profit." This is like a person saying his mission is to breathe sufficiently.

A mission statement should not commit a firm to what it must do to survive but to what it chooses to do in order to thrive. Nor should it be filled with operationally meaningless superlatives such as biggest, best, optimum, and maximum; for example, one company says it wants to "maximize its growth potential," another "to provide products of the highest quality." How in the world can a company determine whether it has attained growth potential or highest quality?

To test for the appropriateness of an assertion in a mission statement, determine whether it can be disagreed with reasonably. If not, it should be excluded. Can you imagine any company disagreeing with the objective "to provide the best value for the money." If you can't, it's not worth saying.

What characteristics should a mission statement have?

First it should contain a formulation of the firm's objectives that enables progress toward them to be measured. To state objectives that cannot be used to evaluate performance is hypocrisy. Unless the adoption of a mission statement changes the behavior of the firm that makes it, it has no value. The behavior of a Mexican firm was profoundly affected by the following passage from its mission statement:
To create a wholesome, varied, pluralistic, multi-class recreational area incorporating tourist facilities and permanent residences, and to produce locally as much of the goods and services required by the area as possible, so as to improve the standard of living and quality of life of its inhabitants.

Second, a company's mission statement should differentiate it from other companies. It should establish the individuality, if not the uniqueness of the firm. A company that wants only what most other companies want--for example, "to manufacture products in an efficient manner, at costs that help yield adequate profits"--wastes its time in formulating a mission statement. Individuality can be attained in many ways, including that in which a company's business is defined.

Third, a mission statement should define the business that the company wants to be in, not necessarily is in. However diverse its current business, it should try to find a unifying concept that enlarges its view of itself and brings it into focus; for example, a company that produces beverages, snacks, and baked good and operates a variety of dining, recreational, and entertainment facilities identified its business as "increasing the satisfaction people derive from use of their discretionary time." This suggested completely new directions for its diversification and growth. The same was true of a company that said it was in the "sticking" business, enabling objects and materials to stick together.

Fourth, a mission statement should be relevant to all the firm's stakeholders. These include its customers, suppliers, the public, shareholders, and employees. The mission should state how the company intends to serve each of them; for example, one company committed itself "to providing all its employees with adequate and fair compensation, safe working conditions, stable employment, challenging work, opportunities for personal development, and a satisfying quality of work life." It also wanted "to provide those who supply the material used in the business with continuing, if not expanding, sources of business, and with incentives to improve their products and services and their use through research and development."
Most mission statements address only shareholders and managers. Their most serious deficiency is their failure to motivate non-managerial employees. Without their commitment, a company's mission has little chance of being fulfilled, whatever its managers and shareholders do.

Finally, and of greatest importance, a mission statement should be exciting and inspiring. It should motivate all those whose participation in its pursuit is sought; for example, one Latin American company committed itself to being "an active force for economic and social development, fostering economic integration of Latin America and, within each country, collaboration between government, industry, labor and the public." A mission should play the same role in a company that the Holy Grail did in the Crusades. It does not have to appear to be feasible; it only has to be desirable.

"man has been able to grow enthusiastic over his vision of ... unconvincing enterprises. He has put himself to work for the sake of an idea, seeking by magnificent exertions to arrive at the incredible. And in the end he has arrived there. Beyond all doubt it is one of the vital sources of man's power, to be thus able to kindle enthusiasm from the mere glimmer of something improbable, difficult, remote."

If your firm has a mission statement, test it against these five criteria. If it fails to meet any of them, it should be redone.

"The Billing System We Use Is Insane"

noreply@blogger.com (Mark Frisse) — Fri, 25 Apr 2008 14:50:00 +0000

These are not my words. According to Government Health IT's coverage of the World Healthcare Congress, these are the words of Secretary Michael Leavitt, a man who understands that the bureaucracy for which he is responsible is to a significant degree responsible for this sad state. (The transcript of the Secretary's talk as of April 25 "has been removed to update and will be posted again later this week.") But this remark seems to be less an indictment on those who try to navigate the complex health care financing landscape and more a global indictment that we - as citizens - have allowed for the evolution of such a complex and absolutely inscrutable array of details that increasingly takes valuable health care dollars away from the quality of care and into the myriad organizations who are scrambling to administer and maintain compliance with the regs. It is almost as if one says "spend more money on complexity and compliance at the expense of better health care, or go to prison for fraud."

The real thrust of the Secretary's remarks seems to be focused on the importance of his "Four Cornerstones" and his urgent plea for the health care industry and the public to understand that change is critical, it takes time and it requires both vigilance and persistence. According to News-Medical.net's coverage, the Secretary said "Better information about quality and cost will not appear all at once, nor will the benefits of its use," adding, "It will happen gradually over the next decade, but we will get benefits at every step in our progress. ... So it is with every social and economic transformation." He added, "My hope is we will see a foundation that others can build on."

The Secretary was speaking to the World Healthcare Congress - an audience that is both part of the solution and part of the problem. If one looks at the speakers, it arguably is, as the banner add quoting the CEO of Wal-Mart says: "This is the largest gathering of health care providers, thinkers and experts anywhere in this world…." (Of course, a convocation of these professionals in a hotel may not lead to any more action than if they happened to find themselves in Reagan Airport at the same time.)

This writer views the World Healthcare Congress with a slightly jaded eye. To some extent it is a positive "group think" on the pulse of the health care industry that provides participants wiht a broad overview of current opinion, in another sense it is the quintessential "defensive meeting" where everyone goes to see what their competitors are up to. It would be interesting to view the average gross income of the speakers; by and large, these are powerful people who profit a great deal from the status quo. It is very much these people who must be convinced - through argument or legislative coercion - to accelerate their efforts to improve the collective health of the public even if at slight expense to their own short-term financial gain. Without such improvements, a far more adverse public response is a matter of months or years, may be inevitable.

