Readers Write 8/6/08

The following are recently received writings from readers of HIStalk. Your submissions are welcome, subject to editing and with a suggested length of 500 words or less. E-mail me.

Campaign 2008
By Donald Trigg, Managing Director, Cerner UK

Don lived in Washington, D.C. for ten years where he worked in a number of senior public policy roles prior to coming to Cerner in 2002.

Barack Obama swung through London recently for the final stop on a global tour designed to buttress his foreign policy credentials in advance of the Denver convention later this month. Even the oblivious found it hard to miss, as Obama met separately with Prime Minister Gordon Brown and Tory opposition leader David Cameron.

But the US election will not be decided by foreign policy photo-ops. The economy is set to dominate the next 100 days. And the question that Mr. H posed for my guest column was: what are the implications for healthcare if the economy defines the fall campaign?

An understanding of the US healthcare debate begins with what Theda Skopol described as “the rise and resounding demise of the Clinton plan.” From a grand start that embraced Health Security amid an economic downturn, it ended in stunning defeat.

The assumed political lessons for the two parties have held for the better part of fifteen years. The Democrats, wounded by Arlen Specter’s organizational chart and Dick Armey’s glossary of terms, embraced “smaller, faster” policy pursuits. The Republicans, with the exception of the Medicare Modernization Act (MMA), decried calls for more government-funded coverage such as their depiction of SCHIP reauthorization last fall as “welfare for the middle class.”

The trend lines of the core policy issues, meanwhile, have been almost as stubborn as the political framing. On cost, spending as a percent of GDP has risen from 13 percent in 1993 to 16 percent today. On access, the number of Americans without health insurance exceeds 47 million. On quality, OECD data shows the US with the third-highest rate of medical error among the 26 countries submitting data.

Of course, the intractability of these health issues is a claim that might have been advanced in 2004. The shift in 2008 is a relative decline in Iraqi violence (allowing electoral mindshare for other issues) coupled with a teetering economy that offers a powerful contextual framework for a debate on healthcare.

In June, more than 60,000 non-farm payroll jobs were lost. Existing home sales dropped for the sixth straight month. Inflation increased to its highest level in seventeen years. These uncertainties have stoked middle class anxieties and healthcare costs are part of that increasing duress.

Substantively, Obama and McCain play to type on healthcare.

Obama’s starting point is coverage for the uninsured –guaranteed eligibility and a new National Health Insurance Exchange to ensure individuals can purchase private plans. He advocates greater transparency. He champions disease management. He backs strategies to elevate care coordination, including $10 billion per year for five years to drive “broad adoption of standards-based electronic health information systems” (not quite as catchy as “Yes, We Can!” and unlikely to make it to yard signs in Ohio).

Like Obama, McCain supports elevated transparency. He promotes “21st Century information technology” (absent much detail). He also calls (notably) for a single patient bill for high-quality disease care over the lifetime of treatment. McCain’s animating principle is cost containment, with choice and competition as core strategies.

As we watch the two candidates in the months ahead, we shouldn’t anticipate exchanges on whether Obama knows what CCHIT is (he doesn’t) or whether McCain had the same problems with EHR becoming HER as he was drafting his plan (he didn’t). Neither Obama nor McCain have the deep healthcare policy acumen of a, say, Hillary Clinton. It is not their comfortable terrain.

We will see broad brush strokes. Obama will challenge McCain for failing to offer a true plan to cover everyone. McCain will question Obama on cost. They will make competing claims about who will be better at standing up to special interests and working across party lines. The exchanges will definitional and foundational.

And so, if the global tour that ended here in London begins to answer the threshold national security question for Obama, the past will be prologue. A recessionary economy will make fiscal matters the paramount campaign topic, delivering a mandate –including healthcare—to a new President for the first time since 1992.

Transformation of the IT Department
By Art Vandelay

There have been a number of articles about CIOs taking-on responsibilities beyond simply the Information Systems (IS) Department. Here are two of them (1, 2).

