Four high-ranking members of Congress wrote a letter to HHS Secretary Kathleen Sebelius (PDF) last week urging her to halt federal electronic health-record incentive payments to hospitals and office-based physicians because of an alleged lack of interoperability spawned by weak rulemaking.
At the $7.1 billion mark in an estimated $27 billion program, what's up with that?
How about an honest difference of opinion?
Nope.
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I want to say something quickly about outsourcing mobile app development.
At the Health 2.0 conference this week in San Francisco, HHS and the Advisory Board Co. announced the winners of their competitions for apps using the Blue Button technology developed by the U.S. Veterans Affairs Department.
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Here's today's tip for healthcare website developers.
If you're like the CMS, and having just revamped your website, you feel compelled to issue a news release to explain how the site's frequently-asked-questions section actually works, you probably should have first asked yourself a few questions, such as this one from my colleague: "What the FAQ?"
The CMS release I'm talking about came today. It announced that the CMS has updated its system. So far, so good.
But then came trouble, under the headline: "Learn How to Directly Link to FAQs with the Updated System."
The CMS' FAQ on the electronic health-records incentive programs, which is what the e-mail was about, prints out to 10 pages and has 197 linked questions.
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Here’s a conversation somebody should have had with an empty chair.
Let’s pretend the chair is U.S. Attorney General Eric Holder.
“You know, Mr. Holder, we pay doctors as if they're sewing shirtwaists in some sweatshop loft in New York's garment district in the 19th century. If they whip in some more-elaborate stitching, so to speak, we try to keep track of that and pay them a little more, but basically, we just pay them like pieceworkers.
“So, Mr. Holder, work with me on this analogy.
“Let's suppose, instead of making them sew (i.e., treat patients) the old-fashioned way, whipping in stitches (I mean documenting their work) with needle (pen) in hand, let's make them all get pedal-powered sewing machines (by that, of course, I mean electronic health-record systems).
“Old ways die hard, Mr. Holder, and the best of these machines are, admittedly, kinda clunky, but still, I think we can sell the docs on switching over to them by explaining that once they buy and install the machines and once they figure out how to use them, they should be able to crank out in a given day a lot more shirtwaists (by that, I mean patient visits).
“But this is the real selling point, Mr. Holder. With the machines, the docs' production of the more-difficult, intricately stitched shirtwaists (the more thoroughly evaluated patients) will jump. That'll be good for the patients and docs, particularly if we don't change the piece rate.
"So, the sales staffs of the machine vendors will sell the docs on the machines by saying they're gonna make a lot more money. It's brilliant.
“We can try this first as a pilot, Mr. Holder. Then, we'll toss in a few billion bucks for down payments on new machines. We'll get all that money back and more through the docs' increased productivity.
“But wait, just thinking out loud here: Won't we have to pay the docs more? Because once they get handy with these machines, they'll produce more, especially the higher-cost stuff.
“What's that, Mr. Holder? You've got an idea? Cut the docs' piece rate, right?
“No?
“What?
“Accuse the docs of fraud?
"Really?
“You're kidding, right?
“You'll come off like Claude Raines in Casablanca.
“Didn't we just tell the docs to use the machines?
“And what if this all comes down in an election year?
“OK, so you figure, it's a big country, someone will have to be using the machines up against the chalk lines. Right, and then you say, 'I'm shocked, shocked!' Just like Claude Raines. We'll have a couple of show trials and the docs will dial it down on their own.
“Beautiful!
“Do you really think it will work?
“Nah, me neither.”
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How long did it take American farmers to widely adopt hybrid corn?
Honestly, I don't know, but I do remember what I was told about that kind of adoption—30 years.
I was age 22 at the time and had just started my agriculture extension training with the Peace Corps in Sierra Leone, where we learned the basics of rice paddy construction and swamp rice cultivation. It wasn't until later, when we were posted to our villages to serve our two-year hitches, that we learned just how hard it was going to be to convince wary farmers to abandon their familiar but ecologically destructive slash-and-burn cultivation techniques.
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Sarah Krug, president of the Society for Participatory Medicine, had taken her stab at diplomacy before I spoke with her over the phone last week.
I had been reading news releases and calling people I know to put together a story about industry leaders' reaction to the massive, 1,354-page, three-rule phone book the feds dropped on the industry Aug. 23 and Aug. 24 when I received a hedged e-mail from Krug's group.
"Although we're disappointed this final rule does not give patients next-day access to their electronic medical record after they leave the hospital, we believe that on balance the Stage 2 meaningful-use requirements go a long way towards patient empowerment and feature a number of important patient-centered innovations," it said.
In a follow-up phone call, she was more direct: "Long story short, we're disappointed."
The goal of the New York-based not-for-profit, Krug said, is for patients to have immediate access to their updated records. They had been hoping for next-day access in the Stage 2 rule. Instead, the rule requires hospitals to make available online to more than 50% of their patients their information within 36 hours of discharge.
"It's definitely a step in the right direction,' Krug said, before adding, "I'm sure there are going to be a lot of patients that are going to be just as disappointed."
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HHS certainly backed up the old regulatory dump truck and pulled the lever, spilling out 1,354 pages of legalese in three separate health information technology-related rules.