Let's revisit Secretary Leavitt's Four Cornestones and understand why they are important and why their intent - if not the means of implementation - should transcend any changes in the Executive or Congress. The Four Cornerstones are:

Interoperable Health Information Technology (Health IT Standards)
Measured and Published Quality Information (Quality Standards)
Measured and Published Price Information (Price Standards)
Incentives: Promotion of Quality and Efficiency of Care (Incentives)

Her is my brief take on where we are and where we should be on a few of these cornerstones:

Interoperable Health Information Technology (Health IT Standards)

Adoption of standards by a committee is not the rate-limiting step, it is adoption of standardized products in the marketplace. Indeed, one can be "certified" as a vendor but offer older versions of software products that do not meet certification criteria. Furthermore, there is an issue of granularity. Some standards (e.g., NCPDP SCRIPT) are fairly non-controversial. Others (ICD-10) actually reinforce the very complexity that this writer believes to be at times a threat to innovation and consumer value.
The Secretary is promoting e-Prescribing (disclosure: this writer is a member of the SureScripts Board - an organization that shares this enthusiasm). E-prescribing, or more broadly, medication management, is a critical requirement, but the degree of social change required is underestimated by many enthusiasts. There are issues of authentication, authorization, pharmacy workflow, prescriber back-office work changes, and incentives (e.g., pay the prescribers and pharmacists - not third party disease management companies - t0 foster compliance among the people they care for). Additionally, some of the e-prescribing standards were not sufficiently evaluated in the rushed CMS pilot and need more work - notably RxFill, RxNorm, and prior authorization. Here the issue again is not the standards but the very complexity of process. What is needed is not more high-level technology standards groups but a systematic, grass-roots, community-based program to work through the technical and cultural issues pharmacy-by-pharmacy, clinic-by-clinic and consumer-by-consumer. Much is being done here by consumer advocates, pharmacy groups, and clinicians; all see the benefit of a safe and effective medication management infrastructure. The Federal government should telegraph its commitment to push society into a digital world, but it should be respectful of the complexities often ignored when enthusiasts, full of excitement, promulgate before federal groups in Washington.
ACTION: Keep it simple. Work on a safe and effective, national program for medication management - a win-win for all - and get that right. This activity will bring up most of the other issues that are critical to Health IT adoption. Add to the mix clinical laboratories, and clinicians will have great incentives to adopt.

Measured and Published Quality Information (Quality Standards)

How can one argue with this? But as has been stated, quality is an elusive thing and is to some a "multi-agent, multi-attribute utility model problem." That means that different people have different view of what quality is and that different attributes contribute to our overall perception.
Our problem? The lingua franca of quality metrics are claims data. These data are designed for accommodating the ever-evolving complex reimbursement schemes. Why should one assume that an increasingly complex claims infrastructure will necessarily be optimal for quality measurement? And if we are increasingly and justifiably moving to a transparent, price-oriented, consumer-driven health savings account structure, shouldn't quality be defined in terms we understand and not in terms of complex claims? Fortunately, many federal agencies and organizations focusing on quality are doing just that.
ACTION: Promote quality metrics that mean something to the individual and that foster long-term well-being. These metrics should complement internal, delivery-focused quality metrics that should arise naturally if providers - particularly hospitals and other large delivery organizations - are paid for doing the right thing and not necessarily just "doing more."

Measured and Published Price Information (Price Standards)

This is ideal, but problematic. Again one would benefit from trying the simplest thing first. But aside from immunizations and commercial, over-the-counter offerings, what should be the first issue? I'd argue for clear and understandable prescription drug prices. The problem? No one I know is quite sure what a prescription drug really costs various suppliers, pharmacists, and consumers. I tried to summarize what little I knew of this in a blog entry about a year ago - pricing of prescription drugs. I will update this soon.
ACTION: We should continue to look to the large pharmacies to push prices for common drugs. We should assume that price pressure for specialty drugs and other offerings will continue but that the true costs and rebates will remain controversial. Two things must be distinguished when looking at specialty drugs: the high cost of these miraculous drugs and the hidden profits. Unfortunately, even great journalism from organizations like the New York Times sometimes confuse the two issues. (See Milt Freudenheim's insightful but somewhat flawed piece in the April 19, 2008 issue.) Ironic that in an era where drugs literally save lives (including those of people I love), the cost of these are not compared more rationally to the costs of other interventions or, something more acute - simple things like gasoline and other failed policies.

Incentives: Promotion of Quality and Efficiency of Care (Incentives)

The vision is a good one. If one has price information, quality information, and rational decision-makers, one will get good results. The challenges are several. First, most long-term wins in health come at the expense of short-term sacrifice (remember this principle the next time you grab for a cookie!). Second, our very human sense of denial comes into play. I'm not going to get sick, it's going to be the other guy. How else can one explain well-educated professionals in their 20s going without health care coverage? Third, we have competing priorities. When one is paying off one's credit cards and yearning for a plasma TV, emphasis on deferred gratification and long-term tax benefits just don't have much influence.
This writer agrees that, by and large, health professionals, like other small business people, should pay for their own information technology, but where health care providers are concerned, the infrastructure and connectivity simply are not there. So imposing electronic health records before they can communicate and individual's information to wherever it is needed is a bit like mandating telephone purchases before the telephone switches and other communication allow one to use the telephone to talk with others. One example: providing e-prescribing incentives to providers in rural communities when rural pharmacies do not have the capabilities to received e-prescriptions! In some instances, a Hill-Burton type capital infrastructure approach seems relevant. But the approach could be revenue bonds or some other debt instrument and not outright grants. If we achieve the equitable system many envision, cash flow should offset expenditures across all sectors required to make an investment. But until we get the pump primed, we won't see this laudable effect take place in a systematic way.
ACTION: Once again, pick a few things and achieve evolutionary progress. The overall emphasis on smoking cessation and exercise are two examples of success in some enlightened employer-sponsored programs. But these efforts do little for the unemployed and isolated. As someone observed in a recent conference in Puerto Rico, virtually everything in our environment - from sidewalks to staircases - can be designed and promoted as ways of improving health. But often they are not.
ACTION: In addition to creating a social climate for better health, one can continue a trend that is growing in popularity: focusing on prescription drug adherence, find a suitably priced effective drug (often a generic) and create incentives that actually cost a consumer less if they take medications regularly rather than intermittently. Or, a more controversial pick, provide all pregnant women with a financial reward for behaviors that reduce low birthweight infants (e.g., nutrition, vitamins, smoking cessation). Don't think of it as welfare; think of it as cost-avoidance resulting from fewer premature infants. Think of it as an investment in the next generation to ensure they start off in healthier shape.

This writer doesn't know very much, but it's hard to argue with the passion and principles espoused by Secretary Leavitt. Although partisanship always dominates the Washington debate, there is nothing partisan in the principles espoused; they are a great start and an essential prerequisite for effective decision-making. There are clear philosophical differences about priorities and execution among various groups both within and among various political parties, but every candidate and white paper has some points worth pondering.

The real question? What will the organizations represented by the speakers and audience at the World Healthcare Congress do to advance these aims? They represent enlightened and knowledgeable groups with focus, finances, and the wisdom to change on their own behalf before change is imposed from without. But what will these organizations do? And what will it mean to those of us (all of us), whose lives and well-being are at risk?

