Where's Epic?
In his keynote address Tuesday, cardiologist and healthcare information technology futurist Dr. Eric Topol asked that question.
The context was a much-ballyhooed consortium of five health IT vendors announced Monday at the Healthcare Information and Management Systems Society conference in New Orleans.
They joined hands to launch a not-for-profit consortium called the CommonWell Health Alliance, with the stated aim of improving health information interoperability. The founding members of the consortium are Allscripts Healthcare Solutions, Athenahealth, Cerner Corp., Greenway Medical Technologies, and McKesson Corp., along with its connectivity unit RelayHealth. At the launch, the founders said the consortium is open to everyone.
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Professionally speaking, I am a connoisseur of a certain kind of crankiness.
I like to listen to people who don't like the deal we've been handed and are willing to grump about it.
Decorum may make the world turn smoothly, but noisy people make it change. Often, they also make my job more fun.
A lot of people in leadership pay lip service to the ideal that they're open to new ideas, but we all know from experience that many are not.
In the magazine this week are short profiles on four of the squeakiest wheels in healthcare information technology—three physicians and a researcher with a doctorate in sociology. They are Dr. Lawrence Weed, Dr. Scot Silverstein, Dr. Deborah Peel, and Ross Koppel, Ph.D.
Each are self-professed fans of health information technology, but each have bones to pick with current systems and practices.
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Give RAND Corp. researchers Arthur Kellermann and Spencer Jones a gold star for integrity for pointing out the predictions in a totemic 2005 RAND report haven't quite panned out yet.
Their latest analysis of the value of health IT, published in the January edition of Health Affairs, notes that the billions of dollars in annual savings from the adoption of health IT systems projected by RAND peer Richard Hillestad in 2005 haven't materialized.
The Hillestad study was often cited by EHR advocates, including a few federal legislators, as an economic argument for promotion of health IT.
What seems to be getting lost in some recent news reports and follow-up discussions about both RAND reports, however, is that while the predictions of Hillestad and his team “have not yet come to pass,” it is not because their cost-savings projections were flawed, according to Kellermann and Jones, but rather because of “sluggish adoption of health IT systems,” EHRs that are “neither interoperable nor easy to use,” and providers who fail to re-engineer their care process to best leverage the IT systems they have.
Some analysts have interpreted Kellermann and Jones' report as RAND crawfishing.
Hillestad, now retired, says he has been keeping up on the controversy and is standing firm.
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A reader was confused by an article we ran saying 48% of doctors were e-prescribing using an electronic health-record system. Another article, published Dec. 6, based on an annual survey of ambulatory care physicians by the National Center for Health Statistics at the Centers for Disease Control, placed "basic" EHR adoption at 39.6%. A basic EHR includes e-prescribing capabilities. That seemed like an 8-point spread in physician EHR use.
To make matters worse, the NCHS surveyors calculated two other EHR penetration rates (PDF) for ambulatory care physicians of 71.8% and 23.5%, while Dr. Farzad Mostashari, head of HHS' Office of the National Coordinator for Health Information Technology, quoted in a third article, said 31% of physicians and other eligible professionals have been paid federal EHR incentive money, which means they'd also have to be e-prescribers.
So, that leaves us with quite a range of physician EHR users—71.8% to 23.5%— and several rates in between.
Why so many?
Here's some background and an explanation.
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What am I thankful for today?
The usual stuff. A loving family. My faith and my church home. Good health. An interesting job where I can put my skills to good use.
And—as a professional skeptic, this is weird for me to say—I'm also grateful for our government, or at least some aspects of it.
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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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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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It was déjà vu for data security expert Michael "Mac" McMillan when he heard a hacker had tried to extort money from an Illinois medical group whose patient records and e-mail messages the intruder had accessed and encrypted.
"This is classic," McMillian said. "We saw this countless times in the 1990s with community banks. They would get access to the accounts with people's data and send the bank director a ransom note."
McMillan is the founder and CEO of CynergisTek, an Austin, Texas-based security consulting firm serving the healthcare industry.
He hasn't heard of another incidence in the healthcare industry in which encryption was used to hold a provider's data hostage—at least not yet—but "it doesn't surprise me that it's happened," he said.
When other industries computerized their business processes, security trailed, McMillan said. "They all went through these phases, where the big guys at the top did it first and the little guys dragged their feet."
In healthcare, "with all this digitization and data-sharing, you become more and more vulnerable to threats from the Internet," he said.
The hack job on the computer system of three surgeons in Libertyville, Ill., a northwest suburb of Chicago, was discovered in June but wasn't publicly revealed until recently. The investigation was turned over to the Secret Service—an agency most widely known for its work protecting the U.S. president, but that possesses other skills, too.
"The Secret Service is the organization within the federal government that has executive agency over computer security crimes," McMillan said. "Typically, when they get involved, there is some form of interstate extortion or threat or something big that can cross state lines or international boundaries."
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I wrote Wednesday about the new ambulatory electronic health-record system survey report from the National Center for Health Statistics, and I want to elaborate today on what I think was a key finding from it.
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We heard from our healthcare information technology cheerleader-in-chief Dr. Farzad Mostashari on Tuesday that many office-based physicians are, if not deliriously happy with their electronic health-record systems, at least not storming EHR vendor headquarters with flaming torches and pitchforks.
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We heard from our healthcare information technology cheerleader-in-chief Dr. Farzad Mostashari on Tuesday that many office-based physicians are, if not deliriously happy with their electronic health-record systems, at least not storming EHR vendor headquarters with flaming torches and pitchforks.
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