One was the CMS' long awaited Stage 2 meaningful-use final rule affecting providers, running a sumo-sized 672 pages.
Another was a companion rule from the Office of the National Coordinator for Health Information Technology, coming in at a hefty 474 pages and targeting IT developers on certification criteria for electronic health-record systems.
Finally, the third rule, also from the CMS and weighing in at a comparatively svelte heavyweight 208 pages, does three things. It pushes back to 2014 the compliance deadline for ICD-10, tweaks an earlier rule on the national provider identifiers, and—after 16 years—establishes a set of health plan identification numbers first called for in the Health Insurance Portability and Accountability Act of 1996.
Like many of you, I'll be spending the weekend poring over the new rules, and I'll be giving you my take on them in the coming weeks.
A few things come to mind right now, one being that perhaps the feds got a few things right, based on the mixed criticism that quickly emanated from healthcare industry leaders tracking—and lobbying—the federal rulemakers.
For example, the American Hospital Association quickly fired off a summary, praising the feds and the CMS in particular for "a shorter meaningful-use reporting period for 2014," but quickly adding expression of disappointment "that this rule sets an unrealistic date by which hospitals must achieve the initial meaningful-use requirements to avoid penalties." The AHA also said that CMS "complicated the reporting of clinical quality measures and added to the meaningful use objectives, creating significant new burdens."
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Personal health records and health record banks are nothing new.
Then again, neither are data breaches, consumer surveys saying people want their privacy rights respected and provider surveys indicating, within limits, that they'd like to respect their patients' privacy desires.
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Healthcare providers, if I'm wrong, you can taunt me with this in 2013, but I'm going to predict that in a year's time, without government intervention, patients are going to jackhammer their way into your electronic health-record systems with data from their Apple or Android phones and tablets.
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In a story in Modern Healthcare magazine this week are some numbers from the CMS on electronic health-record systems that hospitals, physicians and other "eligible professionals" are using to meet their meaningful-use obligations under the Medicare EHR incentive payment program.
There were more than 77,600 records in the CMS database, with basic product information on "complete" EHR systems used by 1,027 hospitals and 71,183 EPs.
The CMS data shows that hospitals have used complete EHRs from 27 developers and EPs have used EHRs from 327 different vendors to qualify for federal payments.
Facing "a plethora of options" has long been the rule for office-based primary-care physicians shopping for EHRs, with variables including cost, functionality, service and vendor size, according to Dr. Steve Waldren director of the Center for Health Information Technology at the American Academy of Family Physicians.
Since 2007, the Leawood, Kan.-based medical specialty society has run a website with not only an EHR guide but also a library where members can post peer reviews of their EHRs.
"We've tried to educate our members on the key things they need to look at," Waldren said, adding that one of those is "creating a peer network of people" to help them in their decision-making.
Another is advising physicians to investigate in advance how they'll be able get their patients' records out of their EHR system when their developer goes belly-up.
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I had no idea.
There is simply a horde, a herd, a whole Wild West stampede of electronic health-record systems out there.
Anyone who's wandered the showroom floor at a Healthcare Information and Management Systems Society convention knows there are tons of health information technology companies. There were upwards of 1,100 exhibitors this year.
But earlier this month, Jodi Daniel, director of the Office of Policy and Research within the Office of the National Coordinator for Health Information Technology, presented a slide at an Health Information Technology Policy Committee meeting with some health IT market numbers that I found nothing short of astonishing.
Believe it or not, according to Daniel, there are 613 "complete" electronic health record systems and 399 "modular" systems that have been tested and certified for use in the federal EHR incentive payment program in the ambulatory-care market alone.
There are another 87 complete and 378 modular EHR systems for inpatient venues.
All totaled, as of July 5, there were 816 different EHR vendors offering 1,477 "unique" certified products on the ONC's official Certified Health IT Product List, from which Daniel drew her incredible numbers.
Chase Titensor is a researcher and data analyst for KLAS Enterprises who worked on his company's latest report on the ambulatory EHR market released earlier this week. We talked Thursday and when I asked what surprised him most from the research for the report this year, it was just how large and increasingly diverse, the ambulatory EHR market is.
Titensor and his fellow KLAS researchers interviewed 318 shoppers for ambulatory-care EHRs—either first-time buyers or those looking to replace existing systems. Of those buyers, 64% are considering EHRs other than the top 11 brands, up from 49% in a similar research a year earlier.
Consideration of products from these "other" vendors spiked to 88% for those docs in the solo or small-group market (up to 10 physicians).
Simply put, it is a market that is still expanding and not yet consolidating.
"It is amazing to see the rise of solutions being considered outside of the top 11," Titensor said. "You can see that in the ONC numbers and the number of private venture capital groups getting into the business. It's just a market in total upheaval."
So, I asked Titensor, do you think it's possible there's an EHR out there in that herd of 602 “other” EHRs not in your top 11 that's the "killer app" in the making, one that may one day challenge today's market leaders?
He said he's had conversations with several CEOs of name brand companies and "they're very cognizant of the fact there is somebody out there who could replace them."
"I'm sure there is somebody in the weeds," Titensor said. "I just can't say who it is. I just don't know."
Follow Joseph Conn on Twitter @MHJConn.
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