For once, this change is happening at nearly the same pace in health care as it is in non-health care organizations. The CIOs of Alegent, Trinity Health System, and UPMC own significant functions outside of IS. These functions are more than clinical engineering.

Alegent’s CIO owns the project management for construction, retail business, and the budget process. This has come after some glowing successes in managing the build-out of a new facility with new technologies. UPMC’s CIO has struck some innovative partnerships and created new products. This has lead to revenue as well as some notoriety. Paul Browne, from Trinity, operates the organization’s program management office and functions as a COO. This evolution has occurred while they developed and deployed their Project Genesis.

Why has this happened? There was true alignment. This was spurred by their dynamic CIOs and leadership teams. These IS departments have successfully delivered major enterprise-wide projects.

We (IS) often lament about being in the back room. From the case studies and first hand accounts I have heard, IS didn’t tell them what wasn’t possible. They showed what was possible and drove the transformation. These leaders were able to garner business support in the forms of trust and human and financial resources.

In these organizations, IT matters. Structurally, the organizations have strong project management (PM) functions and business analysis (BA) capabilities. In many of our organizations, PM capabilities haven’t developed or matured. This has occurred while our BA capabilities have eroded.

As applications have become more easily configured, more users are comfortable owning their own destiny. Our organizations have a major decision to make. Will they support our transformation to deliver these capabilities, or will they develop them elsewhere in the organization? Think Allina. There is definitely a balance to strike between IS central control and departmental ownership in health care. At the same time, PM and BA resources are scarce and need to be centrally managed for the good of the organization.

What I Did on My Summer Vacation
By Matt Grob

We were in Mexico and stopped in at a couple of pharmacies looking for an topical anti-histamine gel that we like which is used for treating bug bites, but is not yet available in the US. I had always heard about the availability of prescription drugs available in Mexico OTC, but was truly amazed that virtually everything was available.

Aside from getting a kick out of watching the men (and some women) lining up to buy their Viagra, Levitra, and Cialis, what truly caused concern was the lack of knowledge on the part of the customers regarding potential interactions, side effects, and dosage limits. On top of that, many active ingredients for even common OTC drugs were in Spanish and therefore not easy to decipher. Sure, many customers asked the people behind the counter questions regarding the drugs, but these are – for the most part – simply retail clerks with no pharmacy training at all. I finally found one guy in a shop who, while not a pharmacist, did have some training and knew enough to answer my question by pulling out their version of the PDR to look up the active ingredient.

Were the drugs cheaper? For the most part, yes. Were they easy to obtain? Certainly. This is why so many people – especially in the current economy – are seeking their meds from beyond our borders. I wonder, however, what happens when they then re-enter our healthcare system with ailments or illnesses caused by improperly self-medicating.

The Future of RHIOs
By William A. Yasnoff, MD, PhD

Bill is founder and managing partner of NHII Advisors, a consulting firm, and was previously HHS Senior Advisor, National Health Information Infrastructure.

In answer to your question about the future of RHIOs, I’d direct your attention to the health record bank (HRB) model, a central community repository of complete health records controlled by patients (including both medical records and patient-entered information — all clearly marked as to source).  

Whenever a patient receives care, the new information generated is deposited in her health record bank account (note that HIPAA requires that all records be released on patient request, thereby ensuring that such deposits will occur when patients ask for them). A non-profit community organization provides governance and hires a for-profit to develop and operate the HRB (the for-profit would raise the capital, and pay ongoing fees to the non-profit to defray its operating expenses).  

The HRB accounts are free to everyone, with the costs defrayed by a combination of advertising (to patients), fees to researchers for searches (to protect privacy, patient permission would be required and only anonymized tables of summary results would be released), and fees for reminders (paid by patients and/or third parties). In addition, the HRB would incentivize physician use of EMRs by either paying physicians a small fee (e.g. $3 each) for deposits of standard encounter reports from their EMR (for those who have them already) or subsidizing ASP-model EMRs for those who do not.  