Tectonic Shifts in the Health Information Economy

noreply@blogger.com (Mark Frisse) — Wed, 16 Apr 2008 14:10:00 +0000

In the April 17, 2008 edition of the New England Journal of Medicine, Kenneth Mandl and Isaac Kohane provide an insightful overview of personally controlled health records (PCHR) and their implications on health care delivery. Their article emphasizes in particular the impact PHCRs will have on the biomedical research enterprise. The authors discuss how the shift to consumer control will impact the very way researchers and the public view the process of studying health information. It is very similar in spirit to the disruptive potential of sites like PatientsLikeMe.com.

Every successful prototype throws more cold water on those who have not yet faced the obvious - information is not solely the property of the care delivery organization or payer intermediary - aside for certain stewardship and limited fiduciary purposes, personal health information should be under the management of the individual patient. The rules of the game are changing.

Mandl and Kohane have already authored significant works on public health infrastructure (JAMIA) and authentication (JAMIA, reference 37, PKI that "rings"). Kohane and Altmann have also published a wonderful article on the "health-information altruist" to be found in the New England Journal of Medicine ( 2005:53:2074-7).

What is new in the article released today? A few summary points:

There are two very signficant new constituents focusing on consumer empowerment and technologies to realize this empowerment. The first are the employers who are seeking efficiencies, improved health, and cost savings. The second are strong technology entrants like Google and Microsoft - each with comprehensive offerings capable of creating a more "seamless" digital relationship between an individual identity personal health information. (These two firms are attracting the most attention. WebMD, Intuit, and many other pioneers also have exciting offerings with great potential.)

What differs these new entrants from the established health IT vendors is their primary emphasis on the individual consumer. They aren't encumbered with a large provider-centric infrastructure model like those large firms who have made great technical and financial strides servicing hospitals, clinics, pharmacies, and health plans. Simply put, provider-centric reflexes and financial growth imperatives focus established vendors to refine offerings along established lines. As Clayton Christensen would put it, becoming a "disruptive" force is difficult when your earnings depend more on expanding your current strategic trajectory. Hence, many of these vendors are of necessity trying to build a better steam locomotive while hybrid autos and highways are appearing everywhere around the railroad tracks.

Mandl and Kohane emphasis that the shift in the locus of control of health information from provider to beneficiary will most directly impact daily care delivery, but their article focuses this general argument on the "threat" such technologies will have to academic medical centers and clinical research.

In their scenario, several challenging technical problems are raised.

First their individual must become authenticated and authorize subscriptions from providers and sources of clinical data (e.g., clinical labs, pharmacies, plans).
Second, they would authorize access views or even copies of records to providers, health care proxies, and possibly intelligent software agents that seek goods and services of value to the individual (e.g., disease management programs).

They describe PCHRs as a preview into a new era of "data liquidity" that will in turn updend traditional information information hegemony practices while fostering new markets for health care services. These new markets will open both to large new entrants like Microsoft and Google as well as to smaller and more regional innovators. The PCHR vision emphasizes a subscription model. Through its "hub and spoke" approach to personal consent and control, this model avoids many of the combinatoric complexities of inter-institutional data-sharing agreements and may legitimately circumvent some barriers imposed by differences among state privacy laws.

Although the basic architecture and principles behind a PCHR are relatively straightforward, some of the policies and complexities of course remain unsolved. The illustration in the Mandl and Kohane article describing the relationships among sources of health information and a centrally-controlled health record platform allows PCHR vendors to aggregate data across individuals and, barring policies and practices limiting use, provides the technical capability for these vendors to use group data against the intent of some who would retain their personal information in such systems. Explicit policies and rights along the lines of the Markle Foundation's Connecting for Health work will become essential to maintain public trust. Along the same lines, the authors note both use of de-identified data both in the HIPAA sense (which often really isn't de-identified the way you or I would like) as well as in the more mathematically sound way espoused by Sweeny, Malin, and others cited within the article.

No matter how you slice it, significant growth in PCHRs will significantly disrupt the traditional vision of exclusive institutional control often held by academic medical centers, health plans, and many other care delivery organizations. Business as usual, is over.

If one believes these new sources will provide valuable insights (and again, PatientsLikeMe.com is one possible test of this hypothesis), then the authors of this article are prescient when they say that "an entire generation of clinical researchers in training will find themselves with second-class or no access to the best research resources." Add to this problem the necessary growing reliance of academic medical centers on commercial health information systems that at times make clinical research technology modifications expensive. In response, the research community could take more more proactive approach to PCHR and for open-source systems devoted to clinical research and patient care.

The authors' treatment of certification and regulation is necessarily ambiguous. As an apocryphal quote goes: "it is difficult to make predictions, especially about the future." Mandl and Kohane rightly emphasize the importance of "guideposts such as a certification or a seal of approval with regard to services, software, and projects from a trusted authority."

This writer's problem: It is not clear those in charge of such certification efforts are certifying the right things. Emphasis should be first on clarifying CLIA and employer-individual privacy relationships. Some statement on data use limitations must be made since PCHR organizations are not HIPAA-covered entities. But does anyone think HIPAA is going to be fixed in the year before or after a national election such as this?

The authors identify a framework that in this writer's mind is very similar to the conundrum of the Treasury department looking at financial regulation. They speak of a "balance between patient control and a paternalistic protection against coercion and false claims made across the multiple channels of communication that are possible between these new...entities and...consumers." The speak of the urgent need for "creative and effective on-line consent processes."

They identify five hurdles:

Standards
Commitment of health care delivery organizations and others to publish to PCHRs
CLIA revision
Incorporation of information now only in paper form
New approaches to identifying identity and trust

One conclusion is inescapable: the horse is out of the barn. Gradually, these many efforts will coalesce not into a standard "certified product" but perhaps at least a consensus on what is really important policy-making and what is a distraction. With this knowledge in hand, one can address the critical issues surrounding confidentiality, safety, and integrity.

The article is an inspiration. Give it a read!

Privacy and e-Prescribing

noreply@blogger.com (Mark Frisse) — Tue, 15 Apr 2008 14:28:00 +0000

On April 14, 2008, a broad coalition of organizations sent a letter to Senator John Kerry and Representative Allyson Schwartz expressing strong support of their proposed electronic prescribing legislation - the Medicare Electronic Medication and Safety Protection (E-MEDS) Act of 2007.

One suggestion bears particular note. Mindful of the broad public concern over privacy and confidentiality (and the appeals of a small group of privacy advocates that arguably excessively dominate Congressional hearings), the group argues for a systematic evaluation by GAO of prescription data use practices as a necessary part of any legislation.

Rather than focus on a particular technology, the organizations lending support seem to be pointing to a more extensive set of data sale and use practices already in place and often not included in the public debate.

This emphasis places needed attention not only on the future implications of a more comprehensive digital medication management framework but also on the current array of data use practices. Before one argues for more policy and legislation, this writer believes it would indeed be valuable for GAO to conduct this study - even if the E-MEDS bill does not advance.