Thus, the HRB model solves the key problems of making all the information electronic (by subsidizing physician EMRs), ensuring stakeholder cooperation (via HIPAA), earning and maintaining public trust (through patient control and community governance), and establishing financial sustainability (with a realistic business model that does not depend on charges to health care entities or capturing health care savings).  

The central repository is much simpler and cheaper to operate than the financially and technically infeasible "fetch and show" model that has been widely promoted (but is not operational on a large scale anywhere). In addition, HRBs do not need to connect to each other since the complete records for each patient are in a single HRB — this eliminates an entire class of interoperability. An HRB using this approach can be started for a modest one-time investment in a community non-profit (less than $1 million), since the cost of building the infrastructure would be paid by the capital raised by the for-profit HRB provider and ongoing operational expenses are covered by the business model.  

Washington State, Oregon, Louisville (KY), and Kansas City (MO) are all working towards this model. Note that while Microsoft, Google, and Dossia have all embraced the central repository approach, they are not complete HRBs because they lack community governance and mechanisms for incentivizing physician EMRs. The Health Record Banking Alliance (http://www.healthbanking.org ) is a national non-profit that is promoting this approach and has developed a set of principles for HRBs. I’d be happy to share more details with anyone who may be interested.

My blog has detailed articles about the concept, including Why Your Complete Lifetime Health Record Needs to be Stored in One Place, Health Record Banking: A Practical Approach to the National Health Information Infrastructure, and Health Record Banks Facilitate Consumer Control and Promote Privacy.

LinuxWorld Presentation Response
By Randy Spratt

Randy is the CIO of McKesson.

You apparently read Information Week regarding my recent address at LinuxWorld and were unfortunately not able to attend and listen in person. I’m afraid that Information Week got it a bit wrong: I said nothing about insurance companies footing the bill, and I do not regard that as a viable option.   

Rather, my point was that healthcare providers are increasingly insistent on technology that provides a real and demonstrable benefit – either a strong ROI or strong guardrails regarding patient safety or both – and that vendors who layer on costs without providing those benefits are unlikely to succeed. I noted that hospitals and physicians are heavily regulated, under enormous financial pressure, and struggle to be able to afford the technologies that have proven benefits. 

The case studies I advanced showed how systems that have a reduced third-party embedded cost (the basic value proposition of open source architectures) allow hospitals to absorb more needed technology without expanding their budget, or to divert money to other areas while attaining critical levels of reliability and performance. 

Finally, my discussion about MUMPS was not about the adequacy or quality of the platform – after all, our own STAR platform is MUMPS-based – but rather to show that IT investments in healthcare tend to have long lives, as hospitals cannot afford to make a mistake and require many many years to gradually and continuously improve their IT portfolio. The solution to funding, I opined, is to drive to the standards and the technologies that will allow reliable and facile interchange of healthcare information electronically amongst all of the stakeholders in the healthcare system. Until we achieve that, the high administrative costs we see today will continue to permeate the reimbursement system.

In every other information-based industry, where market forces are alive and well, LINUX and other open-source strategies have delivered exceptional levels of performance at much lower cost when compared to the alternatives. We are showing that the same value proposition can be delivered to the healthcare sector.

MedicalPlexus
By Brijesh P. Mehta, MD

Brijesh is a co-founder of MedicalPlexus and a medical resident at Mass General and Brigham & Women’s. He asked for a little PR for his new company MedicalPlexus, so since he’s a medical resident, I agreed. Here’s an abbreviated version of the e-mail interview.

What’s your background?

I have done clinical neuroimaging and translational laboratory research in neuroscience with publications in high impact peer-reviewed journals. I Completed medical school at the University of North Carolina and am currently a resident physician in the department of neurology at the Massachusetts General and Brigham & Women’s Hospitals. I plans to become a vascular and interventional neurologist.

What led you to start MedicalPlexus?

Advances in medical technology, the electronic transformation of medical education, and widespread use of digital tools in medical practice has led to a proliferation of digital multimedia content with valuable educational merit. However, the content is scattered on individual physicians’ computers, department intranets, and behind firewalls, making content management and sharing among physicians extremely ineffective. Concerns about patient privacy and intellectual property issues have also restricted content sharing.