Quoting from the letter to Senator Kerry and Representative Schwartz:

We believe that efforts to realize the safety and savings benefits of comprehensive health information technology (HIT) must move forward within a framework of privacy and security protections. For example, many consumers have concerns about the data mining of prescription drug information, and the success of efforts to promote widespread adoption of HIT ultimately will depend on the willingness of consumers to accept the technology.

In the absence of a national privacy and security framework for the exchange of health data, we feel strongly that obtaining more definitive information about how prescription data are currently being used is a key step to addressing privacy concerns. Thus, we strongly support including in any e-prescribing legislation a requirement that the General Accounting Office (GAO) investigate the prescription data mining industry and publish a report to Congress. The report should define clearly from whom data miners are getting data, whether it is fully de-identified, how easy it is to re-identify, what the policies/procedures are for ensuring that it is de-identified (or not re-identified), and to whom they are selling data.

[Selective use of bold font added for emphasis in this posting ]

The coalition includes:

AARP
AFL-CIO
American Federation of State, County, and Municipal Employees
Center for Medical Consumers
Childbirth Connection
Consumers Union
Health Care For All
National Consumers League
National Family Caregivers Association
National Partnership for Women & Families
SEIU

Read other related letters:

AHIC

noreply@blogger.com (Mark Frisse) — Wed, 09 Apr 2008 12:24:00 +0000

This writer had the opportunity to participate in some AHIC Successor discussions this week. Although it is early in the process and the overall scope and intent are not clear by purpose and will evolve, the need for some group to convene and reconcile various sincere efforts seems important. With the diversity of talent and (by and large) altruistic intent of the many individuals who spent some hours in the Brookings Intitution this week, optimism in the democratic process should be the dominant theme.

But even optimists need focus. At present, the process resembles the classic "prisoner's dilemma" known to every student of game theory. In one room sits a group of prisoners thinking though the governance of the organization; in a separate room sits a group of prisoners thinking about membership; in a third sits a group concerned a group of prisoners reflecting on how a nascent organization with no clear membership will be sustainable. Later (only 24 hours) convenes a group to transition from the current AHIC to the successor.

When the prisoners get together in the prison yard (or the "plenary session") they are inclined to speak with humor and diplomacy. All are too uncertain of the positions of others to make strong declarations. (The guards are watching; premature disclosure and commitment may have serious consequences.)

Fortunately in this case, the resolution to the prisoner's dilemma - information exchange - is under the stewardship of a talented group from Brookings. Informed and highly focused coordination is essential at this juncture.

Those who confuse broad concepts and generic white papers with the coordination required of this task need to get out and talk to the various stakeholders who are too busy holding their stakes to attend a seemly endless array of meetings. To relate to the current airline inspection quandary, the travellers suffering from the inspection debacle are all waiting in line - they are not in a position to solve the problem, but they are the ones actually affected by it.

spAceHIC 2.0?

Perhaps an analogy to America's space program is relevant. Long ago, John Kennedy said "we're going to put a man on the moon within the decade." That was an idea the nation identified with and it left to the engineers the difficult tasks of making it happen. One can argue that all we did was fly up there, take some great pictures, and exchange our cameras for a few rocks. Or one can argue that the collateral benefits were enormous and help define the productivity we enjoy today.

But Kennedy didn't say "Let's convene a public-private, inclusive partnership to address in a broad and aggressive way all of the problems of outer space, because, well, you know space is important and if we don't figure it out someone else will." He didn't emphasize astronomer participation or anything else. He left that to the collective talents of those responsible. Those individuals did not translate the President's clear vision into a public rhetoric that emphasized "thruster milestones" and "interoperability between the fuel-sensors and the whatchamacallits." He just said "get to the moon." Although there were strict requirements emphasizing safety, mistakes were made (astronauts literally were cooked, if one remembers the tragic 1967 Apollo 1 catastrophe), but we got to the moon and those who participated in this effort developed new an unimagined technologies that were applied outside of the moon project to the public and private good. Neither Kennedy nor NASA had people who said "let's certify asteroids because, well, they can destroy the earth; we don't want to be the next dinosaurs, do we?" Cooler heads prevailed. Milestones were set, and collectively things were accomplished.

This writer suggests that although the analogy to "space exploration and understanding" is the right long term goal and the analogy to "thruster technology interoperability" is essential, these are not the right means of leading an effort and either capturing nor maintaining the public imagination.

Our current President did that. He said something like "Let's make sure everyone has an EHR by 2014." Clearly such an effort requires a lot of moving parts, and it must be effective. But the vision was clear. In this writer's view, "EHR" really stands for "availability of my health information when - and only when - I need it for my care." It is a broad mandate.

The 2004 Brailer and Thompson report elaborated on this by articulating four very important goals.

Informing clinical practice
Interconnecting clinicians
Personalize care
Improve population health

These goals again can be simply articulated to the public and to the health care community - although the interpretations will vary. They have been further enhanced by Secretary Leavitt's "four conerstones" approach. Great ideas that will make an enormous difference.

Such ideas are not partisan and should transcend administrative changes at the federal and state level. They are aspirations we as patients all should internalize and act on.

This writer was inspired by the talents trying to work through some very important issues. There seemed a great belief that there is a window of opportunity governed more by our Nation's health care needs and technology evolution than by the electoral calendar. There is a commitment here that should be refined and supported.

From this writer's perspective, let's find the people who can focus on a path toward a more effective health care system. Let's stay highly focused on a "version 1.0" and let it grow. Let's keep all essential parties focused on technical matters in the back room and bring them out with someone who can translate to the many beneficiaries of technology. Let's charge the "let's certify asteroids" and others who lose the forest for the trees with a very important task within their capabilities: Ask them to go out and return coffee and snacks while reasoned minds learn from our past mistakes and drive a critical agenda forward. We'll worry about the asteroids later.

If we do not focus on a few, generic initiatives that will, of their own accord, raise in a rational way all of the broader concerns, we will not have met public expectations and we will have squandered a precious opportunity.

Microsoft's new Health Vault Fund

noreply@blogger.com (Mark Frisse) — Tue, 26 Feb 2008 16:27:00 +0000

On February 25, Microsoft announced a $3 million dollar effort called the Microsoft HealthVault Be Well Fund. The initiative is designed to "empower providers with targeted funding to stimulate the research and development of online tools that improve health." Microsoft expects to fund approximately 20 qualified institutions with an average award of $150,000 (maximum of $500,000). Indirect costs are not funded by the Microsoft proposal. Proposals must be submitted by May 9, 2008 12:00 (noon) PST and notification will occur no later than July 1, 2008.

Microsoft envisions a range of application areas, including but not restricted to (quoting):

Primary Prevention Applications (Track 1)
Proposals targeting primary prevention could help people and caregivers create and maintain strategies that prevent or delay onset of disease by reinforcing healthy lifestyle factors and addressing modifiable risk factors such as hypertension and weight.

Secondary Prevention Applications (Track 2)
The identification of major modifiable risk factors (such as dyslipidemia, hypertension, smoking, obesity and inactivity) is a prerequisite to the implementation of preventative interventions — known as secondary prevention. Proposals in this category could help people and their caregivers measure things such as blood pressure, lipid profile components (LDL and HDL cholesterol and triglycerides), diet and nutrition, weight, smoking, and activity level to create the optimal plan to prevent or delay morbidity and acute care.

Acute Care Applications (Track 3)
Certain conditions require immediate diagnosis and treatment, whether at the doctor’s office or in an urgent care setting. Proposals targeting acute care scenarios might track progress, improve communication and share data between the silos in the healthcare system, providing caregivers with a longitudinal view of a patient’s health history that ultimately may lead to superior outcomes.

Juvenile Disease Management Applications (Track 4)
Health conditions in children often require specialized detection, diagnosis and treatment. Parents typically become eager partners in the plan of care, and seek information specifically related to their child’s condition. Proposals focusing on juvenile disease management might provide age-appropriate tools to help children, parents and caregivers understand and manage their conditions.

Women’s Health Management Applications (Track 5)
Women’s health issues can be complex and are often influenced by biopsychosocial and environmental factors. Proposals targeting this track might choose to create online tools or services that help manage health within the context of lifestyle and family.

Community and Social Health Applications (Track 6)
Patients and caregivers dealing with illness or people interested in wellness are increasingly sharing information and support with each other through various Web-based social applications. Proposals targeting this category might include applications for health in areas such as collaboration, communication and the use of social relationships to improve care.

AT&T / Tennessee: Removing the Impediment of Connectivity

noreply@blogger.com (Mark Frisse) — Mon, 25 Feb 2008 23:53:00 +0000

Today AT&T announced a major program with the State of Tennessee.

Pertinent links:

Here's a portion what the AT&T press release said:

AT&T is actively engaged with the state and health care providers statewide in building the eHealth Exchange Zone. Plans call for eHealth applications to be phased in as participation by health care providers grows.

The AT&T solution features a secure online collaboration center — a Virtual Private Network (VPN)-based portal — designed to safely and securely enable such applications as:

Prescribing pharmaceuticals online (also known as "ePrescribing").
Securing clinical messaging among the state's health care providers.
Sharing high-density images, including X-rays, MRIs and CT scans.
Exchanging patient information via portable health records, which provides patient profiles, medical history, prescriptions, etc.
Delivering telemedicine applications for remote diagnostics and care.
Accessing Tennessee Department of Health applications, including the immunization registry, disease registries, death certificate applications and processing and medical license renewal.
Accessing other health care applications and systems, including laboratory systems.

The network has an added component especially for protecting health information provided by the Covisint OnDemand Platform. The platform is a hosted solution that provides dual-factor authentication of health care providers using the VPN-based portal, which supports HIPAA privacy requirements. It also centralizes, automates and streamlines the access to information across health care communities statewide by giving physicians the ability to use many health-information applications with a single sign-on. The platform from Covisint, a division of Compuware Corporation (NASDAQ: CPWR), provides an on-demand, industry-leading infrastructure for secure collaboration and interoperability among health care providers.

Reading carefully, the AT&T announcement does not declare an intention to become the "exchange zone," to provide health care applications, or do more than two very important things: 1.) establish Internet connectivity for providers who do not have this capabilities because of locale; 2.) work with Covisint to provide dual-factor authentication - a critical aspect of any future health care application (don't you want to be sure that clinicians accessing your personal health information are who they say they are?) Covisint has been active in this area. See, for example, the testimony of their Chief Security officer to the U.S. Senate Judiciary Committee on the Future of e-Prescribing of Controlled Substances.

Reading carefully, the AT&T announcement does not seem to be exclusive, but potential grants from the state may be available to those who wish to use this network or switch to AT&T from their current means of Internet access.

According to the TN eHealth Council physician connectivity grant Web site, the State of Tennessee will distribute through intermediary organizations connectivity grants designed to "offset the costs offset the costs of connecting health care providers to Tennessee eHealth resources" including "hardware, software, peripherals, broadband connectivity, and HIPAA compliant authentication." The grant contract funding includes $3,500 per actively practicing physician as well as $6,000 per site.

This is a boon especially to rural practitioners who at this date do not have access to high-speed internet services in their community. It is not clear how much practitioners will be charged for this connectivity, nor is it clear how the Covisint authentication will work, but both seem to be good ideas in selected circumstances.

But what are the requirements?

Excerpting from the sample grant contract at the TN eHealth site one notes the following conditions:

A.3.d Grantee agrees, for a period of two (2) years, to actively participate in electronic prescribing (ePrescribing) and capturing prescription information to populate a patient’s medication history as directed by the eHealth Council. Grantee should use a software application with SureScripts and/or RxHub certifications.
A.3.d.1. Electronic prescribing, as defined by the National Council for Prescription Drug Programs (NCPDP), is two way [electronic] communication between physicians and pharmacies involving new prescriptions, refill authorizations, change requests, cancel prescriptions, and prescription fill messages to track patient compliance. Electronic prescribing is not Faxing or printing paper prescriptions. ePrescribing also includes the potential for information sharing with other health are partners including eligibility/formulary information and medication history.
A.3.e. Grantee agrees to participate in discussions with any health information exchange “HIE” or regional health information organization “RHIO” operating in that geographic area.
A.4. Grantees, who are TennCare providers, must adopt the health information technology in accordance with TennCare metrics. When serving TennCare patients, Grantee agrees to use an electronic medical record to document and track pertinent preventive health services (e.g. immunizations, pap smears, mammograms) and/or access and populate (as appropriate) a claims-based electronic health record for the same purpose.

What are the implications of these provisions? Here's one person's guess:

A.3.d
This measure will ensure that e-prescribing is adopted in a way that ensures security and authentication. This measure will place practitioners ahead of the curve - particularly if controlled substances and stronger authentication are required. One problem with the current system: It is not clear how many rural pharmacies are ready to accept e-prescriptions. Progress in the chains is striking and growth of adoption in independent pharmacies is rapid, but some communities may have to await new initiatives by independent pharmacists to achieve Internet connectivity and upgrade their systems.