Because the medical community is predicated on continuous learning, many physicians and researchers have begun to share digital medical multimedia on existing social networking communities such as iTunes, YouTube, Flickr, Slideshare, and even Facebook. Given the uncontrolled nature of these broad communities, physicians simply are not able to efficiently find relevant content, trust the content, or candidly discuss the content.

Based on their frustrations finding, accessing, and sharing digital medical multimedia content as a medical student and a resident physician, respectively, Mr. Nallasamy and Dr. Mehta created the MedicalPlexus concept for the purpose of improving patient care by more effectively disseminating medical knowledge.

Who is your intended audience?

Two tiers. Individual users: physicians (academic and community), residents/fellows, medical students. Groups: medical societies, clinical departments, residency training programs, medical schools, research laboratories.

Who are your competitors?

Online physician communities are still in an early stage with low barriers to entry, moderate competition, and uncertain revenue models. Although a few companies have grown their membership base, there is yet no market dominance.

Current sites range in their focus from enabling physician interactions to social networking to information sharing. The majority of these sites provide a service to physicians with the packaging of traditional social networking sites. Most do not address important patient privacy guidelines, content ownership guidelines, or ensure the exclusivity of these communities to physicians. This combined with the lack of appropriate content oversight is a barrier to providing an online educational platform to physicians that is  trustworthy.

For other sites, trust and privacy concerns stem from their revenue model, which is dependent on providing third parties, such as pharmaceutical companies, fee-based access to physician postings and interactions on their sites.

How would MedicalPlexus be used?

View content with a built-in media streaming module.
Upload, manage, share, rate, discuss content.
Aggregate content from online medical sites.
Subscribe to physician profiles and medical groups.
Add meta tags to community content.
Search PubMed, link e-publications to content.
Receive newsletters and email alerts of activity on MedicalPlexus.
Full access to unlimited multimedia content.
Personal, scalable storage space for archiving content.
Browse and bookmark content by specialties, groups, ratings, times.
Search with tags, labels, groups, diseases, imaging modalities.
Create personal user profiles to display own content, showcase work.
Assign sharing level for each piece of content: private, specific users, groups.
View, share media on mobile devices.
Private messaging between physicians.

Is the site live?

Currently we have presented the platform to select Harvard medical school departments for beta testing and their feedback has been very positive. As such, at this time, we have a couple hundred users which reflects the departments we have presented to. We have not done any publicity so far. It has been primarily word of mouth and through our presentations. At this time, any medical student, physician, or resident around the country who is affiliated with an academic medical center may create an account and begin using MedicalPlexus.

How will you get the word out?

Viral marketing, company blog to provide updates and highlights of  platform features, recent launch of a revenue sharing model, and reaching out to influential blogs such as yours to profile the site. Once we obtain funding, we will launch a national ad campaign in print/online media such as scientific/medical journals and presentation booths at annual medical society conferences.

What are the next steps? 

Traction at key Harvard medical school departments and tracking usage with our analytic tools. Adding more interactive features to the platform based on feedback from our users. Collaboration with Cisco Systems’ global life sciences group to add live video conferencing, chat. Partnerships with medical societies to develop clinical registry database.

What do you hope to get from HIStalk’s readers?

We’re looking to spread awareness of the platform to ramp up usage and make improvements. As such, we would be very interested if your readers, who may have great deal of experience in health IT, take a look at MedicalPlexus, sign up for an account, and ideally give us some feedback on their initial impressions, dream features they would want, parts of the interface they may or may not like, etc.

We have some great ideas in the pipeline about future directions for the site, but we’re very interested in making sure that we continue to develop a product that will be useful to doctors and researchers in their daily workflow.

If your readers really like what they see, it would be great to have them pass it along to physicians in their respective hospitals. The more use we have, the more content there will be on the site with potential to translate into a valuable resource.