E-prescribing brings new opportunities to communities. Because the linkages are between the prescriber and the pharmacy (with eligibility checks via RxHub or SureScripts in some instances), there is the potential for a leaner system and new methods of ensuring better compliance with needed medications. Remember, the real "quick win" with e-prescribing may be simplifying refills and ensuring that patients take the meds required to avoid long-term complications.

One unknown: it is not clear what "population of a medication history" means. This will be resolved. But clearly both providers with e-prescribing and plans have these data and additional overhead does not seem warranted.

A.3.e
This caveat seems to urge collaboration but does not impose additional burdens on practitioners. It is not clear which "RHIOs" are really valid here - and which are even exchanging data. It is assumed that the list includes initiatives in Memphis, Knoxville, the Tri-Cities area, and the Shared Health Initiative.

A.4.
This clause focuses on TennCare. It is not clear what "TennCare metrics" are, but the need to document care for these patients is acute. One requirement is that for TennCare patients, providers must "use an electronic medical record to document and track pertinent preventive health services (e.g. immunizations, pap smears, mammograms) and/or access and populate (as appropriate) a claims-based electronic health record for the same purpose."

Optimists can read this as a means of enabling choice among ambulatory care systems, although it's not clear how such systems will transmit "TennCare metrics" to the State. The only "claims-based electronic health record" available is Shared Health. Cynics can argue that such a requirement limits choice. In reality, it all depends on the extent to which the state encourages open choices among exchanges. The objective - improving the care of TennCare patients - seems a good one.

The Suggestion of a Framework

There are several different components that are alluded to in these documents:

The "back end" - a database that TennCare uses to document care and quality
One or more "health information exchanges" - the means by which health care providers (and someday consumers) communicate their information among authorized parties
Authentication mechanisms - means by which one can be sure of valid communications
Authorization - means by which policies and technologies ensure that the person authenticated is authorized to transmit or receive information
The "front end" - the means by which data are captured by clinicians, consumers, and fiscal intermediaries

Aligning all of these moving parts is complex and involves assuring that components at each layer are able to communicate with others. Such "interoprability" is important so that each consumer and provider can chose systems best suited for these needs. (Example: as much as we Tennesseans like Nissan, I don't think we all want to drive a Tundra, nor do we want excessing intrusion into our auto purchasing decisions.)

Unanswered Questions

This program seems worthy of strong consideration by practitioners who do not at present have access to the Internet. Among the unanswered questions are:

Internet connectivity is essential to health care delivery. But what of those who already have such access by some other means? In essence, receiving grant funding would require them to change carriers to AT&T. And what about pharmacies, nursing homes, and other essential care sites? Ultimately, every care provider is going to have to pay their way, so understanding the total cost of participation - over a 5 year period - would be valuable.

Authentication is a vital service. Can a physician gain access to these services without using AT&T? Is there any grant funding for this? Will other means of authentication be developed over time, or is Covisint the only authorized authentication broker?

Choice is important. Many practices are adopting comprehensive electronic medical record systems? How will these systems interact with the authentication mechanisms proposed? How will exchanges collaborate? How will the public's concerns over privacy and confidentiality be addressed?

Each of these topics has been the matter of hard work and collaboration. It may take time for answers to emerge.

This announcement should be viewed as a part of a broader framework enabling better care. Putting the pieces together will be somewhat a process of trial and error; that's the price a state pays for staying ahead of the curve.

GAO's Latest ONC Report

noreply@blogger.com (Mark Frisse) — Wed, 20 Feb 2008 23:24:00 +0000

The considerable progress in health information technology correlated with the HHS Office of the Network Coordinator is summarized in the most recent GAO report on this office. This report describes a "numerator" of programs funded by ONC, but fails to include the "denominator" that would include the far greater degree of innovation congruent with the Secretary's vision but equally the product of thousands of professionals and consumers across our country who - on their own and without strong government mandate - have concluded that a more effective health care technology infrastructure is essential to any improvements in our ailing health care system.

A "coordinator," one could argue, should address how the growing momentum created by all of these myriad programs can be harnessed to a greater social good. This writer remains a cautious optimist in this regard.

In testimony before the Senate Committee on the Budget on February 14, Valerie C. Melvin of the GAO summarized the overall HHS efforts, urging again for a national strategy.

Follow this link to the report (GAO-08-499T)

The report describes the considerable progress achieved . And it concludes with mention of the strategic planning process underway by the relatively new leadership at ONC.

The report states:

The National Coordinator ...told us that HHS intended to release a strategic plan with detailed plans and milestones in late 2006. Nonetheless, today the office still lacks the detailed plans, milestones, and performance measures that are needed. According to its fiscal year 2009 performance plans, the Office of the National Coordinator has prepared a draft health IT strategic plan, which it intends to release in the second quarter of 2008. If properly developed and implemented, this strategy should help ensure that HHS’s various health IT initiatives are integrated and effectively support the goal of widespread adoption of interoperable electronic health records.

The current GAO report builds on previous reports cited and provides a high-level overview of budgets, progress, and challenges. The report repeatedly makes statements like "HHS has not yet defined detailed plans and milestones for integrating the various initiatives, nor has it developed performance measures for tracking progress toward the President’s goal for widespread adoption of interoperable electronic health records by 2014. "

Since 2002, ONC has received about $200 million and has made considerable progress along several critical areas. Cited in the report are details on the progress made in:

Advancing the implementation of both outpatient and in-patient electronic health records
Recognition by the Secretary of some interoperability standards
Trial "NHIN II" implementations
A toolkit and report on the extensive privacy and security efforts at the state and national level

One could challenge the impact of some of these efforts. This writer is of the belief that the NHIN I initiate was conducted in too much haste over too short a time to achieve its true impact. The GAO report states (p 10) that "according to HHS, in early 2007 its contrators delivered final prototypes that could form the foundation (emphasis added) of a nationwide network for health information exchange. The NHIN I summary report cited 24 "core services" 12 "common transaction features," and 14 "annexes on common themes like identity arbitration, consumer data-sharing permission, and data routing. Among these 50 "things" (not counting the many other features and specifications decried by the use cases, one hopes that some immediate and fundamental high priority steps will emerge as initial steps in the road map. This writer believes that about 12 of the core services lists are "must do" high priorities, but that many others may best be left for later consideration.

The report later states (p 11) that at the end of the first contract year (September 2008), "HHS intends for the nine organizations and the federal agencies that provide health care services to test their ability to work together and to demonstrate real-time information exchange based on the nationwide health information exchange specifications they define." The specifications and test materials will be placed in the public domain so that "they can be used by other health information exchange organizations to guide their efforts to adopt interoperable health IT." These documents will be valuable. (One hopes that the NHIN I materials will someday be more easily accessed as well.)

But how should - and how can - even an organization as talented as ONC develop a national strategy. This writer has a few suggestions:

Look to the successes, not just NHIN contractors. A lot is going on in health care delivery organizations, health plans, and exchanges that are funded by AHRQ, private resources, and other sources. Indeed, many of the largest and most vibrant exchanges have chosen not to participate in NHIN at this juncture.

Build on the idea - first raised by the Commission on Systemic Interoperability - that strongly suggested the availability of a medication history for every American as a top priority
If a second "quick win" is desired, focus the same approach on clinical laboratories
Create guidelines for identity management. This is a critical topic for consumers, for e-prescribing, and for other applications. If e-prescribing is expanded to include controlled substances, identity management will become even more pressing
Focus on simple core guidelines for confidentiality and privacy that transcend applications that that can serve as a basis for new and revised legislative and policy remedy
Focus - as HHS is - on incentives to adopt helpful technologies that foster a more effective system of care
Table or adjourn 50% of the discussions taking place on topics that are not "foundational." To paraphrase Governor Phil Bredesen's remarks at the 2007 HIMSS meeting, don't try to build version 6.0 before you've got version 1.0 working.

The literature - and our experience - are full of examples of successful approaches to strategy. Such a strategy is possible in a way that transcends the transfer of power at the executive branch of the federal government and the ongoing changes in states and communities. Central to every approach is a realistic set of expectations, focus, and incremental steps.

MidSouth eHealth Alliance Update - February 12, 2008

noreply@blogger.com (Mark Frisse) — Tue, 12 Feb 2008 17:55:00 +0000

The MidSouth eHealth Alliance published its first newsletter in January of this year. The newsletter provides some background on the Alliance's recent work and data on our health information exchange in Memphis.

Follow this link for a more current update (May 8, 2008)

Additionally, the CHCF report was cited today by the Health Affairs blog and makes mention of our work in Memphis.

What can be said of the Exchange in early 2009?

Security and confidentiality remain paramount. Use and participation is governed by patietn consent, data sharing agreements, and user agreements
Information from the secure Web browser is used to care for 100 - 200 individuals today in most of Memphis' major emergency departments and a growing number of ambulatory settings.
Over 2 million events can be accessed on over 1.3 million medical records or demographic files from over 900,000 unique individuals.
Over 50 million laboratory tests are available, as well as discharge summaries, radiography reports, some medications, and a range of other clinical data elements.
Annual costs are less than $3 per person per year.
The Exchange remains committed to the care of every consenting individual without regard to health care coverage.

What are priorities for the year?

The Exchange continues to work through integration with an array of ambulatory care systems and providers.
The Exchange seeks to follow national guidelines to foster collaboration with other systems and exchanges in the region, the state, and the country.
The focus of the Exchange remains identification of ways to improve the quality of care provided to individuals both by presenting valuable clinical information and studying. consumer-driven "version 1.0" markets where patients and providers can focus first on their care and secondarily on the complexities of reimbursement.

Governor Bredesen Mentions the Memphis Effort in His Annual Address to the Legislature

noreply@blogger.com (Mark Frisse) — Tue, 29 Jan 2008 20:45:00 +0000

Four years ago - Feburary, 2004 - Governor Phil Bredesen made note of a newly-formed collaboration between the Regional Medical Center in Memphis and Vanderbilt University. This collaboration led to the AHRQ initiative governed by the MidSouth eHealth Alliance and managed by the Vanderbilt Regional Informatics Group.

On January 28, 2008 the Governor returned to the Memphis project briefly in his address to the legislature.

He made two remarks that are relevant to the direct health care value of the Exchange as well as a way it may be used as part of the State's emergency preparedness efforts.

The Governor’s talk:

http://www.tennesseeanytime.org/govfiles/2008-SOS-Address.pdf

Security and preparedness. This is a bedrock responsibility of any Governor. This past summer Tennessee was named by the U.S. Department of Homeland Security as one of the ten states in the nation to achieve their highest ranking for our disaster response plans. And we were one of eight states to get a perfect score--10 out of 10--from the Trust for America's Health for emergency preparedness. To David Mitchell and Jim Basham and Gus Hargett and Susan Cooper, and to all your supporters in the General Assembly, thank you.

.............

Education, safety, jobs, employees. I'd like now to address the subject of health.
We have a lot of things underway in the health field.

I'm particularly proud of the efforts that our state is making to fight some of the underlying causes of serious health problems, particularly in the areas of obesity and smoking. This is the real frontier in public health, and we're starting to show some real successes here; the smoking rate in middle school has declined from 17% to 10% over the past year, for example. That 10% is still 10% too high.

We are also a national leader in e-health, in the use of electronic data and communication technology to maintain and make accessible to providers a person's health records. There are advantages to both the cost and quality of health care that flow from this use of technology. We have paid a great deal of attention to the privacy and security of these records as we have proceeded. The initiative we have developed in conjunction with Vanderbilt University in the greater Memphis area is frequently held up as one of the two or three top e-health efforts in the nation.

California HealthCare Foundation NHIN Report

noreply@blogger.com (Mark Frisse) — Fri, 18 Jan 2008 18:05:00 +0000

On January 17, 2008, the California HealthCare Foundation released are report entitled: Gauging the Progress of the National Health Information Technology Initiative: Perspectives from the Field. Authored by Bruce Merlin Fried, a noted authority and past architect of the Clinton health plan and many other initiatives, the report draws its conclusions on the basis of interviews with nearly two dozen leaders and experts in health information technology. The report suggests that while the federal initiative has raised awareness about a number of important issues, NHIN has not produced the kind of fundamental changes needed to assure the realization of a nationwide EHR system.

Follow this link to the Report home page

HHS / CMS ambulatory Care Initiatives

noreply@blogger.com (Mark Frisse) — Thu, 17 Jan 2008 22:43:00 +0000

Last Fall, Secretary of HHS Michael Leavitt announced several initiatives to foster ambulatory care system adoption and use by small- and medium-sized practices. In addition to the certification initiatives designed to assure stability and value, the Federal Government has also announced several other important elements to ambulatory practice.

CMS completed its proposed rules on e-prescribing (CMS-0016-P). These are available online at http://www.cms.hhs.gov/EPrescribing/.
The FCC awarded significant sums for rural connectivity. A press release on the broadband initiative is available at: http://hraunfoss.fcc.gov/edocs_public/attachmatch/DOC-278125A1.doc.
CMS announced ambulatory care pilot programs. The link to this initiative is available at: http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1204776

Little information is yet available on the latter pilot. The HHS page says:

CMS is developing a new demonstration initiative that aims to reward delivery of high-quality care supported by the adoption and use of electronic health records in physician practices. This initiative expands upon the foundation created by the Medicare Care Management Performance (MCMP) Demonstration. The goal of this 5-year demonstration is to foster the implementation and adoption of EHRs and health information technology (HIT) more broadly as effective vehicles not only to improve the quality of care provided, but also to transform the way medicine is practiced and delivered.

Additional documentation suggests that the program will be awarded through the Medicare waiver process. The goal would be to foster adoption and effective use in order to improve care quality and to transform medical practice and delivery. It is designed to leverage the force of private and public payers to drive physician practices to widespread adoption of EHRs.

Participating physicians will be required to have a certified CCHIT-EHR in the second year. They must demonstrate utilization of the EHR to support core functions that may include clinical documentation, laboratory testing, and prescription management. But the core incentive payment "will be based on performance on the quality measures, with an enhanced bonus on the degree of HIT functionality used to manage care."

The demonstration project is designed to be operational for five years. Year one payments wil be based on degree of use (and sophistication, including "sharing of records among providers of care") Payments will be determined by the Office Systems Survey. Payments in year two will depend also on reporting quality measures, and in outlying years will then be based on performance on the designated clinical quality measures with an "added bonus each year based on the degree to which the practice has used the EHR to change and improve the way it operates."

The Memphis, Tennesse area is one of many likely candidates for such a program within the state. It's attributes include:

A functioning data exchange involving all of the major hospitals and some major clinics (with records on 950,000 individuals)
A strong ASP provider base and experience with multiple platforms for ambulatory care including Allscripts, Cerner, eClinicalWorks, and NextGen.
A new program - NetTN to provide additional support for connectivity to practitioners
Strong support from State Government

With or without federal support, independent of political persuasions or philosophy, the challenges have moved beyond technical standards and now are more cultural and policy-driven. They include:

True connectivity with laboratories, pharmacies, and other providers
Data privacy and security
Data exchange operating policies
Meaningful transparency
A critical mass of data for appropriate alignment of incentives
Meaningful quality metrics
Comparable pricing and quality information
Patient engagement

There is sufficient momentum, this writer believes, to focus on key areas of concern and begin the challenging job of implementing and demonstrating value. These challenges are addressed primarily through local issues but also require support at the state and federal level.

The Budget

noreply@blogger.com (Mark Frisse) — Sat, 15 Dec 2007 14:30:00 +0000

On December 13, 2007, CBO director Richard Orszag testified before the Committee on Budget of the United States House of Representatives.

Quoting directly from the Director's introductory comments:

Significant uncertainty surrounds long-term fiscal projections, but under any plausible scenario, the federal budget is on an unsustainable path—that is, federal debt will grow much faster than the economy over the long run. In the absence of significant changes in policy, rising costs for health care and the aging of the U.S. population will cause federal spending to grow rapidly. If federal revenues as a share of gross domestic product (GDP) remain at their current level, that rise in spending will eventually cause future budget deficits to become unsustainable. To prevent deficits from growing to levels that could impose substantial costs on the economy, revenues must rise as a share of GDP, or projected spending must fall—or some combination of the two outcomes must be achieved.

For decades, spending on Medicare and Medicaid—the federal government’s major health care programs—has been growing faster than the economy, as has health spending in the private sector. The rate at which health care costs grow relative to national income—rather than the aging of the population—will be the most important determinant of future federal spending. The Congressional Budget Office (CBO) projects that under current law, federal spending on Medicare and Medicaid measured as a share of GDP will rise from 4 percent today to 12 percent in 2050 and 19 percent in 2082—which, as a share of the economy, is roughly equivalent to the total amount that the federal government spends today.

This report and testimony are not as "dry" as one would expect. In some respects, the CBO projections lag behind the analyses of many state governments. State governments are even more constrained in terms of debt creation and revenue generation. State governments and communities bear an increasing burden of health care costs relative to federal expenditures for health (particularly through Medicaid, uninsured, and taxes to business). State government leaders are canaries in a mine that appears to have few escape routes.

The Federal "fiscal gap" analysis (difference between federal revenues and outlays as a percent of the GDP adjusted to 2007 dollars) "represents the extent to which the government would need to immediately and permanently either raise tax revenues or cut spending—or do both, to some degree—to make the government’s debt the same size (in relation to the economy) at the end of that period as it was at the beginning."

What are the implications?

Testimony states: "growing budget deficits and the resulting increases in federal debt could lead to slower economic growth. The risking federal debt (particularly under an alternative scenario that includes many expected legislative actions including indexing the alternative minimum tax to inflation and indexes physician payments to Medicare inflation "would affect the capital stock (businesses’ equipment and structures as well as housing). In CBO’s estimation, debt would reduce the capital stock—compared with what it would be if deficits were held to their share of the economy in 2007—by 40 percent in 2050 and would lower real gross national product (GNP) by 25 percent. (GNP rather than GDP is used for this calculation "because rising deficits can increase borrowing from foreigners.")

What is the reader interested in health information technology to conclude?

Setting aside the revenue issues (corporate taxes, AMT, excise, etc.) economic security of our nation seems to depend on an evolutionary but radical approach to managing health care costs. These costs can be managed only if the following conditions are met:

The public - both as individuals and as a collective - must understand how their behavior impacts costs both out of their own pockets as well as in terms of economic opportunities for the next generation. We need a clear understanding of the individual and national consequences of our health care decisions both in present and future economic terms.
Each of us must identify means where we can make wiser resource allocations both in receiving care and forestalling the consequences of chronic illnesses
Organizations that obscure these costs - particularly if done for organizational gain - profit at the expense of the economic future of the country, must be identified and their behavior changed - through self-regulation or through coercion.
Every effort to contain costs must be viewed both in terms of the short-term and the long-term. Addition of the long-term costs changes the equation dramatically because some expensive short-term interventions are actually beneficial if they lead to great long-term economic gains. Such interventions include many procedures and therapies that from a short-term perspective are deemed "costly."
Information technology must not be directed solely at refining the status quo but must also be directed towards innovations that give consumers and providers better knowledge to create an environment where everyone not only focuses on the short steps ahead but also over the horizon to a lifetime of better health.
Incremental steps are not enough. One must hope that beneficial "disruptive" technologies and behavior changes are identified and adopted over time.

Clearly, an economy based solely on delivering health care services under the status quo is not sustainable.

Can anyone envision an America whose workforce is composed only of a health care service sector providing service to a country whose population is dominated only by other low-wage service workers?
Is it not apparent that rising health care costs will lead not only to the outsourcing not only of most economically-favorable knowledge workers in manufacturing and engineering but also of the outsourcing of the health professional knowledge workers providing these services?

Under these circumstances, reports of marginal impact and improved ROI, although laudable (if credible) will make a difference, but in isolation will not make sufficient difference to change the fundamentals of the relatively dire CBO projections.